Problem-v4.6.1(2022EN)

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General information

Name: nl.zorg.Problem NL.png
Version: 4.6.1
HCIM Status:Final
Release: 2022
Release status: Prepublished
Release date: 15-10-2023


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Metadata

DCM::CoderList Kerngroep Registratie aan de Bron
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::CreationDate 11-6-2012
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name PM
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.5.1
DCM::KeywordList problemen, klachten, diagnosen
DCM::LifecycleStatus Final
DCM::ModelerList Kerngroep Registratie aan de Bron
DCM::Name nl.zorg.Probleem
DCM::PublicationDate 15-10-2023
DCM::PublicationStatus Prepublished
DCM::ReviewerList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 04-09-2023
DCM::Supersedes nl.zorg.Probleem-v4.6
DCM::Version 4.6.1
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (15-02-2013) -

Publicatieversie 1.1 (01-07-2013) -

Publicatieversie 1.2 (01-04-2015)

Issue summaries niet beschikbaar
Bevat: ZIB-150, ZIB-267, ZIB-268, ZIB-269, ZIB-305, ZIB-310, ZIB-353.

Incl. algemene wijzigingsverzoeken: ZIB-94, ZIB-154, ZIB-200, ZIB-201, ZIB-309, ZIB-324, ZIB-326.

Publicatieversie 3.0 (01-05-2016) Bevat: ZIB-400, ZIB-453.

Publicatieversie 4.0 (04-09-2017) Bevat: ZIB-107, ZIB-108, ZIB-446, ZIB-459, ZIB-467, ZIB-549, ZIB-564, ZIB-529, ZIB-576.

Publicatieversie 4.1 (31-12-2017) Bevat: ZIB-579, ZIB-646.

Publicatieversie 4.1.1 (01-10-2018) Bevat: ZIB-661.

Publicatieversie 4.2 (26-02-2019) Bevat: ZIB-624, ZIB-627.

Publicatieversie 4.2.1 (06-07-2019) Bevat: ZIB-816.

Publicatieversie 4.3 (31-01-2020) Bevat: ZIB-908, ZIB-963, ZIB-987.

Publicatieversie 4.4 (01-09-2020) Bevat: ZIB-1116, ZIB-1147, ZIB-1175, ZIB-1202, ZIB-1133.

Publicatieversie 4.5 (01-12-2021) Bevat: ZIB-1433, ZIB-1477, ZIB-1575.

Publicatieversie 4.6 (10-06-2022) Bevat: ZIB-1571, ZIB-1610.

Publicatieversie 4.6.1 (15-10-2023) Bevat: ZIB-1828, ZIB-1974.

Concept

A problem describes a situation with regard to an individual’s health and/or welfare. This situation can be described by the person involved (the patient) themselves (in the form of a complaint), or by their healthcare provider (in the form of a diagnosis, for example). The situation can form cause for diagnostic or therapeutic policy.
A problem includes all kinds of medical or nursing information that represents a health problem. A problem can represent various types of health problems:
 

  • A complaint, finding by patient: a subjective, negatively experienced observation of the patient’s health. Examples: stomach ache, amnesia.
  • A symptom: an observation by or about the patient which may indicate a certain disease. Examples: fever, blood in stool, white spots on the roof of the mouth.
  • A diagnosis: medical interpretation of complaints and findings. Examples: Diabetes Mellitus type II, pneumonia, hemolytic-uremic syndrome.
  • A functional limitation: a reduction of functional options. Examples: reduced mobility, help required for dressing.
  • A complication: Every diagnosis seen by the healthcare provider as an unforeseen and undesired result of medical action. Examples: post-operative wound infections, loss of hearing through the use of antibiotics.

Purpose

An overview of a patient’s health problems has the purpose of informing all healthcare providers involved in the patient’s care on the patient’s current and past health condition. It provides insight into which problems require medical action, which are under control and which are no longer current. The problem overview also directly provides medical context for medication administered and procedures carried out.
The overview promotes an efficient, targeted continuation of the patient’s care.
A complete list of problems is of importance for automated decision support and determining contraindications.

Information Model


#VerificationStatusCodelist#1245#1250#ProblemNameCodelist#1243#ProblemStatusCodelist#ProblemTypeCodelist#1241#1249#1251#1239#1248#1918AnatomicalLocation-v1.0.2(2022EN)Problem-v4.6.1Model(2022EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:5.1.1 Arrowdown.pngProblem Root concept of the Problem information model.

A problem describes a situation with regard to an individual’s health and/or welfare. This situation can be described by the patient (in the form of a complaint) or by the health professional (in the form of a diagnosis, for example).

CD.png NL-CM:5.1.8 Arrowright.pngProblemType 0..1 The type of problem; see the concept description.
List2.png ProblemTypeCodelist
CD.png NL-CM:5.1.3 Arrowright.pngProblemName 1 The problem name defines the problem. Depending on the setting, different code systems can be used. The ProblemNameCodelist provides an overview of the possible code systems.
List2.png ProblemNameCodelist
ST.png NL-CM:5.1.13 Arrowright.pngFurtherSpecificationProblemName 0..1 Further specification of problem name when it is recorded via a thesaurus or code system in which the required level of detail is not (yet) available.
Verwijzing.png NL-CM:5.1.14 Arrowright.pngProblemAnatomicalLocation::AnatomicalLocation 0..* Anatomical location which is the focus of the problem.
363698007 Finding site
Block.png AnatomicalLocation
TS.png NL-CM:5.1.6 Arrowright.pngProblemStartDate 0..1 Onset of the symptom, complaint, functional limitation, complication or date of diagnosis. A ‘vague’ date, such as only the year or the month and the year, is permitted.
TS.png NL-CM:5.1.9 Arrowright.pngProblemEndDate 0..1 Date on which the disorder to which the problem applies, is considered not to be present anymore.This datum needs not to be the same as the date of the change in problem status. A ‘vague’ date, such as only the year or the month and the year, is permitted.
CD.png NL-CM:5.1.4 Arrowright.pngProblemStatus 1 The problem status describes the condition of the problem:

<ol> <li>Active problems are problems of which the patient experiences symptoms or for which evidence exists. <li>Problems with the status 'Inactive' refer to problems that don't affect the patient anymore or that of which there is no evidence of existence anymore. </li></ol>

List2.png ProblemStatusCodelist
CD.png NL-CM:5.1.10 Arrowright.pngVerificationStatus 0..1 Clinical status of the problem or the diagnosis.
408729009 Finding context
List2.png VerificationStatusCodelist
ST.png NL-CM:5.1.5 Arrowright.pngComment 0..1 Comment on the Problem that is determined.
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

Voorbeeld file fout: Unable to find the specified file. : nl.zorg.Zib of versie niet gevonden-v4.6.1(NL)_Voorbeeld.docx

Instructions


For the nursing domain: When two parties use different coding systems, the Snomed CT-based V&VN Dutch nursing problem list should be used for exchange, so data becomes comparable and exchangeable. A mapping table is available from the V&VN Dutch nursing problem list to Omaha System, NANDA-I and ICF.
For the mental health domain, if the GGZ diagnosis list is used then the description of the relevant diagnosis from the DSM-5 or DSM-IV must be entered in the 'comments' of this HCIM.

References

1. openEHR-EHR-EVALUATION.problem.v1 [Online] Beschikbaar op: http://www.openehr.org/knowledge/ [Geraadpleegd: 23 juli 2014].

2. North American Nursing Diagnosis Association [Online] Beschikbaar op: http://www.nanda.org [Geraadpleegd: 23 juli 2014].

3. Diagnosethesaurus. Dutch Hospital Data [Online] Beschikbaar op: http://www.dutchhospitaldata.nl [Geraadpleegd: 23 juli 2014].

4. Health Level Seven International EHR Technical Committee (February 2007) Electronic Health Record–System Functional Model, Release 1. Chapter Three: Direct Care Functions.

5. HL7 (April 2007) HL7 Implementation Guide: CDA Release 2 – Continuity of Care Document (CCD)

6. Nederlands Huisartsen Genootschap (2013) HIS-Referentiemodel 2013

Valuesets

ProblemNameCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.1.3 Binding: Required
Conceptname Codesystem name Codesystem OID
All values DHD Diagnosethesaurus 2.16.840.1.113883.2.4.3.120.5.1
All values ICD-10, dutch translation 2.16.840.1.113883.6.3.2
SNOMED CT: ^11721000146100|Dutch nursing problem simple reference set| SNOMED CT 2.16.840.1.113883.6.96
All values ICF 2.16.840.1.113883.6.254
All values ICPC-1 NL 2.16.840.1.113883.2.4.4.31.1
All values DSM-IV 2.16.840.1.113883.6.126
All values DSM-5 2.16.840.1.113883.6.344
All values GGZ Diagnoselijst 2.16.840.1.113883.3.3210.14.2.2.35

ProblemStatusCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.1.2 Binding: Required
Conceptname Conceptcode Codesystem name Codesystem OID Description
Active 55561003 SNOMED CT 2.16.840.1.113883.6.96 Actueel
Inactive 73425007 SNOMED CT 2.16.840.1.113883.6.96 Niet actueel

ProblemTypeCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.1.1 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Diagnosis interpretation 282291009 SNOMED CT 2.16.840.1.113883.6.96 Diagnose
Finding reported by subject or history provider 418799008 SNOMED CT 2.16.840.1.113883.6.96 Symptoom
Clinical finding 404684003 SNOMED CT 2.16.840.1.113883.6.96 Bevinding
Complaint [DEPRECATED] 409586006 SNOMED CT 2.16.840.1.113883.6.96 Klacht
Finding of functional performance and activity 248536006 SNOMED CT 2.16.840.1.113883.6.96 Functionele Beperking
Complication [DEPRECATED] 116223007 SNOMED CT 2.16.840.1.113883.6.96 Complicatie

VerificationStatusCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.1.4 Binding: Required
Conceptname Conceptcode Codesystem name Codesystem OID Description
Suspected 415684004 SNOMED CT 2.16.840.1.113883.6.96 Werk
Known possible 410590009 SNOMED CT 2.16.840.1.113883.6.96 Differentiaal
Confirmed present 410605003 SNOMED CT 2.16.840.1.113883.6.96 Bevestigd
Known absent 410516002 SNOMED CT 2.16.840.1.113883.6.96 Uitgesloten
Unknown UNK NullFlavor 2.16.840.1.113883.5.1008 Onbekend

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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.<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 Pre-release 2022-1
SNOMED CT and LOINC codes are based on:

  • SNOMED Clinical Terms versie: 20230930 [R] (september 2023-editie)
  • LOINC version 2.76

Conditions for use are located on the mainpage List2.png
This page is generated on 27/03/2024 11:10:59 with ZibExtraction v. 9.3.8851.20230


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