EncounterReport-v1.0(2022EN): verschil tussen versies

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(2 tussenliggende versies door dezelfde gebruiker niet weergegeven)
Regel 8: Regel 8:
Release<!--hdPublication-->: '''2022''' <br>
Release<!--hdPublication-->: '''2022''' <br>
Release status<!--hdPublicationStatus-->: Prepublished<br>
Release status<!--hdPublicationStatus-->: Prepublished<br>
Release date<!--hdPublicationDate-->: 10-06-2022
Release date<!--hdPublicationDate-->: 15-10-2023
<!-- Aanroep Errata transclude page -->
<!-- Aanroep Errata transclude page -->
{{ErrataEN<!--hdErrata-->|2022|{{PAGENAME}}}}
{{ErrataEN<!--hdErrata-->|2022|{{PAGENAME}}}}
Regel 50: Regel 50:
|style="width:250px; "|DCM::Name||nl.zorg.ContactVerslag
|style="width:250px; "|DCM::Name||nl.zorg.ContactVerslag
|-  
|-  
|style="width:250px; "|DCM::PublicationDate||10-06-2022
|style="width:250px; "|DCM::PublicationDate||15-10-2023
|-  
|-  
|style="width:250px; "|DCM::PublicationStatus||Prepublished
|style="width:250px; "|DCM::PublicationStatus||Prepublished
Regel 81: Regel 81:
<BR>
<BR>
<imagemap> Bestand:EncounterReport-v1.0Model(2022EN).png | center  
<imagemap> Bestand:EncounterReport-v1.0Model(2022EN).png | center  
rect 496 151 586 221 [[#15092]]
rect 496 151 586 221 [[#2555]]
rect 184 151 274 221 [[Encounter-v5.0(2022EN)]]
rect 184 151 274 221 [[Encounter-v5.0(2022EN)]]
rect 327 267 417 337 [[HealthProfessional-v3.5.2(2022EN)]]
rect 327 267 417 337 [[HealthProfessional-v3.5.2(2022EN)]]
rect 318 43 429 113 [[#15090]]
rect 318 43 429 113 [[#2577]]
rect 328 151 418 221 [[#15089]]
rect 328 151 418 221 [[#2576]]
desc none
desc none
</imagemap>
</imagemap>
Regel 95: Regel 95:
|style = "text-align:center" |[[Bestand: block.png| 20px | link=]]
|style = "text-align:center" |[[Bestand: block.png| 20px | link=]]
||NL-CM:15.3.1
||NL-CM:15.3.1
|colspan ="6" style ="padding-left: 0px"|<span Id=15089 Title="NL: ContactVerslag">[[Bestand: arrowdown.png | 10px | link=]]EncounterReport</span>
|colspan ="6" style ="padding-left: 0px"|<span Id=2576 Title="NL: ContactVerslag">[[Bestand: arrowdown.png | 10px | link=]]EncounterReport</span>
|
|
|Root concept of the EncounterReport information model.This root concept contains all data elements of the EncounterReport information model.
|Root concept of the EncounterReport information model.This root concept contains all data elements of the EncounterReport information model.
Regel 101: Regel 101:
{|
{|
|-
|-
|<span title = "Codesystem: SNOMED CT; Patiëntcontactverslag (record artifact)" >[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=11591000146107 11591000146107] Patient encounter report</span>
|<span title = "Codesystem: SNOMED CT; Pati&#235;ntcontactverslag (record artifact)" >[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=11591000146107 11591000146107] Patient encounter report</span>
|}
|}
|
|
Regel 108: Regel 108:
||NL-CM:15.3.2
||NL-CM:15.3.2
|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 Id=15093 Title="NL: Auteur::Zorgverlener">[[Bestand: arrowright.png | 10px | link=]]Author::HealthProfessional</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=2556 Title="NL: Auteur::Zorgverlener">[[Bestand: arrowright.png | 10px | link=]]Author::HealthProfessional</span>
|1
|1
|The healthcare provider who prepared the report and who is responsible for its content.
|The healthcare provider who prepared the report and who is responsible for its content.
Regel 121: Regel 121:
||NL-CM:15.3.3
||NL-CM:15.3.3
|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 Id=15094 Title="NL: Contact">[[Bestand: arrowright.png | 10px | link=]]Encounter</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=2557 Title="NL: Contact">[[Bestand: arrowright.png | 10px | link=]]Encounter</span>
|1
|1
|The encounter the report is about.
|The encounter the report is about.
Regel 127: Regel 127:
{|
{|
|-
|-
|<span title = "Codesystem: SNOMED CT; Patiëntcontact (procedure)" >[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=308335008 308335008] Patient encounter procedure</span>
|<span title = "Codesystem: SNOMED CT; Pati&#235;ntcontact (procedure)" >[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=308335008 308335008] Patient encounter procedure</span>
|}
|}
|
|
Regel 138: Regel 138:
||NL-CM:15.3.4
||NL-CM:15.3.4
|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 Id=15090 Title="NL: ContactVerslagDatumTijd">[[Bestand: arrowright.png | 10px | link=]]EncounterReportDateTime</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=2577 Title="NL: ContactVerslagDatumTijd">[[Bestand: arrowright.png | 10px | link=]]EncounterReportDateTime</span>
|1
|1
|Date and, if applicable, the time the report was made.
|Date and, if applicable, the time the report was made.
Regel 147: Regel 147:
||NL-CM:15.3.5
||NL-CM:15.3.5
|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 Id=15092 Title="NL: ContactVerslagTekst">[[Bestand: arrowright.png | 10px | link=]]EncounterReportText</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=2555 Title="NL: ContactVerslagTekst">[[Bestand: arrowright.png | 10px | link=]]EncounterReportText</span>
|1
|1
|The actual content of the contact as free text.
|The actual content of the contact as free text.
Regel 163: Regel 163:
''Only available in Dutch<!--noTranslation-->''
''Only available in Dutch<!--noTranslation-->''


