Problem-v4.1(2017EN)

General information

Name: nl.zorg.Problem
Version: 4.1
HCIM Status:Final
Release: 2017
Release status: Published
Release date: 31-12-2017

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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	PM
DCM::EndorsingAuthority.Telecom
DCM::Id	2.16.840.1.113883.2.4.3.11.60.40.3.5.1
DCM::KeywordList	problemen, klachten, diagnosen
DCM::LifecycleStatus	Final
DCM::ModelerList	Kerngroep Registratie aan de Bron
DCM::Name	nl.zorg.Probleem
DCM::PublicationDate	31-12-2017
DCM::PublicationStatus	Published
DCM::ReviewerList	Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate	31-12-2017
DCM::Superseeds	nl.zorg.OverdrachtConcern-v4.0
DCM::Version	4.1
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-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

Publicatieversie 3.0 (01-05-2016)

ZIB-400

DHD Codesysteem onbekend

Publicatieversie 4.0 (04-09-2017)

ZIB-107	OverdrachtProblemen aanpassen zodat Probleem het rootconcept wordt i.p.v. Concern.
ZIB-108	ProbleemstatusCodelijst in OverdrachtProblemen leidt qua naamgeving/vertaling van de concepten tot verwarring
ZIB-446	ProbleemType mist status
ZIB-459	Toevoegen extra opties voor ProbleemTypeCodelijst
ZIB-467	aanpassen naam, type en naamcodelijst, type e status
ZIB-549	De Engelse naam van de bouwsteen en het rootconcept zijn niet correct
ZIB-564	Aanpassing/harmonisatie Engelse conceptnamen
ZIB-529	Voorbeelden bij ProbleemType Conditie onlogisch
ZIB-576	Aanpassen bouwstenen die nog de prefix overdracht hebben, zodat de prefix kan vervallen.

Publicatieversie 4.1 (nn-nn-nnn)

ZIB-579	Geen informatie
ZIB-646	Geen informatie

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). 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 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.

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.

Information Model

Type	Id	Concept						Card.	Definition	DefinitionCode	Reference
	NL-CM:5.1.1	Problem							Root concept of the Problem information model. A problem describes a situation with regard to an individual’s health and/or welfare. This situation can be described by the patient himselve (in the form of a complaint) or by their healthprofessional (in the form of a diagnosis, for example).
	NL-CM:5.1.11		ProblemAnatomicalLocation					0..1	Anatomical location which is the focus of the procedure.	405813007 Procedure site - Direct	ProblemAnatomicalLocationCodelist
	NL-CM:5.1.12		ProblemLaterality					0..1	Laterality adds information about body side to the anatomic location, e.g. left	272741003 Laterality	ProblemLateralityCodelist
	NL-CM:5.1.8		ProblemType					0..1	The type of problem; see the concept description.		ProblemTypeCodelist
	NL-CM:5.1.3		ProblemName					1	The problem name defines the problem. Depending on the setting, different code systems can be used. The ProblemNameCodelist provides an overview of the possible code systems.		ProblemNameCodelist
	NL-CM:5.1.6		ProblemStartDate					0..1	Onset 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:5.1.9		ProblemEndDate					0..1	Date on which the disorder to which the problem applies, is considered not to be present anymore.This datum needs not to be the same as the date of the change in problem status. 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: Active problems are problems of which the patient experiences symptoms or for which evidence exists. Problems with the status 'Inactive' refer to problems that don't affect the patient anymore or that of which there is no evidence of existence anymore.		ProblemStatusCodelist
	NL-CM:5.1.10		VerificationStatus					0..1	Clinical status of the problem or the diagnosis.	408729009 Finding context	VerificationStatusCodelist
	NL-CM:5.1.5		Comment					0..1	Comment 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

Example Instances

Only available in Dutch

Probleem
ProbleemType	ProbleemNaam	Probleem BeginDatum	ProbleemStatus	Probleem EindDatum	Verificatie Status	Toelichting
Klacht	Oedeem	10-08-2012	Actueel			Geleidelijk in de loop van dagen erger geworden. Geen roodheid of pijn.
Diagnose	Nefrotisch syndroom	11-2012	Actueel		Werkdiagnose	Membraneuze glomerulopathie.

