ComfortScale-v1.0(2018EN): verschil tussen versies

Huidige versie van 13 mrt 2019 om 01:52

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.ComfortScale
Version: 1.0
HCIM Status:Final
Release: 2018
Release status: Prepublished
Release date: 26-02-2019

Back to HCIM list

Metadata

DCM::CoderList	Werkgroep RadB Verpleegkundige Gegevens
DCM::ContactInformation.Address	*
DCM::ContactInformation.Name	*
DCM::ContactInformation.Telecom	*
DCM::ContentAuthorList	Werkgroep RadB Verpleegkundige Gegevens
DCM::CreationDate	1-8-2016
DCM::DeprecatedDate
DCM::DescriptionLanguage	nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name	zorg
DCM::EndorsingAuthority.Telecom
DCM::Id	2.16.840.1.113883.2.4.3.11.60.40.3.12.12
DCM::KeywordList	Pijnscore, assessment, comfort, comfortneo
DCM::LifecycleStatus	Final
DCM::ModelerList	Werkgroep RadB Verpleegkundige Gegevens
DCM::Name	nl.zorg.ComfortScore
DCM::PublicationDate	26-02-2019
DCM::PublicationStatus	Prepublished
DCM::ReviewerList	Projectgroep RadB Verpleegkundige Gegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate	31-12-2017
DCM::Superseeds
DCM::Version	1.0
HCIM::PublicationLanguage	EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (04-09-2017).

Concept

The Comfort Behaviour scale /Comfortneo scale is an assessment tool, that is used to assess the pain behaviour of neonates (new born).
The Comfort Behaviour scale has 7 observation points that that need to be addressed. For each on observation is value is assigned from a 5-point scale, the final score indicates whether the observed child suffers pain and 'how much'. The score is combined with an NRS score that is completed by the nurses on basis of clinical experience.

Purpose

> A pain observation instrument is a tool in determining the intensity of pain and can be useful in order to determine the effectiveness of pain treatment interventions (pharmacological or non-pharmacological). For new born it is nevertheless difficult to differentiate between pain or distress/anxiety. This is relevant in determining the treatment. The score on a pain measurement instrument remains a snapshot in time.

Evidence Base

For determining the degree of pain in children with difficulty expressing themselves there are divers pain observation instruments available

CPB
Comfort behaviour scale/ Comfortneo scale
Flacc

Patient Population

The COMFORT assessment scale is validated for young children up to the age of 4.
The COMFORT and COMFORTneo assessment score is validated for preterm neonates

Information Model

Type

Id

Concept

Card.

Definition

DefinitionCode

Reference

NL-CM:12.12.1

ComfortScale

Rootconcept of the ComfortScale information model. This root concept contains all data elements of the ComfortScale information model.

NL-CM:12.12.2

TotalScore

0..1

The total score is the sum of all the individual scores. The total score has a range from 0 - 35.

NL-CM:12.12.3

Alertness

0..1

Observation of: Alertness

AlertnessCodelist

NL-CM:12.12.4

Calmness_Agitation

0..1

Observation: Calmness/ agitation

Calmness_AgitationCodelist

NL-CM:12.12.5

RespiratoryResponse

0..1

Observation Respiratory response (only in mechanically ventilated children)

RespiratoryResponseCodelist

NL-CM:12.12.6

Crying

0..1

Observation Crying (only in spontaneously breathing children)

CryingCodelist

NL-CM:12.12.8

BodyMovement

0..1

Observation Physical movement

BodyMovementCodelist

NL-CM:12.12.9

FacialTone

0..1

Observation Facial tension

FacialToneCodelist

NL-CM:12.12.10

BodyMuscleTone

0..1

Observation Muscle tone

BodyMuscleToneCodelist

NL-CM:12.12.11

ScoreDateTime

1

The date and time at which the Comfort Behaviour scale/ComfortNeo scale was determined.

