HCIM Release 2015(EN): verschil tussen versies

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Regel 6: Regel 6:
*[[Media:Errata Publicatieversie 2015 - Zorginformatiebouwstenen.pdf | Errata 2015]] [[File:PDF.png|link=]].
*[[Media:Errata Publicatieversie 2015 - Zorginformatiebouwstenen.pdf | Errata 2015]] [[File:PDF.png|link=]].


== Health and care information models release 2015 ==
== Health and care information models release<!--rlHeader--> 2015 ==
==== group: Administrative, number: 6 ====
==== group<!--rlGroup-->: Administrative, count<!--rlNumber-->: 6 ====
{| width="1000" style="background-color:#F8F8FF"
{| width="1000" style="background-color:#F8F8FF"
|-
|-
Regel 20: Regel 20:
|
|
|}
|}
==== group: Basic elements, number: 1 ====
==== group<!--rlGroup-->: Basic elements, count<!--rlNumber-->: 1 ====
{| width="1000" style="background-color:#F8F8FF"
{| width="1000" style="background-color:#F8F8FF"
|-
|-
Regel 28: Regel 28:
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|}
|}
==== group: Medical, number: 23 ====
==== group<!--rlGroup-->: Clinical context, count<!--rlNumber-->: 25 ====
{| width="1000" style="background-color:#F8F8FF"
{| width="1000" style="background-color:#F8F8FF"
|-
|-
|width="25%" |[[Alert-v1.0(2015EN)|Alert-v1.0]]
|width="25%" |[[Alert-v1.0(2015EN)|Alert-v1.0]]
|width="25%" |[[BodyWeight-v1.2(2015EN)|BodyWeight-v1.2]]
|width="25%" |[[FeedingTubeSystem-v1.0(2015EN)|FeedingTubeSystem-v1.0]]
|width="25%" |[[LaboratoryTestResultForTransfer-v1.2.2(2015EN)|LaboratoryTestResultForTransfer-v1.2.2]]
|width="25%" |[[NutritionAdvice-v1.0(2015EN)|NutritionAdvice-v1.0]]
|width="25%" |[[PulseRate-v1.2(2015EN)|PulseRate-v1.2]]
|width="25%" |[[Stoma-v1.0(2015EN)|Stoma-v1.0]]
|-
|-
|[[AllergyIntolerance-v1.0.2(2015EN)|AllergyIntolerance-v1.0.2]]
|[[AllergyIntolerance-v1.0.2(2015EN)|AllergyIntolerance-v1.0.2]]
|[[ConcernForTransfer-v1.2(2015EN)|ConcernForTransfer-v1.2]]
|[[FunctionalOrMentalStatus-v1.0.1(2015EN)|FunctionalOrMentalStatus-v1.0.1]]
|[[Pregnancy-v1.0(2015EN)|Pregnancy-v1.0]]
|[[Vaccination-v1.2(2015EN)|Vaccination-v1.2]]
|-
|[[BladderFunction-v1.0(2015EN)|BladderFunction-v1.0]]
|[[GeneralMentalFunctions-v1.0(2015EN)|GeneralMentalFunctions-v1.0]]
|[[PressureUlcer-v1.0(2015EN)|PressureUlcer-v1.0]]
|[[VisualFunction-v1.0(2015EN)|VisualFunction-v1.0]]
|-
