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==General information==
Name: '''nl.zorg.template.ClinicalNote''' [[Bestand:NL.png|link=ZorgNotitie-v1.0(NL)]] 
Version: '''1.0''' 
HCIM Status:Final 
Release status: Published 
Release date: 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''

Publicatieversie 1.0 (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. 
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==
 
<imagemap> Bestand:ClinicalNote-v1.0Model(EN).png | center
rect 503 137 613 187 [[#[Section]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 [[#[Section]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>
 
{| 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||style="width:100px;"|Id||colspan="6 " style="width:140px;"|Concept||Card.||style="width: 600px;"|Definition||style="width:200px;"|DefinitionCode||style="width:200px;"|Reference
|-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"|[[Bestand: arrowdown.png | 10px | link=]][ClinicalNote]
|
|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"|[[Bestand: arrowright.png | 10px | link=]][ClinicalNote]DateTime
|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"|[[Bestand: arrowright.png | 10px | link=]]Author::HealthProfessional
|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"|[[Bestand: arrowright.png | 10px | link=]][Files]
|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"|[[Bestand: arrowdown.png | 10px | link=]][Section]
|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"|[[Bestand: arrowright.png | 10px | link=]][Section]Code
|0..*
|One or more coded values can be added to a section that describe essential aspects of the section.
|
|
{|
|-
|[[Bestand: List2.png | link=#[Section]CodeCodelist]]||[[#[Section]CodeCodelist|[Section]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"|[[Bestand: arrowright.png | 10px | link=]][Section]Header
|0..1
|The name of the section as an coded description.
|
|
{|
|-
|[[Bestand: List2.png | link=#[Section]HeaderCodelist]]||[[#[Section]HeaderCodelist|[Section]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"|[[Bestand: arrowright.png | 10px | link=]][Section]Text
|1
|The actual content of the section as free formatted text.
|
{|
|-
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=422813005 422813005] Document section
|}
|
|}
Columns Concept and DefinitionCode: hover over the values for more information 
For explanation of the symbols, please see the legend page [[Bestand:list2.png|link=Legend]]

== Valuesets ==
=== [Section]CodeCodelist===
{| class="wikitable" width="60%"
|-style='vertical-align:top; background-color: #E8D7BE;'
|Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.21.3.1
|Binding: Extensible
|}
{| class="wikitable" width="60% "
|-style="background-color: #1F497D; color: white; font-weight: bold; "
|Conceptname
|Conceptcode
|Codesystem name||Codesystem OID
|Description
|-style="vertical-align:top; "
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|-style="vertical-align:top; "
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|-style="vertical-align:top; "
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|}
=== [Section]HeaderCodelist===
{| class="wikitable" width="60%"
|-style='vertical-align:top; background-color: #E8D7BE;'
|Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.21.3.2
|Binding: Extensible
|}
{| class="wikitable" width="60% "
|-style="background-color: #1F497D; color: white; font-weight: bold; "
|Conceptname
|Conceptcode
|Codesystem name||Codesystem OID
|Description
|-style="vertical-align:top; "
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|}

==About this information==
The information in this wikipage is based on Release 2020 
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 [[Bestand:list2.png|link=HCIM_Mainpage]] 
This page is generated on 03/09/2020 14:29:13 with ZibExtraction v. 4.0.7551.21411 
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ClinicalNote-v1.0(EN) - Bewerkingsoverzicht

Update bot: Nieuwe pagina aangemaakt met '==General information== Name: '''nl.zorg.template.ClinicalNote''' link=ZorgNotitie-v1.0(NL) Version...'

Update bot: Nieuwe pagina aangemaakt met '==General information== Name: '''nl.zorg.template.ClinicalNote''' link=ZorgNotitie-v1.0(NL)
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