NL-CM:12.12.12

Comment

0..1

A comment on the circumstances during the measurement.

48767-8 Annotation comment [Interpretation] Narrative

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

ComfortScore
ScoreDatumTijd	21-12-2016 12:05
Alertheid	4 (wakker en alert)
Kalmte_Agitatie	2 (licht angstig)
Huilen	2 (af en toe snikken of kreunen)
Lichaamsbeweging	2 (incidentele beweging)
Gezichtsspanning	2 (normale spanning van het gelaat)
Spierspanning	2 (verminderde spierspanning)
Totaalscore	14
Toelichting	Controle na verhogen pijnmedicatie.

ComfortNeoScore
ScoreDatumTijd	21-12-2016 12:05
Alertheid	4 (wakker en alert)
Kalmte_Agitatie	2 (licht angstig)
Ademhalingsreactie	3 (af en toe hoesten of verzet tegen de ventilator)
Lichaamsbeweging	2 (incidentele beweging)
Gezichtsspanning	2 (normale spanning van het gelaat)
Spierspanning	2 (verminderde spierspanning)
Totaalscore	15
Toelichting	Controle na verhogen pijnmedicatie.

Instructions

In the ComfortNeo scale the item crying is replaced by respiratory reaction.
In the Comfort scale the item respiratory reaction is replaced by crying.

References

1. Comfort assessment [Online] Beschikbaar op:http://www.comfortassessment.nl/ [Geraadpleegd: 2 augustus 2016] 2. Richtlijn Pijnmeting en Behandeling van pijn bij kinderen, NVK, 2007 [Online] Beschikbaar op:https://www.nvk.nl/Kwaliteit/Richtlijnenoverzicht/Details/tabid/1558/articleType/ArticleView/articleId/760/Pijn-meting-en-behandeling-van.aspx [Geraadpleegd: 21 december 2016]

Valuesets

AlertnessCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.1	Binding: Required

Conceptname	Conceptcode	Conceptvalue	Codesystem name	Codesystem OID	Description
Deeply asleep	Alert1	1	CN_Alertheid	2.16.840.1.113883.2.4.3.11.60.40.4.20.1	Diep in slaap (ogen dicht, geen reactie op omgeving)
Lightly asleep	Alert2	2	CN_Alertheid	2.16.840.1.113883.2.4.3.11.60.40.4.20.1	Licht in slaap (ogen grotendeels gesloten, af en toe reactie)
Drowsy	Alert3	3	CN_Alertheid	2.16.840.1.113883.2.4.3.11.60.40.4.20.1	Slaperig (kind sluit vaak zijn ogen, reageert minder op omgeving)
Awake and alert	Alert4	4	CN_Alertheid	2.16.840.1.113883.2.4.3.11.60.40.4.20.1	Wakker en alert (kind reageert op omgeving)
Awake and hyperalert	Alert5	5	CN_Alertheid	2.16.840.1.113883.2.4.3.11.60.40.4.20.1	Wakker en hyper-alert (overdreven reactie op veranderingen)

BodyMovementCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.5	Binding: Required

Conceptname	Conceptcode	Conceptvalue	Codesystem name	Codesystem OID	Description
No movement	Mov1	1	CN_Lichaamsbeweging	2.16.840.1.113883.2.4.3.11.60.40.4.20.5	Geen beweging
Occasional, slight movements	Mov2	2	CN_Lichaamsbeweging	2.16.840.1.113883.2.4.3.11.60.40.4.20.5	Incidentele (3 of minder) kleine bewegingen
Frequent, slight movements	Mov3	3	CN_Lichaamsbeweging	2.16.840.1.113883.2.4.3.11.60.40.4.20.5	Frequente (3 of meer) kleine bewegingen
Vigorous movements limited to extremities	Mov4	4	CN_Lichaamsbeweging	2.16.840.1.113883.2.4.3.11.60.40.4.20.5	Heftige bewegingen met armen en benen
Vigorous movements including torso and head	Mov5	5	CN_Lichaamsbeweging	2.16.840.1.113883.2.4.3.11.60.40.4.20.5	Heftige bewegingen ook met romp en hoofd

BodyMuscleToneCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.7	Binding: Required

Conceptname	Conceptcode	Conceptvalue	Codesystem name	Codesystem OID	Description
Muscles fully relaxed	Musc1	1	CN_Spierspanning	2.16.840.1.113883.2.4.3.11.60.40.4.20.7	Spieren volledig ontspannen; geen spierspanning
Reduced muscle tone	Musc2	2	CN_Spierspanning	2.16.840.1.113883.2.4.3.11.60.40.4.20.7	Verminderde spierspanning; minder weerstand dan normaal
Normal muscle tone	Musc3	3	CN_Spierspanning	2.16.840.1.113883.2.4.3.11.60.40.4.20.7	Normale spierspanning
Increased muscle tone	Musc4	4	CN_Spierspanning	2.16.840.1.113883.2.4.3.11.60.40.4.20.7	Toegenomen spierspanning en buiging van vingers en tenen
Extreme muscle rigidity	Musc5	5	CN_Spierspanning	2.16.840.1.113883.2.4.3.11.60.40.4.20.7	Extreme spierstijfheid en buiging van vingers en tenen

Calmness_AgitationCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.2	Binding: Required

Conceptname	Conceptcode	Conceptvalue	Codesystem name	Codesystem OID	Description
Calm	Calm1	1	CN_Kalmte_Agitatie	2.16.840.1.113883.2.4.3.11.60.40.4.20.2	Kalm (kind helder en rustig)
Slightly anxious	Calm2	2	CN_Kalmte_Agitatie	2.16.840.1.113883.2.4.3.11.60.40.4.20.2	Licht angstig (kind toont lichte onrust)
Anxious	Calm3	3	CN_Kalmte_Agitatie	2.16.840.1.113883.2.4.3.11.60.40.4.20.2	Angstig (kind lijkt onrustig, kan zich beheersen)
Very anxious	Calm4	4	CN_Kalmte_Agitatie	2.16.840.1.113883.2.4.3.11.60.40.4.20.2	Zeer angstig (kind lijkt zeer onrustig, kan zich nog net beheersen)
Panicky	Calm5	5	CN_Kalmte_Agitatie	2.16.840.1.113883.2.4.3.11.60.40.4.20.2	Paniekerig (ernstige onrust met verlies van beheersing)

CryingCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.4	Binding: Required

Conceptname	Conceptcode	Conceptvalue	Codesystem name	Codesystem OID	Description
Quiet breathing	Cry1	1	CN_Huilen	2.16.840.1.113883.2.4.3.11.60.40.4.20.4	Geen huilgeluiden
Occasional sobbing or moaning	Cry2	2	CN_Huilen	2.16.840.1.113883.2.4.3.11.60.40.4.20.4	Af en toe snikken of kreunen (nasnikken)
Whining	Cry3	3	CN_Huilen	2.16.840.1.113883.2.4.3.11.60.40.4.20.4	Jengelen of dreinen (monotoon geluid)
Crying	Cry4	4	CN_Huilen	2.16.840.1.113883.2.4.3.11.60.40.4.20.4	Huilen
Screaming or shrieking	Cry5	5	CN_Huilen	2.16.840.1.113883.2.4.3.11.60.40.4.20.4	Schreeuwen of krijsen

FacialToneCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.6	Binding: Required