{|class="wikitable" width="590px" style= "font-size: 9.5pt;"
Voorbeeld file fout: Unable to find the specified file. : nl.zorg.ContactVerslag-v1.0(NL)_Voorbeeld.docx
|-style=vertical-align:top;
|colspan="2" style="background-color: #1F497D; width: 100%; "|<font color=#FFFFFF><b>ContactVerslag</b></font>
|-style=vertical-align:top;
| style="width: 30%; "|ContactVerslagDatumTijd
| style="width: 70%; "|21-11-2020
|-style=vertical-align:top;
|colspan="2" style="background-color: #BFBFBF; width: 100%; "|Auteur
|-style=vertical-align:top;
| style="width: 30%; "|Medewerkerscode
| style="width: 70%; "|01299
|-style=vertical-align:top;
| style="width: 30%; "|AGBCode
| style="width: 70%; "|01999999
|-style=vertical-align:top;
| style="width: 30%; "|Initialen
| style="width: 70%; "|G.L.
|-style=vertical-align:top;
| style="width: 30%; "|Geslachtsnaam
| style="width: 70%; "|Klaassen
|-style=vertical-align:top;
| style="width: 30%; "|ZorgverlenersRol
| style="width: 70%; "|Psychiater
|-style=vertical-align:top;
|colspan="2" style="background-color: #4F81BD; width: 100%; "|
|-style=vertical-align:top;
| style="width: 30%; "|ContactVerslagTekst
| style="width: 70%; "|Goed verzorgde man, normaal contact, wanhopige klachtenpresentatie, onrustige motoriek (grimasseren, oor vastgrijpen). Bewustzijn helder, oriëntatie intact, geheugen en zelfwaarneming ongestoord, bovengemiddeld intelligent, geen psychotische kenmerken, denken normaal van tempo en vorm, inhoudelijk preoccupatie met oorsuizen, stemming somber (er kan een lachje af), rationaliseren, isoleren van het affect, niet actief suïcidaal.
|}
 