|[[BowelFunction-v1.0(2015EN)|BowelFunction-v1.0]]
|[[HearingFunction-v1.0(2015EN)|HearingFunction-v1.0]]
|[[SensoryObservationFunction-v1.0(2015EN)|SensoryObservationFunction-v1.0]]
|[[Wound-v1.0(2015EN)|Wound-v1.0]]
|-
|[[Burnwound-v1.0(2015EN)|Burnwound-v1.0]]
|[[Infusion-v1.0(2015EN)|Infusion-v1.0]]
|[[SkinDisorder-v1.0(2015EN)|SkinDisorder-v1.0]]
|
|-
|[[CommunicationSkills-v1.0(2015EN)|CommunicationSkills-v1.0]]
|[[MedicalDevice-v1.2(2015EN)|MedicalDevice-v1.2]]
|[[MedicalDevice-v1.2(2015EN)|MedicalDevice-v1.2]]
|[[Respiration-v1.0.2(2015EN)|Respiration-v1.0.2]]
|[[Sleepfunction-v1.0(2015EN)|Sleepfunction-v1.0]]
|
|-
|-
|[[BarthelADLIndex-v1.2.1(2015EN)|BarthelADLIndex-v1.2.1]]
|[[ConcernForTransfer-v1.2(2015EN)|ConcernForTransfer-v1.2]]
|[[FunctionalOrMentalStatus-v1.0.1(2015EN)|FunctionalOrMentalStatus-v1.0.1]]
|[[MenstrualCycle-v1.0(2015EN)|MenstrualCycle-v1.0]]
|[[O2Saturation-v1.2(2015EN)|O2Saturation-v1.2]]
|[[SpecificMentalFunctions-v1.0(2015EN)|SpecificMentalFunctions-v1.0]]
|[[TextResultForTransfer-v1.2(2015EN)|TextResultForTransfer-v1.2]]
|
|}
==== group<!--rlGroup-->: Measurements, count<!--rlNumber-->: 11 ====
{| width="1000" style="background-color:#F8F8FF"
|-
|-
|[[BloodPressure-v1.2(2015EN)|BloodPressure-v1.2]]
|width="25%" |[[BloodPressure-v1.2(2015EN)|BloodPressure-v1.2]]
|[[GeneralMeasurement-v1.0(2015EN)|GeneralMeasurement-v1.0]]
|width="25%" |[[BodyWeight-v1.2(2015EN)|BodyWeight-v1.2]]
|[[PainScore-v1.2.1(2015EN)|PainScore-v1.2.1]]
|width="25%" |[[LaboratoryTestResultForTransfer-v1.2.2(2015EN)|LaboratoryTestResultForTransfer-v1.2.2]]
|[[TreatmentDirective-v1.0.1(2015EN)|TreatmentDirective-v1.0.1]]
|width="25%" |[[Respiration-v1.0.2(2015EN)|Respiration-v1.0.2]]
|-
|-
|[[BodyHeight-v1.2(2015EN)|BodyHeight-v1.2]]
|[[BodyHeight-v1.2(2015EN)|BodyHeight-v1.2]]
|[[GlasgowComaScale-v1.2.1(2015EN)|GlasgowComaScale-v1.2.1]]
|[[GeneralMeasurement-v1.0(2015EN)|GeneralMeasurement-v1.0]]
|[[PlannedCareActivityForTransfer-v1.2.1(2015EN)|PlannedCareActivityForTransfer-v1.2.1]]
|[[O2Saturation-v1.2(2015EN)|O2Saturation-v1.2]]
|[[Vaccination-v1.2(2015EN)|Vaccination-v1.2]]
|[[TextResultForTransfer-v1.2(2015EN)|TextResultForTransfer-v1.2]]
|-
|-
|[[BodyTemperature-v1.2.1(2015EN)|BodyTemperature-v1.2.1]]
|[[BodyTemperature-v1.2.1(2015EN)|BodyTemperature-v1.2.1]]
|[[HeartRate-v1.2(2015EN)|HeartRate-v1.2]]
