Problem-v4.0(2017EN)
General information
Name: nl.zorg.Problem 
Version: 4.0
HCIM Status:Final
Publication: 2017
Release status: Prepublished
Publication date: 04-09-2017
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 | 04-09-2017 |
| DCM::PublicationStatus | Prepublished |
| DCM::ReviewerList | Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron |
| DCM::RevisionDate | 04-09-2017 |
| DCM::Superseeds | nl.zorg.OverdrachtConcern-v3.1 |
| DCM::Version | 4.0 |
| HCIM::PublicationLanguage | EN |
Revision History
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
.png)
| 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:5.1.8 |  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, different code systems can be used. The ProblemNameCodelist provides an overview of the possible code systems. |
| ||||||||
|
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:
|
| ||||||||
|
|
NL-CM:5.1.10 | VerificationStatus
|
0..1 | Clinical status of the problem or the diagnosis. |
| ||||||||
|
NL-CM:5.1.5 | Comment
|
0..1 | Comment by the one who determined or updated the Problem. |
|
||||||||
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 | Probleem BeginDatum |
ProbleemStatus | Probleem EindDatum |
Verificatie Status |
Toelichting |
| Diagnose | Polsfractuur 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
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 |
| Working diagnosis | 5558000 | SNOMED CT | 2.16.840.1.113883.6.96 | Werk |
| Differential diagnosis | 47965005 | 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 |
More on this information model
More technical information and HL7/XML documentation you can find on the Nictiz Art-Decor page about this information model[1]
This information model is also available as pdf file 
or as spreadsheet 
About this information
The information in this wikipage is based on Prerelease 2017 #1
Conditions for use are located on the mainpage
This page is generated on 21/09/2017 13:52:00