Procedure-v4.1(2018EN): verschil tussen versies

Huidige versie van 24 dec 2018 om 12:58

Attention!! This is not the most recent version of this information model. You can find the most recent version ''here''.

General information

Name: nl.zorg.Procedure
Version: 4.1
HCIM Status:Final
Release: 2018
Release status: Prepublished
Release date: 01-10-2018

Back to HCIM list

Metadata

DCM::CoderList	Kerngroep Registratie aan de Bron
DCM::ContactInformation.Address	*
DCM::ContactInformation.Name	*
DCM::ContactInformation.Telecom	*
DCM::ContentAuthorList	Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::CreationDate	6-6-2012
DCM::DeprecatedDate
DCM::DescriptionLanguage	nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name	PM
DCM::EndorsingAuthority.Telecom
DCM::Id	2.16.840.1.113883.2.4.3.11.60.40.3.14.1
DCM::KeywordList	procedure,verrichting
DCM::LifecycleStatus	Final
DCM::ModelerList	Kerngroep Registratie aan de Bron
DCM::Name	nl.zorg.Verrichting
DCM::PublicationDate	01-10-2018
DCM::PublicationStatus	Prepublished
DCM::ReviewerList	Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate	31-12-2017
DCM::Superseeds	nl.zorg.Verrichting-v4.0
DCM::Version	4.1
HCIM::PublicationLanguage	EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (15-02-2013) -

Publicatieversie 1.1 (01-07-2013)

ZIB-55	RFC Bouwsteen Procedure
ZIB-24	Diagnostische verrichtingen onderdeel van Results

Publicatieversie 1.2 (01-04-2015)

ZIB-84	Klinische bouwsteen nl.nfu.OverdrachtProcedure uitbreiden met Aanvrager (n.a.v. issue #077)
ZIB-93	Bouwsteennaam Procedure wijzigen in Verrichting
ZIB-95	Elementen in Example of the Instrument OverdrachtProcedure komen niet terug in model
ZIB-122	De definitie van de sectie Concept van de bouwsteen OverdrachtProcedure aanpassen.
ZIB-270	Aanpassen DCM::DefinitionCode van rootconcept Verrichting van NL-CM-14.1.1 naar NL-CM:14.1.1.
ZIB-271	In de klinische bouwsteen OverdrachtProcedure DCM::ValueSet SNOMED CT aangepast van concept AnatomischeLokalisatie naar tagged value DCM::ContentExpression.
ZIB-272	In klinische bouwsteen OverdrachtProcedure DCM::ValueSet CBV verrichtingen van concept VerrichtingType aangepast naar tagged value DCM::CodeSystem.
ZIB-273	Tagged value DCM::ReferencedDefinitionCode is onjuist voor classes UitgevoerdDoor::Zorgverlener en AangevraagdDoor::Zorgverlener, dit zou NL-CM:17.1.1 moeten zijn i.p.v. NL-CM:17.1.2.
ZIB-308	Prefix Overdracht weggehaald bij de generieke bouwstenen
ZIB-325	AnatomischeLokaisatie wijzigen in AnatomischeLocatie
ZIB-353	Tagged values DCM::CodeSystem aanpassen naar DCM::ValueSet incl. gekoppelde codelijst.

Incl. algemene wijzigingsverzoeken:

ZIB-94	Aanpassen tekst van Disclaimer, Terms of Use & Copyrights
ZIB-154	Consequenties opsplitsing Medicatie bouwstenen voor overige bouwstenen.
ZIB-200	Naamgeving SNOMED CT in tagged values klinische bouwstenen gelijk getrokken.
ZIB-201	Naamgeving OID: in tagged value notes van klinische bouwstenen gelijk getrokken.
ZIB-309	EOI aangepast
ZIB-324	Codelijsten Name en Description beginnen met een Hoofdletter
ZIB-326	Tekstuele aanpassingen conform de kwaliteitsreview kerngroep 2015

Publicatieversie 3.0 (01-05-2016)

ZIB-401	CBV Verrichtingen mist geldig OID
ZIB-453	Wijziging naamgeving ZIB's en logo's door andere opzet van beheer

Publicatieversie 3.1 (04-09-2017)

ZIB-475	Terminologiekoppeling Drugsgebruik
ZIB-549	De Engelse naam van de bouwsteen en het rootconcept zijn niet correct
ZIB-564	Aanpassing/harmonisatie Engelse conceptnamen
ZIB-576	Aanpassen bouwstenen die nog de prefix overdracht hebben, zodat de prefix kan vervallen.

