Implementation Guide for fælleskommunal informationsmodel
1.2.0 - release

This page is part of the KLCore (v1.2.0: Release) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: CitizensOwnObservation

Official URL: http://fhir.kl.dk/core/StructureDefinition/KLCommonCareSocialCitizensOwnObservation Version: 1.2.0
Active as of 2023-06-07 Computable Name: KLCommonCareSocialCitizensOwnObservation

Citizens own observation of performance level (udførelse) or importance level (betydning) as defined by FSIII

Scope and usage

CommonCareSocialCitizensOwnObservation is used to document, performance level (udførelse) or importance level (betydning) as defined by FSIII. Note that each of the observations require its own instance of this model. The observation only makes sense linked to an already defined Condition or MatterOfInterest. Consequently, the focus-attribute is mandatory.

The code-attribute refers to either performance level or importance level using a required ValueSet, and the result is expressed in valueCodeableConcept, which is also bound to a required FSIII valueSet. Observation and value codes should be correctly matched, so that a performance-result is not used with a importance observation-code.

Note that the profile does not specify explicitely, which role the citizen had in evaluating his or her own performance/importance level. The model just presumes that the citizen (refered in Observation.subject) has been asked about their own evaluation of the matter, and that is has been documented by a municipality practitioner (refered in Observation.performer). However, if further specification of roles in the documentation proces is required for a specific use case, please use Provenance.

The encounter in which the citizen make the observation can be refered to in Observation.encounter. Notice that the status-attribute is mandatory. For normal use, just set to “final”. If data is missing or another problem has occured, follow the FHIR guidance to populate the field correctly.

Conversions between Danish information model and FHIR-profile

Nedenstående tabel oversætter mellem de attributter, der er defineret i den fælleskommunale informationsmodel (FKI), definerer kort den enkelte attribut på dansk og specificerer, hvilke af FHIR-profilens atributter der skal bruges til specifikation af indholdet.

FKI-attribut Definition FHIR
borgervurderingskode Klasse som udtrykker, at der observeres på borgers evne til at udføre funktion eller aktivitet. Observation.code.coding
borgervurderingsresultat Klasse, der udtrykker resultatet af borgers vurdering. Observation.valueCodeableConcept.coding
borgervurderingssubjekt Den borger, som er genstad for vurdering. Observation.subject
borgervurderingskontakt Den kontakt, hvor vurderingen er foretaget. Observation.encounter
borgervurderingsansvarlig Den fagperson der er ansvarlig for observationen. Observation.performer
borgervurderingsfokus Tilstand eller matter of interest, som denne borgervurdering er direkte observation på. Observation.focus
borgervurderingstid Tidspunkt for borgervurderingen. Observation.effectiveDateTime
borgervurderingsstatus Klasse der udtrykker, hvor i sin proces, borgervurderingen er. Observation.status

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*ObservationMeasurements and simple assertions
... status 1..1code[DK] borgervurderingsstatus
... code 1..1CodeableConceptType of observation (code / type)
Binding: KLBorgervurderingsObservationskoderFSIII (required)
.... coding 0..*Coding[DK] borgervurderingskode
... subject 0..1Reference(Citizen)[DK] borgervurderingssubjekt
... encounter 0..1Reference(Encounter)[DK] borgervurderingskontakt
... effective[x] 1..1dateTime[DK] borgervurderingstid
... performer 0..*Reference(Practioner)[DK] observationsansvarlig
... value[x] 0..1CodeableConceptActual result
Binding: KLBorgervurderingsResultatkoderFSIII (required)
.... coding 0..*Coding[DK] borgervurderingsresultat

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.coderequiredKLCitizenObservationCodesFSIII
Observation.value[x]requiredKLCitizenObservationResultCodesFSIII
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationMeasurements and simple assertions
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!Σ1..1code[DK] borgervurderingsstatus
Binding: ObservationStatus (required): Codes providing the status of an observation.

.... coding Σ0..*Coding[DK] borgervurderingskode
... subject Σ0..1Reference(Citizen)[DK] borgervurderingssubjekt
... focus Σ1..1Reference(Condition | MatterOfInterest)[DK] borgervurderingsfokus
... encounter Σ0..1Reference(Encounter)[DK] borgervurderingskontakt
... effective[x] Σ1..1dateTime[DK] borgervurderingstid
... performer Σ0..*Reference(Practioner)[DK] observationsansvarlig
... value[x] ΣC0..1CodeableConceptActual result
Binding: KLBorgervurderingsResultatkoderFSIII (required)
.... coding Σ0..*Coding[DK] borgervurderingsresultat

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Observation.statusrequiredObservationStatus
Observation.coderequiredKLCitizenObservationCodesFSIII
Observation.value[x]requiredKLCitizenObservationResultCodesFSIII
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationMeasurements and simple assertions
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!Σ1..1code[DK] borgervurderingsstatus
Binding: ObservationStatus (required): Codes providing the status of an observation.