|[[HeartRate-v1.2(2015EN)|HeartRate-v1.2]]
|[[ProcedureForTransfer-v1.2(2015EN)|ProcedureForTransfer-v1.2]]
|[[PulseRate-v1.2(2015EN)|PulseRate-v1.2]]
|
|
|}
|}
==== group: Medication, number: 4 ====
==== group<!--rlGroup-->: Medication, count<!--rlNumber-->: 4 ====
{| width="1000" style="background-color:#F8F8FF"
{| width="1000" style="background-color:#F8F8FF"
|-
|-
Regel 69: Regel 92:
|width="25%" |[[MedicationUse-v1.0.1(2015EN)|MedicationUse-v1.0.1]]
|width="25%" |[[MedicationUse-v1.0.1(2015EN)|MedicationUse-v1.0.1]]
|}
|}
==== group: Nursing, number: 43 ====
==== group<!--rlGroup-->: Patient context, count<!--rlNumber-->: 15 ====
{| width="1000" style="background-color:#F8F8FF"
{| width="1000" style="background-color:#F8F8FF"
|-
|-
|width="25%" |[[AbilityToDressOneself-v1.0(2015EN)|AbilityToDressOneself-v1.0]]
|width="25%" |[[AdvanceDirective-v1.0(2015EN)|AdvanceDirective-v1.0]]
|width="25%" |[[FallRiskForTransfer-v1.0(2015EN)|FallRiskForTransfer-v1.0]]
|width="25%" |[[FamilyHistory-v2.0(2015EN)|FamilyHistory-v2.0]]
|width="25%" |[[LanguageProficiency-v1.0(2015EN)|LanguageProficiency-v1.0]]
|width="25%" |[[LanguageProficiency-v1.0(2015EN)|LanguageProficiency-v1.0]]
|width="25%" |[[PressureUlcer-v1.0(2015EN)|PressureUlcer-v1.0]]
|width="25%" |[[Nationality-v2.0(2015EN)|Nationality-v2.0]]
|-
|-
|[[AbilityToDrink-v1.0(2015EN)|AbilityToDrink-v1.0]]
|[[AlcoholUse-v1.2.1(2015EN)|AlcoholUse-v1.2.1]]
|[[FamilySituation-v1.0(2015EN)|FamilySituation-v1.0]]
|[[FamilySituation-v1.0(2015EN)|FamilySituation-v1.0]]
|[[Malnutrition-v1.0(2015EN)|Malnutrition-v1.0]]
|[[LifeStance-v1.2.1(2015EN)|LifeStance-v1.2.1]]
|[[SensoryObservationFunction-v1.0(2015EN)|SensoryObservationFunction-v1.0]]
|[[ParticipationInSociety-v1.0(2015EN)|ParticipationInSociety-v1.0]]
|-
|[[DrugUse-v1.2.2(2015EN)|DrugUse-v1.2.2]]
|[[HelpFromOthers-v1.0(2015EN)|HelpFromOthers-v1.0]]
|[[LivingSituation-v1.2(2015EN)|LivingSituation-v1.2]]
|[[TobaccoUse-v1.2.1(2015EN)|TobaccoUse-v1.2.1]]
|-
|-
|[[AbilityToEat-v1.0(2015EN)|AbilityToEat-v1.0]]
|[[Education-v1.2.1(2015EN)|Education-v1.2.1]]
|[[FeedingTubeSystem-v1.0(2015EN)|FeedingTubeSystem-v1.0]]
|[[IllnessPerception-v1.0(2015EN)|IllnessPerception-v1.0]]
|[[MenstrualCycle-v1.0(2015EN)|MenstrualCycle-v1.0]]
|[[MaritalStatus-v1.2.1(2015EN)|MaritalStatus-v1.2.1]]
