TextResult-v4.1(2017EN): verschil tussen versies

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(2 tussenliggende versies door dezelfde gebruiker niet weergegeven)
Regel 1: Regel 1:
==General information==
<!-- Hieronder wordt een transclude page aangeroepen -->
Name: '''nl.zorg.TextResult''' [[Bestand:NL.png|link=TekstUitslag-v4.1(2017NL)]]<BR>
{{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.13.2(EN)|1|TextResult-v4.1(2017EN)}}
Version: '''4.1''' <br>
<!-- Tot hier de transclude page -->
HCIM Status:Final<br>
==General information<!--hdGeneralInformation-->==
Release: '''2017''' <br>
Name<!--hdName-->: '''nl.zorg.TextResult''' [[Bestand:NL.png|link=TekstUitslag-v4.1(2017NL)]]<BR>
Release status: Published<br>
Version<!--hdVersion-->: '''4.1''' <br>
Release date: 31-12-2017
HCIM Status<!--hdStatus-->:Final<br>
Release<!--hdPublication-->: '''2017''' <br>
Release status<!--hdPublicationStatus-->: Published<br>
Release date<!--hdPublicationDate-->: 31-12-2017
-----
-----
<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<!--wikiReleasePage-->_2017(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2017(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div>


==Metadata==
==Metadata==
Regel 61: Regel 64:
==Revision History==
==Revision History==
<div class="mw-collapsible mw-collapsed">
<div class="mw-collapsible mw-collapsed">
''Only available in Dutch''
''Only available in Dutch<!--noTranslation-->''


<u>Publicatieversie 1.0</u> (15-02-2013)
<u>Publicatieversie 1.0</u> (15-02-2013)
Regel 141: Regel 144:
|-
|-
|style="width:75px; "|[[ZIBIssues#ZIB-646 | ZIB-646 ]]
|style="width:75px; "|[[ZIBIssues#ZIB-646 | ZIB-646 ]]
|Geen informatie
|Aanpassing SNOMED codes
|}
|}
.
.
Regel 162: Regel 165:
==Information Model==
==Information Model==
<BR>
<BR>
<imagemap> Bestand:TextResult-v4.1Model(EN).png | center  
<imagemap> Bestand:TextResult-v4.1Model(2017EN).png | center  
rect 164 59 280 129 [[#13063]]
rect 174 67 290 137 [[#13063]]
rect 545 60 661 130 [[Procedure-v4.1(2017EN)]]
rect 555 68 671 138 [[Procedure-v4.1(2017EN)]]
rect 361 202 451 272 [[#13066]]
rect 371 210 461 280 [[#13066]]
rect 163 319 292 369 [[#TextResultStatusCodelist]]
rect 173 327 302 377 [[#TextResultStatusCodelist]]
rect 503 319 667 369 [[#TextResultTypeCodelist]]
rect 513 327 677 377 [[#TextResultTypeCodelist]]
rect 348 59 466 129 [[#13065]]
rect 358 67 476 137 [[#13065]]
rect 173 202 271 272 [[#13062]]
rect 183 210 281 280 [[#13062]]
rect 533 202 635 272 [[#13068]]
rect 543 210 645 280 [[#13068]]
desc none
desc none
</imagemap>
</imagemap>
Regel 176: Regel 179:
{| 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"  
|-style="background-color: #1F497D; color: white; font-weight: bold; font-variant: small-caps; "
|-style="background-color: #1F497D; color: white; font-weight: bold; font-variant: small-caps; "
|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<!--imType-->||style="width:100px;"|Id<!--imId-->||colspan="6 " style="width:140px;"|Concept<!--imConcept-->||Card.<!--imCard-->||style="width: 600px;"|Definition<!--imDefinition-->||style="width:200px;"|DefinitionCode<!--imDefinitionCode-->||style="width:200px;"|Reference<!--imReference-->
|-style="vertical-align:top; background-color: #E3E3E3; "
|-style="vertical-align:top; background-color: #E3E3E3; "
|style = "text-align:center" |[[Bestand: block.png| 20px | link=]]
|style = "text-align:center" |[[Bestand: block.png| 20px | link=]]
Regel 206: Regel 209:
{|
{|
|-
|-
|<span Title="Codesystem: SNOMED CT">363714003 Interprets</span>
|<span title = "Codesystem: SNOMED CT>[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=363714003 363714003] Interprets</span>
|}
|}
|
|
Regel 249: Regel 252:
|}
|}
|}
|}
Columns Concept and DefinitionCode: hover over the values for more information<BR>
Columns Concept and DefinitionCode: hover over the values for more information<!--imHover--><BR>
For explanation of the symbols, please see the legend page [[Bestand:list2.png|link=Legend]]
For explanation of the symbols, please see the legend page<!--imLegend--> [[Bestand:list2.png|link=Legend<!--wikiLegend-->]]


