Problem-v4.0(2017EN): verschil tussen versies
Geen bewerkingssamenvatting |
Geen bewerkingssamenvatting |
||
Regel 3: | Regel 3: | ||
Version: '''4.0''' <br> | Version: '''4.0''' <br> | ||
HCIM Status:Final<br> | HCIM Status:Final<br> | ||
Release: '''2017''' <br> | |||
Release status: Prepublished<br> | Release status: Prepublished<br> | ||
Release date: 04-09-2017 | |||
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<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release_2017(EN)]] [[HCIM_Release_2017(EN) |Back to HCIM list ]]</div> | <div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release_2017(EN)]] [[HCIM_Release_2017(EN) |Back to HCIM list ]]</div> | ||
Regel 178: | Regel 178: | ||
==Information Model== | ==Information Model== | ||
<BR> | <BR> | ||
<imagemap> Bestand:Problem-v4.0Model(EN).png | center | |||
rect 693 372 839 422 [[#VerificationStatusCodelist]] | |||
rect 513 362 638 432 [[#13034]] | |||
rect 159 103 283 173 [[#13039]] | |||
rect 326 470 469 520 [[#ProblemNameCodelist]] | |||
rect 512 228 637 298 [[#13032]] | |||
rect 692 239 838 289 [[#ProblemStatusCodelist]] | |||
rect 150 372 292 422 [[#ProblemTypeCodelist]] | |||
rect 335 362 457 432 [[#13030]] | |||
rect 160 229 282 299 [[#13038]] | |||
rect 512 103 637 173 [[#13040]] | |||
rect 335 103 459 173 [[#13028]] | |||
rect 351 229 441 299 [[#13037]] | |||
desc none | |||
</imagemap> | |||
<BR> | <BR> | ||
{| border= "1" width="1500px" style = "font-size: 9.5pt; border: solid 1px silver; border-collapse:collapse;" cellpadding = "3px" cellspacing ="0px" | {| border= "1" width="1500px" style = "font-size: 9.5pt; border: solid 1px silver; border-collapse:collapse;" cellpadding = "3px" cellspacing ="0px" | ||
Regel 184: | Regel 198: | ||
|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="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="vertical-align:top; background-color: #E3E3E3; " | ||
|style = "text-align:center" |[[Bestand: block.png| 20px]] | |style = "text-align:center" |[[Bestand: block.png| 20px | link=]] | ||
||NL-CM:5.1.1 | ||NL-CM:5.1.1 | ||
|colspan ="6" style ="padding-left: 0px"|<span Title="NL: Probleem">[[Bestand: arrowdown.png | 10px]]Problem</span> | |colspan ="6" style ="padding-left: 0px"|<span Id=13037 Title="NL: Probleem">[[Bestand: arrowdown.png | 10px | link=]]Problem</span> | ||
| | | | ||
|Root concept of the Problem information model. | |Root concept of the Problem information model. | ||
Regel 194: | Regel 208: | ||
| | | | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: CD.png| 16px]] | |style = "text-align:center" |[[Bestand: CD.png| 16px | link=]] | ||
||NL-CM:5.1.8 | ||NL-CM:5.1.8 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: ProbleemType">[[Bestand: arrowright.png | 10px]]ProblemType</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=13038 Title="NL: ProbleemType">[[Bestand: arrowright.png | 10px | link=]]ProblemType</span> | ||
|0..1 | |0..1 | ||
|The type of problem; see the concept description. | |The type of problem; see the concept description. | ||
Regel 204: | Regel 218: | ||
{| | {| | ||
|- | |- | ||
|[[Bestand: List2.png]]||[[#ProblemTypeCodelist|ProblemTypeCodelist]] | |[[Bestand: List2.png | link=#ProblemTypeCodelist]]||[[#ProblemTypeCodelist|ProblemTypeCodelist]] | ||
|} | |} | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: CD.png| 16px]] | |style = "text-align:center" |[[Bestand: CD.png| 16px | link=]] | ||
||NL-CM:5.1.3 | ||NL-CM:5.1.3 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: ProbleemNaam">[[Bestand: arrowright.png | 10px]]ProblemName</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=13030 Title="NL: ProbleemNaam">[[Bestand: arrowright.png | 10px | link=]]ProblemName</span> | ||
|1 | |1 | ||
