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{{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.4.26(EN)|1|FunctionalOrMentalStatus-v3.2.1(2021EN)}}<br />
<!-- Tot hier de transclude page --><br />
==General information<!--hdGeneralInformation-->==<br />
Name<!--hdName-->: '''nl.zorg.FunctionalOrMentalStatus''' [[Bestand:NL.png|link=FunctioneleOfMentaleStatus-v3.2.1(2021NL)]]<BR><br />
Version<!--hdVersion-->: '''3.2.1''' <br><br />
HCIM Status<!--hdStatus-->:Final<br><br />
Release<!--hdPublication-->: '''2021''' <br><br />
Release status<!--hdPublicationStatus-->: Prepublished<br><br />
Release date<!--hdPublicationDate-->: 01-12-2021<br />
<!-- Aanroep Errata transclude page --><br />
{{ErrataEN<!--hdErrata-->|2021|{{PAGENAME}}}}<br />
<!-- tot hier --><br />
-----<br />
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2021(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2021(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div><br />
<br />
==Metadata==<br />
{| class="wikitable" style="font-size:90%; width: 750px"<br />
|- <br />
|style="width:250px; "|DCM::CoderList||Kerngroep Registratie aan de Bron<br />
|- <br />
|style="width:250px; "|DCM::ContactInformation.Address||*<br />
|- <br />
|style="width:250px; "|DCM::ContactInformation.Name||*<br />
|- <br />
|style="width:250px; "|DCM::ContactInformation.Telecom||*<br />
|- <br />
|style="width:250px; "|DCM::ContentAuthorList||Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron<br />
|- <br />
|style="width:250px; "|DCM::CreationDate||12-9-2014<br />
|- <br />
|style="width:250px; "|DCM::DeprecatedDate||<br />
|- <br />
|style="width:250px; "|DCM::DescriptionLanguage||nl<br />
|- <br />
|style="width:250px; "|DCM::EndorsingAuthority.Address||<br />
|- <br />
|style="width:250px; "|DCM::EndorsingAuthority.Name||PM<br />
|- <br />
|style="width:250px; "|DCM::EndorsingAuthority.Telecom||<br />
|- <br />
|style="width:250px; "|DCM::Id||2.16.840.1.113883.2.4.3.11.60.40.3.4.26<br />
|- <br />
|style="width:250px; "|DCM::KeywordList||mentale status, functionele status, functionele beperking, mentale stoornis, ADL<br />
|- <br />
|style="width:250px; "|DCM::LifecycleStatus||Final<br />
|- <br />
|style="width:250px; "|DCM::ModelerList||Kerngroep Registratie aan de Bron<br />
|- <br />
|style="width:250px; "|DCM::Name||nl.zorg.FunctioneleOfMentaleStatus<br />
|- <br />
|style="width:250px; "|DCM::PublicationDate||01-12-2021<br />
|- <br />
|style="width:250px; "|DCM::PublicationStatus||Prepublished<br />
|- <br />
|style="width:250px; "|DCM::ReviewerList||Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron<br />
|- <br />
|style="width:250px; "|DCM::RevisionDate||17-11-2021<br />
|- <br />
|style="width:250px; "|DCM::Supersedes||nl.zorg.FunctioneleOfMentaleStatus-v3.2<br />
|- <br />
|style="width:250px; "|DCM::Version||3.2.1<br />
|- <br />
|style="width:250px; "|HCIM::PublicationLanguage||EN<br />
|}<br />
<br />
==Revision History==<br />
<div class="mw-collapsible mw-collapsed"><br />
'' Only available in Dutch<!--noTranslation-->''<br />
<br />
<u>Publicatieversie 1.0</u> (01-04-2015)<br />
{|<br />
|-<br />
|style="width:75px; "|[[ZIBIssues#ZIB-89 | ZIB-89 ]]<br />
|Aanpassing OverdrachtFuntioneleStatus door deze te vervangen door een nieuwe bouwsteen die alleen een generieke functionele beperking bevat.<br />
|-<br />
|style="width:75px; "|[[ZIBIssues#ZIB-308 | ZIB-308 ]]<br />
|Prefix Overdracht weggehaald bij de generieke bouwstenen<br />
|}<br />
<br />
Incl. algemene wijzigingsverzoeken: <br />
{|<br />
|-<br />