Publicatieversie 4.0 (04-09-2017)

ZIB-457	Uitbreiding AnatomischeLocatieCodelijst met Snomed qualifiers
ZIB-458	Uitbreiding met dataelement "werkwijze"
ZIB-515	Geen informatie
ZIB-518	Geen informatie
ZIB-549	De Engelse naam van de bouwsteen en het rootconcept zijn niet correct
ZIB-564	Aanpassing/harmonisatie Engelse conceptnamen
ZIB-574	Alleen verwijzen naar het rootconcept van de ZIB.
ZIB-576	Aanpassen bouwstenen die nog de prefix overdracht hebben, zodat de prefix kan vervallen.
ZIB-578	Aan het concept anatomische locatie moet een concept Laterariteit toegevoegd worden.
ZIB-581	Geen informatie
ZIB-585	Toevoegen concept Lateraliteit aan het concept Anatomische Locatie

Publicatieversie 4.1 (31-12-2017)

ZIB-646

Aanpassing SNOMED codes

Concept

The concept Procedure indicates a therapeutic or diagnostic procedure undergone by the patient.
A procedure can be a simple blood pressure measurement, but also a complex heart surgery.

Purpose

A procedure is carried out as part of a planned policy or to obtain additional information in the diagnostic process. Procedures are documented to gain insight into the treatment of a patient. In addition, procedures are documented for administrative purposes such as invoicing and workload measurement, scientific research and/or education.

Information Model

Type

Id

Concept

Card.

Definition

DefinitionCode

Reference

NL-CM:14.1.1

Procedure

Root concept of the Procedure information model. This root concept contains all data elements of the Procedure information model.

71388002 Procedure

NL-CM:14.1.2

ProcedureStartDate

0..1

The start date (and if possible start time) of the procedure. A ‘vague’ date, such as only the year, is permitted.

The element offers the option to indicate the start of the period of a series of related procedures.

NL-CM:14.1.3

ProcedureEndDate

0..1

The end date (and if possible end time) of the procedure. A ‘vague’ date, such as only the year, is permitted.

The element offers the option to indicate the end of the period of a series of related procedures.

NL-CM:14.1.8

ProcedureAnatomicalLocation

0..1

Anatomical location which is the focus of the procedure.

405813007 Procedure site - Direct

ProcedureAnatomicalLocationCodelist

NL-CM:14.1.11

ProcedureLaterality

0..1

Laterality adds information about body side to the anatomic location, e.g. left

272741003 Laterality

ProcedureLateralityCodelist

NL-CM:14.1.9

Indication::Problem

0..*

The indication is the reason for the procedure.

363702006 Has focus

Problem

NL-CM:14.1.4

ProcedureType

1

The name of the procedure.

As of 1 January 2013, all procedures in the primary process have to be documented with CBV codes. To meet this requirement, the DHD procedure thesaurus (CBV procedures set) is used to code procedures. It is possible that in addition to the CBV procedures set, the NIC will be used for nurse procedures and that a “coded value set” will be introduced for paramedic procedures.

ProcedureTypeCodelist

NL-CM:14.1.12

ProcedureMethod

0..*

the method or technique that was used to perform the procedure, e.g. approach, lavage, pressuring, ets

260686004 Method

ProcedureMethodCodelist

NL-CM:14.1.7

MedicalDevice

0..*

The product, the placing of which in or on the body is the purpose of the procedure, for example placing an implant.

405815000 Procedure device

MedicalDevice

NL-CM:14.1.5

Location::HealthcareProvider

0..1

The healthcare center where the procedure was or is carried out.

HealthcareProvider

NL-CM:14.1.6

Performer::HealthProfessional

0..*

The healthcare provider who carried out the procedure. In most cases, only the medical specialty is entered, and not the name of the healthcare provider.

HealthProfessional

NL-CM:14.1.10

Requester::HealthProfessional

0..*

The healthcare provider who requested the procedure.

