ConcernForTransfer-v1.2(2015EN)
General information
Name: nl.nfu.ConcernForTransfer
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 | 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
Type | Id | Concept | Card. | Definition | DefinitionCode | Reference | |||||||
NL-CM:5.1.1 | Concern | Root concept of the ConcernTransfer building block. This root concept contains all data elements of the ConcernTransfer building block. | |||||||||||
NL-CM:5.1.9 | ConcernLabel | 0..1 | If needed, a short, written description of the concern. Mainly in first-line care this will be used for the episode name. | ||||||||||
NL-CM:5.1.2 | Problem | 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). |
||||||||||
NL-CM:5.1.8 | ProblemType | 0..1 | The type of problem; see the concept description. |
| |||||||||
NL-CM:5.1.3 | ProblemName | 1 | The problem name defines the problem.
Depending on the setting, one or more of the code systems below can be used:
|
| |||||||||
NL-CM:5.1.6 | ProblemStartDate | 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. | ||||||||||
NL-CM:5.1.4 | ProblemStatus | 1 | The problem status describes the condition of the problem:
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| |||||||||
NL-CM:5.1.7 | ProblemStatusDate | 1 | Date from when the current value of the ProblemStatus applies: since when is the problem current, under control or non-current. | ||||||||||
NL-CM:5.1.5 | Explanation | 0..1 | Explanation by the one who determined or updated the Problem. |
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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
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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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
This information model is also available as pdf file or as spreadsheet
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
This page is generated on 24/01/2018 17:13:22