|style="width:75px; "|[[ZIBIssues#ZIB-94 | ZIB-94 ]]<br />
|Aanpassen tekst van Disclaimer, Terms of Use & Copyrights<br />
|-<br />
|style="width:75px; "|[[ZIBIssues#ZIB-154 | ZIB-154 ]]<br />
|Consequenties opsplitsing Medicatie bouwstenen voor overige bouwstenen.<br />
|-<br />
|style="width:75px; "|[[ZIBIssues#ZIB-200 | ZIB-200 ]]<br />
|Naamgeving SNOMED CT in tagged values klinische bouwstenen gelijk getrokken.<br />
|-<br />
|style="width:75px; "|[[ZIBIssues#ZIB-201 | ZIB-201 ]]<br />
|Naamgeving OID: in tagged value notes van klinische bouwstenen gelijk getrokken.<br />
|-<br />
|style="width:75px; "|[[ZIBIssues#ZIB-309 | ZIB-309 ]]<br />
|EOI aangepast <br />
|-<br />
|style="width:75px; "|[[ZIBIssues#ZIB-324 | ZIB-324 ]]<br />
|Codelijsten Name en Description beginnen met een Hoofdletter<br />
|-<br />
|style="width:75px; "|[[ZIBIssues#ZIB-326 | ZIB-326 ]]<br />
|Tekstuele aanpassingen conform de kwaliteitsreview kerngroep 2015<br />
|}<br />
<br />
<u>Publicatieversie 1.0.1</u> (22-05-2015)<br />
{|<br />
|-<br />
|style="width:75px; "|[[ZIBIssues#ZIB-384 | ZIB-384 ]]<br />
|Inconsistent gebruik van de naam StatusWaardeSnomedCodelijst.<br />
|-<br />
|style="width:75px; "|[[ZIBIssues#ZIB-383 | ZIB-383 ]]<br />
|Inconsistent gebruik van de naam StatusWaardeNOCCodelijst.<br />
|-<br />
|style="width:75px; "|[[ZIBIssues#ZIB-382 | ZIB-382 ]]<br />
|Inconsistent gebruik van de naam StatusWaardeOMAHACodelijst.<br />
|}<br />
<br />
<u>Publicatieversie 3.0</u> (01-05-2016)<br />
{|<br />
|-<br />
|style="width:75px; "|[[ZIBIssues#ZIB-453 | ZIB-453 ]]<br />
|Wijziging naamgeving ZIB's en logo's door andere opzet van beheer<br />
|}<br />
<br />
<u>Publicatieversie 3.1</u> (04-09-2017)<br />
{|<br />
|-<br />
|style="width:75px; "|[[ZIBIssues#ZIB-564 | ZIB-564 ]]<br />
|Aanpassing/harmonisatie Engelse conceptnamen<br />
|}<br />
<br />
<u>Publicatieversie 3.1</u> (26-02-2019)<br />
{|<br />
|-<br />
|style="width:75px; "|[[ZIBIssues#ZIB-681 | ZIB-681 ]]<br />
|ICF 'alle waarden' n.v.t. op FunctioneleOfMentaleStatus antwoord<br />
|}<br />
<br />
Publicatieversie <u>3.2</u> (01-09-2020)<br />
{|<br />
|-<br />
|style="width:75px; "|[[ZIBIssues#ZIB-1110 | ZIB-1110 ]]<br />
|Laten vervallen Omaha en NOC<br />
|-<br />
|style="width:75px; "|[[ZIBIssues#ZIB-1142 | ZIB-1142 ]]<br />
|Toevoegen element Geslacht aan ZIB zorgverlener<br />
|}<br />
<br />
Publicatieversie <u>3.2.1</u> (01-12-2021)<br />
{|<br />
|-<br />
|style="width:75px; "|[[ZIBIssues#ZIB-1575 | ZIB-1575 ]]<br />
|Deprecated termen en waardelijsten uit de prepublicatie halen<br />
|}<br />
</div><br />
<br />
==Concept==<br />
The functional or mental status provides insight into the patient’s functional and mental limitations.<br />
<br />
==Purpose==<br />
The patient’s functional and mental status can be recorded to provide insight into the patient’s limitations which need to be taken into account for further treatment and care and in order to evaluate the effects of a treatment.<BR><br />
<BR><br />
Diagnoses with (the potential for) functional limitations are not to be recorded here. To record these, please use the Problem information model.<BR><br />
<br />
==Information Model==<br />
<BR><br />
<imagemap> Bestand:FunctionalOrMentalStatus-v3.2.1Model(2021EN).png | center <br />
rect 165 81 293 151 [[#11272]]<br />
rect 631 82 759 152 [[MedicalDevice-v3.4(2021EN)]]<br />
rect 632 247 760 317 [[#11267]]<br />
rect 374 247 502 317 [[#11266]]<br />
rect 165 246 293 316 [[#11269]]<br />
rect 357 76 521 156 [[#11273]]<br />
rect 70 356 213 406 [[#StatusNameICFCodelist]]<br />