HealthProfessional

Columns Concept and DefinitionCode: hover over the values for more information
For explanation of the symbols, please see the legend page

Example Instances

Only available in Dutch

VerrichtingType	Verrichting Anatomische Locatie	Verrichting Lateraliteit	Verrichting Start Datum	Product			Indicatie		Uitgevoerd Door	Locatie
				ProductType	ProductID		ProbleemNaam	Toelichting	Specialisme	OrganisatieNaam

Knie - prothese implantatie gewricht	Knie	Links	05-06-2012	Orthopedic surgical implants	(01)05050474530799 (17)160131 (21)1148130801	Implantant, Gen 2 Tibia Insert 5/6-9mm	Artrose	Beperking bij het bewegen van het gewricht, drukpijn door slijtage van twee compartimenten van de linker knie.	Orthopedie	UMCG

Instructions

Only the procedures are described in this information model, not the results of the procedures. The LaboratoryResult and TextResult information models can be used to document the results.

References

1. GS1 Global Traceability Standard for Healthcare 1.2.0 (2013) [Online] Beschikbaar op: http://www.gs1.org/traceability/healthcare-traceability/1-2-0 [Geraadpleegd: 19 juni 2014].

2. Vektis Zorgverlenersspecificatie (subberoepsgroep) [Online] Beschikbaar op: http://ei.vektis.nl/WespCodelijstenDetail.aspx?Co_Ge_Code=COD016&Co_Or_Code=VEKT [Geraadpleegd: 19 juni 2014].

3. AZR-AGB-codelijst [Online] Beschikbaar op: http://www.agbcode.nl/MainPage/opzoeken.aspx?soort=IS [Geraadpleegd: 19 juni 2014].

Valuesets

ProcedureAnatomicalLocationCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.1.1	Binding: Extensible

Conceptname	Codesystem name	Codesystem OID
SNOMED CT: <442083009\|Anatomical or acquired body structure\|	SNOMED CT	2.16.840.1.113883.6.96

ProcedureLateralityCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.1.3	Binding: Extensible

Conceptname	Conceptcode	Codesystem name	Codesystem OID	Description
Left	7771000	SNOMED CT	2.16.840.1.113883.6.96	Links
Right	24028007	SNOMED CT	2.16.840.1.113883.6.96	Rechts
Right and left	51440002	SNOMED CT	2.16.840.1.113883.6.96	Rechts en links

ProcedureMethodCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.1.4	Binding: Extensible

Conceptname	Codesystem name	Codesystem OID
SNOMED CT: <129264002\|Action\|	SNOMED CT	2.16.840.1.113883.6.96

ProcedureTypeCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.1.2	Binding: Extensible

Conceptname	Codesystem name	Codesystem OID
Alle waarden	Verrichtingenthesaurus DHD	2.16.840.1.113883.2.4.3.120.5.2

This information model in other releases

Information model references

This information model refers to

This information model is used in

Technical specifications in HL7v3 CDA and HL7 FHIR

To exchange information based on health and care information models, additional, more technical specifications are required.
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:

HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment
HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR

Downloads

This information model is also available as pdf file or as spreadsheet

About this information

The information in this wikipage is based on Prerelease 2018 #1
SNOMED CT and LOINC codes are based on:

SNOMED Clinical Terms version: 20180731 [R] (July 2018 Release)
LOINC version 2.64

Conditions for use are located on the mainpage
This page is generated on 23/12/2018 01:20:11 with ZibExtraction v. 3.0.6929.24609

