Scope and usage

The CarePlan for §119 is used whenever a prevention/health promotion care pathway is planned for a citizen in Danish municipalities. Care pathway or plan is a way to describe when a number of planned interventions are delivered together with a common schedule.

The two types of plan in §119 are ‘Intervention efter §119’ and ‘Opfølgningsforløb efter §119’ and one of these two codes should be documented in CarePlan.category.

It is important to distiguish correctly between the dates and times stated in the model. CarePlan.period.start is when the CarePlan was authorized (bevillingstid). The planned end-date is CarePlan.period.end, unless the date has already occured and the status is ‘completed’, then it is the actual end-date. Notice that end-date is not mandatory to report. All dates may be repported with or without time of day.

CarePlan.status and CarePlan.intent are mandatory in the FHIR CarePlan resource. CarePlan.intent is always ‘plan’ in this implementation guide. CarePlan status should at least distiguish between ‘unknown’ and ‘entered-in-error’, but the actual status of the care plan may also be reported. Note that the meaning of ‘active’ is “ready to be acted upon”, so it does not signify that the first activity has occured.

CarePlan.activity.detail.status is also mandatory, and all the statuses in the FHIR ValueSet may be used. It is recommended not to use ‘entered-in-error’ - if the CarePlan is entered-in-error use CarePlan.status. To get the needed data-quality, the detail-status should at least distinguish between ‘unknown’ and ‘cancelled’. Although it is better to use the appropriate FHIR-statuses, ‘unknown’ is permitted from the time where the care plan occurs in the record until its completion. ‘Cancelled’ (or ‘stopped’) are mandatory, if an care plan is cancelled. It is mandatory to report cancelled care plans, so that the reason for the cancellation can inform the dataset. This is done using CarePlan.activity.detail.statusReason, and a set of codes that represents different reasons for the cancellation. The codes are as follows:

• ‘Hændelse medfører ophør’
• ‘Borger har ikke henvendt sig eller er udeblevet’
• ‘Ikke yderligere behov (borger-vurderet)’
• ‘Ikke yderligere behov (fagperson-vurderet)’
• ‘Aktivt fravalg’
  • ‘Aktivt fravalg pga. anden sygdom’
  • ‘Aktivt fravalg pga. økonomi ifm. transport’
  • ‘Aktivt fravalg pga. logisik ifm. transport’
  • ‘Aktivt fravalg pga. anden træning’

It is premitted to use the code ‘Aktivt fravalg’ for reporting, but the more detailed codes, though not mandatory, provides for a more nuanced dataset.

CarePlan.subject references the citizen. CarePlan.activity.detail.performer is the organisation that carries out the care plan (leverandør).

Different reasons for changing a CarePlan may exist, and here we provide guidance for how it should be reproted:

• Errors should be corrected by reporting the same CarePlan again with the entered-in-error status. And reporting the correct one with a new Id.
• If cancelled, set the CarePlan.activity.detail.status and CarePlan.activity.detail.statusreason and report the Careplan again with the same Id as used earlier.
• If the timing is changing, it is most likely because a status has shown an new or extra added need of the citizen. Report this in a new CarePlan with a new start-date, rather than correcting the timing in the existing plan. This goes for PlannedInterventions that references the CarePlan as well.

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 specificere hvilke af FHIR-profilens atributter der skal bruges til specifikation af indholdet