rect 70 417 240 467 [[#StatusNameSnomedCodelist]]<br />
rect 453 356 603 406 [[#StatusValueICFCodelist]]<br />
rect 425 413 599 463 [[#StatusValueSnomedCodelist]]<br />
desc none<br />
</imagemap><br />
<BR><br />
{| border= "1" width="1500px" style = "font-size: 9.5pt; border: solid 1px silver; border-collapse:collapse;" cellpadding = "3px" cellspacing ="0px" <br />
|-style="background-color: #1F497D; color: white; font-weight: bold; font-variant: small-caps; "<br />
|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--><br />
|-style="vertical-align:top; background-color: #E3E3E3; "<br />
|style = "text-align:center" |[[Bestand: block.png| 20px | link=]]<br />
||NL-CM:4.26.1<br />
|colspan ="6" style ="padding-left: 0px"|<span Id=11273 Title="NL: FunctioneleOfMentaleStatus">[[Bestand: arrowdown.png | 10px | link=]]FunctionalOrMentalStatus</span><br />
|<br />
|Root concept of FunctionalOrMentalStatus. This concept contains all data elements of the FunctionalOrMentalStatus information model.<br />
|<br />
|<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: CD.png| 16px | link=]]<br />
||NL-CM:4.26.2<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="5" style ="padding-left: 0px"|<span Id=11269 Title="NL: StatusNaam">[[Bestand: arrowright.png | 10px | link=]]StatusName</span><br />
|1<br />
|Coded description of the functional or mental status or limitation. <br />
Code systems used include: <br />
<ul><br />
<li>SNOMED CT</li><br />
<li>ICF (International Classification of Functioning, Disability and Health) </li><br />
<li>NOC (Nursing Outcomes Classification)</li><br />
<li>OMAHA</li><br />
</ul><br />
<br />
|<br />
|<br />
{|<br />
|-<br />
|[[Bestand: List2.png | link=#StatusNameICFCodelist]]||[[#StatusNameICFCodelist|StatusNameICFCodelist]]<br />
|-<br />
|[[Bestand: List2.png | link=#StatusNameSnomedCodelist]]||[[#StatusNameSnomedCodelist|StatusNameSnomedCodelist]]<br />
|}<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: CO.png| 16px | link=]]<br />
||NL-CM:4.26.3<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="5" style ="padding-left: 0px"|<span Id=11266 Title="NL: StatusWaarde">[[Bestand: arrowright.png | 10px | link=]]StatusValue</span><br />
|0..1<br />
|The extent to which the patient is limited by the functional or mental condition. <br />
If both the status name and the status value are recorded in code, then both values must come from the same code system. <br />
If the patient uses a medical device, the evaluation of the extent of the limitation will take place without this aid.<br />
The answer codes must be selected from the subselection of the code system corresponding with the request in accordance with the rules applicable to that system.<br />
|<br />
|<br />
{|<br />
|-<br />
|[[Bestand: List2.png | link=#StatusValueICFCodelist]]||[[#StatusValueICFCodelist|StatusValueICFCodelist]]<br />
|-<br />
|[[Bestand: List2.png | link=#StatusValueSnomedCodelist]]||[[#StatusValueSnomedCodelist|StatusValueSnomedCodelist]]<br />
|}<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: TS.png| 16px | link=]]<br />
||NL-CM:4.26.6<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="5" style ="padding-left: 0px"|<span Id=11272 Title="NL: StatusDatum">[[Bestand: arrowright.png | 10px | link=]]StatusDate</span><br />
|0..1<br />
|Date on which the status was determined. A ‘vague’ date, such as only the year, is permitted.<br />
|<br />
|<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: ST.png| 16px | link=]]<br />
