Update bot op 24 dec 2018 om 11:10

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	==Information Model==		==Information Model==
	<BR>		<BR>
	<imagemap> Bestand:TextResultForTransfer-v3.0Model(EN).png \| center		<imagemap> Bestand:TextResultForTransfer-v3.0Model(2016EN).png \| center
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	The information in this wikipage is based on<!--ftInfoBase--> Release summer 2016 <BR>		The information in this wikipage is based on<!--ftInfoBase--> Release summer 2016 <BR>
	Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png\|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR>		Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png\|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR>
	This page is generated on 20/12/2018 10:17:09 with ZibExtraction v. 3.0.~~6928~~.~~1309~~<!--ftDate--> <BR>		This page is generated on 21/12/2018 15:40:42 with ZibExtraction v. 3.0.6929.24609<!--ftDate--> <BR>
	-----		-----
	<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png\| link= HCIM_Release<!--wikiReleasePage-->_2016(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2016(EN) \|Back to HCIM list<!--hdBackToMainPage--> ]]</div>		<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png\| link= HCIM_Release<!--wikiReleasePage-->_2016(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2016(EN) \|Back to HCIM list<!--hdBackToMainPage--> ]]</div>

Update bot op 20 dec 2018 om 12:40

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Update bot op 24 jan 2018 om 23:13

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HCIM St...'

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==General information==
Name: '''nl.zorg.TextResultForTransfer''' [[Bestand:NL.png|link=OverdrachtTekstUitslag-v3.0(2016NL)]] 
Version: '''3.0''' 
HCIM Status:Final 
Publication: '''2016''' 
Release status: Published 
Publication date: 1-5-2016
-----
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release_2016(EN)]] [[HCIM_Release_2016(EN) |Back to HCIM list ]]</div>

==Metadata==
{| class="wikitable" style="font-size:90%; width: 750px"
|-
|style="width:250px; "|DCM::CoderList||Kerngroep Registratie aan de Bron
|-
|style="width:250px; "|DCM::ContactInformation.Address||*
|-
|style="width:250px; "|DCM::ContactInformation.Name||*
|-
|style="width:250px; "|DCM::ContactInformation.Telecom||*
|-
|style="width:250px; "|DCM::ContentAuthorList||Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
|-
|style="width:250px; "|DCM::CreationDate||14-12-2012
|-
|style="width:250px; "|DCM::DeprecatedDate||
|-
|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||2.16.840.1.113883.2.4.3.11.60.40.3.13.2
|-
|style="width:250px; "|DCM::KeywordList||laboratorium uitslagen, verslagen
|-
|style="width:250px; "|DCM::LifecycleStatus||Final
|-
|style="width:250px; "|DCM::ModelerList||Kerngroep Registratie aan de Bron
|-
|style="width:250px; "|DCM::Name||nl.zorg.OverdrachtTekstUitslag
|-
|style="width:250px; "|DCM::PublicationDate||1-5-2016
|-
|style="width:250px; "|DCM::PublicationStatus||Published
|-
|style="width:250px; "|DCM::ReviewerList||Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
|-
|style="width:250px; "|DCM::RevisionDate||25-8-2015
|-
|style="width:250px; "|DCM::Superseeds||nl.nfu.OverdrachtTekstUitslag-v1.2
|-
|style="width:250px; "|DCM::Version||3.0
|-
|style="width:250px; "|HCIM::PublicationLanguage||EN
|}

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

Publicatieversie 1.0 (15-02-2013)

Publicatieversie 1.1 (01-07-2013)

Publicatieversie 1.2 (01-04-2015)
{|
|-
|style="width:75px; "|[[ZIBIssues#ZIB-76 | ZIB-76 ]]
|OverdrachtTekstUitslag Omschrijving
|-
|style="width:75px; "|[[ZIBIssues#ZIB-130 | ZIB-130 ]]
|Samenvoegen bouwstenen OverdrachtLabuitslag en OverdrachtTekstuitslag tot een bouwsteen.
|-
|style="width:75px; "|[[ZIBIssues#ZIB-274 | ZIB-274 ]]
|In de klinische bouwsteen OverdrachtTekstUitslag kwam de naam van de gekoppelde waardenlijst van concept TekstUitslagStatus niet overeen met de tagged value van het concept.
|-
|style="width:75px; "|[[ZIBIssues#ZIB-275 | ZIB-275 ]]
|In de klinische bouwsteen OverdrachtTekstUitslag kwam de naam van de gekoppelde waardenlijst van concept TekstUitslagType niet overeen met de tagged value van het concept.
|-
|style="width:75px; "|[[ZIBIssues#ZIB-322 | ZIB-322 ]]
|Wijziging paragraaf concept
|-
|style="width:75px; "|[[ZIBIssues#ZIB-323 | ZIB-323 ]]
|Wijzing paragraaf Purpose
|-
|style="width:75px; "|[[ZIBIssues#ZIB-370 | ZIB-370 ]]
|ResultaatStatusCodelijst en TekstUitslagCodelijst codes aanpassen
|}