|The problem name defines the problem. Depending on the setting, different code systems can be used. The ProblemNameCodelist provides an overview of the possible code systems. | |The problem name defines the problem. Depending on the setting, different code systems can be used. The ProblemNameCodelist provides an overview of the possible code systems. | ||
Regel 217: | Regel 231: | ||
{| | {| | ||
|- | |- | ||
|[[Bestand: List2.png]]||[[#ProblemNameCodelist|ProblemNameCodelist]] | |[[Bestand: List2.png | link=#ProblemNameCodelist]]||[[#ProblemNameCodelist|ProblemNameCodelist]] | ||
|} | |} | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: TS.png| 16px]] | |style = "text-align:center" |[[Bestand: TS.png| 16px | link=]] | ||
||NL-CM:5.1.6 | ||NL-CM:5.1.6 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: ProbleemBeginDatum">[[Bestand: arrowright.png | 10px]]ProblemStartDate</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=13028 Title="NL: ProbleemBeginDatum">[[Bestand: arrowright.png | 10px | link=]]ProblemStartDate</span> | ||
|0..1 | |0..1 | ||
|Onset of the disorder to which the problem applies. Especially in symptoms in which it takes longer for the final diagnosis, it is important to know not only the date of the diagnosis, but also how long the patient has had the disorder. A ‘vague’ date, such as only the year or the month and the year, is permitted. | |Onset of the disorder to which the problem applies. Especially in symptoms in which it takes longer for the final diagnosis, it is important to know not only the date of the diagnosis, but also how long the patient has had the disorder. A ‘vague’ date, such as only the year or the month and the year, is permitted. | ||
Regel 229: | Regel 243: | ||
| | | | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: TS.png| 16px]] | |style = "text-align:center" |[[Bestand: TS.png| 16px | link=]] | ||
||NL-CM:5.1.9 | ||NL-CM:5.1.9 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: ProbleemEindDatum">[[Bestand: arrowright.png | 10px]]ProblemEndDate</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=13039 Title="NL: ProbleemEindDatum">[[Bestand: arrowright.png | 10px | link=]]ProblemEndDate</span> | ||
|0..1 | |0..1 | ||
|Date on which the disorder to which the problem applies, is considered not to be present anymore.This datum needs not to be the same as the date of the change in problem status. A ‘vague’ date, such as only the year or the month and the year, is permitted. | |Date on which the disorder to which the problem applies, is considered not to be present anymore.This datum needs not to be the same as the date of the change in problem status. A ‘vague’ date, such as only the year or the month and the year, is permitted. | ||
Regel 238: | Regel 252: | ||
| | | | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: CD.png| 16px]] | |style = "text-align:center" |[[Bestand: CD.png| 16px | link=]] | ||
||NL-CM:5.1.4 | ||NL-CM:5.1.4 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: ProbleemStatus">[[Bestand: arrowright.png | 10px]]ProblemStatus</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=13032 Title="NL: ProbleemStatus">[[Bestand: arrowright.png | 10px | link=]]ProblemStatus</span> | ||
|1 | |1 | ||
|The problem status describes the condition of the problem: | |The problem status describes the condition of the problem: | ||
<ol> | <ol> | ||
<li>Active problems are problems of which the patient experiences symptoms or for which evidence exists.</li> | <li>Active problems are problems of which the patient experiences symptoms or for which evidence exists.</li> | ||
<li>Problems with the status 'Inactive' refer to problems that don't affect the patient anymore or that of which there is no evidence of existence anymore. | <li>Problems with the status 'Inactive' refer to problems that don't affect the patient anymore or that of which there is no evidence of existence anymore.</li> | ||
