ConcernForTransfer-v1.2(2015EN)

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General information

Name: nl.nfu.ConcernForTransfer NL.png
Version: 1.2
HCIM Status:Final
Release: 2015
Release status: Published
Release date: 1-4-2015

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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 11-6-2012
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name NFU
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.5.1
DCM::KeywordList problemen, klachten, diagnosen, episode
DCM::LifecycleStatus Final
DCM::ModelerList Kerngroep Registratie aan de Bron
DCM::Name nl.nfu.OverdrachtConcern
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-150 Aanpassingen in SNOMED CT codes en omschrijvingen voor codelijst ProbleemTypeCodelijst n.a.v. review terminologie expert.
ZIB-267 In klinische bouwsteen OverdrachtProblemen kwam de waarde van de tagged value DCM::ValueSet van concept ProbleemType niet overeen met naam van de gekoppelde valueset.
ZIB-268 In de klinische bouwsteen OverdrachtProblemen waren verschillende externe valuesets aan een DCM::ValueSet tagged value toegevoegd voor het concept ProbleemOmschrijving. Dit is aangepast en uitgesplitst.
ZIB-269 In de klinische bouwsteen OverdrachtProblemen kwam de naamgeving van de tagged value van concept ProbleemStatus niet overeen met de naam van de onderliggende waardelijst.
ZIB-305 Toevoegen ICPC codestelsel aan concept definitie en aan tagged values
ZIB-310 Bouwsteen OverdrachtProbelemen hernoemd naar OverdrachtConcern
ZIB-353 Tagged values DCM::CodeSystem aanpassen naar DCM::ValueSet incl. gekoppelde codelijst.

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

Determining relevant health issues of the patient involves two important aspects: observing the problem itself on the one hand (complaints, symptoms, diagnosis, etc.) and evaluation of whether or not an active policy is required on the other. This evaluation by the healthcare provider is documented in the ‘Concern’, the point of attention. Multiple, linked Problems can be subsumed under a single Concern.
The difference between recorded problems and the attention they require enables an indication of which issues medical or nursing policy applies to, or in which issues policy is necessary. An example is well-managed diabetes; this requires no active policy of the healthcare provider.

A problem describes a situation with regard to an individual’s health and/or welfare. This situation can be described by the person involved (the patient) themselves (in the form of a complaint), or by their healthcare provider (in the form of a diagnosis, for example). The situation can form cause for diagnostic or therapeutic policy.
A problem includes all kinds of medical or nursing information that represents a health problem. A problem can represent various types of health problems:

  • A complaint, finding by patient: a subjective, negatively experienced observation of the patient’s health. Examples: stomach ache, amnesia
  • A symptom: an observation by or about the patient which may indicate a certain disease. Examples: fever, blood in stool, white spots on the roof of the mouth;
  • A finding: a healthcare provider’s observation of a patient’s health. Examples: enlarged liver, pathological plantar reflex, deviating Minimal Mental State, missing teeth.
  • A condition: a description of a (deviating) bodily state, which may or may not be seen as a disease. Examples: pregnancy, circulatory disorder, poisoning.
  • A diagnosis: medical interpretation of complaints and findings. Examples: Diabetes Mellitus type II, pneumonia, hemolytic-uremic syndrome.
  • A functional limitation: a reduction of functional options. Examples: reduced mobility, help required for dressing.
  • A complication: Every diagnosis seen by the healthcare provider as an unforeseen and undesired result of medical action. Examples: post-operative wound infections, loss of hearing through the use of antibiotics.
  • A problem: any circumstance that is relevant to the medical treatment, but does not fit into one of the categories listed. Examples: Patient resides in the Netherlands without a legal status and is not insured; patient is not able to check their own blood sugar levels.


In first-line care the Episode concept fills the role of Concern.

Purpose

An overview of a patient’s health problems has the purpose of informing all healthcare providers involved in the patient’s care on the patient’s current and past health condition. It provides insight into which problems require medical action, which are under control and which are no longer current. The problem overview also directly provides medical context for medication administered and procedures carried out.
The overview promotes an efficient, targeted continuation of the patient’s care.
A complete list of problems is of importance for automated decision support and determining contraindications.

Evidence Base

The working group has decided to only use the values 'Current', 'Non-current' and 'Under control' for the ProblemStatus concept. The other CCR/CCD attributes are at another level and cannot be used instead of Current or Non-current.

CCD concept HealthStatus:
It was decided not to document the patient’s condition with the problem, as it is more generic patient information.

Information Model


#11871#9862#ProblemStatusCodelist#9857#9863#ProblemTypeCodelist#9860#9859#9864#9861#9858#ProblemNameCodelistConcernForTransfer-v1.2Model(EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:5.1.1 Arrowdown.pngConcern Root concept of the ConcernTransfer building block. This root concept contains all data elements of the ConcernTransfer building block.
ST.png NL-CM:5.1.9 Arrowright.pngConcernLabel 0..1 If needed, a short, written description of the concern. Mainly in first-line care this will be used for the episode name.
Folder.png NL-CM:5.1.2 Arrowdown.pngProblem 1..* Container of the Problem concept. This container contains all data elements of the Problem concept.

A problem describes a situation with regard to an individual’s health and/or welfare. This situation can be described by the person involved (the patient) themselves (in the form of a complaint) or by their healthcare provider (in the form of a diagnosis, for example).

CD.png NL-CM:5.1.8 Arrowright.pngProblemType 0..1 The type of problem; see the concept description.
List2.png ProblemTypeCodelist
CD.png NL-CM:5.1.3 Arrowright.pngProblemName 1 The problem name defines the problem.

