TextResult-v4.4(2022EN): verschil tussen versies

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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 26: Regel 26:
|style="width:250px; "|DCM::ContactInformation.Telecom||*
|style="width:250px; "|DCM::ContactInformation.Telecom||*
|-  
|-  
|style="width:250px; "|DCM::ContentAuthorList||Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
|style="width:250px; "|DCM::ContentAuthorList||Projectgroep Generieke Overdrachtsgegevens &amp; Kerngroep Registratie aan de Bron
|-  
|-  
|style="width:250px; "|DCM::CreationDate||14-12-2012
|style="width:250px; "|DCM::CreationDate||14-12-2012
Regel 50: Regel 50:
|style="width:250px; "|DCM::Name||nl.zorg.TekstUitslag
|style="width:250px; "|DCM::Name||nl.zorg.TekstUitslag
|-  
|-  
|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
|-  
|-  
|style="width:250px; "|DCM::ReviewerList||Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
|style="width:250px; "|DCM::ReviewerList||Projectgroep Generieke Overdrachtsgegevens &amp; Kerngroep Registratie aan de Bron
|-  
|-  
|style="width:250px; "|DCM::RevisionDate||17-07-2020
|style="width:250px; "|DCM::RevisionDate||17-07-2020
Regel 75: Regel 75:
<u>Publicatieversie 1.2</u> (01-04-2015)
<u>Publicatieversie 1.2</u> (01-04-2015)
{|
{|
|-
Issue summaries niet beschikbaar<BR>
|style="width:75px; "|[[ZIBIssues500_0#ZIB-76 | ZIB-76 ]]
Bevat: ZIB-76, ZIB-130, ZIB-274, ZIB-275, ZIB-322, ZIB-323, ZIB-370.
|OverdrachtTekstUitslag Omschrijving
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-130 | ZIB-130 ]]
|Samenvoegen bouwstenen OverdrachtLabuitslag en OverdrachtTekstuitslag tot een bouwsteen.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-274 | 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.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-275 | 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.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-322 | ZIB-322 ]]
|Wijziging paragraaf concept
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-323 | ZIB-323 ]]
|Wijzing paragraaf Purpose
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-370 | ZIB-370 ]]
|ResultaatStatusCodelijst en TekstUitslagCodelijst codes aanpassen
|}
|}


Incl. algemene wijzigingsverzoeken:  
Incl. algemene wijzigingsverzoeken:  
{|
ZIB-94, ZIB-154, ZIB-200, ZIB-201, ZIB-309, ZIB-324, ZIB-326.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-94 | ZIB-94 ]]
|Aanpassen tekst van Disclaimer, Terms of Use & Copyrights
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-154 | ZIB-154 ]]
|Consequenties opsplitsing Medicatie bouwstenen voor overige bouwstenen.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-200 | ZIB-200 ]]
|Naamgeving SNOMED CT in tagged values klinische bouwstenen gelijk getrokken.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-201 | ZIB-201 ]]
|Naamgeving OID: in tagged value notes van klinische bouwstenen gelijk getrokken.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-309 | ZIB-309 ]]
|EOI aangepast
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-324 | ZIB-324 ]]
|Codelijsten Name en Description beginnen met een Hoofdletter
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-326 | ZIB-326 ]]
|Tekstuele aanpassingen conform de kwaliteitsreview kerngroep 2015
|}


<u>Publicatieversie 3.0</u> (01-05-2016)
<u>Publicatieversie 3.0</u> (01-05-2016)
{|
Bevat: ZIB-423, ZIB-453.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-423 | ZIB-423 ]]
|Verkeerd bron-codestelsel gekoppeld aan de 'TestStatusCodelijst'.
|-
|style="width:75px; "|[[ZIBIssues500_0#ZIB-453 | ZIB-453 ]]
|Wijziging naamgeving ZIB's en logo's door andere opzet van beheer
|}


<u>Publicatieversie 4.0</u> (04-09-2017)
<u>Publicatieversie 4.0</u> (04-09-2017)
{|
Bevat: ZIB-549, ZIB-576.
|-
|style="width:75px; "|[[ZIBIssues500_1#ZIB-549 | ZIB-549 ]]
|De Engelse naam van de bouwsteen en het rootconcept zijn niet correct
|-
|style="width:75px; "|[[ZIBIssues500_1#ZIB-576 | ZIB-576 ]]
|Aanpassen bouwstenen die nog de prefix overdracht hebben, zodat de prefix kan vervallen.
|}


