Condition-v1.0(2024EN)

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General information

Name: nl.zorg.Condition NL.png
Version: 1.0
HCIM Status:Final
Release: 2024
Release status: Prepublished
Release date: 15-04-2024


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Metadata

DCM::CoderList Zib-centrum
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList Zib-centrum
DCM::CreationDate 26-04-2023
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name *
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.5.4
DCM::KeywordList
DCM::LifecycleStatus Final
DCM::ModelerList *
DCM::Name nl.zorg.AandoeningOfGesteldheid
DCM::PublicationDate 15-04-2024
DCM::PublicationStatus Prepublished
DCM::ReviewerList Zib-centrum
DCM::RevisionDate
DCM::Supersedes *
DCM::Version 1.0
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (15-04-2024)

ZIB-1146 nieuwe datums toevoegen aan zib Probleem ivm onderliggend lijden
ZIB-1295 correctie en toevoegen SNOMED CT termen in de zib probleem
ZIB-1370 Verschillende waardenlijsten voor status in zib-problem en zib-allergyintolerance
ZIB-1394 Codelijst ProbleemType in zib Probleem
ZIB-2170 ZIB Probleem Diagnosedatum

Concept

A condition is pathological or non-pathological state of the patient that generally presents with symptoms. It is 'that what the patient has'. A care professional can assign a (differential) diagnosis to the condition. The symptoms as well as the diagnostic insight with respect to the same condition may change over time.

Purpose

A clear representation of the symptoms and diagnostic insight per condition. This contributes to the insight of the health care professionals involved into the patient's health status. It helps evaluate the effect of the care provided and determine follow-up policy.

Evidence Base

Note on zib Condition This zib describes the characteristics of a patient's condition: the period during which the condition is present, its severity and course. The designation of the condition is not a characteristic, but an interpretation by the health professional. The zib DiagnosticInsight represents this interpretation. The condition presents itself with symptoms for which there is the zib Symptom.
Both the interpretation of the condition and the symptoms, with which it presents itself, can change independently over time.
 
If possible, a health professional will communicate about a condition by its interpretation in the form of a (differential) diagnosis. If there is not yet a (differential) diagnosis, he/she will communicate about it on the basis of ≥ 1 major symptoms that he/she thinks belong together and can probably be explained by one condition.
Relationship between (differential) diagnosis and symptoms The zibs DiagnosticInsight for the (differential) diagnosis and the zib Symptom each refer to the zib Condition. Via this reference it is clear to which condition the (differential) diagnosis and symptoms refer. This makes it clear at any moment in time what the diagnostic insight is and what the status of the symptoms is.

Functionality (informative) If the patient presents with a new request for care or problem, the health professional will register this using a (differential) diagnosis and/or ≥ 1 symptoms.
To do this, the EHR must create an instance of a Condition with the corresponding fields for PeriodPresent, Severity, Course, and a StatusDate indicating the time from which the values entered apply. In addition, the EHR must support the representation of the (differential) diagnosis and/or symptoms entered by the health professional, with a reference to the corresponding Condition.
In the EHR, the content of the fields StartDate, EndDate, Severity and Course will be recorded with the Condition.

Patient Population

The entire patient population.

Information Model


TimeInterval-v1.3(2024EN)#CourseCodelist#4901#SeverityCodelist#4904#4899#4900#4905Condition-v1.0Model(2024EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:5.4.1 Arrowdown.pngCondition This is a reference to the root concept of information model Condition. This root concept contains all data elements of the information model Condition.
365860008 General clinical state finding
Verwijzing.png NL-CM:5.4.8 Arrowright.pngPeriodPresent::TimeInterval 1 The period in which the condition is (was) present.
Block.png TimeInterval
TS.png NL-CM:5.4.3 Arrowright.pngStatusDate 1 The moment from when the data regarding the condition apply. It may be a vague moment.
350351000146106 Date health condition changed
CD.png NL-CM:5.4.5 Arrowright.pngCourse 0..1 The course of the condition. This is independent of the diagnostic insight for the condition. The course indicates how the condition is developing: such as stable, progression, remission, etc..
List2.png CourseCodelist
CD.png NL-CM:5.4.6 Arrowright.pngSeverity 1 Indication of the severity of the condition. A condition may cause few or mild symptoms and yet be serious, but the reverse is also possible.
246112005 Severity
List2.png SeverityCodelist
ST.png NL-CM:5.4.7 Arrowright.pngComment 0..1 A comment in free text with respect to the condition, that is not represented by the other data elements in the information model.
48767-8 Annotation comment [Interpretation] Narrative

