NursingIntervention-v4.0(2021EN)

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General information

Name: nl.zorg.NursingIntervention NL.png
Version: 4.0
HCIM Status:Final
Release: 2021
Release status: Prepublished
Release date: 01-12-2021


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Metadata

DCM::CoderList Werkgroep RadB Verpleegkundige Gegevens
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList Werkgroep RadB Verpleegkundige Gegevens
DCM::CreationDate 7-7-2014
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name PM
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.14.2
DCM::KeywordList Interventie, verpleegkundige actie
DCM::LifecycleStatus Final
DCM::ModelerList Werkgroep RadB Verpleegkundige Gegevens
DCM::Name nl.zorg.VerpleegkundigeInterventie
DCM::PublicationDate 01-12-2021
DCM::PublicationStatus Prepublished
DCM::ReviewerList Projectgroep RadB Verpleegkundige Gegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 10-09-2021
DCM::Supersedes nl.zorg.VerpleegkundigeInterventie-v3.2
DCM::Version 4.0
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (01-07-2015)

Publicatieversie 3.0 (01-05-2016)

ZIB-453 Wijziging naamgeving ZIB's en logo's door andere opzet van beheer

Publicatieversie 3.1 (04-09-2017)

ZIB-542 Verwijderen verwijzingen naar codesystemen ICF, Omaha System, NANDA,,NIC en NOC

Publicatieversie 3.2 (01-10-2018)

ZIB-728 aanpassing zib verpleegkundige interventie

Publicatieversie 4.0 (01-12-2021)

ZIB-1252 CLONE - VerpleegkundigeInterventie-v3.2, aanpassing verwijzing codelijst
ZIB-1281 diverse refsets voor verpleegkundige interventies/observaties.
ZIB-1483 Voorbeelden verpleegkundige interventie niet aangepast
ZIB-1486 Code nodig voor frequentie/interval verpleegkundige interventie
ZIB-1502 Intentie van VerpleegkundigeInterventie wordt niet duidelijk gemaakt
ZIB-1510 zib VerpleegkundigeInterventie: voorbeeld voldoet niet (meer) aan zib
ZIB-1558 Verander conceptnaam "HealthcareProvider" naar "HealthProfessional"

Concept

A nursing intervention is the care and/or treatment that a nurse performs on the basis of expert judgment and clinical knowledge. It is part of the nursing process; interventions are determined on the basis of indicated care problems (nursing diagnoses) and on the basis of treatment goals. In the home care situation, after instruction, some actions can also be performed by the patient himself or by a caregiver. In the right context, the concept can describe historical, future and advised nursing interventions.

Purpose

Nursing interventions are an essential part of the nursing process. A nursing intervention is recorded to document nursing actions and to inform other healthcare providers. In this way, optimal nursing and continuity of care can be facilitated.

Information Model


Patient-v4.0(2021EN)ContactPerson-v3.5(2021EN)#12363#12366TreatmentObjective-v3.2(2021EN)MedicalDevice-v3.4(2021EN)#12361#12354#12370HealthProfessional-v3.5.1(2021EN)Problem-v4.5(2021EN)#12357#12359#12356HealthProfessional-v3.5.1(2021EN)#12371#NursingInterventionCodelist#NursingActivityCodelistNursingIntervention-v4.0Model(2021EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:14.2.1 Arrowdown.pngNursingIntervention Root concept of the NursingIntervention information model. This root concept contains all data elements of the NursingIntervention information model.
9632001 Nursing procedure
CD.png NL-CM:14.2.2 Arrowright.pngIntervention 1 A nursing intervention is a treatment carried out by a nurse based on an expert opinion and clinical knowledge for the benefit of the person requesting healthcare. The intervention is targeted towards a certain problem (diagnosis) and has a predetermined healthcare result. It is possible to build a hierarchy of nursing interventions (where one intervention is part of another).
List2.png NursingActivityCodelist
List2.png NursingInterventionCodelist
Verwijzing.png NL-CM:14.2.6 Arrowright.pngIndication::Problem 0..1 The nursing-related problem (indication) providing cause for the intervention.
Block.png Problem
Verwijzing.png NL-CM:14.2.14 Arrowright.pngTreatmentObjective 0..1 The description of the treatment goal that the intervention decision is based on.
Block.png TreatmentObjective
PQ.png NL-CM:14.2.3 Arrowright.pngInterval 0..1 Interval indicates the time between planned procedures.

When entering an interval, the focus is on the time between the consecutive procedures, such as in the treatment of a wound, for example. The exact times are of lesser importance.