</ol> | |||
| | | | ||
| | | | ||
{| | {| | ||
|- | |- | ||
|[[Bestand: List2.png]]||[[#ProblemStatusCodelist|ProblemStatusCodelist]] | |[[Bestand: List2.png | link=#ProblemStatusCodelist]]||[[#ProblemStatusCodelist|ProblemStatusCodelist]] | ||
|} | |} | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: CD.png| 16px]] | |style = "text-align:center" |[[Bestand: CD.png| 16px | link=]] | ||
||NL-CM:5.1.10 | ||NL-CM:5.1.10 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: VerificatieStatus">[[Bestand: arrowright.png | 10px]]VerificationStatus</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=13034 Title="NL: VerificatieStatus">[[Bestand: arrowright.png | 10px | link=]]VerificationStatus</span> | ||
|0..1 | |0..1 | ||
|Clinical status of the problem or the diagnosis. | |Clinical status of the problem or the diagnosis. | ||
Regel 264: | Regel 280: | ||
{| | {| | ||
|- | |- | ||
|[[Bestand: List2.png]]||[[#VerificationStatusCodelist|VerificationStatusCodelist]] | |[[Bestand: List2.png | link=#VerificationStatusCodelist]]||[[#VerificationStatusCodelist|VerificationStatusCodelist]] | ||
|} | |} | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: ST.png| 16px]] | |style = "text-align:center" |[[Bestand: ST.png| 16px | link=]] | ||
||NL-CM:5.1.5 | ||NL-CM:5.1.5 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: Toelichting">[[Bestand: arrowright.png | 10px]]Comment</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=13040 Title="NL: Toelichting">[[Bestand: arrowright.png | 10px | link=]]Comment</span> | ||
|0..1 | |0..1 | ||
|Comment by the one who determined or updated the Problem. | |Comment by the one who determined or updated the Problem. | ||
Regel 288: | Regel 304: | ||
{|class="wikitable" width="1043px" style= "font-size: 9.5pt;" | {|class="wikitable" width="1043px" style= "font-size: 9.5pt;" | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
|colspan="7" style="background-color: #548DD4; width: 100%; color | |colspan="7" style="background-color: #548DD4; width: 100%; "|<font color=#FFFFFF><b>Probleem</b></font> | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
| style="background-color: #D9D9D9; width: 13% | | style="background-color: #D9D9D9; width: 13%; "|<b>ProbleemType</b> | ||
| style="background-color: #D9D9D9; width: 16% | | style="background-color: #D9D9D9; width: 16%; "|<b>ProbleemNaam</b> | ||
| style="background-color: #D9D9D9; width: 11% | | style="background-color: #D9D9D9; width: 11%; "|<b>Probleem</b><BR><b>BeginDatum</b> | ||
| style="background-color: #D9D9D9; width: 14% | | style="background-color: #D9D9D9; width: 14%; "|<b>ProbleemStatus</b> | ||
| style="background-color: #D9D9D9; width: 10% | | style="background-color: #D9D9D9; width: 10%; "|<b>Probleem</b><BR><b>EindDatum</b> | ||
| style="background-color: #D9D9D9; width: 12% | | style="background-color: #D9D9D9; width: 12%; "|<b>Verificatie</b><BR><b>Status</b> | ||
| style="background-color: #D9D9D9; width: 24% | | style="background-color: #D9D9D9; width: 24%; "|<b>Toelichting</b> | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
| style="width: 13%; "|Klacht | | style="width: 13%; "|Klacht | ||
Regel 316: | Regel 332: | ||
{|class="wikitable" width="1043px" style= "font-size: 9.5pt;" | {|class="wikitable" width="1043px" style= "font-size: 9.5pt;" | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
|colspan="7" style="background-color: #548DD4; width: 100%; color | |colspan="7" style="background-color: #548DD4; width: 100%; "|<font color=#FFFFFF><b>Probleem</b></font> | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
| style="background-color: #D9D9D9; width: 13% | | style="background-color: #D9D9D9; width: 13%; "|<b>ProbleemType</b> | ||
| style="background-color: #D9D9D9; width: 16% | | style="background-color: #D9D9D9; width: 16%; "|<b>ProbleemNaam</b> | ||