Incl. algemene wijzigingsverzoeken:
{|
|-
|style="width:75px; "|[[ZIBIssues#ZIB-94 | ZIB-94 ]]
|Aanpassen tekst van Disclaimer, Terms of Use & Copyrights
|-
|style="width:75px; "|[[ZIBIssues#ZIB-154 | ZIB-154 ]]
|Consequenties opsplitsing Medicatie bouwstenen voor overige bouwstenen.
|-
|style="width:75px; "|[[ZIBIssues#ZIB-200 | ZIB-200 ]]
|Naamgeving SNOMED CT in tagged values klinische bouwstenen gelijk getrokken.
|-
|style="width:75px; "|[[ZIBIssues#ZIB-201 | ZIB-201 ]]
|Naamgeving OID: in tagged value notes van klinische bouwstenen gelijk getrokken.
|-
|style="width:75px; "|[[ZIBIssues#ZIB-309 | ZIB-309 ]]
|EOI aangepast
|-
|style="width:75px; "|[[ZIBIssues#ZIB-324 | ZIB-324 ]]
|Codelijsten Name en Description beginnen met een Hoofdletter
|-
|style="width:75px; "|[[ZIBIssues#ZIB-326 | ZIB-326 ]]
|Tekstuele aanpassingen conform de kwaliteitsreview kerngroep 2015
|}

Publicatieversie 3.0 (01-05-2016)
{|
|-
|style="width:75px; "|[[ZIBIssues#ZIB-453 | ZIB-453 ]]
|Wijziging naamgeving ZIB's en logo's door andere opzet van beheer
|}
.
</div>

==Concept==
Textual results describe the findings and interpretation of diagnostic or therapeutic procedures carried out on patients or on specimens from the patient.

==Purpose==
Recording the results of diagnostic procedures for the purpose of communicating these with the person requesting the procedure and documenting the findings resulting from therapeutic procedures.

==Evidence Base==
Most results of procedures and some laboratory test results are descriptive in nature. The supplying and receiving systems usually lack formal structure. Therefore, further structuring of the transfer information for these data is not advisable. This includes reports from radiology, pathology, scopies, ultrasounds, etc. and laboratory tests such as cultures, in which results, interpretation and advice form integral parts of the result. 
 
For laboratory test results, it is difficult to clearly indicate exactly when to use this information model and when to use the LaboratoryTestResultTransfer information model. 
In general, laboratory tests resulting in a value (7.1 mmol/L), ordinal number (++ from series to ++++) or a quantitative result (Low) can best be transferred using the LaboratoryTestResultTransfer, whereas this information model is better suited for textual results containing more than just a few words. 
Both types of tests occur in almost all laboratories. 
Applicability is not determined by the kind of lab but by the kind of result. 

==Information Model==
 
[[Bestand: TextResultForTransfer-v3.0Model(EN).png | center]]
 
{| 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]]
||NL-CM:13.2.1
|colspan ="6" style ="padding-left: 0px"|[[Bestand: arrowdown.png | 10px]]TextResult
|
|Root concept of the TextResultTransfer information model. This root concept contains all data elements of the TextResultTransfer information model.
|
|
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: TS.png| 16px]]
||NL-CM:13.2.3
|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]]TextResultDateTime
|0..1
|Date and if possible time of the result.
Date on which the procedure took place as recorded in the ProcedureTransfer information model.

|
|
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: Verwijzing.png| 20px]]
||NL-CM:13.2.5
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="5" style ="padding-left: 0px"|[[Bestand: arrowright.png | 10px]]Procedure
|0..1
|Reference to the ProcedureTransfer information model including the date of the procedure, requesting and executive specialty.
|
|
{|
|-
|[[Bestand: block.png]]||[[ProcedureForTransfer-v3.0(2016EN) |ProcedureForTransfer]]
|}
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: CD.png| 16px]]
||NL-CM:13.2.6
|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]]TextResultStatus
|0..1
|The status of the result.
|
|
{|
|-
|[[Bestand: List2.png]]||[[#TextResultStatusCodelist|TextResultStatusCodelist]]
|}
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: ST.png| 16px]]
||NL-CM:13.2.2
|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]]TextResultReport
|1
|The text report detailing the actual results of the test or procedure.
|
|
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: CD.png| 16px]]
||NL-CM:13.2.4
|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]]TextResultType
|1
|The type of result.
|
|
{|
|-
|[[Bestand: List2.png]]||[[#TextResultTypeCodelist|TextResultTypeCodelist]]
|}
|}
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]]

==Example Instances==
''Only available in Dutch''