... category 0..*CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


... code Σ1..1CodeableConceptType of observation (code / type)
Binding: KLBorgervurderingsObservationskoderFSIII (required)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*Coding[DK] borgervurderingskode
.... text Σ0..1stringPlain text representation of the concept
... subject Σ0..1Reference(Citizen)[DK] borgervurderingssubjekt
... focus Σ1..1Reference(Condition | MatterOfInterest)[DK] borgervurderingsfokus
... encounter Σ0..1Reference(Encounter)[DK] borgervurderingskontakt
... effective[x] Σ1..1dateTime[DK] borgervurderingstid
... issued Σ0..1instantDate/Time this version was made available
... performer Σ0..*Reference(Practioner)[DK] observationsansvarlig
... value[x] ΣC0..1CodeableConceptActual result
Binding: KLBorgervurderingsResultatkoderFSIII (required)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*Coding[DK] borgervurderingsresultat
.... text Σ0..1stringPlain text representation of the concept
... dataAbsentReason C0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..*AnnotationComments about the observation
... bodySite 0..1CodeableConceptObserved body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1CodeableConceptHow it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange C0..*BackboneElementProvides guide for interpretation
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low C0..1SimpleQuantityLow Range, if relevant
.... high C0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember Σ0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)Related resource that belongs to the Observation group
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component Σ0..*BackboneElementComponent results
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason C0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


.... referenceRange 0..*See referenceRange (Observation)Provides guide for interpretation of component result

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Observation.statusrequiredObservationStatus
Observation.categorypreferredObservationCategoryCodes
Observation.coderequiredKLCitizenObservationCodesFSIII
Observation.value[x]requiredKLCitizenObservationResultCodesFSIII
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySiteexampleSNOMEDCTBodyStructures
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes

Differential View

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*ObservationMeasurements and simple assertions
... status 1..1code[DK] borgervurderingsstatus
... code 1..1CodeableConceptType of observation (code / type)
Binding: KLBorgervurderingsObservationskoderFSIII (required)
.... coding 0..*Coding[DK] borgervurderingskode
... subject 0..1Reference(Citizen)[DK] borgervurderingssubjekt
... encounter 0..1Reference(Encounter)[DK] borgervurderingskontakt
... effective[x] 1..1dateTime[DK] borgervurderingstid
... performer 0..*Reference(Practioner)[DK] observationsansvarlig
... value[x] 0..1CodeableConceptActual result
Binding: KLBorgervurderingsResultatkoderFSIII (required)
.... coding 0..*Coding[DK] borgervurderingsresultat

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.coderequiredKLCitizenObservationCodesFSIII
Observation.value[x]requiredKLCitizenObservationResultCodesFSIII

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationMeasurements and simple assertions
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!Σ1..1code[DK] borgervurderingsstatus
Binding: ObservationStatus (required): Codes providing the status of an observation.

.... coding Σ0..*Coding[DK] borgervurderingskode
... subject Σ0..1Reference(Citizen)[DK] borgervurderingssubjekt
... focus Σ1..1Reference(Condition | MatterOfInterest)[DK] borgervurderingsfokus
... encounter Σ0..1Reference(Encounter)[DK] borgervurderingskontakt
... effective[x] Σ1..1dateTime[DK] borgervurderingstid
... performer Σ0..*Reference(Practioner)[DK] observationsansvarlig
... value[x] ΣC0..1CodeableConceptActual result
Binding: KLBorgervurderingsResultatkoderFSIII (required)
.... coding Σ0..*Coding[DK] borgervurderingsresultat

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Observation.statusrequiredObservationStatus
Observation.coderequiredKLCitizenObservationCodesFSIII
Observation.value[x]requiredKLCitizenObservationResultCodesFSIII

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationMeasurements and simple assertions
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!Σ1..1code[DK] borgervurderingsstatus
Binding: ObservationStatus (required): Codes providing the status of an observation.

... category 0..*CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


... code Σ1..1CodeableConceptType of observation (code / type)
Binding: KLBorgervurderingsObservationskoderFSIII (required)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*Coding[DK] borgervurderingskode
.... text Σ0..1stringPlain text representation of the concept
... subject Σ0..1Reference(Citizen)[DK] borgervurderingssubjekt
... focus Σ1..1Reference(Condition | MatterOfInterest)[DK] borgervurderingsfokus
... encounter Σ0..1Reference(Encounter)[DK] borgervurderingskontakt
... effective[x] Σ1..1dateTime[DK] borgervurderingstid
... issued Σ0..1instantDate/Time this version was made available
... performer Σ0..*Reference(Practioner)[DK] observationsansvarlig
... value[x] ΣC0..1CodeableConceptActual result
Binding: KLBorgervurderingsResultatkoderFSIII (required)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*Coding[DK] borgervurderingsresultat
.... text Σ0..1stringPlain text representation of the concept
... dataAbsentReason C0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..*AnnotationComments about the observation
... bodySite 0..1CodeableConceptObserved body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1CodeableConceptHow it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange C0..*BackboneElementProvides guide for interpretation
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low C0..1SimpleQuantityLow Range, if relevant
.... high C0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember Σ0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)Related resource that belongs to the Observation group
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component Σ0..*BackboneElementComponent results
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason C0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


.... referenceRange 0..*See referenceRange (Observation)Provides guide for interpretation of component result

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Observation.statusrequiredObservationStatus
Observation.categorypreferredObservationCategoryCodes
Observation.coderequiredKLCitizenObservationCodesFSIII
Observation.value[x]requiredKLCitizenObservationResultCodesFSIII
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySiteexampleSNOMEDCTBodyStructures
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes

 

Other representations of profile: CSV, Excel, Schematron