GeneralMentalFunctions-v3.0(2016EN)

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General information

Name: nl.zorg.GeneralMentalFunctions
Version: 3.0
HCIM Status:Final
Release: 2016
Release status: Published
Release date: 1-5-2016

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Metadata

DCM::CoderList Werkgroep RadB Verpleegkundige Gegevens
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList Werkgroep RadB Verpleegkundige Gegevens
DCM::CreationDate 1-4-2014
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name PM
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.18.1
DCM::KeywordList Mentale functies, intellectuele functies, oriëntatie, bewustzijn
DCM::LifecycleStatus Final
DCM::ModelerList Werkgroep RadB Verpleegkundige Gegevens
DCM::Name nl.zorg.AlgemeneMentaleFuncties
DCM::PublicationDate 1-5-2016
DCM::PublicationStatus Published
DCM::ReviewerList Projectgroep RadB Verpleegkundige Gegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 8-9-2015
DCM::Superseeds nl.nfu.AlgemeneMentaleFuncties-v1.0
DCM::Version 3.0
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (01-07-2015)

Publicatieversie 3.0 (01-05-2016)

ZIB-453 Wijziging naamgeving ZIB's en logo's door andere opzet van beheer

Concept

Important parts of the brain’s general mental functions are intellectual functions, orientation and consciousness.
If there is a disorder in the intellectual functions as a result of a mental disability, it is not described in this information model but is recorded as a medical diagnosis.
Disorders in orientation and consciousness combined with disorders in attention, memory and observation are seen as important symptoms for the potential presence of a delirium. The latter disorders are recorded in the SpecificMentalFunctions information model.

Purpose

Together, consciousness, orientation and intellectual functions provide a good insight into a patient’s mental condition.
This information is essential in drawing up the healthcare plan. The availability of this information allows you to take into account the patient’s wishes and capabilities. Furthermore, it offers a handle in approaching and supporting the patient.
Having this information available earlier on for a transfer enables procedures to be promptly initiated to continue the care as well as possible.

Evidence Base

This information model assumes that if the patient has a disorder in intellectual functions as a result of a mental disability, this disorder is to be included on the problem list in the medical transfer (if possible using the DSM classification).
The aforementioned assumes the following definition of a mental disability: “A patient with a mental disability has a congenital disability or a disability which occurred at a later developmental stage in intellectual function. They have an IQ of 70/75 or lower. This is accompanied by limitations in social (self-)reliance. This diagnosis is partially based on the need for support."
(Source: Meijer S (RIVM). Verstandelijke beperking samengevat. In: Volksgezondheid Toekomst Verkenning, Nationaal Kompas Volksgezondheid. Bilthoven: RIVM.)

The need for support involved can be described in the relevant information model.

The definitions of the concepts were (partially) taken from the ICF definitions.

Information Model


#9513#ConsciousnessCodelist#9076#OrientationInPersonCodelist#OrientationInTimeCodelistNursingIntervention-v3.0(2016EN)#9051#9057#9067#9077#OrientationInLocationCodelist#9054#9065#IntellectualFunctionsCodelist


Type Id Concept Card. Definition DefinitionCode Reference
NL-CM:18.1.1 GeneralMentalFunctions Root concept of the GeneralMentalFunctions information model. This concept contains all data elements of the GeneralMentalFunctions information model.
NL-CM:18.1.2 Consciousness 0..1 General mental function relating to the extent of consciousness and alertness including the lucidity and continuity of being awake.

Contains: the extent of consciousness, continuity of consciousness, and quality of consciousness. Examples of disorders that may occur include: loss of consciousness, coma, vegetative state, dissociative fugue, trance, frenzy, altered consciousness caused by drugs, delirium and stupor.

b110 Bewustzijn
ConsciousnessCodelist
NL-CM:18.1.6 Orientation 0..1 Container of the Orientation concept. This container contains all data elements of the Orientation concept.
43173001 Orientation, function
NL-CM:18.1.7 OrientationInTime 0..1 Orientation in time describes a patient being aware of the day, date, month and year.
b1140 Orientatie in tijd
OrientationInTimeCodelist
NL-CM:18.1.8 OrientationInLocation 0..1 Orientation in location describes a patient being aware of their physical location, such as their immediate surroundings or their city or country of residence.


b1141 Orientatie in plaats
OrientationInLocationCodelist
NL-CM:18.1.9 OrientationInPerson 0..1 Orientation in person describes a patient being aware of their own identity and of the identity of people in their immediate environment.
b1142 Orientatie in persoon
OrientationInPersonCodelist
NL-CM:18.1.3 IntellectualFunctions 0..1 Intellectual functions describe general mental functions needed for the ability to understand things and to constructively integrate different mental functions, including all cognitive functions and development, for the duration of the patient’s life.

