ConcernForTransfer-v1.2(2015EN)

General information

Name: nl.nfu.ConcernForTransfer
Version: 1.2
HCIM Status:Final
Release: 2015
Release status: Published
Release date: 1-4-2015

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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	NFU
DCM::EndorsingAuthority.Telecom
DCM::Id	2.16.840.1.113883.2.4.3.11.60.40.3.5.1
DCM::KeywordList	problemen, klachten, diagnosen, episode
DCM::LifecycleStatus	Final
DCM::ModelerList	Kerngroep Registratie aan de Bron
DCM::Name	nl.nfu.OverdrachtConcern
DCM::PublicationDate	1-4-2015
DCM::PublicationStatus	Published
DCM::ReviewerList	Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate	1-4-2015
DCM::Superseeds
DCM::Version	1.2
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

Concept

Determining relevant health issues of the patient involves two important aspects: observing the problem itself on the one hand (complaints, symptoms, diagnosis, etc.) and evaluation of whether or not an active policy is required on the other. This evaluation by the healthcare provider is documented in the ‘Concern’, the point of attention. Multiple, linked Problems can be subsumed under a single Concern.
The difference between recorded problems and the attention they require enables an indication of which issues medical or nursing policy applies to, or in which issues policy is necessary. An example is well-managed diabetes; this requires no active policy of the healthcare provider.

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 finding: a healthcare provider’s observation of a patient’s health. Examples: enlarged liver, pathological plantar reflex, deviating Minimal Mental State, missing teeth.
• A condition: a description of a (deviating) bodily state, which may or may not be seen as a disease. Examples: pregnancy, circulatory disorder, poisoning.
• 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.
• A problem: any circumstance that is relevant to the medical treatment, but does not fit into one of the categories listed. Examples: Patient resides in the Netherlands without a legal status and is not insured; patient is not able to check their own blood sugar levels.

In first-line care the Episode concept fills the role of Concern.

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.

Evidence Base

The working group has decided to only use the values 'Current', 'Non-current' and 'Under control' for the ProblemStatus concept. The other CCR/CCD attributes are at another level and cannot be used instead of Current or Non-current.

CCD concept HealthStatus:
It was decided not to document the patient’s condition with the problem, as it is more generic patient information.

Information Model

Type	Id	Concept						Card.	Definition	DefinitionCode	Reference
	NL-CM:5.1.1	Concern							Root concept of the ConcernTransfer building block. This root concept contains all data elements of the ConcernTransfer building block.
	NL-CM:5.1.9		ConcernLabel					0..1	If needed, a short, written description of the concern. Mainly in first-line care this will be used for the episode name.
	NL-CM:5.1.2		Problem					1..*	Container of the Problem concept. This container contains all data elements of the Problem 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).
	NL-CM:5.1.8			ProblemType				0..1	The type of problem; see the concept description.		ProblemTypeCodelist
	NL-CM:5.1.3			ProblemName				1	The problem name defines the problem. Depending on the setting, one or more of the code systems below can be used: Structured terms: SNOMED CT Medical diagnoses: national DHD list Nurse diagnoses: NANDA Paramedic diagnoses: DHD and NANDA (partially offer solutions for this) For functional constraints: ICF For first-line care: ICPC-1 NL		ProblemNameCodelist
	NL-CM:5.1.6			ProblemStartDate				0..1	Start 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.
	NL-CM:5.1.4			ProblemStatus				1	The problem status describes the condition of the problem: Current problems are the focus of the current medical policy. Non-current (historic) problems are part of the case history. Problems with the status 'Under control' refer to problems that still exist, but which currently do not require specific medical policy (such as well-managed diabetes).		ProblemStatusCodelist
	NL-CM:5.1.7			ProblemStatusDate				1	Date from when the current value of the ProblemStatus applies: since when is the problem current, under control or non-current.
	NL-CM:5.1.5			Explanation				0..1	Explanation by the one who determined or updated the Problem.	48767-8 Annotation comment

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

Concern
Probleem
ProbleemType	ProbleemNaam	Probleem BeginDatum	ProbleemStatus	Probleem StatusDatum	Toelichting
Bevinding	Oedeem	10-08-2012	Actueel	20-10-2012	Geleidelijk in de loop van dagen erger geworden. Geen roodheid of pijn.
Diagnose	Nefrotisch syndroom	11-2012	Actueel	15-11-2012	Membraneuze glomerulopathie.

Concern
Probleem
ProbleemType	ProbleemNaam	Probleem BeginDatum	ProbleemStatus	Probleem StatusDatum	Toelichting
Diagnose	Anteroseptaal myocardinfarct	24-05-1998	Niet actueel	11-06-1998	Coronarialijden als complicatie diabetes.
Diagnose	Hartfalen		Actueel	20-11-2012	Opnieuw actief geworden.
Klacht	Kortademigheid	15-11-2012	Onder controle	20-11-2012
Diagnose	Diabetes mellitus type II	1996	Onder controle	10-09-2012

Concern
Probleem
ProbleemType	ProbleemNaam	Probleem BeginDatum	ProbleemStatus	Probleem StatusDatum	Toelichting
Diagnose	Polsfractuur links	20-04-2011	Niet actueel	07-06-2011	Gevallen op kunstijsbaan.

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	ICPC-1 NL	2.16.840.1.113883.2.4.4.31.1
<<404684003 |Clinical Finding|	SNOMED CT	2.16.840.1.113883.6.96
Alle waarden	NANDA	2.16.840.1.113883.6.20
Alle waarden	ICF	2.16.840.1.113883.6.254
Alle waarden	ICD-10	2.16.840.1.113883.6.90
Alle waarden	G-Standaard Contra Indicaties (Tabel 40)	2.16.840.1.113883.2.4.4.1.902.40
Alle waarden	Diagnosethesaurus DHD	9999

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
Resolved	413322009	SNOMED CT	2.16.840.1.113883.6.96	Onder controle

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
Problem	55607006	SNOMED CT	2.16.840.1.113883.6.96	Probleem
Condition	64572001	SNOMED CT	2.16.840.1.113883.6.96	Conditie
Diagnosis	282291009	SNOMED CT	2.16.840.1.113883.6.96	Diagnose
Symptom	418799008	SNOMED CT	2.16.840.1.113883.6.96	Symptoom
Finding	404684003	SNOMED CT	2.16.840.1.113883.6.96	Bevinding
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

This information model in other releases

• Release 2016, (Version 3.0)
• Release 2017, (Version 4.1)

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 Registratie aan de bron publication 2015 including errata dd. 16-07-2015
Conditions for use are located on the mainpage
This page is generated on 24/01/2018 17:13:22

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