Probleem
ProbleemType	ProbleemNaam	Probleem BeginDatum	ProbleemStatus	Probleem EindDatum	Verificatie Status	Toelichting
Diagnose	Anteroseptaal myocardinfarct	24-05-1998	Niet actueel	11-12-1998	Bevestigd	Coronarialijden als complicatie diabetes.
Diagnose	Hartfalen		Actueel		Bevestigd	Opnieuw actief geworden.
Klacht	Kortademigheid	15-11-2012	Niet actueel
Diagnose	Diabetes mellitus type II	1996	Actueel		Bevestigd

Probleem
ProbleemType	ProbleemNaam	Anatomische locatie	Lateraliteit	Probleem BeginDatum	ProbleemStatus	Probleem EindDatum	Verificatie Status	Toelichting
Diagnose	Polsfractuur	Pols	Links	20-04-2011	Niet actueel	07-06-2011	Bevestigd	Gevallen op kunstijsbaan.

Instructions

For the nursing domain: When two parties use different coding systems, the Snomed CT-based V&VN Dutch nursing problem list should be used for exchange, so data becomes comparable and exchangeable. A mapping table is available from the V&VN Dutch nursing problem list to Omaha System, NANDA-I and ICF.

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

ProblemAnatomicalLocationCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.5.1.5

Conceptname	Codesystem name	Codesystem OID
SNOMED CT: < 442083009 |Anatomical or acquired body structure|	SNOMED CT	2.16.840.1.113883.6.96

ProblemLateralityCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.5.1.6

Conceptname	Conceptcode	Codesystem name	Codesystem OID	Description
Left	7771000	SNOMED CT	2.16.840.1.113883.6.96	Links
Right	24028007	SNOMED CT	2.16.840.1.113883.6.96	Rechts
Right and left	51440002	SNOMED CT	2.16.840.1.113883.6.96	Rechts en links

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	Diagnosethesaurus DHD (SNOMED CT)	2.16.840.1.113883.2.4.3.120.5.1
Alle waarden	ICD-10	2.16.840.1.113883.6.90
Alle waarden	Nationale Kernset Patiëntproblemen V&VN (SNOMED CT)	2.16.840.1.113883.2.4.3.11.26.4
Alle waarden	NANDA-I	2.16.840.1.113883.6.20
Alle waarden	Omaha Systems	2.16.840.1.113883.6.98
Alle waarden	ICF	2.16.840.1.113883.6.254
Alle waarden	ICPC-1 NL	2.16.840.1.113883.2.4.4.31.1
Alle waarden	G-Standaard Contra Indicaties (Tabel 40)	2.16.840.1.113883.2.4.4.1.902.40
Alle waarden	DSM-IV	2.16.840.1.113883.6.126
Alle waarden	DSM-V	Nog niet bekend

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

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
Diagnosis	282291009	SNOMED CT	2.16.840.1.113883.6.96	Diagnose
Symptom	418799008	SNOMED CT	2.16.840.1.113883.6.96	Symptoom
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

VerificationStatusCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.5.1.4

Conceptname	Conceptcode	Codesystem name	Codesystem OID	Description
Suspected	415684004	SNOMED CT	2.16.840.1.113883.6.96	Werk
Known possible	410590009	SNOMED CT	2.16.840.1.113883.6.96	Differentiaal
Confirmed present	410605003	SNOMED CT	2.16.840.1.113883.6.96	Bevestigd
Known absent	410516002	SNOMED CT	2.16.840.1.113883.6.96	Uitgesloten
Unknown	UNK	NullFlavor	2.16.840.1.113883.5.1008	Onbekend

This information model in other releases

• Release 2015, (Version 1.2)
• Release 2016, (Version 3.0)

More on this information model

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 Release 2017
Conditions for use are located on the mainpage
This page is generated on 23/01/2018 00:35:33

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