<u>Publicatieversie 4.1</u> (31-12-2017)
<u>Publicatieversie 4.1</u> (31-12-2017)
{|
Bevat: ZIB-646.
|-
|style="width:75px; "|[[ZIBIssues500_1#ZIB-646 | ZIB-646 ]]
|Aanpassing SNOMED codes
|}


<u>Publicatieversie 4.2</u> (01-10-2018)
<u>Publicatieversie 4.2</u> (01-10-2018)
{|
Bevat: ZIB-630.
|-
|style="width:75px; "|[[ZIBIssues500_1#ZIB-630 | ZIB-630 ]]
|Optie PET CT toevoegen aan TekstUitslagTypeCodelijst
|}


<u>Publicatieversie 4.3</u> (31-01-2020)
<u>Publicatieversie 4.3</u> (31-01-2020)
{|
Bevat: ZIB-955.
|-
|style="width:75px; "|[[ZIBIssues500_1#ZIB-955 | ZIB-955 ]]
|verduidelijking dataelementen TekstUitslag en correctie teksten.
|}


Publicatieversie <u>4.4</u> (01-09-2020)
Publicatieversie <u>4.4</u> (01-09-2020)
{|
Bevat: ZIB-631, ZIB-1187.
|-
|style="width:75px; "|[[ZIBIssues500_1#ZIB-631 | ZIB-631 ]]
|Toevoegen optie om link naar het oorspronkelijke beeld/materiaal op te nemen.
|-
|style="width:75px; "|[[ZIBIssues500_2#ZIB-1187 | ZIB-1187 ]]
|DefinitionCodes zib Nl.zorg.tekstuitslag
|}
</div>
</div>


Regel 192: Regel 118:
<BR>
<BR>
<imagemap> Bestand:TextResult-v4.4Model(2022EN).png | center  
<imagemap> Bestand:TextResult-v4.4Model(2022EN).png | center  
rect 173 84 289 154 [[#13063]]
rect 173 84 289 154 [[#1221]]
rect 554 85 670 155 [[Procedure-v5.4(2022EN)]]
rect 554 85 670 155 [[Procedure-v5.4(2022EN)]]
rect 306 227 404 297 [[#13066]]
rect 306 227 404 297 [[#1224]]
rect 158 344 286 394 [[#TextResultStatusCodelist]]
rect 158 344 286 394 [[#TextResultStatusCodelist]]
rect 539 344 703 394 [[#TextResultTypeCodelist]]
rect 539 344 703 394 [[#TextResultTypeCodelist]]
rect 357 84 475 154 [[#13065]]
rect 357 84 475 154 [[#1223]]
rect 173 227 271 297 [[#13062]]
rect 173 227 271 297 [[#1220]]
rect 572 227 670 297 [[#13068]]
rect 572 227 670 297 [[#1226]]
rect 439 226 537 296 [[#13832]]
rect 439 226 537 296 [[#1922]]
desc none
desc none
</imagemap>
</imagemap>
Regel 210: Regel 136:
|style = "text-align:center" |[[Bestand: block.png| 20px | link=]]
|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 Id=13065 Title="NL: TekstUitslag">[[Bestand: arrowdown.png | 10px | link=]]TextResult</span>
|colspan ="6" style ="padding-left: 0px"|<span Id=1223 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 223: Regel 149:
||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 Id=13063 Title="NL: TekstUitslagDatumTijd">[[Bestand: arrowright.png | 10px | link=]]TextResultDateTime</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=1221 Title="NL: TekstUitslagDatumTijd">[[Bestand: arrowright.png | 10px | link=]]TextResultDateTime</span>
|0..1
|0..1
|Date and if possible time of the result report. 
|Date and if possible time of the result report.&#160;
|
|
{|
{|
Regel 236: Regel 162:
||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 Id=13069 Title="NL: Verrichting">[[Bestand: arrowright.png | 10px | link=]]Procedure</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=1227 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 253: Regel 179:
||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 Id=13062 Title="NL: TekstUitslagStatus">[[Bestand: arrowright.png | 10px | link=]]TextResultStatus</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=1220 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 270: Regel 196:
||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 Id=13066 Title="NL: TekstResultaat">[[Bestand: arrowright.png | 10px | link=]]TextResultReport</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=1224 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 283: Regel 209:
||NL-CM:13.2.7
||NL-CM:13.2.7
|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=13832 Title="NL: VisueelResultaat">[[Bestand: arrowright.png | 10px | link=]]VisualResult</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=1922 Title="NL: VisueelResultaat">[[Bestand: arrowright.png | 10px | link=]]VisualResult</span>
|0..*
|0..*
|Visual examination results that are the starting point and reason for the textual report. These results include visual material - e.g. radiological images, scopy images, medical photos and videos - as well as graphic recordings - e.g. ECGs, EEGs etc.
|Visual examination results that are the starting point and reason for the textual report. These results include visual material - e.g. radiological images, scopy images, medical photos and videos - as well as graphic recordings - e.g. ECGs, EEGs etc.
Regel 296: Regel 222:
||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 Id=13068 Title="NL: TekstUitslagType">[[Bestand: arrowright.png | 10px | link=]]TextResultType</span>
|colspan ="5" style ="padding-left: 0px"|<span Id=1226 Title="NL: TekstUitslagType">[[Bestand: arrowright.png | 10px | link=]]TextResultType</span>
|1
|1
|The type of result.
|The type of result.
Regel 312: Regel 238:
''Only available in Dutch<!--noTranslation-->''
''Only available in Dutch<!--noTranslation-->''