Back to HCIM list

@@ Regel 221: / Regel 221: @@
 ==Information Model==
 <BR>
-<imagemap> Bestand:Procedure-v4.1Model(EN).png | center
+<imagemap> Bestand:Procedure-v4.1Model(2018EN).png | center
-rect 120 496 288 546 [[#ProcedureMethodCodelist]]
+rect 130 504 298 554 [[#ProcedureMethodCodelist]]
-rect 187 400 317 470 [[#13108]]
+rect 197 408 327 478 [[#13108]]
-rect 747 496 925 546 [[#ProcedureLateralityCodelist]]
+rect 757 504 935 554 [[#ProcedureLateralityCodelist]]
-rect 708 400 841 470 [[#13095]]
+rect 718 408 851 478 [[#13095]]
-rect 499 496 725 546 [[#ProcedureAnatomicalLocationCodelist]]
+rect 509 504 735 554 [[#ProcedureAnatomicalLocationCodelist]]
-rect 309 496 477 546 [[#ProcedureTypeCodelist]]
+rect 319 504 487 554 [[#ProcedureTypeCodelist]]
-rect 708 303 841 373 [[HealthProfessional-v3.2(2018EN)]]
+rect 718 311 851 381 [[HealthProfessional-v3.2(2018EN)]]
-rect 189 206 319 276 [[Problem-v4.1.1(2018EN)]]
+rect 199 214 329 284 [[Problem-v4.1.1(2018EN)]]
-rect 187 109 317 179 [[#13106]]
+rect 197 117 327 187 [[#13106]]
-rect 450 109 576 179 [[#13097]]
+rect 460 117 586 187 [[#13097]]
-rect 708 206 841 276 [[HealthcareProvider-v3.2(2018EN)]]
+rect 718 214 851 284 [[HealthcareProvider-v3.2(2018EN)]]
-rect 187 303 317 373 [[MedicalDevice-v3.1.1(2018EN)]]
+rect 197 311 327 381 [[MedicalDevice-v3.1.1(2018EN)]]
-rect 339 400 501 472 [[#13094]]
+rect 349 408 511 480 [[#13094]]
-rect 708 108 841 178 [[HealthProfessional-v3.2(2018EN)]]
+rect 718 116 851 186 [[HealthProfessional-v3.2(2018EN)]]
-rect 453 254 573 334 [[#13096]]
+rect 463 262 583 342 [[#13096]]
-rect 523 400 685 472 [[#13100]]
+rect 533 408 695 480 [[#13100]]
 desc none
 </imagemap>
@@ Regel 494: / Regel 494: @@
 |Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
 |-style="vertical-align:top; "
-|SNOMED CT: < [https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=442083009 442083009]<noWiki>|</noWiki><span title = "Anatomische of verworven lichaamsstructuur" >Anatomical or acquired body structure</span><noWiki>|</noWiki>
+|SNOMED CT: <[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=442083009 442083009]<noWiki>|</noWiki><span title = "Anatomische of verworven lichaamsstructuur">Anatomical or acquired body structure</span><noWiki>|</noWiki>
 |SNOMED CT
 |2.16.840.1.113883.6.96
@@ Regel 511: / Regel 511: @@
 |Description<!--vsDescription-->
 |-style="vertical-align:top; "
-|<span title = "Links" >Left</span>
+|<span title = "Links">Left</span>
 |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=7771000 7771000]
 |SNOMED CT
@@ Regel 517: / Regel 517: @@
 |Links
 |-style="vertical-align:top; "
-|<span title = "Rechts" >Right</span>
+|<span title = "Rechts">Right</span>
 |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=24028007 24028007]
 |SNOMED CT
@@ Regel 523: / Regel 523: @@
 |Rechts
 |-style="vertical-align:top; "
-|<span title = "Bilateraal" >Right and left</span>
+|<span title = "Bilateraal">Right and left</span>
 |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=51440002 51440002]
 |SNOMED CT
@@ Regel 540: / Regel 540: @@
 |Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
 |-style="vertical-align:top; "
-|SNOMED CT: < [https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=129264002 129264002]<noWiki>|</noWiki><span title = "Handeling" >Action</span><noWiki>|</noWiki>
+|SNOMED CT: <[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=129264002 129264002]<noWiki>|</noWiki><span title = "Handeling">Action</span><noWiki>|</noWiki>
 |SNOMED CT
 |2.16.840.1.113883.6.96
@@ Regel 570: / Regel 570: @@
 *[[MedicalDevice-v3.1.1(2018EN)|MedicalDevice-v3.1.1]]
 *[[Problem-v4.1.1(2018EN)|Problem-v4.1.1]]
-====This inforation model is used in<!--ftReferredBy-->====
+====This information model is used in<!--ftReferredBy-->====
 *[[Encounter-v3.1(2018EN)|Encounter-v3.1]]
 *[[PlannedCareActivityForTransfer-v3.1(2018EN)|PlannedCareActivityForTransfer-v3.1]]
@@ Regel 591: / Regel 591: @@
 </ul>
 Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR>
-This page is generated on 01/11/2018 17:38:09 with ZibExtraction v. 2.0.6879.31307<!--ftDate--> <BR>
+This page is generated on 23/12/2018 01:20:11 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-->_2018(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2018(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div>

Procedure-v4.1(2018EN): verschil tussen versies

Huidige versie van 24 dec 2018 om 12:58

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General information

Metadata

Revision History

Concept

Purpose

Information Model

Example Instances

Instructions

References