Encounter-v3.1(2018EN)
General information
Name: nl.zorg.Encounter 
Version: 3.1
HCIM Status:Final
Release: 2018
Release status: Prepublished
Release date: 01-10-2018
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 | 19-4-2012 |
| DCM::DeprecatedDate | |
| DCM::DescriptionLanguage | nl |
| DCM::EndorsingAuthority.Address | |
| DCM::EndorsingAuthority.Name | PM |
| DCM::EndorsingAuthority.Telecom | |
| DCM::Id | 2.16.840.1.113883.2.4.3.11.60.40.3.15.1 |
| DCM::KeywordList | Contacten, contact, patiëntcontact |
| DCM::LifecycleStatus | Final |
| DCM::ModelerList | Kerngroep Registratie aan de Bron |
| DCM::Name | nl.zorg.Contact |
| DCM::PublicationDate | 01-10-2018 |
| DCM::PublicationStatus | Prepublished |
| DCM::ReviewerList | Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron |
| DCM::RevisionDate | 31-12-2017 |
| DCM::Superseeds | nl.zorg.Contact-v3.0 |
| DCM::Version | 3.1 |
| 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-163 | Naamgeving concept Probleem::Probleem uit OverdrachtContact aanpassen. |
| ZIB-164 | Het concept Locatie::Zorgaanbieder uit bouwsteen OverdrachtContact niet verplicht maken, maar als cardinaliteit 0..1 opgeven. |
| ZIB-165 | Het concept Procedure in OverdrachtContact dient referentie naar bouwsteen te zijn. |
| ZIB-306 | Aanpassen modellering keuzebox, boundary en cardinaliteit |
| ZIB-308 | Prefix Overdracht weggehaald bij de generieke bouwstenen |
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-453 | Wijziging naamgeving ZIB's en logo's door andere opzet van beheer |
Publicatieversie 3.1 (04-09-2017)
| ZIB-463 | Toevoegen IC aan ContactTypeCodelijst |
| ZIB-465 | Uitbreiding met datacontainers "Herkomst" en "Ontslagbestemming" |
| ZIB-553 | Example Instances Contact Type komt niet overeen met ContactTypeCodelijst |
| ZIB-563 | Engelse vertaling van Contact is Encounter |
| ZIB-564 | Aanpassing/harmonisatie Engelse conceptnamen |
| ZIB-565 | ContactTypeCodelijst niet compleet |
| ZIB-574 | Alleen verwijzen naar het rootconcept van de ZIB. |
Concept
A contact is any interaction, regardless of the situation, between a patient and the healthcare provider, in which the healthcare provider has primary responsibility for diagnosing, evaluating and treating the patient’s condition and informing the patient. These can be visits, appointments or non face-to-face interactions.
Contacts can be visits to the general practitioner or other practices, home visits, admissions (in hospitals, nursing homes or care homes, psychiatric institutions or convalescent homes) or other relevant contacts. This only includes past contacts. Future contacts can be documented in the PlannedCareActivity information model.
Purpose
Contacts can be recorded to provide insight on the interactions that have taken place between the patient and healthcare professional and in which context these took place.
Evidence Base
The codelists for Origin and Destination generally correspond to the ‘Landelijke Basisregistratie Ziekenhuiszorg’ (National Basic Registration Hospital Care)
Information Model
| Type | Id | Concept | Card. | Definition | DefinitionCode | Reference | |||||||
|
NL-CM:15.1.1 |  Encounter
|
Root concept of the Contact information model. This concept contains all data elements of the Contact information model. | ||||||||||
|
NL-CM:15.1.2 |  ContactType
|
1 | The type of contact. |
| ||||||||
|
NL-CM:15.1.7 | ContactWith::HealthProfessional
|
0..* | The health professional with whom the contact took place. The specialty and role of the health professional can be entered in the HealthProfessional information model. |
| ||||||||
|
|
NL-CM:15.1.8 | Location::HealthcareProvider
|
0..1 | The physical location at which the contact took place. |
| ||||||||
|
NL-CM:15.1.3 | StartDateTime
|
1 | The date and time at which the contact took place. | |||||||||
|
|
NL-CM:15.1.4 | EndDateTime
|
0..1 | The date and time at which the contact ended. If the contact takes place over a period of time, this indicates the end of the period, in the case of an admission, for example. | |||||||||
|
NL-CM:15.1.13 | ContactReason
|
1 | Container of the ContactReason concept. This container contains all data elements of the ContactReason concept. | |||||||||
|
|
NL-CM:15.1.6 | Problem
|
(0..1) | The problem that led to the contact. |
| ||||||||
|
|
NL-CM:15.1.11 | Procedure
|
(0..1) | The procedure carried out during the contact. |
| ||||||||
|
NL-CM:15.1.12 | DeviatingResult
|
(0..1) | A deviating result which serves as the reason for the contact. | |||||||||
|
|
NL-CM:15.1.14 | Origin
|
0..1 | Location from which the patient came before the encounter. In most cases this will only be used when the patient is admitted. |
| ||||||||
|
|
NL-CM:15.1.16 | Destination
|
0..1 | Location to which the patient will go after the encounter. In most cases this will only be used when the patient is discharged. |
| ||||||||
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
| Contact Type |
BeginDatum Tijd |
RedenContact | ContactMet | Locatie | |
| ProbleemNaam | Zorgverlener Naam |
OrganisatieType | Organisatie Naam | ||
| SEH | 16-08-2012 | Gebroken been | J.H.R. Peters | Ziekenhuis | Universitair Medisch Centrum Groningen |
| Contact Type |
Begin Datum Tijd |
Eind Datum Tijd |
RedenContact | ContactMet | Locatie | |
| VerrichtingType | Zorgverlener Naam |
OrganisatieType | Organisatie Naam | |||
| Klinisch | 16-08-2012 | 19-08-2012 | Operatie been | G.Z.M. de Wit | Ziekenhuis | St. Lucas Andreas Ziekenhuis |
Instructions
Explanation ‘Eigen woonomgeving’ (Home) from the ‘Landelijke Basisregistratie Ziekenhuiszorg’ (National Basic Registration Hospital Care) (concepts Origin and Destination)
The home environment is the environment where the patient stays regular. This distinguishes between living in a private home and living in an institution for nursing and care. This distinction is the difference between "independent living with any additional care" and "being taken care of including living". Thus, residential homes are counted as the first and stay in a nursing home to the second.