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

Example Instances

Only available in Dutch

AandoeningOfGesteldheid
PeriodeAanwezig
StartDatumTijd 22-02-2023 22-02-2023 22-02-2023
EindDatumTijd
StatusDatum 01-03-2023 05-03-2023 20-03-2023
Beloop Verslechterd Verbeterd
Ernst Mild Matig Mild
Toelichting
SymptoomNaam Hoest Hoest, Koorts Hoest
DiagnoseNaam Bronchitis Longontsteking Longontsteking
AandoeningOfGesteldheid
PeriodeAanwezig
StartDatumTijd 15-01-2023 15-01-2023 15-01-2023
EindDatumTijd 08-05-2023
StatusDatum 15-01-2023 26-02-2023 08-05-2023
Beloop Herstellend Niet meer aanwezig
SymptoomNaam Pijn, zwelling, standsafwijking Stijfheid
DiagnoseNaam Radiusfractuur Radiusfractuur Radiusfractuur

Valuesets

CourseCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.4.1 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
NTB NTB SNOMED CT 2.16.840.1.113883.6.96 Asymptomatisch
Improved 385425000 SNOMED CT 2.16.840.1.113883.6.96 Verbeterd
Worse 231877006 SNOMED CT 2.16.840.1.113883.6.96 Verslechterd
No status change 260388006 SNOMED CT 2.16.840.1.113883.6.96 Onveranderd
Progressive 255314001 SNOMED CT 2.16.840.1.113883.6.96 Progressief
NTB NTB SNOMED CT 2.16.840.1.113883.6.96 Opvlammend
No longer present 350361000146109 SNOMED CT 2.16.840.1.113883.6.96 Niet meer aanwezig
Other OTH NullFlavor 2.16.840.1.113883.5.1008 Anders

SeverityCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.4.3 Binding: Required
Conceptname Conceptcode Codesystem name Codesystem OID Description
Mild 255604002 SNOMED CT 2.16.840.1.113883.6.96 Mild
Mild to moderate 371923003 SNOMED CT 2.16.840.1.113883.6.96 Mild tot matig
Moderate severity 6736007 SNOMED CT 2.16.840.1.113883.6.96 Matig
Moderate to severe 371924009 SNOMED CT 2.16.840.1.113883.6.96 Matig tot ernstig
Severe 24484000 SNOMED CT 2.16.840.1.113883.6.96 Ernstig
Life threatening severity 442452003 SNOMED CT 2.16.840.1.113883.6.96 Levensbedreigend
Fatal 399166001 SNOMED CT 2.16.840.1.113883.6.96 Fataal

This information model in other releases

Information model references

This information model refers to

This information model is used in

Technical specifications in HL7v3 CDA and HL7 FHIR

To exchange information based on health and care information models, additional, more technical specifications are required.<BR> 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 Artdecor.jpg
  • HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR Fhir.png

Downloads

This information model is also available as pdf file PDF.png or as spreadsheet Xlsx.png

About this information

The information in this wikipage is based on Prerelease 2024-1
SNOMED CT and LOINC codes are based on:

  • SNOMED Clinical Terms versie: 20240331 [R] (maart 2024-editie)
  • LOINC version 2.77

Conditions for use are located on the mainpage List2.png
This page is generated on 25/04/2024 12:39:51 with ZibExtraction v. 9.3.8880.19756


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