TextResult-v4.0(2017EN): verschil tussen versies
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(Nieuwe pagina aangemaakt met '==General information== Name: '''nl.zorg.TextResult''' link=TekstUitslag-v4.0(2017NL)<BR> Version: '''4.0''' <br> HCIM Status:Final<br> Publi...') |
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| (2 tussenliggende versies door dezelfde gebruiker niet weergegeven) | |||
| 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 | |||
----- | ----- | ||
<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 155: | Regel 155: | ||
==Information Model== | ==Information Model== | ||
<BR> | <BR> | ||
<imagemap> Bestand:TextResult-v4.0Model(EN).png | center | |||
rect 164 59 280 129 [[#13063]] | |||
rect 545 60 661 130 [[Procedure-v4.0(2017EN)]] | |||
rect 361 202 451 272 [[#13066]] | |||
rect 163 319 292 369 [[#TextResultStatusCodelist]] | |||
rect 503 319 667 369 [[#TextResultTypeCodelist]] | |||
rect 348 59 466 129 [[#13065]] | |||
rect 173 202 271 272 [[#13062]] | |||
rect 533 202 635 272 [[#13068]] | |||
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 161: | Regel 171: | ||
|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:13.2.1 | ||NL-CM:13.2.1 | ||
|colspan ="6" style ="padding-left: 0px"|<span Title="NL: TekstUitslag">[[Bestand: arrowdown.png | 10px]]TextResult</span> | |colspan ="6" style ="padding-left: 0px"|<span Id=13065 Title="NL: TekstUitslag">[[Bestand: arrowdown.png | 10px | link=]]TextResult</span> | ||
| | | | ||
|Root concept of the TextResult information model. This root concept contains all data elements of the TextResult information model. | |Root concept of the TextResult information model. This root concept contains all data elements of the TextResult information model. | ||
| Regel 169: | Regel 179: | ||
| | | | ||
|-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:13.2.3 | ||NL-CM:13.2.3 | ||
|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: TekstUitslagDatumTijd">[[Bestand: arrowright.png | 10px]]TextResultDateTime</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=13063 Title="NL: TekstUitslagDatumTijd">[[Bestand: arrowright.png | 10px | link=]]TextResultDateTime</span> | ||
|0..1 | |0..1 | ||
|Date and if possible time of the result. | |Date and if possible time of the result. | ||
| Regel 180: | Regel 190: | ||
| | | | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: Verwijzing.png| 20px]] | |style = "text-align:center" |[[Bestand: Verwijzing.png| 20px | link=]] | ||
||NL-CM:13.2.5 | ||NL-CM:13.2.5 | ||
|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: Verrichting">[[Bestand: arrowright.png | 10px]]Procedure</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=13069 Title="NL: Verrichting">[[Bestand: arrowright.png | 10px | link=]]Procedure</span> | ||
|0..1 | |0..1 | ||
|Reference to the Procedure information model including the date of the procedure, requesting and executive specialty. | |Reference to the Procedure information model including the date of the procedure, requesting and executive specialty. | ||
| Regel 190: | Regel 200: | ||
{| | {| | ||
|- | |- | ||
|[[Bestand: block.png]]||[[Procedure-v4.0(2017EN) |Procedure]] | |[[Bestand: block.png | link=Procedure-v4.0(2017EN)]]||[[Procedure-v4.0(2017EN) |Procedure]] | ||
|} | |} | ||
|-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:13.2.6 | ||NL-CM:13.2.6 | ||
|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: TekstUitslagStatus">[[Bestand: arrowright.png | 10px]]TextResultStatus</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=13062 Title="NL: TekstUitslagStatus">[[Bestand: arrowright.png | 10px | link=]]TextResultStatus</span> | ||
|0..1 | |0..1 | ||
|The status of the result. | |The status of the result. | ||
| Regel 203: | Regel 213: | ||
{| | {| | ||
|- | |- | ||
|[[Bestand: List2.png]]||[[#TextResultStatusCodelist|TextResultStatusCodelist]] | |[[Bestand: List2.png | link=#TextResultStatusCodelist]]||[[#TextResultStatusCodelist|TextResultStatusCodelist]] | ||
|} | |} | ||
|-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:13.2.2 | ||NL-CM:13.2.2 | ||
|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: TekstResultaat">[[Bestand: arrowright.png | 10px]]TextResultReport</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=13066 Title="NL: TekstResultaat">[[Bestand: arrowright.png | 10px | link=]]TextResultReport</span> | ||
|1 | |1 | ||
|The text report detailing the actual results of the test or procedure. | |The text report detailing the actual results of the test or procedure. | ||
| Regel 215: | Regel 225: | ||
| | | | ||
|-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:13.2.4 | ||NL-CM:13.2.4 | ||
|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: TekstUitslagType">[[Bestand: arrowright.png | 10px]]TextResultType</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=13068 Title="NL: TekstUitslagType">[[Bestand: arrowright.png | 10px | link=]]TextResultType</span> | ||