Depending on the setting, one or more of the code systems below can be used:

  • Structured terms: SNOMED CT
  • Medical diagnoses: national DHD list
  • Nurse diagnoses: NANDA
  • Paramedic diagnoses: DHD and NANDA (partially offer solutions for this)
  • For functional constraints: ICF
  • For first-line care: ICPC-1 NL
List2.png ProblemNameCodelist
TS.png NL-CM:5.1.6 Arrowright.pngProblemStartDate 0..1 Start of the disorder to which the problem applies. Especially in symptoms in which it takes longer for the final diagnosis, it is important to know not only the date of the diagnosis, but also how long the patient has had the disorder. A ‘vague’ date, such as only the year or the month and the year, is permitted.
CD.png NL-CM:5.1.4 Arrowright.pngProblemStatus 1 The problem status describes the condition of the problem:
  1. Current problems are the focus of the current medical policy.
  2. Non-current (historic) problems are part of the case history.
  3. Problems with the status 'Under control' refer to problems that still exist, but which currently do not require specific medical policy (such as well-managed diabetes).
List2.png ProblemStatusCodelist
TS.png NL-CM:5.1.7 Arrowright.pngProblemStatusDate 1 Date from when the current value of the ProblemStatus applies: since when is the problem current, under control or non-current.
ST.png NL-CM:5.1.5 Arrowright.pngExplanation 0..1 Explanation by the one who determined or updated the Problem.
48767-8 Annotation comment

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

Concern
Probleem
ProbleemType ProbleemNaam Probleem
BeginDatum 		ProbleemStatus Probleem
StatusDatum 		Toelichting
Bevinding Oedeem 10-08-2012 Actueel 20-10-2012 Geleidelijk in de loop van dagen erger geworden. Geen roodheid of pijn.
Diagnose Nefrotisch syndroom 11-2012 Actueel 15-11-2012 Membraneuze glomerulopathie.
Concern
Probleem
ProbleemType ProbleemNaam Probleem
BeginDatum 		ProbleemStatus Probleem
StatusDatum 		Toelichting
Diagnose Anteroseptaal myocardinfarct 24-05-1998 Niet actueel 11-06-1998 Coronarialijden als complicatie diabetes.
Diagnose Hartfalen Actueel 20-11-2012 Opnieuw actief geworden.
Klacht Kortademigheid 15-11-2012 Onder controle 20-11-2012
Diagnose Diabetes mellitus type II 1996 Onder controle 10-09-2012
Concern
Probleem
ProbleemType ProbleemNaam Probleem
BeginDatum 		ProbleemStatus Probleem
StatusDatum 		Toelichting
Diagnose Polsfractuur links 20-04-2011 Niet actueel 07-06-2011 Gevallen op kunstijsbaan.

References

1. openEHR-EHR-EVALUATION.problem.v1 [Online] Beschikbaar op: http://www.openehr.org/knowledge/ [Geraadpleegd: 23 juli 2014].

2. North American Nursing Diagnosis Association [Online] Beschikbaar op: http://www.nanda.org [Geraadpleegd: 23 juli 2014].

3. Diagnosethesaurus. Dutch Hospital Data [Online] Beschikbaar op: http://www.dutchhospitaldata.nl [Geraadpleegd: 23 juli 2014].

4. Health Level Seven International EHR Technical Committee (February 2007) Electronic Health Record–System Functional Model, Release 1. Chapter Three: Direct Care Functions.

5. HL7 (April 2007) HL7 Implementation Guide: CDA Release 2 – Continuity of Care Document (CCD)

6. Nederlands Huisartsen Genootschap (2013) HIS-Referentiemodel 2013

Valuesets

ProblemNameCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.5.1.3
Conceptname Codesystem name Codesystem OID
Alle waarden ICPC-1 NL 2.16.840.1.113883.2.4.4.31.1
<<404684003 |Clinical Finding| SNOMED CT 2.16.840.1.113883.6.96
Alle waarden NANDA 2.16.840.1.113883.6.20
Alle waarden ICF 2.16.840.1.113883.6.254
Alle waarden ICD-10 2.16.840.1.113883.6.90
Alle waarden G-Standaard Contra Indicaties (Tabel 40) 2.16.840.1.113883.2.4.4.1.902.40
Alle waarden Diagnosethesaurus DHD 9999

ProblemStatusCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.5.1.2
Conceptname Conceptcode Codesystem name Codesystem OID Description
Active 55561003 SNOMED CT 2.16.840.1.113883.6.96 Actueel
Inactive 73425007 SNOMED CT 2.16.840.1.113883.6.96 Niet actueel
Resolved 413322009 SNOMED CT 2.16.840.1.113883.6.96 Onder controle

ProblemTypeCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.5.1.1
Conceptname Conceptcode Codesystem name Codesystem OID Description
Problem 55607006 SNOMED CT 2.16.840.1.113883.6.96 Probleem
Condition 64572001 SNOMED CT 2.16.840.1.113883.6.96 Conditie
Diagnosis 282291009 SNOMED CT 2.16.840.1.113883.6.96 Diagnose
Symptom 418799008 SNOMED CT 2.16.840.1.113883.6.96 Symptoom
Finding 404684003 SNOMED CT 2.16.840.1.113883.6.96 Bevinding
Complaint 409586006 SNOMED CT 2.16.840.1.113883.6.96 Klacht
Functional Limitation 248536006 SNOMED CT 2.16.840.1.113883.6.96 Functionele Beperking
Complication 116223007 SNOMED CT 2.16.840.1.113883.6.96 Complicatie


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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
Conditions for use are located on the mainpage List2.png
This page is generated on 24/01/2018 17:13:22

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