Encounter-v3.1(2018EN): verschil tussen versies

Versie van 24 dec 2018 11:57

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.Encounter
Version: 3.1
HCIM Status:Final
Release: 2018
Release status: Prepublished
Release date: 01-10-2018

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	19-4-2012
DCM::DeprecatedDate
DCM::DescriptionLanguage	nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name	PM
DCM::EndorsingAuthority.Telecom
DCM::Id	2.16.840.1.113883.2.4.3.11.60.40.3.15.1
DCM::KeywordList	Contacten, contact, patiëntcontact
DCM::LifecycleStatus	Final
DCM::ModelerList	Kerngroep Registratie aan de Bron
DCM::Name	nl.zorg.Contact
DCM::PublicationDate	01-10-2018
DCM::PublicationStatus	Prepublished
DCM::ReviewerList	Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate	31-12-2017
DCM::Superseeds	nl.zorg.Contact-v3.0
DCM::Version	3.1
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-163	Naamgeving concept Probleem::Probleem uit OverdrachtContact aanpassen.
ZIB-164	Het concept Locatie::Zorgaanbieder uit bouwsteen OverdrachtContact niet verplicht maken, maar als cardinaliteit 0..1 opgeven.
ZIB-165	Het concept Procedure in OverdrachtContact dient referentie naar bouwsteen te zijn.
ZIB-306	Aanpassen modellering keuzebox, boundary en cardinaliteit
ZIB-308	Prefix Overdracht weggehaald bij de generieke bouwstenen

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-453

Wijziging naamgeving ZIB's en logo's door andere opzet van beheer

Publicatieversie 3.1 (04-09-2017)

ZIB-463	Toevoegen IC aan ContactTypeCodelijst
ZIB-465	Uitbreiding met datacontainers "Herkomst" en "Ontslagbestemming"
ZIB-553	Example Instances Contact Type komt niet overeen met ContactTypeCodelijst
ZIB-563	Engelse vertaling van Contact is Encounter
ZIB-564	Aanpassing/harmonisatie Engelse conceptnamen
ZIB-565	ContactTypeCodelijst niet compleet
ZIB-574	Alleen verwijzen naar het rootconcept van de ZIB.

Concept

A contact is any interaction, regardless of the situation, between a patient and the healthcare provider, in which the healthcare provider has primary responsibility for diagnosing, evaluating and treating the patient’s condition and informing the patient. These can be visits, appointments or non face-to-face interactions.

Contacts can be visits to the general practitioner or other practices, home visits, admissions (in hospitals, nursing homes or care homes, psychiatric institutions or convalescent homes) or other relevant contacts. This only includes past contacts. Future contacts can be documented in the PlannedCareActivity information model.

Purpose

Contacts can be recorded to provide insight on the interactions that have taken place between the patient and healthcare professional and in which context these took place.

Evidence Base

The codelists for Origin and Destination generally correspond to the ‘Landelijke Basisregistratie Ziekenhuiszorg’ (National Basic Registration Hospital Care)

Information Model

Type

Id

Concept

Card.

Definition

DefinitionCode

Reference

NL-CM:15.1.1

Encounter

Root concept of the Contact information model. This concept contains all data elements of the Contact information model.

NL-CM:15.1.2

ContactType

1

The type of contact.

ContactTypeCodelist

NL-CM:15.1.7

ContactWith::HealthProfessional

0..*

The health professional with whom the contact took place. The specialty and role of the health professional can be entered in the HealthProfessional information model.

HealthProfessional

NL-CM:15.1.8

Location::HealthcareProvider

0..1

The physical location at which the contact took place.

HealthcareProvider

NL-CM:15.1.3

StartDateTime

1

The date and time at which the contact took place.

NL-CM:15.1.4

EndDateTime

0..1

The date and time at which the contact ended. If the contact takes place over a period of time, this indicates the end of the period, in the case of an admission, for example.

NL-CM:15.1.13

ContactReason

1

Container of the ContactReason concept. This container contains all data elements of the ContactReason concept.

NL-CM:15.1.6

Problem

(0..1)

The problem that led to the contact.

Problem

NL-CM:15.1.11

Procedure

(0..1)

The procedure carried out during the contact.

Procedure

NL-CM:15.1.12

DeviatingResult

(0..1)

A deviating result which serves as the reason for the contact.

NL-CM:15.1.14

Origin

0..1

Location from which the patient came before the encounter. In most cases this will only be used when the patient is admitted.

OriginCodelist

NL-CM:15.1.16

Destination

0..1

Location to which the patient will go after the encounter. In most cases this will only be used when the patient is discharged.