|1 | |1 | ||
|The type of result. | |The type of result. | ||
| Regel 225: | Regel 235: | ||
{| | {| | ||
|- | |- | ||
|[[Bestand: List2.png]]||[[#TextResultTypeCodelist|TextResultTypeCodelist]] | |[[Bestand: List2.png | link=#TextResultTypeCodelist]]||[[#TextResultTypeCodelist|TextResultTypeCodelist]] | ||
|} | |} | ||
|} | |} | ||
| Regel 236: | Regel 246: | ||
{|class="wikitable" width="655px" style= "font-size: 9.5pt;" | {|class="wikitable" width="655px" style= "font-size: 9.5pt;" | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
|colspan="2" style="background-color: #004080; width: 36%; color | |colspan="2" style="background-color: #004080; width: 36%; "|<font color=White><b>Tekst Uitslag Datum Tijd</b></font> | ||
| style="width: 64% | | style="width: 64%; "|05-12-2014 17:00 uur | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
|colspan="2" style="background-color: #004080; width: 36%; color | |colspan="2" style="background-color: #004080; width: 36%; "|<font color=White><b>Tekst Uitslag Type</b></font> | ||
| style="width: 64% | | style="width: 64%; "|Röntgen | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
|colspan="2" style="background-color: #004080; width: 36%; color | |colspan="2" style="background-color: #004080; width: 36%; "|<font color=White><b>Tekst Uitslag Status</b></font> | ||
| style="width: 64% | | style="width: 64%; "|Voorlopig | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
|colspan="2" style="background-color: #004080; width: 36%; color | |colspan="2" style="background-color: #004080; width: 36%; "|<font color=White><b>Verrichting</b></font> | ||
| style="width: 64%; "| | | style="width: 64%; "| | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
| style="background-color: #004080; width: 3%; "| | | style="background-color: #004080; width: 3%; "| | ||
| style="background-color: #BFBFBF; width: 33% | | style="background-color: #BFBFBF; width: 33%; "|<b>VerrichtingType</b> | ||
| style="width: 64% | | style="width: 64%; "|CR THORAX BED (085002BED) | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
| style="background-color: #004080; width: 3%; "| | | style="background-color: #004080; width: 3%; "| | ||
| style="background-color: #BFBFBF; width: 33% | | style="background-color: #BFBFBF; width: 33%; "|<b>Uitvoerder</b> | ||
| style="width: 64% | | style="width: 64%; "|Dr. A | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
| style="background-color: #004080; width: 3%; "| | | style="background-color: #004080; width: 3%; "| | ||
| style="background-color: #BFBFBF; width: 33% | | style="background-color: #BFBFBF; width: 33%; "|<b>Locatie</b> | ||
| style="width: 64% | | style="width: 64%; "|Radiologie | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
| style="background-color: #004080; width: 3%; "| | | style="background-color: #004080; width: 3%; "| | ||
| style="background-color: #BFBFBF; width: 33% | | style="background-color: #BFBFBF; width: 33%; "|<b>Aanvrager</b> | ||
| style="width: 64% | | style="width: 64%; "|Onbekende arts | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
|colspan="3" style="background-color: #004080; width: 100%; color | |colspan="3" style="background-color: #004080; width: 100%; "|<font color=White><b>TekstResultaat</b></font> | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
|colspan="3" style="width: 100% | |colspan="3" style="width: 100%; "|Klinische gegevens: Opname van het respiratoire insufficiëntie bij pneumonie. <BR>Vraagstelling: Afname infiltraat? <BR>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. <BR>Conclusie: Hoge ligging trachea tube. Iets afname van diffuse consolidaties rechter thoraxhelft. Afname stuwingsbeeld. | ||
|} | |} | ||
{|class="wikitable" width="655px" style= "font-size: 9.5pt;" | {|class="wikitable" width="655px" style= "font-size: 9.5pt;" | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
|colspan="2" style="background-color: #004080; width: 36%; color | |colspan="2" style="background-color: #004080; width: 36%; "|<font color=White><b>T</b></font><font color=White><b>ekstUitslagDatumTijd</b></font> | ||
| style="width: 64% | | style="width: 64%; "|15-08-2014 11:00 uur | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
|colspan="2" style="background-color: #004080; width: 36%; color | |colspan="2" style="background-color: #004080; width: 36%; "|<font color=White><b>TekstUitslagType</b></font> | ||
| style="width: 64% | | style="width: 64%; "|Procedure | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
|colspan="2" style="background-color: #004080; width: 36%; color | |colspan="2" style="background-color: #004080; width: 36%; "|<font color=White><b>TekstUitslagStatus</b></font> | ||