{|class="wikitable" width="655px" style= "font-size: 9.5pt;"
Voorbeeld file fout: Unable to find the specified file. : nl.zorg.TekstUitslag-v4.4(NL)_Voorbeeld.docx
|-style=vertical-align:top;
|colspan="2" style="background-color: #004080; width: 36%; "|<font color=White><b>Tekst Uitslag Datum Tijd</b></font>
| style="width: 64%; "|05-12-2014 17:00 uur
|-style=vertical-align:top;
|colspan="2" style="background-color: #004080; width: 36%; "|<font color=White><b>Tekst Uitslag Type</b></font>
| style="width: 64%; "|Röntgen
|-style=vertical-align:top;
|colspan="2" style="background-color: #004080; width: 36%; "|<font color=White><b>Tekst Uitslag Status</b></font>
| style="width: 64%; "|Voorlopig
|-style=vertical-align:top;
|colspan="2" style="background-color: #004080; width: 36%; "|<font color=White><b>Verrichting</b></font>
| style="width: 64%; "|
|-style=vertical-align:top;
| style="background-color: #004080; width: 3%; "|
| style="background-color: #BFBFBF; width: 33%; "|<b>VerrichtingType</b>
| style="width: 64%; "|CR THORAX BED (085002BED)
|-style=vertical-align:top;
| style="background-color: #004080; width: 3%; "|
| style="background-color: #BFBFBF; width: 33%; "|<b>Uitvoerder</b>
| style="width: 64%; "|Dr. A
|-style=vertical-align:top;
| style="background-color: #004080; width: 3%; "|
| style="background-color: #BFBFBF; width: 33%; "|<b>Locatie</b>
| style="width: 64%; "|Radiologie
|-style=vertical-align:top;
| style="background-color: #004080; width: 3%; "|
| style="background-color: #BFBFBF; width: 33%; "|<b>Aanvrager</b>
| style="width: 64%; "|Onbekende arts
|-style=vertical-align:top;
|colspan="3" style="background-color: #004080; width: 100%; "|<font color=White><b>TekstResultaat</b></font>
|-style=vertical-align:top;
|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;"
|-style=vertical-align:top;
|colspan="2" style="background-color: #004080; width: 36%; "|<font color=White><b>TekstUitslagDatumTijd</b></font>
| style="width: 64%; "|15-08-2014 11:00 uur
|-style=vertical-align:top;
|colspan="2" style="background-color: #004080; width: 36%; "|<font color=White><b>TekstUitslagType</b></font>
| style="width: 64%; "|Procedure
|-style=vertical-align:top;
|colspan="2" style="background-color: #004080; width: 36%; "|<font color=White><b>TekstUitslagStatus</b></font>
| style="width: 64%; "|Definitief
|-style=vertical-align:top;
|colspan="2" style="background-color: #004080; width: 36%; "|<font color=White><b>Verrichting</b></font>
| style="width: 64%; "|
|-style=vertical-align:top;
| style="background-color: #004080; width: 3%; "|
| style="background-color: #BFBFBF; width: 33%; "|<b>VerrichtingType</b>
| style="width: 64%; "|Colonoscopie
|-style=vertical-align:top;
| style="background-color: #004080; width: 3%; "|
| style="background-color: #BFBFBF; width: 33%; "|<b>Uitvoerder</b>
| style="width: 64%; "|Dr. B
|-style=vertical-align:top;
|colspan="3" style="background-color: #004080; width: 100%; "|<font color=White><b>TekstResultaat</b></font>
|-style=vertical-align:top;
|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>
|}
 
