ClinicalNote-v1.0(EN)

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General information[bewerken]

Name: nl.zorg.template.ClinicalNote NL.png
Version: 1.0
HCIM Status:Final
Release status: Published
Release date: 01-09-2020


Metadata[bewerken]

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[bewerken]

Only available in Dutch

Publicatieversie 1.0 (01-09-2020) .

Concept[bewerken]

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[bewerken]

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[bewerken]


#[Section]CodeCodelist#13721#13726HealthProfessional-v3.5(2020EN)#[Section]HeaderCodelist#13727#13717#13719#13725#13723ClinicalNote-v1.0Model(EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:21.3.1 Arrowdown.png[ClinicalNote] Root concept of the [ClinicalNote] information model.This root concept contains all data elements of the [ClinicalNote] template.
TS.png NL-CM:21.3.2 Arrowright.png[ClinicalNote]DateTime 0..1 Date and optionally the time the note was created.
Verwijzing.png NL-CM:21.3.3 Arrowright.pngAuthor::HealthProfessional 0..1 The healthcare provider who prepared the report and who is responsible for its content.
Block.png HealthProfessional
ED.png NL-CM:21.3.4 Arrowright.png[Files] 0..* Original files (letters, photos, videos, ..) that are among other things the reason for drawing up the note.
Folder.png NL-CM:21.3.5 Arrowdown.png[Section] 1..* Container of the [Section] concept.This container contains all data elements of the [Section] concept.
CD.png NL-CM:21.3.6 Arrowright.png[Section]Code 0..* One or more coded values can be added to a section that describe essential aspects of the section.
List2.png [Section]CodeCodelist
CD.png NL-CM:21.3.7 Arrowright.png[Section]Header 0..1 The name of the section as an coded description.
List2.png [Section]HeaderCodelist
ST.png NL-CM:21.3.8 Arrowright.png[Section]Text 1 The actual content of the section as free formatted text.
422813005 Document section

Columns Concept and DefinitionCode: hover over the values for more information
For explanation of the symbols, please see the legend page List2.png

Valuesets[bewerken]

[Section]CodeCodelist[bewerken]

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[bewerken]

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[bewerken]

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 List2.png
This page is generated on 03/09/2020 14:29:13 with ZibExtraction v. 4.0.7551.21411