Brontekst bekijken van ClinicalNote-v1.0(EN)

==General information<!--hdGeneralInformation-->==
Name<!--hdName-->: '''nl.zorg.template.ClinicalNote''' [[Bestand:NL.png|link=ZorgNotitie-v1.0(NL)]]<BR>
Version<!--hdVersion-->: '''1.0''' <br>
HCIM Status<!--hdStatus-->:Final<br>
Release status<!--hdPublicationStatus-->: Published<br>
Release date<!--hdPublicationDate-->: 01-09-2020
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==Metadata==
{| class="wikitable" style="font-size:90%; width: 750px"
|- 
|style="width:250px; "|DCM::CoderList||
|- 
|style="width:250px; "|DCM::ContactInformation.Address||*
|- 
|style="width:250px; "|DCM::ContactInformation.Name||*
|- 
|style="width:250px; "|DCM::ContactInformation.Telecom||*
|- 
|style="width:250px; "|DCM::ContentAuthorList||
|- 
|style="width:250px; "|DCM::CreationDate||27-4-2020
|- 
|style="width:250px; "|DCM::DescriptionLanguage||nl
|- 
|style="width:250px; "|DCM::EndorsingAuthority.Address||
|- 
|style="width:250px; "|DCM::EndorsingAuthority.Name||PM
|- 
|style="width:250px; "|DCM::EndorsingAuthority.Telecom||
|- 
|style="width:250px; "|DCM::Id||2.16.840.1.113883.2.4.3.11.60.40.3.21.3
|- 
|style="width:250px; "|DCM::KeywordList||Notitie, Verslag
|- 
|style="width:250px; "|DCM::LifecycleStatus||Final
|- 
|style="width:250px; "|DCM::ModelerList||*
|- 
|style="width:250px; "|DCM::Name||nl.zorg.template.ZorgNotitie
|- 
|style="width:250px; "|DCM::PublicationDate||01-09-2020
|- 
|style="width:250px; "|DCM::PublicationStatus||Published
|- 
|style="width:250px; "|DCM::ReviewerList||*
|- 
|style="width:250px; "|DCM::RevisionDate||
|- 
|style="width:250px; "|DCM::Supersedes||
|- 
|style="width:250px; "|DCM::Version||1.0
|- 
|style="width:250px; "|HCIM::PublicationLanguage||EN
|}

==Revision History==
<div class="mw-collapsible mw-collapsed">
'' Only available in Dutch<!--noTranslation-->''

<u>Publicatieversie 1.0</u> (01-09-2020)
.
</div>

==Concept==
A healthcare note is a structured or unstructured document in which a healthcare professional records free text information regarding a contact or finding with regard to the care for or treatment of a patient.<BR>
This is a template for information models For actual use, meaningful element names and value set concepts must be defined for derived HCIM's.

==Purpose==
A care note offers the possibility to record textual information that, especially in the primary care process, can be consulted at a later date.