|[[SkinDisorder-v1.0(2015EN)|SkinDisorder-v1.0]]
|
|}
==== group<!--rlGroup-->: Scales en screening tools, count<!--rlNumber-->: 8 ====
{| width="1000" style="background-color:#F8F8FF"
|-
|-
|[[AbilityToPerformHaircareActivities-v1.0(2015EN)|AbilityToPerformHaircareActivities-v1.0]]
|width="25%" |[[BarthelADLIndex-v1.2.1(2015EN)|BarthelADLIndex-v1.2.1]]
|[[FreedomRestrictingMeasures-v1.0(2015EN)|FreedomRestrictingMeasures-v1.0]]
|width="25%" |[[GlasgowComaScale-v1.2.1(2015EN)|GlasgowComaScale-v1.2.1]]
|[[Mobility-v1.0(2015EN)|Mobility-v1.0]]
|width="25%" |[[MUSTScore-v1.0(2015EN)|MUSTScore-v1.0]]
|[[Sleepfunction-v1.0(2015EN)|Sleepfunction-v1.0]]
|width="25%" |[[PainScore-v1.2.1(2015EN)|PainScore-v1.2.1]]
|-
|-
|[[AbilityToPerformMouthcareActivities-v1.0(2015EN)|AbilityToPerformMouthcareActivities-v1.0]]
|[[FallRiskForTransfer-v1.0(2015EN)|FallRiskForTransfer-v1.0]]
|[[FreedomRestrictingMeasuresMentalHealthcare-v1.0(2015EN)|FreedomRestrictingMeasuresMentalHealthcare-v1.0]]
|[[Malnutrition-v1.0(2015EN)|Malnutrition-v1.0]]
|[[MUSTScore-v1.0(2015EN)|MUSTScore-v1.0]]
|[[PainPerception-v1.0(2015EN)|PainPerception-v1.0]]
|[[SNAQScore-v1.0(2015EN)|SNAQScore-v1.0]]
|[[SNAQScore-v1.0(2015EN)|SNAQScore-v1.0]]
|}
==== group<!--rlGroup-->: Selfcare, count<!--rlNumber-->: 9 ====
{| width="1000" style="background-color:#F8F8FF"
|-
|-
|[[AbilityToUseToilet-v1.0(2015EN)|AbilityToUseToilet-v1.0]]
|width="25%" |[[AbilityToDressOneself-v1.0(2015EN)|AbilityToDressOneself-v1.0]]
|[[GeneralMentalFunctions-v1.0(2015EN)|GeneralMentalFunctions-v1.0]]
|width="25%" |[[AbilityToPerformHaircareActivities-v1.0(2015EN)|AbilityToPerformHaircareActivities-v1.0]]
|[[NursingIntervention-v1.0(2015EN)|NursingIntervention-v1.0]]
|width="25%" |[[AbilityToWashOneself-v1.0(2015EN)|AbilityToWashOneself-v1.0]]
|[[SpecificMentalFunctions-v1.0(2015EN)|SpecificMentalFunctions-v1.0]]
|
|-
|-
|[[AbilityToWashOneself-v1.0(2015EN)|AbilityToWashOneself-v1.0]]
|[[AbilityToDrink-v1.0(2015EN)|AbilityToDrink-v1.0]]
|[[HearingFunction-v1.0(2015EN)|HearingFunction-v1.0]]
|[[AbilityToPerformMouthcareActivities-v1.0(2015EN)|AbilityToPerformMouthcareActivities-v1.0]]
|[[NutritionAdvice-v1.0(2015EN)|NutritionAdvice-v1.0]]
|[[Stoma-v1.0(2015EN)|Stoma-v1.0]]
|-
|[[BladderFunction-v1.0(2015EN)|BladderFunction-v1.0]]
|[[HelpFromOthers-v1.0(2015EN)|HelpFromOthers-v1.0]]