DestinationCodelist

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

Contact Type	BeginDatum Tijd	RedenContact	ContactMet	Locatie
		ProbleemNaam	Zorgverlener Naam	OrganisatieType	Organisatie Naam
SEH	16-08-2012	Gebroken been	J.H.R. Peters	Ziekenhuis	Universitair Medisch Centrum Groningen

Contact Type	Begin Datum Tijd	Eind Datum Tijd	RedenContact	ContactMet	Locatie
			VerrichtingType	Zorgverlener Naam	OrganisatieType	Organisatie Naam
Klinisch	16-08-2012	19-08-2012	Operatie been	G.Z.M. de Wit	Ziekenhuis	St. Lucas Andreas Ziekenhuis

Instructions

Explanation ‘Eigen woonomgeving’ (Home) from the ‘Landelijke Basisregistratie Ziekenhuiszorg’ (National Basic Registration Hospital Care) (concepts Origin and Destination)
The home environment is the environment where the patient stays regular. This distinguishes between living in a private home and living in an institution for nursing and care. This distinction is the difference between "independent living with any additional care" and "being taken care of including living". Thus, residential homes are counted as the first and stay in a nursing home to the second.

References

1. Landelijke Basisregistratie Ziekenhuiszorg [Online] Beschikbaar op: https://www.dhd.nl/klanten/klantenservice/handleidingen_formulieren/Documents/Handleiding%20LBZ.pdf [Geraadpleegd: 29 juni2017].

Valuesets

ContactTypeCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.15.1.1	Binding: Extensible

Conceptname	Conceptcode	Codesystem name	Codesystem OID	Description
Ambulatory	AMB	ActCode	2.16.840.1.113883.5.4	Poliklinisch
Emergency	EMER	ActCode	2.16.840.1.113883.5.4	SEH
Field	FLD	ActCode	2.16.840.1.113883.5.4	Op lokatie
Home	HH	ActCode	2.16.840.1.113883.5.4	Thuis
Inpatient	IMP	ActCode	2.16.840.1.113883.5.4	Klinisch
Short Stay	SS	ActCode	2.16.840.1.113883.5.4	Dagopname
Virtual	VR	ActCode	2.16.840.1.113883.5.4	Virtueel
Other	OTH	NullFlavor	2.16.840.1.113883.5.1008	Anders

DestinationCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.15.1.3	Binding: Extensible

Conceptname	Conceptcode	Codesystem name	Codesystem OID	Description
Home	264362003	SNOMED CT	2.16.840.1.113883.6.96	Eigen woonomgeving
Left against medical advice	445060000	SNOMED CT	2.16.840.1.113883.6.96	Tegen advies in vertrokken
Rehabilitation hospital	80522000	SNOMED CT	2.16.840.1.113883.6.96	Instelling voor revalidatie
Long term care facility	42665001	SNOMED CT	2.16.840.1.113883.6.96	Instelling voor verpleging/verzorging
Psychiatric hospital	62480006	SNOMED CT	2.16.840.1.113883.6.96	GGZ instelling
Hospital	22232009	SNOMED CT	2.16.840.1.113883.6.96	Ander ziekenhuis
Died in hospital	183676005	SNOMED CT	2.16.840.1.113883.6.96	Overleden
Hospice	284546000	SNOMED CT	2.16.840.1.113883.6.96	Hospice
Other	OTH	NullFlavor	2.16.840.1.113883.5.1008	Overig

OriginCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.15.1.2	Binding: Extensible

Conceptname	Conceptcode	Codesystem name	Codesystem OID	Description
Home	264362003	SNOMED CT	2.16.840.1.113883.6.96	Eigen woonomgeving
Rehabilitation hospital	80522000	SNOMED CT	2.16.840.1.113883.6.96	Instelling voor revalidatie
Long term care facility	42665001	SNOMED CT	2.16.840.1.113883.6.96	Instelling voor verpleging/verzorging
Psychiatric hospital	62480006	SNOMED CT	2.16.840.1.113883.6.96	GGZ instelling
Hospital	22232009	SNOMED CT	2.16.840.1.113883.6.96	Ander ziekenhuis
Liveborn born in hospital	442311008	SNOMED CT	2.16.840.1.113883.6.96	In dit ziekenhuis geboren
Hospice	284546000	SNOMED CT	2.16.840.1.113883.6.96	Hospice
Other	OTH	NullFlavor	2.16.840.1.113883.5.1008	Overig

This information model in other releases

Information model references

This information model refers to

This information model is used in

PlannedCareActivityForTransfer-v3.1

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 #1
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 23/12/2018 01:17:10 with ZibExtraction v. 3.0.6929.24609