Conceptname	Conceptcode	Conceptvalue	Codesystem name	Codesystem OID	Description
Facial muscles totally relaxed	Face1	1	CN_Gezichtsspanning	2.16.840.1.113883.2.4.3.11.60.40.4.20.6	Gezichtsspieren volkomen ontspannen
Normal facial tone	Face2	2	CN_Gezichtsspanning	2.16.840.1.113883.2.4.3.11.60.40.4.20.6	Normale spanning van het gezicht
Tension evident in some facial muscles	Face3	3	CN_Gezichtsspanning	2.16.840.1.113883.2.4.3.11.60.40.4.20.6	Spanning duidelijk in sommige gelaatsspieren (niet aanhoudend)
Tension evident throughout facial muscles	Face4	4	CN_Gezichtsspanning	2.16.840.1.113883.2.4.3.11.60.40.4.20.6	Spanning duidelijk in alle gelaatsspieren (aanhoudend)
Facial muscles contorted and grimacing	Face5	5	CN_Gezichtsspanning	2.16.840.1.113883.2.4.3.11.60.40.4.20.6	Gezichtsspieren verwrongen en in een grimas

RespiratoryResponseCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.3	Binding: Required

Conceptname	Conceptcode	Conceptvalue	Codesystem name	Codesystem OID	Description
No spontaneous respiration	Vent1	1	CN_Ademhalingsreactie	2.16.840.1.113883.2.4.3.11.60.40.4.20.3	Geen spontane ademhaling
Spontaneous respiration on ventilator	Vent2	2	CN_Ademhalingsreactie	2.16.840.1.113883.2.4.3.11.60.40.4.20.3	Spontane ademhaling aan de beademing
Unrest or resistance to ventilator	Vent3	3	CN_Ademhalingsreactie	2.16.840.1.113883.2.4.3.11.60.40.4.20.3	Onrust of verzet tegen de beademing
Actively breathes against ventilator or coughs regularly	Vent4	4	CN_Ademhalingsreactie	2.16.840.1.113883.2.4.3.11.60.40.4.20.3	Ademt actief tegen de beademing in of hoest regelmatig
Fights ventilator	Vent5	5	CN_Ademhalingsreactie	2.16.840.1.113883.2.4.3.11.60.40.4.20.3	Vecht tegen de beademing

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 2018-2
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 12/03/2019 17:16:13 with ZibExtraction v. 3.0.7010.25883