Contains: intellectual growth and intellectual growth disorders such as those that occur in intellectual retardation and dementia.

b117 Intellectuele functies
IntellectualFunctionsCodelist
NL-CM:18.1.4 Explanation 0..1 Explanation or comment on the general mental functions.
48767-8 Annotation comment
NL-CM:18.1.5 NursingProcedure 0..* The nursing procedures needed to help the patient with disorders in general mental functions.
NursingIntervention

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

AlgemeneMentaleFuncties
Bewustzijn Lichte stoornis (5-24%)
IntellectueleFuncties Lichte stoornis (5-24%)
Orientatie
OrientatieInTijd Matige stoornis (25-49%)
OrientatieInPlaats Ernstige stoornis (50-95%)
OrientatieInPersoon Lichte stoornis (5-24%)
VerpleegkundigeActie
Activiteit Ondersteuning dagstructuur aan de hand van programma, lag op een eenpersoonskamer.
Toelichting Patiënt is na operatie acuut verward geweest, gaat al wel beter, maar is soms nog weg kwijt. Heeft wel door dat hij soms in de war is en vindt dit erg vervelend.

References

1. International Classification of Functioning Disability and Health (ICF) [Online] Beschikbaar op:http:/www.rivm.nl/who-fic/icf.htm [Geraadpleegd: 13 februari 2015]

Valuesets

ConsciousnessCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.18.1.4
Conceptname Conceptcode Codesystem name Codesystem OID Description
Geen stoornis b110.0 ICF 2.16.840.1.113883.6.254 Stoornis 0-4%
Lichte stoornis b110.1 ICF 2.16.840.1.113883.6.254 Stoornis 5-24%
Matige stoornis b110.2 ICF 2.16.840.1.113883.6.254 Stoornis 25-49%
Ernstige stoornis b110.3 ICF 2.16.840.1.113883.6.254 Stoornis 50-95%
Volledige stoornis b110.4 ICF 2.16.840.1.113883.6.254 Stoornis 96-100%

IntellectualFunctionsCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.18.1.5
Conceptname Conceptcode Codesystem name Codesystem OID Description
Geen stoornis b117.0 ICF 2.16.840.1.113883.6.254 Stoornis 0-4%
Lichte stoornis b117.1 ICF 2.16.840.1.113883.6.254 Stoornis 5-24%
Matige stoornis b117.2 ICF 2.16.840.1.113883.6.254 Stoornis 25-49%
Ernstige stoornis b117.3 ICF 2.16.840.1.113883.6.254 Stoornis 50-95%
Volledige stoornis b117.4 ICF 2.16.840.1.113883.6.254 Stoornis 96-100%

OrientationInLocationCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.18.1.2
Conceptname Conceptcode Codesystem name Codesystem OID Description
Geen stoornis b1141.0 ICF 2.16.840.1.113883.6.254 Stoornis 0-4%
Lichte stoornis b1141.1 ICF 2.16.840.1.113883.6.254 Stoornis 5-24%
Matige stoornis b1141.2 ICF 2.16.840.1.113883.6.254 Stoornis 25-49%
Ernstige stoornis b1141.3 ICF 2.16.840.1.113883.6.254 Stoornis 50-95%
Volledige stoornis b1141.4 ICF 2.16.840.1.113883.6.254 Stoornis 96-100%

OrientationInPersonCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.18.1.3
Conceptname Conceptcode Codesystem name Codesystem OID Description
Geen stoornis b1142.0 ICF 2.16.840.1.113883.6.254 Stoornis 0-4%
Lichte stoornis b1142.1 ICF 2.16.840.1.113883.6.254 Stoornis 5-24%
Matige stoornis b1142.2 ICF 2.16.840.1.113883.6.254 Stoornis 25-49%
Ernstige stoornis b1142.3 ICF 2.16.840.1.113883.6.254 Stoornis 50-95%
Volledige stoornis b1142.4 ICF 2.16.840.1.113883.6.254 Stoornis 96-100%

OrientationInTimeCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.18.1.1
Conceptname Conceptcode Codesystem name Codesystem OID Description
Geen stoornis b1140.0 ICF 2.16.840.1.113883.6.254 Stoornis 0-4%
Lichte stoornis b1140.1 ICF 2.16.840.1.113883.6.254 Stoornis 5-24%
Matige stoornis b1140.2 ICF 2.16.840.1.113883.6.254 Stoornis 25-49%
Ernstige stoornis b1140.3 ICF 2.16.840.1.113883.6.254 Stoornis 50-95%
Volledige stoornis b1140.4 ICF 2.16.840.1.113883.6.254 Stoornis 96-100%


This information model in other releases

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 summer 2016
Conditions for use are located on the mainpage
This page is generated on 24/01/2018 23:41:58

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