Nieuwe pagina aangemaakt met '<!-- Hieronder wordt een transclude page aangeroepen --> {{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.5.5(EN)|1|Symptom-v2.0(2024EN)}} <!-- Tot hier de transclude page --> ==General information<!--hdGeneralInformation-->== Name<!--hdName-->: '''nl.zorg.Symptom''' link=Symptoom-v2.0(2024NL)<BR> Version<!--hdVersion-->: '''2.0''' <br> HCIM Status<!--hdStatus-->:Final<br> Release<!--hdPublication-->: '''2024''' <br> Release status<!--h…'
A phenomenon with which a condition in the patient presents itself. This also includes a complaint or a finding, but not additional research, such as laboratory tests, function tests and imaging studies.
Purpose
Symptoms are an important basis for interpreting the condition (making the diagnosis) and for assessing the severity of the condition and the need for further examination or treatment. Symptoms and their course are also essential for evaluating the effectiveness of treatment.
Evidence Base
Note on zib Symptom
A symptom refers to a phenomenon in a broad sense (including complaint and finding) with which a condition presents itself, but limited to symptoms that the patient notices himself or that a health professional can observe, if necessary with simple instruments.
Multiple symptoms may refer to the same condition, as a disorder or condition may present with > 1 symptom.
If a symptom changes, a new instance of zib Symptom with the same Symptom Name and a more recent SymptomStatusDate indicates how the symptom presented itself at that more recent date(time). A series of instances of Symptom with the same SymptomName then represents the course of the symptom by means of an increasing value for SymptomStatusDate.
The cardinality of the reference to Condition is 0..*. The cardinality “0” is used because, when a symptom is negated, there is no condition or state of which the symptom is a manifestation. To exclude a symptom on its own (outside the context of a condition), one should use questionnaires or checklists. If a Symptom needs to be excluded in the context of a specific condition—for example, no fever in the case of diverticulitis—the Zib Exclusion should be used. The cardinality ”*” indicates that a symptom can be a manifestation of more than one condition.
Information Model
Type
Id
Concept
Card.
Definition
DefinitionCode
Reference
NL-CM:5.5.1
Symptom
This is a reference to the rootconcept of information model Symptom.
More detailed specification of the symptomName that has been selected from the code list, because that list does not (yet) contain the required level of detail.
NL-CM:5.5.12
AnatomicalLocation
0..*
The location(s) on or in the body where the symptom presents itself.
Actions, events or circumstances that influence the presentation of the symptom. Generally, this pertains to factors that aggravate or alleviate the symptom.
NL-CM:5.5.14
Condition
0..*
The condition of which the symptom is a manifestation.
A comment in free text with respect to the symptom, that is not represented by the other data elements in the information model.
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
Symptoom
SymptoomPeriode
StartDatumTijd
22-02-2023
22-02-2023
22-02-2023
EindDatumTijd
TijdsDuur
SymptoomStatusDatum
01-03-2023
05-03-2023
20-03-2023
SymptoomType
Symptoom
Symptoom
Symptoom
SymptoomNaam
Hoest
Hoest
Hoest
NadereSpecificatieSymptoomNaam
Droge hoest
Productieve hoest
Productieve hoest
Ontstaanswijze
Subacuut
TijdsPatroon
Aanvalsgewijs
Aanvalsgewijs
Beloop
Verslechterd
Verbeterd
Ernst
Mild
Matig
Mild
DuurBijOptreden
minimumWaarde
30 min
5 min
maximumWaarde
1,5 u
10 min
nominaleWaarde
BeïnvloedendeFactoren
Erger bij liggen
Toelichting
AnatomischeLocatie
Locatie
Lateraliteit
AandoeningOfGesteldheid
PeriodeAanwezig
StartDatumTijd
22-02-2023
22-02-2023
22-02-2023
EindDatumTijd
StatusDatum
01-03-2023
05-03-2023
20-03-2023
Beloop
Verslechterd
Verbeterd
Ernst
Mild
Matig
Mild
Symptoom
SymptoomPeriode
StartDatumTijd
15-01-2023 10:30
15-01-2023 10:30
EindDatumTijd
26-02-2023
TijdsDuur
SymptoomStatusDatum
15-01-2023
26-02-2023
SymptoomType
Symptoom
Symptoom
SymptoomNaam
Zwelling
Zwelling
NadereSpecificatieSymptoomNaam
Ontstaanswijze
Acuut
TijdsPatroon
Beloop
Niet meer aanwezig
Ernst
Ernstig
Beïnvloedende actoren
Neemt toe bij beweging en neemt af in rust.
Toelichting
AnatomischeLocatie
Locatie
Pols
Pols
Lateraliteit
Links
Links
AandoeningOfGesteldheid
PeriodeAanwezig
StartDatumTijd
15-01-2023
15-01-2023
EindDatumTijd
StatusDatum
15-01-2023
26-02-2023
Beloop
Herstellend
Ernst
Instructions
A symptom always refers to the condition or state of which it is a manifestation. Multiple symptoms can refer to the same condition or state. When an existing symptom is updated, the new instantiation of Symptom will have the same SymptomName, refer to the same Condition, and have a more recent SymptomStatusDate.
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
Symptom
SymptomPeriod::TimeInterval
or as spreadsheet 