==Information Model==
<BR>
<imagemap> Bestand:ClinicalNote-v1.0Model(EN).png | center 
rect 503 137 613 187 [[#&#91;Section&#93;CodeCodelist]]
rect 655 127 745 197 [[#13721]]
rect 218 246 308 316 [[#13726]]
rect 358 366 448 436 [[HealthProfessional-v3.5(2020EN)]]
rect 504 375 625 425 [[#&#91;Section&#93;HeaderCodelist]]
rect 655 366 745 436 [[#13727]]
rect 655 246 745 316 [[#13717]]
rect 354 127 452 197 [[#13719]]
rect 513 246 603 316 [[#13725]]
rect 354 245 452 315 [[#13723]]
desc none
</imagemap>
<BR>
{| border= "1"  width="1500px" style = "font-size: 9.5pt;  border: solid 1px silver; border-collapse:collapse;" cellpadding = "3px" cellspacing ="0px" 
|-style="background-color: #1F497D; color: white; font-weight: bold; font-variant: small-caps; "
|style="width:30px;"|Type<!--imType-->||style="width:100px;"|Id<!--imId-->||colspan="6 " style="width:140px;"|Concept<!--imConcept-->||Card.<!--imCard-->||style="width: 600px;"|Definition<!--imDefinition-->||style="width:200px;"|DefinitionCode<!--imDefinitionCode-->||style="width:200px;"|Reference<!--imReference-->
|-style="vertical-align:top; background-color: #E3E3E3; "
|style = "text-align:center" |[[Bestand: block.png| 20px | link=]]
||NL-CM:21.3.1
|colspan ="6" style ="padding-left: 0px"|<span Id=13723 Title="NL: &#91;ZorgNotitie&#93;">[[Bestand: arrowdown.png | 10px | link=]]&#91;ClinicalNote&#93;</span>
|
|Root concept of the [ClinicalNote] information model.This root concept contains all data elements of the [ClinicalNote] template.
|
|
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: TS.png| 16px | link=]]
||NL-CM:21.3.2
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="5" style ="padding-left: 0px"|<span Id=13719 Title="NL: &#91;ZorgNotitie&#93;DatumTijd">[[Bestand: arrowright.png | 10px | link=]]&#91;ClinicalNote&#93;DateTime</span>
|0..1
|Date and optionally the time the note was created.
|
|
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: Verwijzing.png| 20px | link=]]
||NL-CM:21.3.3
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="5" style ="padding-left: 0px"|<span Id=13724 Title="NL: Auteur::Zorgverlener">[[Bestand: arrowright.png | 10px | link=]]Author::HealthProfessional</span>
|0..1
|The healthcare provider who prepared the report and who is responsible for its content.
|
|
{|
|-
|[[Bestand: block.png | link=HealthProfessional-v3.5(2020EN)]]||[[HealthProfessional-v3.5(2020EN) |HealthProfessional]]
|}
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: ED.png| 16px | link=]]
||NL-CM:21.3.4
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="5" style ="padding-left: 0px"|<span Id=13726 Title="NL: &#91;Bestanden&#93;">[[Bestand: arrowright.png | 10px | link=]]&#91;Files&#93;</span>
|0..*
|Original files (letters, photos, videos, ..) that are among other things the reason for drawing up the note.
|
|
|-style="vertical-align:top; background-color: #E8D7BE; "
|style = "text-align:center" |[[Bestand: folder.png| 16px | link=]]
||NL-CM:21.3.5
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="5" style ="padding-left: 0px"|<span Id=13725 Title="NL: &#91;Sectie&#93;">[[Bestand: arrowdown.png | 10px | link=]]&#91;Section&#93;</span>
|1..*
|Container of the [Section] concept.This container contains all data elements of the [Section] concept.
|
|
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: CD.png| 16px | link=]]
||NL-CM:21.3.6
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: none;" |
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="4" style ="padding-left: 0px"|<span Id=13721 Title="NL: &#91;Sectie&#93;Code">[[Bestand: arrowright.png | 10px | link=]]&#91;Section&#93;Code</span>
|0..*
|One or more coded values can be added to a section that describe essential aspects of the section.
|
|
{|
|-
|[[Bestand: List2.png | link=#&#91;Section&#93;CodeCodelist]]||[[#&#91;Section&#93;CodeCodelist|&#91;Section&#93;CodeCodelist]]
|}
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: CD.png| 16px | link=]]
||NL-CM:21.3.7
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: none;" |
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="4" style ="padding-left: 0px"|<span Id=13727 Title="NL: &#91;Sectie&#93;Naam">[[Bestand: arrowright.png | 10px | link=]]&#91;Section&#93;Header</span>
|0..1
|The name of the section as an coded description.
|
|
{|
|-
|[[Bestand: List2.png | link=#&#91;Section&#93;HeaderCodelist]]||[[#&#91;Section&#93;HeaderCodelist|&#91;Section&#93;HeaderCodelist]]
|}
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: ST.png| 16px | link=]]
||NL-CM:21.3.8
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: none;" |
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="4" style ="padding-left: 0px"|<span Id=13717 Title="NL: &#91;Sectie&#93;Tekst">[[Bestand: arrowright.png | 10px | link=]]&#91;Section&#93;Text</span>
|1
|The actual content of the section as free formatted text.
|
{|
|-
|<span title = "Codesystem: SNOMED CT (record artifact)" >[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=422813005 422813005] Document section</span>
|}
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|}
Columns Concept and DefinitionCode: hover over the values for more information<!--imHover--><BR>
For explanation of the symbols, please see the legend page<!--imLegend--> [[Bestand:list2.png|link=Legend<!--wikiLegend-->]]

== Valuesets ==
=== [Section]CodeCodelist===
{| class="wikitable" width="60%" 
|-style='vertical-align:top; background-color: #E8D7BE;'
|Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.21.3.1
|Binding<!--vsBindingTag-->: Extensible
|}
{| class="wikitable"  width="60% "
|-style="background-color: #1F497D; color: white; font-weight: bold; "
|Conceptname<!--vsConceptName-->
|Conceptcode<!--vsConceptCode-->
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
|Description<!--vsDescription-->
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=== [Section]HeaderCodelist===
{| class="wikitable" width="60%" 
|-style='vertical-align:top; background-color: #E8D7BE;'
|Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.21.3.2
|Binding<!--vsBindingTag-->: Extensible
|}
{| class="wikitable"  width="60% "
|-style="background-color: #1F497D; color: white; font-weight: bold; "
|Conceptname<!--vsConceptName-->
|Conceptcode<!--vsConceptCode-->
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
|Description<!--vsDescription-->
|-style="vertical-align:top; "
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==About this information<!--ftHeader2-->==
The information in this wikipage is based on<!--ftInfoBase--> Release 2020 <BR>
SNOMED CT and LOINC codes are based on:
<ul>
<li>SNOMED Clinical Terms version: 20200309 [R] (March 2020 Interim Release)</li>
<li>LOINC version 2.67</li>
</ul>
Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR>
This page is generated on 03/09/2020 14:29:13 with ZibExtraction v. 4.0.7551.21411<!--ftDate--> <BR>
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