{|class="wikitable" width="644px" style= "font-size: 9.5pt;"
|-style=vertical-align:top;
| style="background-color: #004080; width: 37%; color: White; font-weight: bold; "|Tekst Uitslag Datum Tijd
| style="width: 63%; color: #000000; "|05-12-2014 17:00 uur
|-style=vertical-align:top;
| style="background-color: #004080; width: 37%; color: White; font-weight: bold; "|Tekst Uitslag Type
| style="width: 63%; color: #000000; "|Röntgen
|-style=vertical-align:top;
| style="background-color: #004080; width: 37%; color: White; font-weight: bold; "|Tekst Uitslag Status
| style="width: 63%; color: #000000; "|Voorlopig
|-style=vertical-align:top;
|colspan="2" style="background-color: #004080; width: 100%; color: White; font-weight: bold; "|TekstResultaat
|-style=vertical-align:top;
|colspan="2" style="width: 100%; color: #000000; "|Aanvr. Arts: Onbekende arts Uitv. Dienst: Radiologie ----------------------------------------------------------------------------------------------------------------- Onderzoeksnummer: ……… Onderzoek: CR THORAX BED (085002BED) uitgevoerd op 05-12-2014 17:00 uur Status verslag: voorlopig getekend. Voorlopig getekend door …………. op 05-12-2014 17:00 uur ----------------------------------------------------------------------------------------------------------------- Verslag: Datum 05-12-2014 CR THORAX Klinische gegevens: Opname van het respiratoire insufficiëntie bij pneumonie. Vraagstelling: Afname infiltraat? Verslag: Liggende opname vergeleken met onderzoek van 31/10/2012. Hoogliggende positie van de trachea tube 7 cm boven de carina, idealiter 4-6 cm. Onveranderd goede positie van jugularislijn over rechts met tip in vena cava superior. Twee lijnstructuren te volgen over de oesophagus tot subdiafragmaal. Hoogstand van het rechter hemidiafragma conform. Pleuravocht rechts. Goede afgrensbaarheid linker diafragma en enige afname stuwingsbeeld. Iets afname van diffuse consolidatie rechter thoraxhelft. Verdichting in de fissura minor, passend bij plaatatelectase. Conclusie: Hoge ligging trachea tube. Iets afname van diffuse consolidaties rechter thoraxhelft. Afname stuwingsbeeld. Dit is een op 05-12-2014 17:00 uur voorlopig rapport.
|}
{|class="wikitable" width="655px" style= "font-size: 9.5pt;"
|-style=vertical-align:top;
| style="background-color: #004080; width: 36%; color: White; font-weight: bold; "|TekstUitslagDatumTijd
| style="width: 64%; color: #000000; "|15-08-2014 11:00 uur
|-style=vertical-align:top;
| style="background-color: #004080; width: 36%; color: White; font-weight: bold; "|TekstUitslagType
| style="width: 64%; color: #000000; "|CT
|-style=vertical-align:top;
| style="background-color: #004080; width: 36%; color: White; font-weight: bold; "|TekstUitslagStatus
| style="width: 64%; color: #000000; "|Definitief
|-style=vertical-align:top;
|colspan="2" style="background-color: #004080; width: 100%; color: White; font-weight: bold; "|TekstResultaat
|-style=vertical-align:top;
|colspan="2" style="width: 100%; "|Onderzoek Coloscopie Datum onderzoek Patiëntnaam Geboortedatum Patiëntnummer Verwijzing door …… Geachte collega, Op 15-08-2014 zag ik uw patiënt, de heer Beem………, voor een Coloscopie (CF-Q160AL; 118) op de afdeling Maag-, darm- en leverziekten. Coloscopie Indicatie gemetastaseerd NSCLC st IV wv chemotherapie en radiotherapie. Sinds 4 wkn persisterende diarree. radiatie proctitis? Premedicatie: Geen. Verslag Het colon is voorbereid met Klean Prep. Introductie vindt plaats tot in het coecum met identificatie van appendixopening en valvula bauhini zonder inspectie van terminale ileum. De darm is goed gereinigd. Anus Hemorrhoiden. Bij RT: geen afwijkingen voelbaar. Darm Het lumen van de dikke darm is normaal van kaliber. Linkszijdige diverticulose. Het slijmvlies van het gehele colon toont geen afwijking. Rectum bij inversie wel bekeken, hemorrhoiden. Inzending voor histologie PA I colon ascendens biopten PA II transversum biopten PA III sigmoid PA IV rectum Complicaties Geen. Indien binnen 30 dagen een mogelijke late complicatie wordt waargenomen, verzoek ik u dit aan ons te melden. Conclusie Geen afwijkingen waarneembaar bij coloscopie. Advies Expectatief tav diarree. Het verdere beleid is afhankelijk van de uitslag van het onderzoek door de patholoog-anatoom; Code: 20829
|}