== Valuesets ==
== Valuesets ==
=== TextResultStatusCodelist===
=== TextResultStatusCodelist===
Regel 446: Regel 312:
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.96
|2.16.840.1.113883.6.96
|röntgen
|r&#246;ntgen
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Diagnostische echografie (procedure)">Ultrasonography</span>
|<span title = "Echografie (procedure)">Ultrasonography</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=16310003 16310003]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=16310003 16310003]
|SNOMED CT
|SNOMED CT
Regel 460: Regel 326:
|CT
|CT
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "(procedure)">Magnetic resonance imaging</span>
|<span title = "MRI (procedure)">Magnetic resonance imaging</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=113091000 113091000]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=113091000 113091000]
|SNOMED CT
|SNOMED CT
Regel 513: Regel 379:
:--
:--
==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|13.2}}</li>
<li>HL7&#174; version 3 CDA compatible specifications, available through the Nictiz ART-DECOR&#174; environment<!--ftArtDecorReference--> {{ArtDecorLinks|2022|13.2}}</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|TekstUitslag}}</li>
</ul>
</ul>
==Downloads<!--ftDownloadTitle-->==
==Downloads<!--ftDownloadTitle-->==
Regel 525: Regel 391:
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>
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Versie van 26 mrt 2024 11:47


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: 4.4
HCIM Status:Final
Release: 2022
Release status: Prepublished
Release date: 15-10-2023

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 15-10-2023
DCM::PublicationStatus Prepublished
DCM::ReviewerList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 17-07-2020
DCM::Supersedes nl.zorg.TekstUitslag-v4.3
DCM::Version 4.4
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)

Issue summaries niet beschikbaar
Bevat: ZIB-76, ZIB-130, ZIB-274, ZIB-275, ZIB-322, ZIB-323, ZIB-370.

Incl. algemene wijzigingsverzoeken: ZIB-94, ZIB-154, ZIB-200, ZIB-201, ZIB-309, ZIB-324, ZIB-326.

Publicatieversie 3.0 (01-05-2016) Bevat: ZIB-423, ZIB-453.

Publicatieversie 4.0 (04-09-2017) Bevat: ZIB-549, ZIB-576.

Publicatieversie 4.1 (31-12-2017) Bevat: ZIB-646.

Publicatieversie 4.2 (01-10-2018) Bevat: ZIB-630.

Publicatieversie 4.3 (31-01-2020) Bevat: ZIB-955.

Publicatieversie 4.4 (01-09-2020) Bevat: ZIB-631, ZIB-1187.

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


#1221Procedure-v5.4(2022EN)#1224#TextResultStatusCodelist#TextResultTypeCodelist#1223#1220#1226#1922TextResult-v4.4Model(2022EN).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.
371525003 Clinical procedure report
TS.png NL-CM:13.2.3 Arrowright.pngTextResultDateTime 0..1 Date and if possible time of the result report. 
399651003 Date of report
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.
71388002 Procedure
Block.png Procedure
CD.png NL-CM:13.2.6 Arrowright.pngTextResultStatus 0..1 The status of the result.
308552006 Report status
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.
423100009 Results section
ED.png NL-CM:13.2.7 Arrowright.pngVisualResult 0..* Visual examination results that are the starting point and reason for the textual report. These results include visual material - e.g. radiological images, scopy images, medical photos and videos - as well as graphic recordings - e.g. ECGs, EEGs etc.
9841000146101 Image
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

Voorbeeld file fout: Unable to find the specified file. : nl.zorg.TekstUitslag-v4.4(NL)_Voorbeeld.docx

Valuesets

TextResultStatusCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.2.2 Binding: Extensible
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: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Microbiology procedure 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
Radiographic imaging procedure 363680008 SNOMED CT 2.16.840.1.113883.6.96 röntgen
Ultrasonography 16310003 SNOMED CT 2.16.840.1.113883.6.96 echografie
Computed tomography 77477000 SNOMED CT 2.16.840.1.113883.6.96 CT
Magnetic resonance imaging 113091000 SNOMED CT 2.16.840.1.113883.6.96 MRI
Angiography 77343006 SNOMED CT 2.16.840.1.113883.6.96 angiografie
Echocardiography 40701008 SNOMED CT 2.16.840.1.113883.6.96 echocardiografie
Nuclear medicine procedure 371572003 SNOMED CT 2.16.840.1.113883.6.96 nucleaire geneeskunde
Anatomic pathology procedure 108257001 SNOMED CT 2.16.840.1.113883.6.96 pathologie
Procedure 71388002 SNOMED CT 2.16.840.1.113883.6.96 procedure
Positron emission tomography with computed tomography 450436003 SNOMED CT 2.16.840.1.113883.6.96 PET CT

This information model in other releases

Information model references

This information model refers to

This information model is used in

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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 26/03/2024 11:43:26 with ZibExtraction v. 9.3.8851.20230

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