TextResultForTransfer-v1.2(2015EN): verschil tussen versies
Geen bewerkingssamenvatting |
Geen bewerkingssamenvatting |
||
Regel 1: | Regel 1: | ||
==General information== | <!-- Hieronder wordt een transclude page aangeroepen --> | ||
Name: '''nl.nfu.TextResultForTransfer''' [[Bestand:NL.png|link=OverdrachtTekstUitslag-v1.2(2015NL)]]<BR> | {{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.13.2(EN)|1|TextResultForTransfer-v1.2(2015EN)}} | ||
Version: '''1.2''' <br> | <!-- Tot hier de transclude page --> | ||
HCIM Status:Final<br> | ==General information<!--hdGeneralInformation-->== | ||
Release: '''2015''' <br> | Name<!--hdName-->: '''nl.nfu.TextResultForTransfer''' [[Bestand:NL.png|link=OverdrachtTekstUitslag-v1.2(2015NL)]]<BR> | ||
Release status: Published<br> | Version<!--hdVersion-->: '''1.2''' <br> | ||
Release date: 1-4-2015 | HCIM Status<!--hdStatus-->:Final<br> | ||
Release<!--hdPublication-->: '''2015''' <br> | |||
Release status<!--hdPublicationStatus-->: Published<br> | |||
Release date<!--hdPublicationDate-->: 1-4-2015 | |||
----- | ----- | ||
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= | <div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2015(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2015(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 135: | Regel 138: | ||
<BR> | <BR> | ||
<imagemap> Bestand:TextResultForTransfer-v1.2Model(EN).png | center | <imagemap> Bestand:TextResultForTransfer-v1.2Model(EN).png | center | ||
rect | rect 161 132 277 202 [[#10841]] | ||
rect | rect 537 132 653 202 [[ProcedureForTransfer-v1.2(2015EN)]] | ||
rect | rect 358 275 448 345 [[#10844]] | ||
rect | rect 160 392 278 442 [[#TextResultStatusCodelist]] | ||
rect | rect 500 392 664 442 [[#TextResultTypeCodelist]] | ||
rect | rect 345 132 463 202 [[#10843]] | ||
rect | rect 170 275 268 345 [[#10840]] | ||
rect | rect 530 275 632 345 [[#10847]] | ||
desc none | desc none | ||
</imagemap> | </imagemap> | ||
Regel 148: | Regel 151: | ||
{| 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 217: | Regel 220: | ||
|} | |} | ||
|} | |} | ||
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="644px" style= "font-size: 9.5pt;" | {|class="wikitable" width="644px" style= "font-size: 9.5pt;" | ||
Regel 258: | Regel 261: | ||
{| 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 297: | Regel 301: | ||
|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 317: | Regel 321: | ||
|-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 323: | Regel 327: | ||
|-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 329: | Regel 333: | ||
|-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 335: | Regel 339: | ||
|-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 341: | Regel 345: | ||
|-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 347: | Regel 351: | ||
|-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 353: | Regel 357: | ||
|-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 359: | Regel 363: | ||
|-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 365: | Regel 369: | ||
|-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 371: | Regel 375: | ||
|-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 377: | Regel 381: | ||
|} | |} | ||
==This information model in other releases<!--ftOtherReleases-->== | |||
==This information model in other releases== | <!-- Hieronder wordt een transclude page aangeroepen --> | ||
< | {{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.13.2(EN)|2|2015}} | ||
<!-- Tot hier de transclude page --> | |||
< | ==Information model references<!--ftReferences-->== | ||
====This information model refers to<!--ftRefersTo-->==== | |||
== | *[[ProcedureForTransfer-v1.2(2015EN)|ProcedureForTransfer-v1.2]] | ||
====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--zib2015bbr-?id=2.16.840.1.113883.2.4.3.11.60.5.4.2.13.2&effectiveDate=2015-04-01T00:00:00&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--zib2015bbr-?id=2.16.840.1.113883.2.4.3.11.60.5.4.2.13.2&effectiveDate=2015-04-01T00:00:00&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 | <li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR<!--ftSimplifierReference--> {{SimplefierLinks|2015}}</li> | ||
</ul> | </ul> | ||
This information model is also available as [[Media:nl.nfu.TextResultForTransfer-v1.2(2015EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.nfu.TextResultForTransfer-v1.2(2015EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]] | ==Downloads<!--ftDownloadTitle-->== | ||
==About this information== | This information model is also available as [[Media:nl.nfu.TextResultForTransfer-v1.2(2015EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.nfu.TextResultForTransfer-v1.2(2015EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]]<!--ftDownloads--> | ||
The information in this wikipage is based on ''Registratie aan de bron'' publication 2015 including errata dd. 16-07-2015 <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--> ''Registratie aan de bron'' publication 2015 including errata dd. 16-07-2015 <BR> | ||
This page is generated on | Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR> | ||
This page is generated on 20/12/2018 12:05:37 with ZibExtraction v. 3.0.6928.21213<!--ftDate--> <BR> | |||
----- | ----- | ||
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= | <div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2015(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2015(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div> |
Versie van 20 dec 2018 14:14
General information
Name: nl.nfu.TextResultForTransfer
Version: 1.2
HCIM Status:Final
Release: 2015
Release status: Published
Release date: 1-4-2015
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 | NFU |
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.nfu.OverdrachtTekstUitslag |
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-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 |
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 in nature. The supplying and receiving systems usually lack formal structure. Therefore, further structuring of the transfer information for these data is not advisable. 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.