== Valuesets ==
=== TextResultStatusCodelist===
{| class="wikitable" width="60%"
|-style='vertical-align:top; background-color: #E8D7BE;'
|Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.13.2.2
|}
{| class="wikitable" width="60% "
|-style="background-color: #1F497D; color: white; font-weight: bold; "
|Conceptname
|Conceptcode
|Codesystem name||Codesystem OID
|Description
|-style="vertical-align:top; "
|Pending
|pending
|ResultaatStatus
|2.16.840.1.113883.2.4.3.11.60.40.4.16.1
|Uitslag volgt
|-style="vertical-align:top; "
|Preliminary
|preliminary
|ResultaatStatus
|2.16.840.1.113883.2.4.3.11.60.40.4.16.1
|Voorlopig
|-style="vertical-align:top; "
|Final
|final
|ResultaatStatus
|2.16.840.1.113883.2.4.3.11.60.40.4.16.1
|Definitief
|-style="vertical-align:top; "
|Appended
|appended
|ResultaatStatus
|2.16.840.1.113883.2.4.3.11.60.40.4.16.1
|Aanvullend
|-style="vertical-align:top; "
|Corrected
|corrected
|ResultaatStatus
|2.16.840.1.113883.2.4.3.11.60.40.4.16.1
|Gecorrigeerd
|}

=== TextResultTypeCodelist===
{| class="wikitable" width="60%"
|-style='vertical-align:top; background-color: #E8D7BE;'
|Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1
|}
{| class="wikitable" width="60% "
|-style="background-color: #1F497D; color: white; font-weight: bold; "
|Conceptname
|Conceptcode
|Codesystem name||Codesystem OID
|Description
|-style="vertical-align:top; "
|Microbiology
|19851009
|SNOMED CT
|2.16.840.1.113883.6.96
|microbiologie
|-style="vertical-align:top; "
|Imaging
|363679005
|SNOMED CT
|2.16.840.1.113883.6.96
|overige beeld vormende techniek
|-style="vertical-align:top; "
|X-ray
|363680008
|SNOMED CT
|2.16.840.1.113883.6.96
|röntgen
|-style="vertical-align:top; "
|Ultrasound
|16310003
|SNOMED CT
|2.16.840.1.113883.6.96
|echografie
|-style="vertical-align:top; "
|CT
|77477000
|SNOMED CT
|2.16.840.1.113883.6.96
|CT
|-style="vertical-align:top; "
|MRI
|113091000
|SNOMED CT
|2.16.840.1.113883.6.96
|MRI
|-style="vertical-align:top; "
|Angiography
|77343006
|SNOMED CT
|2.16.840.1.113883.6.96
|angiografie
|-style="vertical-align:top; "
|Cardiac Echo
|40701008
|SNOMED CT
|2.16.840.1.113883.6.96
|echocardiografie
|-style="vertical-align:top; "
|Nuclear Medicine
|371572003
|SNOMED CT
|2.16.840.1.113883.6.96
|nucleaire geneeskunde
|-style="vertical-align:top; "
|Pathology
|108257001
|SNOMED CT
|2.16.840.1.113883.6.96
|pathologie
|-style="vertical-align:top; "
|Procedure
|71388002
|SNOMED CT
|2.16.840.1.113883.6.96
|procedure
|}

==More on this information model==
More technical information and HL7/XML documentation you can find on the Nictiz Art-Decor page about this information model[http://decor.nictiz.nl/art-decor/decor-datasets--zib1bbr-?id=2.16.840.1.113883.2.4.3.11.60.40.3.13.2] 
This information model is also available as [[Media:nl.zorg.TextResultForTransfer-v3.0(2016EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.TextResultForTransfer-v3.0(2016EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]]
==About this information==
The information in this wikipage is based on Release summer 2016 
Conditions for use are located on the mainpage [[Bestand:list2.png|link=HCIM_Mainpage]] 
This page is generated on 28/09/2017 01:18:34 
-----
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release_2016(EN)]] [[HCIM_Release_2016(EN) |Back to HCIM list ]]</div>

TextResultForTransfer-v3.0(2016EN) - Bewerkingsoverzicht

Update bot op 24 dec 2018 om 11:10

Update bot op 20 dec 2018 om 12:40

Update bot op 24 jan 2018 om 23:13

Update bot: Nieuwe pagina aangemaakt met '==General information== Name: '''nl.zorg.TextResultForTransfer''' link=OverdrachtTekstUitslag-v3.0(2016NL) Version: '''3.0''' HCIM St...'

Update bot: Nieuwe pagina aangemaakt met '==General information== Name: '''nl.zorg.TextResultForTransfer''' link=OverdrachtTekstUitslag-v3.0(2016NL)
Version: '''3.0'''
HCIM St...'