| style="background-color: #D9D9D9; width: 11% | | style="background-color: #D9D9D9; width: 11%; "|<b>Probleem</b><BR><b>BeginDatum</b> | ||
| style="background-color: #D9D9D9; width: 14% | | style="background-color: #D9D9D9; width: 14%; "|<b>ProbleemStatus</b> | ||
| style="background-color: #D9D9D9; width: 10% | | style="background-color: #D9D9D9; width: 10%; "|<b>Probleem</b><BR><b>EindDatum</b> | ||
| style="background-color: #D9D9D9; width: 12% | | style="background-color: #D9D9D9; width: 12%; "|<b>Verificatie</b><BR><b>Status</b> | ||
| style="background-color: #D9D9D9; width: 24% | | style="background-color: #D9D9D9; width: 24%; "|<b>Toelichting</b> | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
| style="width: 13%; "|Diagnose | | style="width: 13%; "|Diagnose | ||
Regel 360: | Regel 376: | ||
{|class="wikitable" width="1043px" style= "font-size: 9.5pt;" | {|class="wikitable" width="1043px" style= "font-size: 9.5pt;" | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
|colspan="7" style="background-color: #548DD4; width: 100%; color | |colspan="7" style="background-color: #548DD4; width: 100%; "|<font color=#FFFFFF><b>Probleem</b></font> | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
| style="background-color: #D9D9D9; width: 13% | | style="background-color: #D9D9D9; width: 13%; "|<b>ProbleemType</b> | ||
| style="background-color: #D9D9D9; width: 16% | | style="background-color: #D9D9D9; width: 16%; "|<b>ProbleemNaam</b> | ||
| style="background-color: #D9D9D9; width: 11% | | style="background-color: #D9D9D9; width: 11%; "|<b>Probleem</b><BR><b>BeginDatum</b> | ||
| style="background-color: #D9D9D9; width: 14% | | style="background-color: #D9D9D9; width: 14%; "|<b>ProbleemStatus</b> | ||
| style="background-color: #D9D9D9; width: 10% | | style="background-color: #D9D9D9; width: 10%; "|<b>Probleem</b><BR><b>EindDatum</b> | ||
| style="background-color: #D9D9D9; width: 12% | | style="background-color: #D9D9D9; width: 12%; "|<b>Verificatie</b><BR><b>Status</b> | ||
| style="background-color: #D9D9D9; width: 24% | | style="background-color: #D9D9D9; width: 24%; "|<b>Toelichting</b> | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
| style="width: 13%; "|Diagnose | | style="width: 13%; "|Diagnose | ||
Regel 559: | Regel 575: | ||
==This information model in other releases== | |||
<ul> | |||
<li>[[ConcernForTransfer-v1.2(2015EN) | Release 2015, (Version 1.2)]]</li> | |||
<li>[[ConcernForTransfer-v3.0(2016EN) | Release 2016, (Version 3.0)]]</li> | |||
</ul> | |||
==More on this information model== | ==More on this information model== | ||
To exchange information based on health and care information models, additional, more technical specifications are required.<BR> | |||
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications: | |||
<ul> | |||
<li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment [http://decor.nictiz.nl/art-decor/decor-scenarios--zib2017bbr-?id=2.16.840.1.113883.2.4.3.11.60.7.4.2.5.1&effectiveDate=2017-09-04T00:00:00&language=en-US&scenariotree=false [[File:artdecor.jpg|16px|link=]]]</li> | |||
<li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR [https://simplifier.net/NictizSTU3/~resources?text=zib&category=StructureDefinition [[File:fhir.png|link=]]]</li> | |||
</ul> | |||
This information model is also available as [[Media:nl.zorg.Problem-v4.0(2017EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.Problem-v4.0(2017EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]] | This information model is also available as [[Media:nl.zorg.Problem-v4.0(2017EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.Problem-v4.0(2017EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]] | ||
==About this information== | ==About this information== | ||