==Example Instances==
==Example Instances==
''Only available in Dutch''
''Only available in Dutch<!--noTranslation-->''


{|class="wikitable" width="655px" style= "font-size: 9.5pt;"
{|class="wikitable" width="655px" style= "font-size: 9.5pt;"
Regel 320: Regel 323:
{| class="wikitable" width="60%"  
{| class="wikitable" width="60%"  
|-style='vertical-align:top; background-color: #E8D7BE;'
|-style='vertical-align:top; background-color: #E8D7BE;'
|Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.13.2.2
|Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.13.2.2
|Binding<!--vsBindingTag-->:
|}
|}
{| class="wikitable"  width="60% "
{| class="wikitable"  width="60% "
|-style="background-color: #1F497D; color: white; font-weight: bold; "
|-style="background-color: #1F497D; color: white; font-weight: bold; "
|Conceptname
|Conceptname<!--vsConceptName-->
|Conceptcode
|Conceptcode<!--vsConceptCode-->
|Codesystem name||Codesystem OID
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
|Description
|Description<!--vsDescription-->
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|Pending
|Pending
Regel 359: Regel 363:
|Gecorrigeerd
|Gecorrigeerd
|}
|}
=== TextResultTypeCodelist===
=== TextResultTypeCodelist===
{| class="wikitable" width="60%"  
{| class="wikitable" width="60%"  
|-style='vertical-align:top; background-color: #E8D7BE;'
|-style='vertical-align:top; background-color: #E8D7BE;'
|Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1
|Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1
|Binding<!--vsBindingTag-->:
|}
|}
{| class="wikitable"  width="60% "
{| class="wikitable"  width="60% "
|-style="background-color: #1F497D; color: white; font-weight: bold; "
|-style="background-color: #1F497D; color: white; font-weight: bold; "
|Conceptname
|Conceptname<!--vsConceptName-->
|Conceptcode
|Conceptcode<!--vsConceptCode-->
|Codesystem name||Codesystem OID
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
|Description
|Description<!--vsDescription-->
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|Microbiology
|Microbiology
|19851009
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=19851009 19851009]
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.96
|2.16.840.1.113883.6.96
Regel 379: Regel 383:
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|Imaging
|Imaging
|363679005
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=363679005 363679005]
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.96
|2.16.840.1.113883.6.96
Regel 385: Regel 389:
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|X-ray
|X-ray
|363680008
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=363680008 363680008]
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.96
|2.16.840.1.113883.6.96
Regel 391: Regel 395:
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|Ultrasound
|Ultrasound
|16310003
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=16310003 16310003]
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.96
|2.16.840.1.113883.6.96
Regel 397: Regel 401:
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|CT
|CT
|77477000
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=77477000 77477000]
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.96
|2.16.840.1.113883.6.96
Regel 403: Regel 407:
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|MRI
|MRI
|113091000
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=113091000 113091000]
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.96
|2.16.840.1.113883.6.96
Regel 409: Regel 413:
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|Angiography
|Angiography
|77343006
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=77343006 77343006]
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.96
|2.16.840.1.113883.6.96
Regel 415: Regel 419:
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|Cardiac Echo
|Cardiac Echo
|40701008
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=40701008 40701008]
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.96
|2.16.840.1.113883.6.96
Regel 421: Regel 425:
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|Nuclear Medicine
|Nuclear Medicine
|371572003
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=371572003 371572003]
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.96
|2.16.840.1.113883.6.96
Regel 427: Regel 431:
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|Pathology
|Pathology
|108257001
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=108257001 108257001]
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.96
|2.16.840.1.113883.6.96
Regel 433: Regel 437:
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|Procedure
|Procedure
|71388002
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=71388002 71388002]
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.96
|2.16.840.1.113883.6.96
Regel 439: Regel 443:
|}
|}