| style="width: 64% | | style="width: 64%; "|Definitief | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
|colspan="2" style="background-color: #004080; width: 36%; color | |colspan="2" style="background-color: #004080; width: 36%; "|<font color=White><b>Verrichting</b></font> | ||
| style="width: 64%; "| | | style="width: 64%; "| | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
| style="background-color: #004080; width: 3%; "| | | style="background-color: #004080; width: 3%; "| | ||
| style="background-color: #BFBFBF; width: 33% | | style="background-color: #BFBFBF; width: 33%; "|<b>VerrichtingType</b> | ||
| style="width: 64% | | style="width: 64%; "|Colonoscopie | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
| style="background-color: #004080; width: 3%; "| | | style="background-color: #004080; width: 3%; "| | ||
| style="background-color: #BFBFBF; width: 33% | | style="background-color: #BFBFBF; width: 33%; "|<b>U</b><b>itvoerder</b> | ||
| style="width: 64% | | style="width: 64%; "|Dr. B | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
|colspan="3" style="background-color: #004080; width: 100%; color | |colspan="3" style="background-color: #004080; width: 100%; "|<font color=White><b>TekstResultaat</b></font> | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
|colspan="3" style="width: 100% | |colspan="3" style="width: 100%; "|<b>Indicatie</b><BR>gemetastaseerd NSCLC st IV wv chemotherapie en radiotherapie. Sinds 4 wkn persisterende diarree. radiatie proctitis?<BR><b>Premedicatie: </b>Geen.<BR><BR><b>Verslag</b><BR>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.<BR><b>Anus</b><BR>Hemorrhoiden. Bij RT: geen afwijkingen voelbaar.<BR><b>Darm</b><BR>Het lumen van de dikke darm is normaal van kaliber. Linkszijdige diverticulose.<BR>Het slijmvlies van het gehele colon toont geen afwijking.<BR>Rectum bij inversie wel bekeken, hemorrhoiden.<BR><b>Inzending voor histologie</b><BR>PA I colon ascendens biopten<BR>PA II transversum biopten<BR>PA III sigmoid <BR>PA IV rectum<BR><b>Complicaties</b><BR>Geen. Indien binnen 30 dagen een mogelijke late complicatie wordt waargenomen, verzoek ik u dit aan ons te melden.<BR><b>Conclusie</b><BR>Geen afwijkingen waarneembaar bij coloscopie.<BR><b>Advies</b><BR>Expectatief tav diarree. Het verdere beleid is afhankelijk van de uitslag van het onderzoek door de patholoog-anatoom; <BR><BR><b>Code: 20829</b> | ||
|} | |} | ||
| Regel 419: | Regel 429: | ||
==This information model in other releases== | |||
<ul> | |||
<li>[[TextResultForTransfer-v1.2(2015EN) | Release 2015, (Version 1.2)]]</li> | |||
<li>[[TextResultForTransfer-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> | |||
This information model is also available as [[Media:nl.zorg.TextResult-v4.0( | 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=2.16.840.1.113883.2.4.3.11.60.7.4.2.13.2&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.TextResult-v4.0(2017EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.TextResult-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 13:38:15 <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 13:42
General information
Name: nl.zorg.TextResult 
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 | 14-12-2012 |
| DCM::DeprecatedDate | |
| DCM::DescriptionLanguage | nl |
| DCM::EndorsingAuthority.Address | |
| DCM::EndorsingAuthority.Name | PM |
| DCM::EndorsingAuthority.Telecom | |
| DCM::Id | 2.16.840.1.113883.2.4.3.11.60.40.3.13.2 |
| DCM::KeywordList | laboratorium uitslagen, verslagen |
| DCM::LifecycleStatus | Final |
| DCM::ModelerList | Kerngroep Registratie aan de Bron |
| DCM::Name | nl.zorg.TekstUitslag |
| 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.OverdrachtTekstUitslag-v3.0 |
| 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-76 | OverdrachtTekstUitslag Omschrijving |
| ZIB-130 | Samenvoegen bouwstenen OverdrachtLabuitslag en OverdrachtTekstuitslag tot een bouwsteen. |
| 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. |
| 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. |
| ZIB-322 | Wijziging paragraaf concept |
| ZIB-323 | Wijzing paragraaf Purpose |
| ZIB-370 | ResultaatStatusCodelijst en TekstUitslagCodelijst codes aanpassen |
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-423 | Verkeerd bron-codestelsel gekoppeld aan de 'TestStatusCodelijst'. |
| ZIB-453 | Wijziging naamgeving ZIB's en logo's door andere opzet van beheer |
Publicatieversie 4.0 (04-09-2017)
| ZIB-549 | De Engelse naam van de bouwsteen en het rootconcept zijn niet correct |
| ZIB-576 | Aanpassen bouwstenen die nog de prefix overdracht hebben, zodat de prefix kan vervallen. |
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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 by nature. 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. This information model can be used for these (mainly unstructured) results.