==This information model in other releases<!--ftOtherReleases-->==
==This information model in other releases<!--ftOtherReleases-->==
<!-- Hieronder wordt een transclude page aangeroepen -->
<!-- Hieronder wordt een transclude page aangeroepen -->
Regel 204: Regel 175:
:--
:--
==Technical specifications in HL7v3 CDA and HL7 FHIR<!--ftHeader-->==
==Technical specifications in HL7v3 CDA and HL7 FHIR<!--ftHeader-->==
To exchange information based on health and care information models, additional, more technical specifications are required.<BR>
To exchange information based on health and care information models, additional, more technical specifications are required.&lt;BR&gt;
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:<!--ftReferenceIntro-->
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:<!--ftReferenceIntro-->
<ul>
<ul>
<li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment<!--ftArtDecorReference--> {{ArtDecorLinks|2022|15.3}}</li>
<li>HL7&#174; version 3 CDA compatible specifications, available through the Nictiz ART-DECOR&#174; environment<!--ftArtDecorReference--> {{ArtDecorLinks|2022|15.3}}</li>
<li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR<!--ftSimplifierReference--> {{SimplefierLinks|2022}}</li>
<li>HL7&#174; FHIR&#174; compatible specifications, available through the Nictiz environment on the Simplifier FHIR<!--ftSimplifierReference--> {{SimplefierLinks|2022|ContactVerslag}}</li>
</ul>
</ul>
==Downloads<!--ftDownloadTitle-->==
==Downloads<!--ftDownloadTitle-->==
Regel 216: Regel 187:
SNOMED CT and LOINC codes are based on:
SNOMED CT and LOINC codes are based on:
<ul>
<ul>
<li>SNOMED Clinical Terms version: 20220131 [R] (January 2022 Release)</li>
<li>SNOMED Clinical Terms versie: 20230930 [R] (september 2023-editie)</li>
<li>LOINC version 2.67</li>
<li>LOINC version 2.76</li>
</ul>
</ul>
Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR>
Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR>
This page is generated on 10/06/2022 12:40:07 with ZibExtraction v. 8.0.8196.20371<!--ftDate--> <BR>
This page is generated on 27/03/2024 11:09:08 with ZibExtraction v. 9.3.8851.20230<!--ftDate--> <BR>
-----
-----
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2022(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2022(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div>
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2022(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2022(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div>

Huidige versie van 27 mrt 2024 om 11:24


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.EncounterReport NL.png
Version: 1.0
HCIM Status:Final
Release: 2022
Release status: Prepublished
Release date: 15-10-2023

Back 16.png Back to HCIM list

Metadata

DCM::CoderList Projectgroep VIPP GGZ
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList Projectgroep VIPP GGZ
DCM::CreationDate 30-3-2022
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name *
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.15.3
DCM::KeywordList
DCM::LifecycleStatus Final
DCM::ModelerList Projectgroep VIPP GGZ
DCM::Name nl.zorg.ContactVerslag
DCM::PublicationDate 15-10-2023
DCM::PublicationStatus Prepublished
DCM::ReviewerList
DCM::RevisionDate
DCM::Supersedes *
DCM::Version 1.0
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (10-06-2022).

Concept

The contact report is a textual report of a (partial) consult between the care provider and the patient.

Purpose

A contact report offers a care provider the possibility to record information in a structured manner in free text about a contact with a patient.

Information Model


#2555Encounter-v5.0(2022EN)HealthProfessional-v3.5.2(2022EN)#2577#2576EncounterReport-v1.0Model(2022EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:15.3.1 Arrowdown.pngEncounterReport Root concept of the EncounterReport information model.This root concept contains all data elements of the EncounterReport information model.
11591000146107 Patient encounter report
Verwijzing.png NL-CM:15.3.2 Arrowright.pngAuthor::HealthProfessional 1 The healthcare provider who prepared the report and who is responsible for its content.
Block.png HealthProfessional
Verwijzing.png NL-CM:15.3.3 Arrowright.pngEncounter 1 The encounter the report is about.
308335008 Patient encounter procedure
Block.png Encounter
TS.png NL-CM:15.3.4 Arrowright.pngEncounterReportDateTime 1 Date and, if applicable, the time the report was made.
ST.png NL-CM:15.3.5 Arrowright.pngEncounterReportText 1 The actual content of the contact as free text.
422813005 Document section

Columns Concept and DefinitionCode: hover over the values for more information
For explanation of the symbols, please see the legend page List2.png

Example Instances

Only available in Dutch

Voorbeeld file fout: Unable to find the specified file. : nl.zorg.ContactVerslag-v1.0(NL)_Voorbeeld.docx

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.<BR> 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 Artdecor.jpg
  • HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR Fhir.png

Downloads

This information model is also available as pdf file PDF.png or as spreadsheet Xlsx.png

About this information

The information in this wikipage is based on Pre-release 2022-1
SNOMED CT and LOINC codes are based on:

  • SNOMED Clinical Terms versie: 20230930 [R] (september 2023-editie)
  • LOINC version 2.76

Conditions for use are located on the mainpage List2.png
This page is generated on 27/03/2024 11:09:08 with ZibExtraction v. 9.3.8851.20230

Back 16.png Back to HCIM list
Overgenomen van "https://zibs.test-nictiz.nl/index.php?title=EncounterReport-v1.0(2022EN)&oldid=27843"