TextResult-v4.2(2018EN): verschil tussen versies

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Regel 171: Regel 171:
==Information Model==
==Information Model==
<BR>
<BR>
<imagemap> Bestand:TextResult-v4.2Model(EN).png | center  
<imagemap> Bestand:TextResult-v4.2Model(2018EN).png | center  
rect 163 76 279 146 [[#13063]]
rect 173 84 289 154 [[#13063]]
rect 544 77 660 147 [[Procedure-v4.1(2018EN)]]
rect 554 85 670 155 [[Procedure-v4.1(2018EN)]]
rect 360 219 450 289 [[#13066]]
rect 370 227 460 297 [[#13066]]
rect 162 336 291 386 [[#TextResultStatusCodelist]]
rect 172 344 301 394 [[#TextResultStatusCodelist]]
rect 501 336 665 386 [[#TextResultTypeCodelist]]
rect 511 344 675 394 [[#TextResultTypeCodelist]]
rect 347 76 465 146 [[#13065]]
rect 357 84 475 154 [[#13065]]
rect 172 219 270 289 [[#13062]]
rect 182 227 280 297 [[#13062]]
rect 532 219 634 289 [[#13068]]
rect 542 227 644 297 [[#13068]]
desc none
desc none
</imagemap>
</imagemap>
Regel 382: Regel 382:
|Description<!--vsDescription-->
|Description<!--vsDescription-->
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Microbiologisch onderzoek" >Microbiology procedure</span>
|<span title = "Microbiologisch onderzoek">Microbiology procedure</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=19851009 19851009]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=19851009 19851009]
|SNOMED CT
|SNOMED CT
Regel 388: Regel 388:
|microbiologie
|microbiologie
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Beeldvormende verrichting" >Imaging</span>
|<span title = "Beeldvormende verrichting">Imaging</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=363679005 363679005]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=363679005 363679005]
|SNOMED CT
|SNOMED CT
Regel 394: Regel 394:
|overige beeld vormende techniek
|overige beeld vormende techniek
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Radiografische beeldvormende verrichting" >Radiographic imaging procedure</span>
|<span title = "Radiografische beeldvormende verrichting">Radiographic imaging procedure</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=363680008 363680008]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=363680008 363680008]
|SNOMED CT
|SNOMED CT
Regel 400: Regel 400:
|röntgen
|röntgen
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Diagnostische echografie" >Ultrasonography</span>
|<span title = "Diagnostische echografie">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 406: Regel 406:
|echografie
|echografie
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Computertomografie" >Computerized axial tomography</span>
|<span title = "Computertomografie">Computerized axial tomography</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=77477000 77477000]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=77477000 77477000]
|SNOMED CT
|SNOMED CT
Regel 412: Regel 412:
|CT
|CT
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Magnetic resonance imaging" >Magnetic resonance imaging</span>
|<span title = "Magnetic resonance imaging">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 418: Regel 418:
|MRI
|MRI
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Angiografie" >Angiography</span>
|<span title = "Angiografie">Angiography</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=77343006 77343006]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=77343006 77343006]
|SNOMED CT
|SNOMED CT
Regel 424: Regel 424:
|angiografie
|angiografie
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Echocardiografie" >Echocardiography</span>
|<span title = "Echocardiografie">Echocardiography</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=40701008 40701008]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=40701008 40701008]
|SNOMED CT
|SNOMED CT
Regel 430: Regel 430:
|echocardiografie
|echocardiografie
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Nucleair geneeskundige verrichting" >Nuclear medicine procedure</span>
|<span title = "Nucleair geneeskundige verrichting">Nuclear medicine procedure</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=371572003 371572003]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=371572003 371572003]
|SNOMED CT
|SNOMED CT
Regel 436: Regel 436:
|nucleaire geneeskunde
|nucleaire geneeskunde
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Pathologisch-anatomische verrichting" >Anatomic pathology procedure</span>
|<span title = "Pathologisch-anatomische verrichting">Anatomic pathology procedure</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=108257001 108257001]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=108257001 108257001]
|SNOMED CT
|SNOMED CT
Regel 442: Regel 442:
|pathologie
|pathologie
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Verrichting" >Procedure</span>
|<span title = "Verrichting">Procedure</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=71388002 71388002]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=71388002 71388002]
|SNOMED CT
|SNOMED CT
Regel 448: Regel 448:
|procedure
|procedure
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Positronemissietomografie met computertomografie" >Positron emission tomography with computed tomography</span>
|<span title = "Positronemissietomografie met computertomografie">Positron emission tomography with computed tomography</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=450436003 450436003]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=450436003 450436003]
|SNOMED CT
|SNOMED CT
Regel 462: Regel 462:
====This information model refers to<!--ftRefersTo-->====
====This information model refers to<!--ftRefersTo-->====
*[[Procedure-v4.1(2018EN)|Procedure-v4.1]]
*[[Procedure-v4.1(2018EN)|Procedure-v4.1]]
====This inforation model is used in<!--ftReferredBy-->====
====This information model is used in<!--ftReferredBy-->====
:--
:--
==Technical specifications in HL7v3 CDA and HL7 FHIR<!--ftHeader-->==
==Technical specifications in HL7v3 CDA and HL7 FHIR<!--ftHeader-->==
Regel 481: Regel 481:
</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 01/11/2018 17:37:47 with ZibExtraction v. 2.0.6879.31307<!--ftDate--> <BR>
This page is generated on 23/12/2018 01:19:51 with ZibExtraction v. 3.0.6929.24609<!--ftDate--> <BR>
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<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>
<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>

Versie van 24 dec 2018 11:58


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: 4.2
HCIM Status:Final
Release: 2018
Release status: Prepublished
Release date: 01-10-2018

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 01-10-2018
DCM::PublicationStatus Prepublished
DCM::ReviewerList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 1-3-2018
DCM::Superseeds nl.zorg.TekstUitslag-v4.1
DCM::Version 4.2
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

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

Publicatieversie 4.2 (01-10-2018)

ZIB-630 Optie PET CT toevoegen aan TekstUitslagTypeCodelijst

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(2018EN)#13066#TextResultStatusCodelist#TextResultTypeCodelist#13065#13062#13068TextResult-v4.2Model(2018EN).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: 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
Computerized axial 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

--

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 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 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 List2.png
This page is generated on 23/12/2018 01:19:51 with ZibExtraction v. 3.0.6929.24609

Back 16.png Back to HCIM list
Overgenomen van "https://zibs.test-nictiz.nl/index.php?title=TextResult-v4.2(2018EN)&oldid=15506"