TextResult-v4.4(2022EN)

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

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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

Type	Id	Concept						Card.	Definition	DefinitionCode	Reference
	NL-CM:13.2.1	TextResult							Root concept of the TextResult information model. This root concept contains all data elements of the TextResult information model.	371525003 Clinical procedure report
	NL-CM:13.2.3		TextResultDateTime					0..1	Date and if possible time of the result report.	399651003 Date of report
	NL-CM:13.2.5		Procedure					0..1	Reference to the Procedure information model including the date of the procedure, requesting and executive specialty.	71388002 Procedure	Procedure
	NL-CM:13.2.6		TextResultStatus					0..1	The status of the result.	308552006 Report status	TextResultStatusCodelist
	NL-CM:13.2.2		TextResultReport					1	The text report detailing the actual results of the test or procedure.	423100009 Results section
	NL-CM:13.2.7		VisualResult					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
	NL-CM:13.2.4		TextResultType					1	The type of result.		TextResultTypeCodelist

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

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

• Release 2015, (Version 1.2)
• Release 2016, (Version 3.0)
• Release 2017, (Version 4.1)
• Prerelease 2018-2, (Version 4.2)
• Prerelease 2019-2, (Version 4.3)
• Release 2020, (Version 4.4)
• Prerelease 2021-2, (Version 4.4)
• Prerelease 2023-1, (Version 4.4)
• Prerelease 2024-1, (Version 4.4)

Information model references

This information model refers to

• Procedure-v5.4

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
• 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 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
This page is generated on 27/03/2024 09:34:35 with ZibExtraction v. 9.3.8851.20230

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