|[[OutcomeOfCare-v1.0(2015EN)|OutcomeOfCare-v1.0]]
|[[TreatmentObjective-v1.0(2015EN)|TreatmentObjective-v1.0]]
|-
|[[BowelFunction-v1.0(2015EN)|BowelFunction-v1.0]]
|[[HelpWithMedication-v1.0(2015EN)|HelpWithMedication-v1.0]]
|[[HelpWithMedication-v1.0(2015EN)|HelpWithMedication-v1.0]]
|[[PainPerception-v1.0(2015EN)|PainPerception-v1.0]]
|
|[[VisualFunction-v1.0(2015EN)|VisualFunction-v1.0]]
|-
|-
|[[Burnwound-v1.0(2015EN)|Burnwound-v1.0]]
|[[AbilityToEat-v1.0(2015EN)|AbilityToEat-v1.0]]
|[[IllnessPerception-v1.0(2015EN)|IllnessPerception-v1.0]]
|[[AbilityToUseToilet-v1.0(2015EN)|AbilityToUseToilet-v1.0]]
|[[ParticipationInSociety-v1.0(2015EN)|ParticipationInSociety-v1.0]]
|[[Mobility-v1.0(2015EN)|Mobility-v1.0]]
|[[Wound-v1.0(2015EN)|Wound-v1.0]]
|-
|[[CommunicationSkills-v1.0(2015EN)|CommunicationSkills-v1.0]]
|[[Infusion-v1.0(2015EN)|Infusion-v1.0]]
|[[Pregnancy-v1.0(2015EN)|Pregnancy-v1.0]]
|
|
|}
|}
==== group: Patient, number: 10 ====
==== group<!--rlGroup-->: Treatment, count<!--rlNumber-->: 8 ====
{| width="1000" style="background-color:#F8F8FF"
{| width="1000" style="background-color:#F8F8FF"
|-
|-
|width="25%" |[[AdvanceDirective-v1.0(2015EN)|AdvanceDirective-v1.0]]
|width="25%" |[[FreedomRestrictingMeasures-v1.0(2015EN)|FreedomRestrictingMeasures-v1.0]]
|width="25%" |[[Education-v1.2.1(2015EN)|Education-v1.2.1]]
|width="25%" |[[NursingIntervention-v1.0(2015EN)|NursingIntervention-v1.0]]
|width="25%" |[[LivingSituation-v1.2(2015EN)|LivingSituation-v1.2]]
|width="25%" |[[PlannedCareActivityForTransfer-v1.2.1(2015EN)|PlannedCareActivityForTransfer-v1.2.1]]
|width="25%" |[[TobaccoUse-v1.2.1(2015EN)|TobaccoUse-v1.2.1]]
|width="25%" |[[TreatmentDirective-v1.0.1(2015EN)|TreatmentDirective-v1.0.1]]
|-
|-
|[[AlcoholUse-v1.2.1(2015EN)|AlcoholUse-v1.2.1]]
|[[FreedomRestrictingMeasuresMentalHealthcare-v1.0(2015EN)|FreedomRestrictingMeasuresMentalHealthcare-v1.0]]
|[[FamilyHistory-v2.0(2015EN)|FamilyHistory-v2.0]]
|[[OutcomeOfCare-v1.0(2015EN)|OutcomeOfCare-v1.0]]
|[[MaritalStatus-v1.2.1(2015EN)|MaritalStatus-v1.2.1]]
|[[ProcedureForTransfer-v1.2(2015EN)|ProcedureForTransfer-v1.2]]
|
|[[TreatmentObjective-v1.0(2015EN)|TreatmentObjective-v1.0]]
|-
|[[DrugUse-v1.2.2(2015EN)|DrugUse-v1.2.2]]
|[[LifeStance-v1.2.1(2015EN)|LifeStance-v1.2.1]]
|[[Nationality-v2.0(2015EN)|Nationality-v2.0]]
|
|}
|}