References
1. Landelijke Basisregistratie Ziekenhuiszorg [Online] Beschikbaar op: https://www.dhd.nl/klanten/klantenservice/handleidingen_formulieren/Documents/Handleiding%20LBZ.pdf [Geraadpleegd: 29 juni2017].
Valuesets
ContactTypeCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.15.1.1 | Binding: Extensible |
| Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
| Ambulatory | AMB | ActCode | 2.16.840.1.113883.5.4 | Poliklinisch |
| Emergency | EMER | ActCode | 2.16.840.1.113883.5.4 | SEH |
| Field | FLD | ActCode | 2.16.840.1.113883.5.4 | Op lokatie |
| Home | HH | ActCode | 2.16.840.1.113883.5.4 | Thuis |
| Inpatient | IMP | ActCode | 2.16.840.1.113883.5.4 | Klinisch |
| Short Stay | SS | ActCode | 2.16.840.1.113883.5.4 | Dagopname |
| Virtual | VR | ActCode | 2.16.840.1.113883.5.4 | Virtueel |
| Other | OTH | NullFlavor | 2.16.840.1.113883.5.1008 | Anders |
DestinationCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.15.1.3 | Binding: Extensible |
| Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
| Home | 264362003 | SNOMED CT | 2.16.840.1.113883.6.96 | Eigen woonomgeving |
| Left against medical advice | 445060000 | SNOMED CT | 2.16.840.1.113883.6.96 | Tegen advies in vertrokken |
| Rehabilitation hospital | 80522000 | SNOMED CT | 2.16.840.1.113883.6.96 | Instelling voor revalidatie |
| Long term care facility | 42665001 | SNOMED CT | 2.16.840.1.113883.6.96 | Instelling voor verpleging/verzorging |
| Psychiatric hospital | 62480006 | SNOMED CT | 2.16.840.1.113883.6.96 | GGZ instelling |
| Hospital | 22232009 | SNOMED CT | 2.16.840.1.113883.6.96 | Ander ziekenhuis |
| Died in hospital | 183676005 | SNOMED CT | 2.16.840.1.113883.6.96 | Overleden |
| Hospice | 284546000 | SNOMED CT | 2.16.840.1.113883.6.96 | Hospice |
| Other | OTH | NullFlavor | 2.16.840.1.113883.5.1008 | Overig |
OriginCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.15.1.2 | Binding: Extensible |
| Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
| Home | 264362003 | SNOMED CT | 2.16.840.1.113883.6.96 | Eigen woonomgeving |
| Rehabilitation hospital | 80522000 | SNOMED CT | 2.16.840.1.113883.6.96 | Instelling voor revalidatie |
| Long term care facility | 42665001 | SNOMED CT | 2.16.840.1.113883.6.96 | Instelling voor verpleging/verzorging |
| Psychiatric hospital | 62480006 | SNOMED CT | 2.16.840.1.113883.6.96 | GGZ instelling |
| Hospital | 22232009 | SNOMED CT | 2.16.840.1.113883.6.96 | Ander ziekenhuis |
| Liveborn born in hospital | 442311008 | SNOMED CT | 2.16.840.1.113883.6.96 | In dit ziekenhuis geboren |
| Hospice | 284546000 | SNOMED CT | 2.16.840.1.113883.6.96 | Hospice |
| Other | OTH | NullFlavor | 2.16.840.1.113883.5.1008 | Overig |
This information model in other releases
- Release 2015, (Version 1.2)
- Release 2016, (Version 3.0)
- Release 2017, (Version 3.1)
- Prerelease 2019-2, (Version 4.0)
- Release 2020, (Version 4.0.1)
- Prerelease 2021-2, (Version 4.0.2)
- Prerelease 2022-1, (Version 5.0)
- Prerelease 2023-1, (Version 6.0)
- Prerelease 2024-1, (Version 6.0)
Information model references
This information model refers to
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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.
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 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
This page is generated on 23/12/2018 01:17:10 with ZibExtraction v. 3.0.6929.24609