The information in this wikipage is based on Prerelease 2017 #1 <BR> | The information in this wikipage is based on Prerelease 2017 #1 <BR> | ||
Conditions for use are located on the mainpage [[Bestand:list2.png|link=HCIM_Mainpage]]<BR> | Conditions for use are located on the mainpage [[Bestand:list2.png|link=HCIM_Mainpage]]<BR> | ||
This page is generated on | This page is generated on 30/11/2017 13:38:08 <BR> | ||
----- | ----- | ||
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release_2017(EN)]] [[HCIM_Release_2017(EN) |Back to HCIM list ]]</div> | <div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release_2017(EN)]] [[HCIM_Release_2017(EN) |Back to HCIM list ]]</div> |
Huidige versie van 30 nov 2017 om 14:42
General information
Name: nl.zorg.Problem
Version: 4.0
HCIM Status:Final
Release: 2017
Release status: Prepublished
Release date: 04-09-2017
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 | 11-6-2012 |
DCM::DeprecatedDate | |
DCM::DescriptionLanguage | nl |
DCM::EndorsingAuthority.Address | |
DCM::EndorsingAuthority.Name | PM |
DCM::EndorsingAuthority.Telecom | |
DCM::Id | 2.16.840.1.113883.2.4.3.11.60.40.3.5.1 |
DCM::KeywordList | problemen, klachten, diagnosen |
DCM::LifecycleStatus | Final |
DCM::ModelerList | Kerngroep Registratie aan de Bron |
DCM::Name | nl.zorg.Probleem |
DCM::PublicationDate | 04-09-2017 |
DCM::PublicationStatus | Prepublished |
DCM::ReviewerList | Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron |
DCM::RevisionDate | 04-09-2017 |
DCM::Superseeds | nl.zorg.OverdrachtConcern-v3.1 |
DCM::Version | 4.0 |
HCIM::PublicationLanguage | EN |
Revision History
Only available in Dutch
Publicatieversie 1.0 (15-02-2013) -
Publicatieversie 1.1 (01-07-2013) -
Publicatieversie 1.2 (01-04-2015)
ZIB-150 | Aanpassingen in SNOMED CT codes en omschrijvingen voor codelijst ProbleemTypeCodelijst n.a.v. review terminologie expert. |
ZIB-267 | In klinische bouwsteen OverdrachtProblemen kwam de waarde van de tagged value DCM::ValueSet van concept ProbleemType niet overeen met naam van de gekoppelde valueset. |
ZIB-268 | In de klinische bouwsteen OverdrachtProblemen waren verschillende externe valuesets aan een DCM::ValueSet tagged value toegevoegd voor het concept ProbleemOmschrijving. Dit is aangepast en uitgesplitst. |
ZIB-269 | In de klinische bouwsteen OverdrachtProblemen kwam de naamgeving van de tagged value van concept ProbleemStatus niet overeen met de naam van de onderliggende waardelijst. |
ZIB-305 | Toevoegen ICPC codestelsel aan concept definitie en aan tagged values |
ZIB-310 | Bouwsteen OverdrachtProbelemen hernoemd naar OverdrachtConcern |
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-400 | DHD Codesysteem onbekend |
Publicatieversie 4.0 (04-09-2017)
ZIB-107 | OverdrachtProblemen aanpassen zodat Probleem het rootconcept wordt i.p.v. Concern. |
ZIB-108 | ProbleemstatusCodelijst in OverdrachtProblemen leidt qua naamgeving/vertaling van de concepten tot verwarring |
ZIB-446 | ProbleemType mist status |
ZIB-459 | Toevoegen extra opties voor ProbleemTypeCodelijst |
ZIB-467 | aanpassen naam, type en naamcodelijst, type e status |
ZIB-549 | De Engelse naam van de bouwsteen en het rootconcept zijn niet correct |
ZIB-564 | Aanpassing/harmonisatie Engelse conceptnamen |
ZIB-529 | Voorbeelden bij ProbleemType Conditie onlogisch |
ZIB-576 | Aanpassen bouwstenen die nog de prefix overdracht hebben, zodat de prefix kan vervallen. |
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Concept
A problem describes a situation with regard to an individual’s health and/or welfare. This situation can be described by the person involved (the patient) themselves (in the form of a complaint), or by their healthcare provider (in the form of a diagnosis, for example). The situation can form cause for diagnostic or therapeutic policy.
