ClinicalNote-v1.0(EN)
General information
Name: nl.zorg.template.ClinicalNote 
Version: 1.0
HCIM Status:Final
Release status: Published
Release date: 01-09-2020
Metadata
| DCM::CoderList | |
| DCM::ContactInformation.Address | * |
| DCM::ContactInformation.Name | * |
| DCM::ContactInformation.Telecom | * |
| DCM::ContentAuthorList | |
| DCM::CreationDate | 27-4-2020 |
| DCM::DescriptionLanguage | nl |
| DCM::EndorsingAuthority.Address | |
| DCM::EndorsingAuthority.Name | PM |
| DCM::EndorsingAuthority.Telecom | |
| DCM::Id | 2.16.840.1.113883.2.4.3.11.60.40.3.21.3 |
| DCM::KeywordList | Notitie, Verslag |
| DCM::LifecycleStatus | Final |
| DCM::ModelerList | * |
| DCM::Name | nl.zorg.template.ZorgNotitie |
| DCM::PublicationDate | 01-09-2020 |
| DCM::PublicationStatus | Published |
| DCM::ReviewerList | * |
| DCM::RevisionDate | |
| DCM::Supersedes | |
| DCM::Version | 1.0 |
| HCIM::PublicationLanguage | EN |
Revision History
Only available in Dutch
Publicatieversie 1.0 (01-09-2020) .
Concept
A healthcare note is a structured or unstructured document in which a healthcare professional records free text information regarding a contact or finding with regard to the care for or treatment of a patient.
This is a template for information models For actual use, meaningful element names and value set concepts must be defined for derived HCIM's.
Purpose
A care note offers the possibility to record textual information that, especially in the primary care process, can be consulted at a later date.
Information Model
| Type | Id | Concept | Card. | Definition | DefinitionCode | Reference | |||||||
|
NL-CM:21.3.1 |  [ClinicalNote]
|
Root concept of the [ClinicalNote] information model.This root concept contains all data elements of the [ClinicalNote] template. | ||||||||||
|
NL-CM:21.3.2 |  [ClinicalNote]DateTime
|
0..1 | Date and optionally the time the note was created. | |||||||||
|
NL-CM:21.3.3 | Author::HealthProfessional
|
0..1 | The healthcare provider who prepared the report and who is responsible for its content. |
| ||||||||
|
NL-CM:21.3.4 | [Files]
|
0..* | Original files (letters, photos, videos, ..) that are among other things the reason for drawing up the note. | |||||||||
|
NL-CM:21.3.5 | [Section]
|
1..* | Container of the [Section] concept.This container contains all data elements of the [Section] concept. | |||||||||
|
NL-CM:21.3.6 | [Section]Code
|
0..* | One or more coded values can be added to a section that describe essential aspects of the section. |
| ||||||||
|
|
NL-CM:21.3.7 | [Section]Header
|
0..1 | The name of the section as an coded description. |
| ||||||||
|
NL-CM:21.3.8 | [Section]Text
|
1 | The actual content of the section as free formatted text. |
|
||||||||
Columns Concept and DefinitionCode: hover over the values for more information
For explanation of the symbols, please see the legend page 
Valuesets
[Section]CodeCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.21.3.1 | Binding: Extensible |
| Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
[Section]HeaderCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.21.3.2 | Binding: Extensible |
| Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
About this information
The information in this wikipage is based on Release 2020
SNOMED CT and LOINC codes are based on:
- SNOMED Clinical Terms version: 20200309 [R] (March 2020 Interim Release)
- LOINC version 2.67
Conditions for use are located on the mainpage
This page is generated on 03/09/2020 14:29:13 with ZibExtraction v. 4.0.7551.21411