||NL-CM:4.26.4<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="5" style ="padding-left: 0px"|<span Id=11267 Title="NL: Toelichting">[[Bestand: arrowright.png | 10px | link=]]Comment</span><br />
|0..1<br />
|Explanatory comments as a description of the functional or mental status.<br />
|<br />
{|<br />
|-<br />
|<span title = "Codesystem: LOINC (Nar)" >[https://terminologie.nictiz.nl/art-decor/loinc?conceptId=48767-8 48767-8] Annotation comment [Interpretation] Narrative</span><br />
|}<br />
|<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: Verwijzing.png| 20px | link=]]<br />
||NL-CM:4.26.5<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="5" style ="padding-left: 0px"|<span Id=11271 Title="NL: Hulpmiddel::MedischHulpmiddel">[[Bestand: arrowright.png | 10px | link=]]MedicalDevice:MedicalDevice</span><br />
|0..*<br />
|Medical aid the patient has to reduce the impact of the disability or disorder.<br />
|<br />
|<br />
{|<br />
|-<br />
|[[Bestand: block.png | link=MedicalDevice-v3.4(2021EN)]]||[[MedicalDevice-v3.4(2021EN) |MedicalDevice]]<br />
|}<br />
|}<br />
Columns Concept and DefinitionCode: hover over the values for more information<!--imHover--><BR><br />
For explanation of the symbols, please see the legend page<!--imLegend--> [[Bestand:list2.png|link=Legend<!--wikiLegend-->]]<br />
<br />
==Example Instances==<br />
''Only available in Dutch<!--noTranslation-->''<br />
<br />
{|class="wikitable" width="451px" style= "font-size: 9.5pt;"<br />
|-style=vertical-align:top;<br />
|colspan="2" style="background-color: #1F497D; width: 100%; "|<font color=#FFFFFF><b>Functionele</b></font><font color=#FFFFFF><b>OfMentaleStatus</b></font><br />
|-style=vertical-align:top;<br />
| style="width: 52%; "|StatusNaam<br />
| style="width: 48%; "|Zich scheren<br />
|-style=vertical-align:top;<br />
| style="width: 52%; "|StatusWaarde<br />
| style="width: 48%; "|Moeite met scheren<br />
|-style=vertical-align:top;<br />
| style="width: 52%; "|StatusDatum<br />
| style="width: 48%; "|23-02-2015<br />
|-style=vertical-align:top;<br />
| style="width: 52%; "|Toelichting<br />
| style="width: 48%; "|<noWiki>-</noWiki>-<br />
|-style=vertical-align:top;<br />
| style="width: 52%; "|MedischHulpmiddel<br />
| style="width: 48%; "|<noWiki>-</noWiki>-<br />
|}<br />
<br />
== Valuesets ==<br />
=== StatusNameICFCodelist===<br />
{| class="wikitable" width="60%" <br />
|-style='vertical-align:top; background-color: #E8D7BE;'<br />
|Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.4.26.3<br />
|Binding<!--vsBindingTag-->: Required<br />
|}<br />
{| class="wikitable" width="60% "<br />
|-style="background-color: #1F497D; color: white; font-weight: bold; "<br />
|Conceptname<!--vsConceptName--><br />
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--><br />
|-style="vertical-align:top; "<br />
|Alle waarden<br />
|ICF<br />
|2.16.840.1.113883.6.254<br />
|}<br />
=== StatusNameSnomedCodelist===<br />
{| class="wikitable" width="60%" <br />
|-style='vertical-align:top; background-color: #E8D7BE;'<br />
|Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.4.26.4<br />
|Binding<!--vsBindingTag-->: Required<br />
|}<br />
{| class="wikitable" width="60% "<br />
|-style="background-color: #1F497D; color: white; font-weight: bold; "<br />
|Conceptname<!--vsConceptName--><br />
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--><br />
|-style="vertical-align:top; "<br />
|<span title = "Unknown code" >Alle waarden</span><br />
|SNOMED CT<br />
|2.16.840.1.113883.6.96<br />
|}<br />
=== StatusValueICFCodelist===<br />
{| class="wikitable" width="60%" <br />