A problem includes all kinds of medical or nursing information that represents a health problem. A problem can represent various types of health problems:
- A complaint, finding by patient: a subjective, negatively experienced observation of the patient’s health. Examples: stomach ache, amnesia
- A symptom: an observation by or about the patient which may indicate a certain disease. Examples: fever, blood in stool, white spots on the roof of the mouth;
- A diagnosis: medical interpretation of complaints and findings. Examples: Diabetes Mellitus type II, pneumonia, hemolytic-uremic syndrome.
- A functional limitation: a reduction of functional options. Examples: reduced mobility, help required for dressing.
- A complication: Every diagnosis seen by the healthcare provider as an unforeseen and undesired result of medical action. Examples: post-operative wound infections, loss of hearing through the use of antibiotics.
Purpose
An overview of a patient’s health problems has the purpose of informing all healthcare providers involved in the patient’s care on the patient’s current and past health condition. It provides insight into which problems require medical action, which are under control and which are no longer current. The problem overview also directly provides medical context for medication administered and procedures carried out.
The overview promotes an efficient, targeted continuation of the patient’s care.
A complete list of problems is of importance for automated decision support and determining contraindications.
Information Model
![Problem-v4.0Model(EN).png](/images/7/70/Problem-v4.0Model%28EN%29.png)
Type | Id | Concept | Card. | Definition | DefinitionCode | Reference | |||||||
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NL-CM:5.1.1 | ![]() |
Root concept of the Problem information model.
A problem describes a situation with regard to an individual’s health and/or welfare. This situation can be described by the patient himselve (in the form of a complaint) or by their healthprofessional (in the form of a diagnosis, for example). |
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NL-CM:5.1.8 | ![]() |
0..1 | The type of problem; see the concept description. |
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NL-CM:5.1.3 | ![]() |
1 | The problem name defines the problem. Depending on the setting, different code systems can be used. The ProblemNameCodelist provides an overview of the possible code systems. |
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NL-CM:5.1.6 | ![]() |
0..1 | Onset of the disorder to which the problem applies. Especially in symptoms in which it takes longer for the final diagnosis, it is important to know not only the date of the diagnosis, but also how long the patient has had the disorder. A ‘vague’ date, such as only the year or the month and the year, is permitted. | |||||||||
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NL-CM:5.1.9 | ![]() |
0..1 | Date on which the disorder to which the problem applies, is considered not to be present anymore.This datum needs not to be the same as the date of the change in problem status. A ‘vague’ date, such as only the year or the month and the year, is permitted. | |||||||||
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NL-CM:5.1.4 | ![]() |
1 | The problem status describes the condition of the problem:
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NL-CM:5.1.10 | ![]() |
0..1 | Clinical status of the problem or the diagnosis. |
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NL-CM:5.1.5 | ![]() |
0..1 | Comment by the one who determined or updated the Problem. |
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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
Probleem | ||||||
ProbleemType | ProbleemNaam | Probleem BeginDatum |
ProbleemStatus | Probleem EindDatum |
Verificatie Status |
Toelichting |
Klacht | Oedeem | 10-08-2012 | Actueel | Geleidelijk in de loop van dagen erger geworden. Geen roodheid of pijn. | ||
Diagnose | Nefrotisch syndroom | 11-2012 | Actueel | Werkdiagnose | Membraneuze glomerulopathie. |
Probleem | ||||||
ProbleemType | ProbleemNaam | Probleem BeginDatum |
ProbleemStatus | Probleem EindDatum |
Verificatie Status |
Toelichting |
Diagnose | Anteroseptaal myocardinfarct | 24-05-1998 | Niet actueel | 11-12-1998 | Bevestigd | Coronarialijden als complicatie diabetes. |
Diagnose | Hartfalen | Actueel | Bevestigd | Opnieuw actief geworden. | ||
Klacht | Kortademigheid | 15-11-2012 | Niet actueel | |||
Diagnose | Diabetes mellitus type II | 1996 | Actueel | Bevestigd |
Probleem | ||||||
ProbleemType | ProbleemNaam | Probleem BeginDatum |
ProbleemStatus | Probleem EindDatum |
Verificatie Status |
Toelichting |
Diagnose | Polsfractuur links | 20-04-2011 | Niet actueel | 07-06-2011 | Bevestigd | Gevallen op kunstijsbaan. |
Instructions
For the nursing domain: When two parties use different coding systems, the Snomed CT-based V&VN Dutch nursing problem list should be used for exchange, so data becomes comparable and exchangeable. A mapping table is available from the V&VN Dutch nursing problem list to Omaha System, NANDA-I and ICF.