Back to HCIM list

@@ Regel 8: / Regel 8: @@
 Release<!--hdPublication-->: '''2018''' <br>
 Release status<!--hdPublicationStatus-->: Prepublished<br>
-Release date<!--hdPublicationDate-->: 01-10-2018
+Release date<!--hdPublicationDate-->: 26-02-2019
 -----
 <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>
@@ Regel 47: / Regel 47: @@
 |style="width:250px; "|DCM::Name||nl.zorg.ComfortScore
 |-
-|style="width:250px; "|DCM::PublicationDate||01-10-2018
+|style="width:250px; "|DCM::PublicationDate||26-02-2019
 |-
 |style="width:250px; "|DCM::PublicationStatus||Prepublished
@@ Regel 90: / Regel 90: @@
 ==Information Model==
 <BR>
-<imagemap> Bestand:ComfortScale-v1.0Model(EN).png | center
+<imagemap> Bestand:ComfortScale-v1.0Model(2018EN).png | center
-rect 607 67 726 137 [[#11394]]
+rect 617 91 736 161 [[#11394]]
-rect 607 465 775 515 [[#BodyMovementCodelist]]
+rect 617 489 785 539 [[#BodyMovementCodelist]]
-rect 232 166 352 236 [[#11406]]
+rect 242 190 362 260 [[#11406]]
-rect 232 266 352 336 [[#11407]]
+rect 242 290 362 360 [[#11407]]
-rect 416 35 534 137 [[#11401]]
+rect 426 59 544 161 [[#11401]]
-rect 415 465 535 515 [[#CryingCodelist]]
+rect 425 489 545 539 [[#CryingCodelist]]
-rect 233 67 352 137 [[#11399]]
+rect 243 91 362 161 [[#11399]]
-rect 415 203 535 283 [[#11402]]
+rect 425 227 545 307 [[#11402]]
-rect 232 367 352 437 [[#11408]]
+rect 242 391 362 461 [[#11408]]
-rect 415 368 535 438 [[#11409]]
+rect 425 392 545 462 [[#11409]]
-rect 607 367 727 437 [[#11410]]
+rect 617 391 737 461 [[#11410]]
-rect 607 267 727 337 [[#11411]]
+rect 617 291 737 361 [[#11411]]
-rect 607 167 727 237 [[#11412]]
+rect 617 191 737 261 [[#11412]]
-rect 65 177 181 227 [[#AlertnessCodelist]]
+rect 75 201 191 251 [[#AlertnessCodelist]]
-rect 25 277 180 327 [[#Calmness_AgitationCodelist]]
+rect 35 301 190 351 [[#Calmness_AgitationCodelist]]
-rect 182 465 352 515 [[#RespiratoryResponseCodelist]]
+rect 192 489 362 539 [[#RespiratoryResponseCodelist]]
-rect 772 177 915 227 [[#BodyMuscleToneCodelist]]
+rect 782 201 925 251 [[#BodyMuscleToneCodelist]]
-rect 772 277 926 327 [[#FacialToneCodelist]]
+rect 782 301 936 351 [[#FacialToneCodelist]]
 desc none
 </imagemap>
@@ Regel 567: / Regel 567: @@
 |CN_Huilen
 |2.16.840.1.113883.2.4.3.11.60.40.4.20.4
-|Schreewen of krijsen
+|Schreeuwen of krijsen
 |}
 === FacialToneCodelist===
@@ Regel 675: / Regel 675: @@
 ====This information model refers to<!--ftRefersTo-->====
 :--
-====This inforation model is used in<!--ftReferredBy-->====
+====This information model is used in<!--ftReferredBy-->====
 :--
 ==Technical specifications in HL7v3 CDA and HL7 FHIR<!--ftHeader-->==
@@ Regel 681: / Regel 681: @@
 Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:<!--ftReferenceIntro-->
 <ul>
-<li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment<!--ftArtDecorReference--> [http://decor.nictiz.nl/art-decor/decor-scenarios--zib2018bbr-?id=2.16.840.1.113883.2.4.3.11.60.8.4.2.12.12&effectiveDate=2018-10-01T00:00:00&language=en-US&scenariotree=false [[File:artdecor.jpg|16px|link=]]]</li>
+<li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment<!--ftArtDecorReference--> [http://decor.nictiz.nl/art-decor/decor-scenarios--zib2018bbr-?id=2.16.840.1.113883.2.4.3.11.60.8.4.2.12.12&effectiveDate=2019-02-26T00:00:00&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<!--ftSimplifierReference--> {{SimplefierLinks|2018}}</li>
 </ul>
@@ Regel 687: / Regel 687: @@
 This information model is also available as [[Media:nl.zorg.ComfortScale-v1.0(2018EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.ComfortScale-v1.0(2018EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]]<!--ftDownloads-->
 ==About this information<!--ftHeader2-->==
-The information in this wikipage is based on<!--ftInfoBase--> Prerelease 2018 #1 <BR>
+The information in this wikipage is based on<!--ftInfoBase--> Prerelease 2018-2 <BR>
 SNOMED CT and LOINC codes are based on:
 <ul>
@@ Regel 694: / Regel 694: @@
 </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 22:21:20 with ZibExtraction v. 2.0.6879.31307<!--ftDate--> <BR>
+This page is generated on 12/03/2019 17:16:13 with ZibExtraction v. 3.0.7010.25883<!--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>

ComfortScale-v1.0(2018EN): verschil tussen versies

Huidige versie van 13 mrt 2019 om 01:52

Inhoud

General information

Metadata

Revision History

Concept

Purpose

Evidence Base

Patient Population

Information Model

Example Instances

Instructions

References