|-style='vertical-align:top; background-color: #E8D7BE;'<br />
|Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.4.26.6<br />
|Binding<!--vsBindingTag-->: Required<br />
|}<br />
{| class="wikitable" width="60% "<br />
|-style="background-color: #1F497D; color: white; font-weight: bold; "<br />
|Conceptname<!--vsConceptName--><br />
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--><br />
|-style="vertical-align:top; "<br />
|Alle waarden<br />
|ICF<br />
|2.16.840.1.113883.6.254<br />
|}<br />
=== StatusValueSnomedCodelist===<br />
{| class="wikitable" width="60%" <br />
|-style='vertical-align:top; background-color: #E8D7BE;'<br />
|Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.4.26.8<br />
|Binding<!--vsBindingTag-->: Required<br />
|}<br />
{| class="wikitable" width="60% "<br />
|-style="background-color: #1F497D; color: white; font-weight: bold; "<br />
|Conceptname<!--vsConceptName--><br />
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--><br />
|-style="vertical-align:top; "<br />
|<span title = "Unknown code" >Alle waarden</span><br />
|SNOMED CT<br />
|2.16.840.1.113883.6.96<br />
|}<br />
<br />
==This information model in other releases<!--ftOtherReleases-->==<br />
<!-- Hieronder wordt een transclude page aangeroepen --><br />
{{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.4.26(EN)|2|2021}}<br />
<!-- Tot hier de transclude page --><br />
==Information model references<!--ftReferences-->==<br />
====This information model refers to<!--ftRefersTo-->====<br />
*[[MedicalDevice-v3.4(2021EN)|MedicalDevice-v3.4]]<br />
====This information model is used in<!--ftReferredBy-->====<br />
*[[OutcomeOfCare-v3.3(2021EN)|OutcomeOfCare-v3.3]]<br />
*[[TreatmentObjective-v3.2(2021EN)|TreatmentObjective-v3.2]]<br />
==Technical specifications in HL7v3 CDA and HL7 FHIR<!--ftHeader-->==<br />
To exchange information based on health and care information models, additional, more technical specifications are required.<BR><br />
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:<!--ftReferenceIntro--><br />
<ul><br />
<li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment<!--ftArtDecorReference--> [http://decor.nictiz.nl/art-decor/decor-scenarios--zib2021bbr-?id=2.16.840.1.113883.2.4.3.11.60.11.4.2.4.26&effectiveDate=2021-12-01T00:00:00&language=en-US&scenariotree=false [[File:artdecor.jpg|16px|link=]]]</li><br />
<li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR<!--ftSimplifierReference--> {{SimplefierLinks|2021}}</li><br />
</ul><br />
==Downloads<!--ftDownloadTitle-->==<br />
This information model is also available as [[Media:nl.zorg.FunctionalOrMentalStatus-v3.2.1(2021EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.FunctionalOrMentalStatus-v3.2.1(2021EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]]<!--ftDownloads--><br />
==About this information<!--ftHeader2-->==<br />
The information in this wikipage is based on<!--ftInfoBase--> Pre-release 2021-2 <BR><br />
SNOMED CT and LOINC codes are based on:<br />
<ul><br />
<li>SNOMED Clinical Terms version: 20210731 [R] (July 2021 Release)</li><br />
<li>LOINC version 2.67</li><br />
</ul><br />
Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR><br />
This page is generated on 30/11/2021 09:42:03 with ZibExtraction v. 6.4.8004.1652<!--ftDate--> <BR><br />
-----<br />
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2021(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2021(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div></div>
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