Versie van 20 dec 2018 15:25

Release 2015

The following summary shows which HCIM's are part of this publication, including the version numbers.
More information on Release 2015 is available in Dutch:

Health and care information models release 2015

group: Administrative, count: 6

ContactPerson-v1.2 HealthcareProvider-v1.2 Patient-v2.0.1
Encounter-v1.2 HealthProfessional-v1.2.1 Payer-v1.2

group: Basic elements, count: 1

BasicElements-v1.0

group: Clinical context, count: 25

Alert-v1.0 FeedingTubeSystem-v1.0 NutritionAdvice-v1.0 Stoma-v1.0
AllergyIntolerance-v1.0.2 FunctionalOrMentalStatus-v1.0.1 Pregnancy-v1.0 Vaccination-v1.2
BladderFunction-v1.0 GeneralMentalFunctions-v1.0 PressureUlcer-v1.0 VisualFunction-v1.0
BowelFunction-v1.0 HearingFunction-v1.0 SensoryObservationFunction-v1.0 Wound-v1.0
Burnwound-v1.0 Infusion-v1.0 SkinDisorder-v1.0
CommunicationSkills-v1.0 MedicalDevice-v1.2 Sleepfunction-v1.0
ConcernForTransfer-v1.2 MenstrualCycle-v1.0 SpecificMentalFunctions-v1.0

group: Measurements, count: 11

BloodPressure-v1.2 BodyWeight-v1.2 LaboratoryTestResultForTransfer-v1.2.2 Respiration-v1.0.2
BodyHeight-v1.2 GeneralMeasurement-v1.0 O2Saturation-v1.2 TextResultForTransfer-v1.2
BodyTemperature-v1.2.1 HeartRate-v1.2 PulseRate-v1.2

group: Medication, count: 4

MedicationAdministration-v1.0 MedicationDispense-v1.0 MedicationPrescription-v1.0.1 MedicationUse-v1.0.1

group: Patient context, count: 15

AdvanceDirective-v1.0 FamilyHistory-v2.0 LanguageProficiency-v1.0 Nationality-v2.0
AlcoholUse-v1.2.1 FamilySituation-v1.0 LifeStance-v1.2.1 ParticipationInSociety-v1.0
DrugUse-v1.2.2 HelpFromOthers-v1.0 LivingSituation-v1.2 TobaccoUse-v1.2.1
Education-v1.2.1 IllnessPerception-v1.0 MaritalStatus-v1.2.1

group: Scales en screening tools, count: 8

BarthelADLIndex-v1.2.1 GlasgowComaScale-v1.2.1 MUSTScore-v1.0 PainScore-v1.2.1
FallRiskForTransfer-v1.0 Malnutrition-v1.0 PainPerception-v1.0 SNAQScore-v1.0

group: Selfcare, count: 9

AbilityToDressOneself-v1.0 AbilityToPerformHaircareActivities-v1.0 AbilityToWashOneself-v1.0
AbilityToDrink-v1.0 AbilityToPerformMouthcareActivities-v1.0 HelpWithMedication-v1.0
AbilityToEat-v1.0 AbilityToUseToilet-v1.0 Mobility-v1.0

group: Treatment, count: 8

FreedomRestrictingMeasures-v1.0 NursingIntervention-v1.0 PlannedCareActivityForTransfer-v1.2.1 TreatmentDirective-v1.0.1
FreedomRestrictingMeasuresMentalHealthcare-v1.0 OutcomeOfCare-v1.0 ProcedureForTransfer-v1.2 TreatmentObjective-v1.0

Special information models

Basic elements

A number of data elements are implicitly present in each information model and are therefore not explicitly specified in the HCIM. These are concepts that are of a more technical nature, often have little or no clinical relevance, but for the sake of clarity and readability of the data are necessary. The basic elements at each HCIM are:

  • Subject: The person to whom the information relates. Often this will be the patient, but for example, in small children it may be information about the parent or caregiver.
  • Source of information: The person who provided the information and ensures the correctness of it. This is not always a healthcare professional who enters the data in the information system, but it may also be the patient or another person, such as a parent, caretaker or guardian.
  • Author: The person who has recorded the information. Depending on the information system in which the data is recorded, this may be the patient, a contact person or the healthcare professional.
  • Identification number: The number that identifies the instantiation of the HCIM (worldwide) uniquely. The number is composed of an identification of the issuer organization and a unique number assigned by this organization
  • DateTime : The date and possibly the time at which the event relates to the information. This is the medically relevant date and time.

A more detailed explanation of the basic elements can be found in Architecture Document Volume 1, paragraph 3.8 PDF.png.


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