 
==This information model in other releases<!--ftOtherReleases-->==
==This information model in other releases==
<!-- Hieronder wordt een transclude page aangeroepen -->
<ul>
{{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.13.2(EN)|2|2017}}
<li>[[TextResultForTransfer-v1.2(2015EN) | Release 2015, (Version 1.2)]]</li>
<!-- Tot hier de transclude page -->
<li>[[TextResultForTransfer-v3.0(2016EN) | Release 2016, (Version 3.0)]]</li>
==Information model references<!--ftReferences-->==
</ul>
====This information model refers to<!--ftRefersTo-->====
==More on this information model==
*[[Procedure-v4.1(2017EN)|Procedure-v4.1]]
====This information model is used in<!--ftReferredBy-->====
:--
==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.<BR>
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:
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 [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=2017-12-31T00:00:00&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--zib2017bbr-?id=2.16.840.1.113883.2.4.3.11.60.7.4.2.13.2&effectiveDate=2017-12-31T00:00:00&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>
<li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR<!--ftSimplifierReference--> {{SimplefierLinks|2017}}</li>
</ul>
</ul>
This information model is also available as [[Media:nl.zorg.TextResult-v4.1(2017EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.TextResult-v4.1(2017EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]]
==Downloads<!--ftDownloadTitle-->==
==About this information==
This information model is also available as [[Media:nl.zorg.TextResult-v4.1(2017EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.TextResult-v4.1(2017EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]]<!--ftDownloads-->
The information in this wikipage is based on Release 2017 <BR>
==About this information<!--ftHeader2-->==
Conditions for use are located on the mainpage [[Bestand:list2.png|link=HCIM_Mainpage]]<BR>
The information in this wikipage is based on<!--ftInfoBase--> Release 2017 <BR>
This page is generated on 22/01/2018 00:32:05 <BR>
Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR>
This page is generated on 21/12/2018 14:11:33 with ZibExtraction v. 3.0.6929.24609<!--ftDate--> <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<!--wikiReleasePage-->_2017(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2017(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div>

Huidige versie van 24 dec 2018 om 12:04


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.TextResult NL.png
Version: 4.1
HCIM Status:Final
Release: 2017
Release status: Published
Release date: 31-12-2017


Back 16.png Back to HCIM list

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 31-12-2017
DCM::PublicationStatus Published
DCM::ReviewerList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 31-12-2017
DCM::Superseeds nl.zorg.TekstUitslag-v4.0
DCM::Version 4.1
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.

Publicatieversie 4.1 (31-12-2017)

ZIB-646 Aanpassing SNOMED codes

.

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


#13063Procedure-v4.1(2017EN)#13066#TextResultStatusCodelist#TextResultTypeCodelist#13065#13062#13068TextResult-v4.1Model(2017EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:13.2.1 Arrowdown.pngTextResult Root concept of the TextResult information model. This root concept contains all data elements of the TextResult information model.
TS.png NL-CM:13.2.3 Arrowright.pngTextResultDateTime 0..1 Date and if possible time of the result.

Date on which the procedure that TextResult documents, took place.

Verwijzing.png NL-CM:13.2.5 Arrowright.pngProcedure 0..1 Reference to the Procedure information model including the date of the procedure, requesting and executive specialty.
363714003 Interprets
Block.png Procedure
CD.png NL-CM:13.2.6 Arrowright.pngTextResultStatus 0..1 The status of the result.
List2.png TextResultStatusCodelist
ST.png NL-CM:13.2.2 Arrowright.pngTextResultReport 1 The text report detailing the actual results of the test or procedure.
CD.png NL-CM:13.2.4 Arrowright.pngTextResultType 1 The type of result.
List2.png TextResultTypeCodelist

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

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 Binding:
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 Binding:
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

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