References
1. openEHR-EHR-EVALUATION.problem.v1 [Online] Beschikbaar op: http://www.openehr.org/knowledge/ [Geraadpleegd: 23 juli 2014].
2. North American Nursing Diagnosis Association [Online] Beschikbaar op: http://www.nanda.org [Geraadpleegd: 23 juli 2014].
3. Diagnosethesaurus. Dutch Hospital Data [Online] Beschikbaar op: http://www.dutchhospitaldata.nl [Geraadpleegd: 23 juli 2014].
4. Health Level Seven International EHR Technical Committee (February 2007) Electronic Health Record–System Functional Model, Release 1. Chapter Three: Direct Care Functions.
5. HL7 (April 2007) HL7 Implementation Guide: CDA Release 2 – Continuity of Care Document (CCD)
6. Nederlands Huisartsen Genootschap (2013) HIS-Referentiemodel 2013
Valuesets
ProblemNameCodelist
Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.5.1.3 |
Conceptname | Codesystem name | Codesystem OID |
Alle waarden | Diagnosethesaurus DHD (SNOMED CT) | 2.16.840.1.113883.2.4.3.120.5.1 |
Alle waarden | ICD-10 | 2.16.840.1.113883.6.90 |
Alle waarden | Nationale Kernset Patiëntproblemen V&VN (SNOMED CT) | 2.16.840.1.113883.2.4.3.11.26.4 |
Alle waarden | NANDA-I | 2.16.840.1.113883.6.20 |
Alle waarden | Omaha Systems | 2.16.840.1.113883.6.98 |
Alle waarden | ICF | 2.16.840.1.113883.6.254 |
Alle waarden | ICPC-1 NL | 2.16.840.1.113883.2.4.4.31.1 |
Alle waarden | G-Standaard Contra Indicaties (Tabel 40) | 2.16.840.1.113883.2.4.4.1.902.40 |
Alle waarden | DSM-IV | 2.16.840.1.113883.6.126 |
Alle waarden | DSM-V | Nog niet bekend |
ProblemStatusCodelist
Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.5.1.2 |
Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
Active | 55561003 | SNOMED CT | 2.16.840.1.113883.6.96 | Actueel |
Inactive | 73425007 | SNOMED CT | 2.16.840.1.113883.6.96 | Niet actueel |
ProblemTypeCodelist
Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.5.1.1 |
Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
Diagnosis | 282291009 | SNOMED CT | 2.16.840.1.113883.6.96 | Diagnose |
Symptom | 418799008 | SNOMED CT | 2.16.840.1.113883.6.96 | Symptoom |
Complaint | 409586006 | SNOMED CT | 2.16.840.1.113883.6.96 | Klacht |
Functional Limitation | 248536006 | SNOMED CT | 2.16.840.1.113883.6.96 | Functionele Beperking |
Complication | 116223007 | SNOMED CT | 2.16.840.1.113883.6.96 | Complicatie |
VerificationStatusCodelist
Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.5.1.4 |
Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
Working diagnosis | 5558000 | SNOMED CT | 2.16.840.1.113883.6.96 | Werk |
Differential diagnosis | 47965005 | SNOMED CT | 2.16.840.1.113883.6.96 | Differentiaal |
Confirmed present | 410605003 | SNOMED CT | 2.16.840.1.113883.6.96 | Bevestigd |
Known absent | 410516002 | SNOMED CT | 2.16.840.1.113883.6.96 | Uitgesloten |
Unknown | UNK | NullFlavor | 2.16.840.1.113883.5.1008 | Onbekend |
This information model in other releases
More on this information model
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
This information model is also available as pdf file or as spreadsheet
About this information
The information in this wikipage is based on Prerelease 2017 #1
Conditions for use are located on the mainpage
This page is generated on 30/11/2017 13:38:08