153691000146106 Interval between procedures
PQ.png NL-CM:14.2.4 Arrowright.pngFrequency 0..1 The frequency describes how often and in which period certain procedures are carried out, e.g. 3x a day.
153681000146109 Procedure frequency
TS.png NL-CM:14.2.11 Arrowright.pngProcedureStartDateTime 0..1 The start date (and if possible start time) of the procedure. The concept offers the option to indicate the start of the period of a series of repeating procedures.
TS.png NL-CM:14.2.12 Arrowright.pngProcedureEndDateTime 0..1 The end date (and if possible end time) of the procedure. The concept offers the option to indicate the end of the period of a series of repeating procedures.
Verwijzing.png NL-CM:14.2.13 Arrowright.pngMedicalDevice 0..* Description of the materials used for the nursing procedure, such as bandages.
Block.png MedicalDevice
ST.png NL-CM:14.2.18 Arrowright.pngInstruction 0..1 Instructions for performing the nursing action. This is particularly at issue when the action is performed by the patient himself or by a caregiver.
Folder.png NL-CM:14.2.15 Arrowdown.pngPerformer 0..1 The person carrying out the nursing procedure.
Verwijzing.png NL-CM:14.2.7 Arrowright.pngHealthProfessional (0..1) The health professional carrying out the nursing procedure.
Block.png HealthProfessional
Verwijzing.png NL-CM:14.2.16 Arrowright.pngCaregiver::ContactPerson (0..1) The caregiver carrying out the nursing procedure.
Block.png ContactPerson
Verwijzing.png NL-CM:14.2.17 Arrowright.pngPatient (0..1) The patient carrying out the nursing procedure.
Block.png Patient
Verwijzing.png NL-CM:14.2.8 Arrowright.pngRequester::HealthProfessional 0..* The health professional who requested the nursing intervention. If desired, only the requester’s specialty can be entered.
Block.png HealthProfessional
ST.png NL-CM:14.2.5 Arrowright.pngComment 0..1 Comment on the nursing intervention.
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

VerpleegkundigeInterventie
Interventie Ondersteunen bij wassen en/of persoonlijke hygiene
ActieStartDatumTijd 10-9-2021
Frequentie 1/dag
Instructie Let op: valrisico
Indicatie
ProbleemNaam Probleem met zichtzelf wassen en drogen
ProbleemBeginDatum 28-8-2021
ProbleemStatus Actueel
Toelichting Meneer kan niet buigen
Behandeldoel
GewenstZorgresultaat Wassen onafhankelijk

Instructions

For the nursing domain: when two parties use different classification systems, the SNOMED CT based Dutch nursing problem list is used for exchange of information, so that data becomes comparable and interchangeable. A mapping table is available from the Dutch nursing problem list to Omaha System, NANDA-I and ICF.

References

1. Richtlijn Verpleegkundige en verzorgende verslaglegging (V&VN, 2011) [Online] Beschikbaar op:http://www.diliguide.nl/document/4060/file/pdf/ [Geraadpleegd: 13 februari 2015]

2. Vreeke E, Klein Wolterink G. Classificatie- en terminologiestelsels voor verpleegkundige informatie. Nictiz & NFU (2014). [Geraadpleegd: 13 februari 2015]

3. The Omaha System [Online] Beschikbaar op:http://www.omahasystem.org/ [Geraadpleegd: 13 februari 2015]

4. Nursing Intervention Classification (NIC) [Online] Beschikbaar op:http://www.nursing.uiowa.edu/center-for-nursing-classification-and-clinical-effectiveness [Geraadpleegd: 13 februari 2015]

5. Nursing Outcome Classification (NOC) [Online] Beschikbaar op:http://www.nursing.uiowa.edu/center-for-nursing-classification-and-clinical-effectiveness [Geraadpleegd: 13 februari 2015]

6. North American Nursing Diagnosis Association (NANDA) [Online] Beschikbaar op:http://www.nanda.org/ [Geraadpleegd: 13 februari 2015]

7. International Classification for Nursing Practice (ICNP) [Online] Beschikbaar op:www.icn.ch[Geraadpleegd: 13 februari 2015]

8. International Classification of Functioning, Disability and Health (ICF) [Online] Beschikbaar op:http://www.rivm.nl/who-fic/icf.htm [Geraadpleegd: 13 februari 2015]

Traceability to other Standards

The HCIM NursingIntervention is a specialization of the HCIM Procedure.

Valuesets

NursingActivityCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.2.6 Binding: Required
Conceptname Codesystem name Codesystem OID
SNOMED CT: ^733990004|Nursing Activities Reference Set| SNOMED CT 2.16.840.1.113883.6.96

NursingInterventionCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.2.5 Binding: Required
Conceptname Codesystem name Codesystem OID
SNOMED CT: ^99051000146107|Dutch nursing intervention simple reference set| SNOMED CT 2.16.840.1.113883.6.96

This information model in other releases

Information model references

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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 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 Pre-release 2021-2
SNOMED CT and LOINC codes are based on:

  • SNOMED Clinical Terms version: 20210731 [R] (July 2021 Release)
  • LOINC version 2.67

Conditions for use are located on the mainpage List2.png
This page is generated on 30/11/2021 10:41:21 with ZibExtraction v. 6.4.8004.1652


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