The diagnosis is the interpretation of the condition by the care provider. This is based on known combinations of conditions and the symptoms with which these present themselves. It may involve a single diagnosis or a differential diagnosis with conditions that are under consideration.
Purpose
The diagnosis is the basis for the care plan and the activities of the health care providers that are involved in the patient's care. The diagnosis is important for evidence-based care and the evaluation of care provided, also in the form of comparative research on the basis of patients with similar conditions.
Evidence Base
The diagnosis is the interpretation of a condition by the health professional. The DiagnosisDate indicates the moment when the health professional made the diagnosis. In the case of a differential diagnosis, the health professional specifies ≥ 2 diagnosis names that he/she is currently considering. When a diagnose has ≥ 2 diagnosis names DiagnosticStatus has the value 'Differential diagnosis'.
At any given time, only one instance of Diagnosis applies to a Condition. The presentation of advancing diagnostic insight then consists of a series of instances of Diagnosis, all of which refer to the same Condition, and where the value of DiagnosisDate represents the chronology. An instance of Diagnosis with a more recent DiagnosisDate therefore replaces the previous diagnosis.
A health professional may wish to record a reason for a diagnosis. You can argue that in fact the condition has a cause, but the specification of the cause is based on the insight into what kind of condition it is. That is why we see the reason as part of the diagnosis.
The reason for a diagnosis can be an incident (e.g. a hip fracture due to a fall), a procedure (e.g. a bowel perforation due to a colonoscopy) or another diagnosis (e.g. neuropathy due to diabetes). There can be > 1 Reason: e.g. a fracture resulting from the combination of a fall and a condition that carries an increased risk of fractures.
Regardless of the diagnosis as specification of the nature of the condition, one may come to the conclusion that it is a complication. This can be represented separately using the IsComplication element. Whether there is a complication generally depends on the reason, but there are of course also reasons for which there is no complication in the sense of unintentional damage due to medical treatment or decisions.
The cardinality of the reference to Condition is 0..1, because when a diagnosis is denied there is no condition to which that diagnosis relates. To represent that a patient is not known to have, for example, diabetes type II or that diabetes type II has been excluded, one should use the Zib Exclusion with a reference to Diagnosis. In this case, the instance of Diagnosis does not refer to a Condition.
Information Model
Type
Id
Concept
Card.
Definition
DefinitionCode
Reference
NL-CM:5.6.1
Diagnosis
Root concept of the Diagnosis information model. This root concept contains all data elements of the Diagnosis information model.
The method that the care professional used to diagnose the condition, such as history taking only, history taking and physical examination or additional diagnostic examination.
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
Diagnose
DiagnoseDatum
01-03-2023
05-03-2023
DiagnoseStatus
Voorlopige diagnose
Bevestigde diagnose
WijzeVanVaststellen
Vastgesteld op basis van het klinisch beeld
Vastgesteld op basis van het klinisch beeld en aanvullend onderzoek
IsComplicatie
Nee
Nee
Toelichting
DiagnoseNaamGegevens
DiagnoseNaam
Bronchitis
Longontsteking
Diagnosesteller::Zorgverlener
Naam
Drs. L.J. Verhagen
Drs. L.J. Verhagen
Specialisme
Huisarts
Huisarts
AnatomischeLocatie
Locatie
Long
Lateraliteit
Links
AandoeningOfGesteldheid
PeriodeAanwezig
StartDatumTijd
22-02-2023
22-02-2023
StatusDatum
01-03-2023
05-03-2023
Beloop
Verslechterd
Ernst
Mild
Matig
Diagnose
DiagnoseDatum
15-01-2023
DiagnoseStatus
Bevestigde diagnose
WijzeVanVaststellen
Vastgesteld op basis van het klinisch beeld en aanvullend onderzoek
IsComplicatie
Nee
Toelichting
Val van fiets na aanrijding
DiagnoseNaamGegevens
DiagnoseNaam
Radiusfractuur
NadereSpecificatieDiagnoseNaam
Distale radiusfractuur
Diagnosesteller::Zorgverlener
Naam
C.A. van der Kamp
Specialisme
Algemene heelkunde
AnatomischeLocatie
Locatie
Radius
Lateraliteit
Links
Aanleiding
Incident
Val
AandoeningOfGesteldheid
PeriodeAanwezig
StartDatumTijd
15-01-2023
StatusDatum
15-01-2023
Beloop
Diagnose
DiagnoseDatum
03-04-2023
03-04-2023
20-04-2023
DiagnoseStatus
Voorlopige diagnose
Voorlopige diagnose
Bevestigde diagnose
WijzeVanVaststellen
Vastgesteld op basis van anamnese en klinisch beeld
Vastgesteld op basis van het klinisch beeld en aanvullend onderzoek
Vastgesteld op basis van het klinisch beeld en aanvullend onderzoek
IsComplicatie
Nee
Toelichting
DiagnoseNaamGegevens
DiagnoseNaamGegevens 1
DiagnoseNaam
Angina pectoris
Angina pectoris
Slokdarmspasme
DiagnoseNaamGegevens 2
DiagnoseNaam
Longembolie
Slokdarmspasme
DiagnoseNaamGegevens 3
DiagnoseNaam
Slokdarmspasme
Diagnosesteller::Zorgverlener
Naam
Drs. L.J. Verhagen
H. verhoeven
G.A. de Jong
Specialisme
Huisarts
Inwendige geneeskunde
Inwendige geneeskunde
AnatomischeLocatie
Locatie
Thorax
Thorax
Slokdarm
Lateraliteit
AandoeningOfGesteldheid
PeriodeAanwezig
StartDatumTijd
03-04-2023
03-04-2023
03-04-2023
StatusDatum
03-04-2023
03-04-2023
20-04-2023
Beloop
Onveranderd
Verbeterd
Ernst
Matig
Diagnose
DiagnoseDatum
08-09-2023
09-09-2023
DiagnoseStatus
Voorlopige diagnose
Bevestigde diagnose
WijzeVanVaststellen
Vastgesteld op basis van anamnese en klinisch beeld
Vastgesteld op basis van het klinisch beeld en aanvullend onderzoek
IsComplicatie
Nee
Ja
Toelichting
DiagnoseNaamGegevens
DiagnoseNaam
Pneumothorax
Longembolie
Diagnosesteller::Zorgverlener
Naam
Drs. L.J. Verhagen
G.A. de Jong
Specialisme
Huisarts
Inwendige geneeskunde
AnatomischeLocatie
Locatie
Thorax
Long
Lateraliteit
links
links
AandoeningOfGesteldheid
PeriodeAanwezig
StartDatumTijd
08-09-2023
08-09-2023
StatusDatum
08-09-2023
09-09-2023
Beloop
Onveranderd
Ernst
Ernstig
Instructions
A diagnosis always refers to the condition of which it is the interpretation. If > 1 instance of Diagnosis refers to the same condition, then the instantiation with the most recent diagnosis date represents the current diagnosis.
Technical specifications in HL7v3 CDA and HL7 FHIR
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
Diagnosis
Diagnostician::HealthProfessional
or as spreadsheet 