In klinische bouwsteen OverdrachtProblemen kwam de waarde van de tagged value DCM::ValueSet van concept ProbleemType niet overeen met naam van de gekoppelde valueset.
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.
In de klinische bouwsteen OverdrachtProblemen kwam de naamgeving van de tagged value van concept ProbleemStatus niet overeen met de naam van de onderliggende waardelijst.
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 It provides insight into which problems require medical action, which are under control and which are no longer current.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.
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.
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.
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
Voorbeeld file fout: Kan het opgegeven bestand niet vinden. : C:\Users\Spruyt\Dropbox\ZIBs\Prepublicatieversie 2017-1\VZIBS_Examples_2017\nl.zorg.Probleem-v4.1(NL)_Voorbeeld.docx
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.
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
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
Problem
ProblemAnatomicalLocation
or as spreadsheet 