For laboratory test results, it is difficult to clearly indicate exactly when to use this information model and when to use the LaboratoryTestResult 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 LaboratoryTestResult, 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
| Type | Id | Concept | Card. | Definition | DefinitionCode | Reference | |||||||
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NL-CM:13.2.1 |  TextResult
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Root concept of the TextResult information model. This root concept contains all data elements of the TextResult information model. | ||||||||||
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NL-CM:13.2.3 |  TextResultDateTime
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0..1 | Date and if possible time of the result.
Date on which the procedure that TextResult documents, took place. |
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NL-CM:13.2.5 | Procedure
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0..1 | Reference to the Procedure information model including the date of the procedure, requesting and executive specialty. |
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NL-CM:13.2.6 | TextResultStatus
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0..1 | The status of the result. |
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NL-CM:13.2.2 | TextResultReport
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1 | The text report detailing the actual results of the test or procedure. | |||||||||
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NL-CM:13.2.4 | TextResultType
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1 | The type of result. |
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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
| Tekst Uitslag Datum Tijd | 05-12-2014 17:00 uur | |
| Tekst Uitslag Type | Röntgen | |
| Tekst Uitslag Status | Voorlopig | |
| Verrichting | ||
| VerrichtingType | CR THORAX BED (085002BED) | |
| Uitvoerder | Dr. A | |
| Locatie | Radiologie | |
| Aanvrager | Onbekende arts | |
| TekstResultaat | ||
| 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. | ||
| TekstUitslagDatumTijd | 15-08-2014 11:00 uur | |
| TekstUitslagType | Procedure | |
| TekstUitslagStatus | Definitief | |
| Verrichting | ||
| VerrichtingType | Colonoscopie | |
| Uitvoerder | Dr. B | |
| TekstResultaat | ||
| 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
| Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.13.2.2 |
| Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
| Pending | pending | ResultaatStatus | 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 | Uitslag volgt |
| Preliminary | preliminary | ResultaatStatus | 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 | Voorlopig |
| Final | final | ResultaatStatus | 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 | Definitief |
| Appended | appended | ResultaatStatus | 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 | Aanvullend |
| Corrected | corrected | ResultaatStatus | 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 | Gecorrigeerd |
TextResultTypeCodelist
| Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1 |
| Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
| Microbiology | 19851009 | SNOMED CT | 2.16.840.1.113883.6.96 | microbiologie |
| Imaging | 363679005 | SNOMED CT | 2.16.840.1.113883.6.96 | overige beeld vormende techniek |
| X-ray | 363680008 | SNOMED CT | 2.16.840.1.113883.6.96 | röntgen |
| Ultrasound | 16310003 | SNOMED CT | 2.16.840.1.113883.6.96 | echografie |
| CT | 77477000 | SNOMED CT | 2.16.840.1.113883.6.96 | CT |
| MRI | 113091000 | SNOMED CT | 2.16.840.1.113883.6.96 | MRI |
| Angiography | 77343006 | SNOMED CT | 2.16.840.1.113883.6.96 | angiografie |
| Cardiac Echo | 40701008 | SNOMED CT | 2.16.840.1.113883.6.96 | echocardiografie |
| Nuclear Medicine | 371572003 | SNOMED CT | 2.16.840.1.113883.6.96 | nucleaire geneeskunde |
| Pathology | 108257001 | SNOMED CT | 2.16.840.1.113883.6.96 | pathologie |
| Procedure | 71388002 | SNOMED CT | 2.16.840.1.113883.6.96 | procedure |
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 13:38:15