For laboratory test results, it is difficult to clearly indicate exactly when to use this building block and when to use the LaboratoryTestResultTransfer building block.
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 LaboratoryTestResultTransfer, whereas this building block 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
![TextResultForTransfer-v1.2Model(EN).png](/images/7/7d/TextResultForTransfer-v1.2Model%28EN%29.png)
Type | Id | Concept | Card. | Definition | DefinitionCode | Reference | |||||||
![]() |
NL-CM:13.2.1 | ![]() |
Root concept of the TextResultTransfer building block. This root concept contains all data elements of the TextResultTransfer building block. | ||||||||||
![]() |
NL-CM:13.2.3 | ![]() |
0..1 | Date and if possible time of the result.
Date on which the procedure took place as recorded in the ProcedureTransfer building block. |
|||||||||
![]() |
NL-CM:13.2.5 | ![]() |
0..1 | Reference to the ProcedureTransfer building block including the date of the procedure, requesting and executive specialty. |
| ||||||||
![]() |
NL-CM:13.2.6 | ![]() |
0..1 | The status of the result. |
| ||||||||
![]() |
NL-CM:13.2.2 | ![]() |
1 | The text report detailing the actual results of the test or procedure. | |||||||||
![]() |
NL-CM:13.2.4 | ![]() |
1 | The type of result. |
|
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
Tekst Uitslag Datum Tijd | 05-12-2014 17:00 uur |
Tekst Uitslag Type | Röntgen |
Tekst Uitslag Status | Voorlopig |
TekstResultaat | |
Aanvr. Arts: Onbekende arts Uitv. Dienst: Radiologie ----------------------------------------------------------------------------------------------------------------- Onderzoeksnummer: ……… Onderzoek: CR THORAX BED (085002BED) uitgevoerd op 05-12-2014 17:00 uur Status verslag: voorlopig getekend. Voorlopig getekend door …………. op 05-12-2014 17:00 uur ----------------------------------------------------------------------------------------------------------------- Verslag: Datum 05-12-2014 CR THORAX 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. Dit is een op 05-12-2014 17:00 uur voorlopig rapport. |
TekstUitslagDatumTijd | 15-08-2014 11:00 uur |
TekstUitslagType | CT |
TekstUitslagStatus | Definitief |
TekstResultaat | |
Onderzoek Coloscopie Datum onderzoek Patiëntnaam Geboortedatum Patiëntnummer Verwijzing door …… Geachte collega, Op 15-08-2014 zag ik uw patiënt, de heer Beem………, voor een Coloscopie (CF-Q160AL; 118) op de afdeling Maag-, darm- en leverziekten. Coloscopie 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 | 2.16.840.1.113883.2.4.3.11.60.40.4.15.1 | Uitslag volgt |
Preliminary | preliminary | ResultaatStatus | 2.16.840.1.113883.2.4.3.11.60.40.4.15.1 | Voorlopig |
Final | final | ResultaatStatus | 2.16.840.1.113883.2.4.3.11.60.40.4.15.1 | Definitief |
Appended | appended | ResultaatStatus | 2.16.840.1.113883.2.4.3.11.60.40.4.15.1 | Aanvullend |
Corrected | corrected | ResultaatStatus | 2.16.840.1.113883.2.4.3.11.60.40.4.15.1 | 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 |
This information model in other releases
- Release 2016, (Version 3.0)
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About this information
The information in this wikipage is based on Registratie aan de bron publication 2015 including errata dd. 16-07-2015
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This page is generated on 20/12/2018 12:05:37 with ZibExtraction v. 3.0.6928.21213