Back to HCIM list

@@ Regel 160: / Regel 160: @@
 ==Information Model==
 <BR>
-<imagemap> Bestand:Encounter-v3.1Model(EN).png | center
+<imagemap> Bestand:Encounter-v3.1Model(2018EN).png | center
-rect 710 130 847 180 [[#DestinationCodelist]]
+rect 720 138 857 188 [[#DestinationCodelist]]
-rect 203 129 340 179 [[#OriginCodelist]]
+rect 213 137 350 187 [[#OriginCodelist]]
-rect 378 119 505 189 [[#12807]]
+rect 388 127 515 197 [[#12807]]
-rect 545 117 673 187 [[#12817]]
+rect 555 125 683 195 [[#12817]]
-rect 429 360 539 430 [[#12811]]
+rect 439 368 549 438 [[#12811]]
-rect 210 318 340 391 [[HealthcareProvider-v3.2(2018EN)]]
+rect 220 326 350 399 [[HealthcareProvider-v3.2(2018EN)]]
-rect 715 507 838 557 [[#ContactTypeCodelist]]
+rect 725 515 848 565 [[#ContactTypeCodelist]]
-rect 559 504 673 577 [[#12806]]
+rect 569 512 683 585 [[#12806]]
-rect 426 504 540 577 [[Procedure-v4.1(2018EN)]]
+rect 436 512 550 585 [[Procedure-v4.1(2018EN)]]
-rect 710 318 833 391 [[#12815]]
+rect 720 326 843 399 [[#12815]]
-rect 293 504 407 577 [[Problem-v4.1.1(2018EN)]]
+rect 303 512 417 585 [[Problem-v4.1.1(2018EN)]]
-rect 210 230 340 303 [[HealthProfessional-v3.2(2018EN)]]
+rect 220 238 350 311 [[HealthProfessional-v3.2(2018EN)]]
-rect 710 230 833 303 [[#12809]]
+rect 720 238 843 311 [[#12809]]
-rect 429 229 539 302 [[#12818]]
+rect 439 237 549 310 [[#12818]]
-rect 710 413 833 486 [[#12813]]
+rect 720 421 843 494 [[#12813]]
 desc none
 </imagemap>
@@ Regel 457: / Regel 457: @@
 |Description<!--vsDescription-->
 |-style="vertical-align:top; "
-|<span title = "Thuis" >Home</span>
+|<span title = "Thuis">Home</span>
 |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=264362003 264362003]
 |SNOMED CT
@@ Regel 475: / Regel 475: @@
 |Instelling voor revalidatie
 |-style="vertical-align:top; "
-|<span title = "Verpleeghuis" >Long term care facility</span>
+|<span title = "Verpleeghuis">Long term care facility</span>
 |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=42665001 42665001]
 |SNOMED CT
@@ Regel 481: / Regel 481: @@
 |Instelling voor verpleging/verzorging
 |-style="vertical-align:top; "
-|<span title = "Psychiatrisch ziekenhuis" >Psychiatric hospital</span>
+|<span title = "Psychiatrisch ziekenhuis">Psychiatric hospital</span>
 |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=62480006 62480006]
 |SNOMED CT
@@ Regel 487: / Regel 487: @@
 |GGZ instelling
 |-style="vertical-align:top; "
-|<span title = "Ziekenhuis" >Hospital</span>
+|<span title = "Ziekenhuis">Hospital</span>
 |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=22232009 22232009]
 |SNOMED CT
@@ Regel 524: / Regel 524: @@
 |Description<!--vsDescription-->
 |-style="vertical-align:top; "
-|<span title = "Thuis" >Home</span>
+|<span title = "Thuis">Home</span>
 |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=264362003 264362003]
 |SNOMED CT
@@ Regel 536: / Regel 536: @@
 |Instelling voor revalidatie
 |-style="vertical-align:top; "
-|<span title = "Verpleeghuis" >Long term care facility</span>
+|<span title = "Verpleeghuis">Long term care facility</span>
 |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=42665001 42665001]
 |SNOMED CT
@@ Regel 542: / Regel 542: @@
 |Instelling voor verpleging/verzorging
 |-style="vertical-align:top; "
-|<span title = "Psychiatrisch ziekenhuis" >Psychiatric hospital</span>
+|<span title = "Psychiatrisch ziekenhuis">Psychiatric hospital</span>
 |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=62480006 62480006]
 |SNOMED CT
@@ Regel 548: / Regel 548: @@
 |GGZ instelling
 |-style="vertical-align:top; "
-|<span title = "Ziekenhuis" >Hospital</span>
+|<span title = "Ziekenhuis">Hospital</span>
 |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=22232009 22232009]
 |SNOMED CT
@@ Regel 583: / Regel 583: @@
 *[[Problem-v4.1.1(2018EN)|Problem-v4.1.1]]
 *[[Procedure-v4.1(2018EN)|Procedure-v4.1]]
-====This inforation model is used in<!--ftReferredBy-->====
+====This information model is used in<!--ftReferredBy-->====
 *[[PlannedCareActivityForTransfer-v3.1(2018EN)|PlannedCareActivityForTransfer-v3.1]]
 ==Technical specifications in HL7v3 CDA and HL7 FHIR<!--ftHeader-->==
@@ Regel 602: / Regel 602: @@
 </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 17:34:48 with ZibExtraction v. 2.0.6879.31307<!--ftDate--> <BR>
+This page is generated on 23/12/2018 01:17:10 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<!--wikiReleasePage-->_2018(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2018(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div>

Encounter-v3.1(2018EN): verschil tussen versies

Versie van 24 dec 2018 11:57

Inhoud

General information

Metadata

Revision History

Concept

Purpose

Evidence Base

Information Model

Example Instances

Instructions

References