Diagnostic insight 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
Diagnostic insight is the basis for the care plan and the activities of the health care providers that are involved in the patient's care. It is important for the application of 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
Note on zib DiagnosticInsight
The diagnostic insight is the interpretation of a condition in the form of a (differential) diagnosis by the health professional. The DiagnosticInsightDate indicates the moment when the health professional acquired the insight. In the case of a differential diagnosis, the health professional specifies ≥ 2 diagnoses that he/she is currently considering. For all diagnoses within one differential diagnosis, CertaintyStatus has the value 'possible'.
At any given time, only one instance of DiagnosticInsight applies to a Condition. The presentation of advancing diagnostic insight then consists of a series of instances of DiagnosticInsight, all of which refer to the same Condition, and where the value of DiagnosticInsightDate represents the chronology. An instance of DiagnosticInsight with a more recent DiagnosticInsightDate therefore replaces the previous diagnostic insight.
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 diagnostic insight.
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).
Regardless of the diagnostic insight 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 DiagnosticInsight. In this case, the instance of DiagnosticInsight does not refer to a Condition.
Functionality (informative)
EHRs already offer the option to distinguish between recording a new diagnosis or changing a diagnosis. When recording a new (differential) diagnosis, the EHR must create a new Condition and have the new instance of DiagnosticInsight refer to it. When changing a diagnosis, the EHR must have the new instance of DiagnosticInsight refer to the same Condition as the previous instance of DiagnosticInsight.
It is highly desirable for the EHR to provide functionality to maintain the order of diagnoses within a differential diagnosis, as many health professionals then record diagnoses in order of descending probability.
Information Model
Type
Id
Concept
Card.
Definition
DefinitionCode
Reference
NL-CM:5.6.1
DiagnosticInsight
Root concept of the DiagnosticInsight information model.This root concept contains all data elements of the DiagnosticInsight information model.
The method that the care professional used to diagnose the condition, such as history taking only, history taking and physical examination, additional diagnostic examination or information from other care professionals.
The diagnostic insight with regard to another condition that, based on that diagnostic insight, is seen as a reason for the condition with the current diagnostic insight.
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
DiagnostischInzicht
DiagnostischInzichtDatum
01-03-2023
05-03-2023
ZekerheidsStatus
In Overweging
Bevestigd
WijzeVanVaststellen
Vastgesteld op basis van het klinisch beeld
Vastgesteld op basis van het klinisch beeld en aanvullend onderzoek
IsComplicatie
Nee
Nee
Toelichting
Diagnose
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
DiagnostischInzicht
DiagnostischInzichtDatum
15-01-2023
ZekerheidsStatus
Bevestigd
WijzeVanVaststellen
Vastgesteld op basis van het klinisch beeld en aanvullend onderzoek
IsComplicatie
Nee
Toelichting
Val van fiets na aanrijding
Diagnose
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
DiagnostischInzicht
DiagnostischInzichtDatum
03-04-2023
03-04-2023
20-04-2023
ZekerheidsStatus
Mogelijk
Mogelijk
Bevestigd
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
Diagnose
Diagnose 1
DiagnoseNaam
Angina pectoris
Angina pectoris
Slokdarmspasme
Diagnose 2
DiagnoseNaam
Longembolie
Slokdarmspasme
Diagnose 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
DiagnostischInzicht
DiagnostischInzichtDatum
08-09-2023
08-09-2023
09-09-2023
ZekerheidsStatus
Mogelijk
Uitgesloten
Bevestigd
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
Ja
Toelichting
Diagnose
DiagnoseNaam
Pneumothorax
Pneumothorax
Longembolie
Diagnosesteller::Zorgverlener
Naam
Drs. L.J. Verhagen
H. verhoeven
G.A. de Jong
Specialisme
Huisarts
SEH-arts
Inwendige geneeskunde
AnatomischeLocatie
Locatie
Thorax
Thorax
Long
Lateraliteit
links
links
links
AandoeningOfGesteldheid
PeriodeAanwezig
StartDatumTijd
08-09-2023
08-09-2023
08-09-2023
StatusDatum
08-09-2023
08-09-2023
09-09-2023
Beloop
Onveranderd
Onveranderd
Ernst
Ernstig
Instructions
A diagnostic insight always refers to the condition of which it is the interpretation. If > 1 instance of diagnostic insight refers to the same condition, then the instantiation with the most recent diagnosis date represents the current diagnostic insight.
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
HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR
DiagnosticInsight
Diagnostician::HealthProfessional
or as spreadsheet 