Procedure-v4.0(2017EN)
General information
Name: nl.zorg.Procedure 
Version: 4.0
HCIM Status:Final
Release: 2017
Release status: Prepublished
Release date: 04-09-2017
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 | 6-6-2012 |
| DCM::DeprecatedDate | |
| DCM::DescriptionLanguage | nl |
| DCM::EndorsingAuthority.Address | |
| DCM::EndorsingAuthority.Name | PM |
| DCM::EndorsingAuthority.Telecom | |
| DCM::Id | 2.16.840.1.113883.2.4.3.11.60.40.3.14.1 |
| DCM::KeywordList | procedure,verrichting |
| DCM::LifecycleStatus | Final |
| DCM::ModelerList | Kerngroep Registratie aan de Bron |
| DCM::Name | nl.zorg.Verrichting |
| DCM::PublicationDate | 04-09-2017 |
| DCM::PublicationStatus | Prepublished |
| DCM::ReviewerList | Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron |
| DCM::RevisionDate | 04-09-2017 |
| DCM::Superseeds | nl.zorg.OverdrachtVerrichting-v3.0 |
| DCM::Version | 4.0 |
| HCIM::PublicationLanguage | EN |
Revision History
Concept
The concept Procedure indicates a therapeutic or diagnostic procedure undergone by the patient.
A procedure can be a simple blood pressure measurement, but also a complex heart surgery.
Purpose
A procedure is carried out as part of a planned policy or to obtain additional information in the diagnostic process. Procedures are documented to gain insight into the treatment of a patient. In addition, procedures are documented for administrative purposes such as invoicing and workload measurement, scientific research and/or education.
Information Model
| Type | Id | Concept | Card. | Definition | DefinitionCode | Reference | ||||||||
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NL-CM:14.1.1 |  Procedure
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Root concept of the Procedure information model. This root concept contains all data elements of the Procedure information model. |
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NL-CM:14.1.2 |  ProcedureStartDate
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0..1 | The start date (and if possible start time) of the procedure. A ‘vague’ date, such as only the year, is permitted.
The element offers the option to indicate the start of the period of a series of related procedures. |
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NL-CM:14.1.3 | ProcedureEndDate
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0..1 | The end date (and if possible end time) of the procedure. A ‘vague’ date, such as only the year, is permitted.
The element offers the option to indicate the end of the period of a series of related procedures. |
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NL-CM:14.1.8 | ProcedureAnatomicalLocation
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0..1 | Anatomical location which is the focus of the procedure. |
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NL-CM:14.1.11 | ProcedureLaterality
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0..1 | Laterality adds information about body side to the anatomic location, e.g. left |
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NL-CM:14.1.9 | Indication::Problem
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0..* | The indication is the reason for the procedure. |
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NL-CM:14.1.4 | ProcedureType
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1 | The name of the procedure.
As of 1 January 2013, all procedures in the primary process have to be documented with CBV codes. To meet this requirement, the DHD procedure thesaurus (CBV procedures set) is used to code procedures. It is possible that in addition to the CBV procedures set, the NIC will be used for nurse procedures and that a “coded value set” will be introduced for paramedic procedures. |
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NL-CM:14.1.12 | ProcedureMethod
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0..* | the method or technique that was used to perform the procedure, e.g. approach, lavage, pressuring, ets |
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NL-CM:14.1.7 | MedicalDevice
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0..* | The product, the placing of which in or on the body is the purpose of the procedure, for example placing an implant. |
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NL-CM:14.1.5 | Location::HealthcareProvider
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0..1 | The healthcare center where the procedure was or is carried out. |
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NL-CM:14.1.6 | Performer::HealthProfessional
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0..* | The healthcare provider who carried out the procedure. In most cases, only the medical specialty is entered, and not the name of the healthcare provider. |
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NL-CM:14.1.10 | Requester::HealthProfessional
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0..* | The healthcare provider who requested the procedure. |
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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
| VerrichtingType | Verrichting Anatomische Locatie |
Verrichting Lateraliteit | Verrichting Start Datum |
Product | Indicatie | Uitgevoerd Door |
Locatie | |||
| ProductType | ProductID | ProbleemNaam | Toelichting | Specialisme | OrganisatieNaam | |||||
| Knie - prothese implantatie gewricht | Knie | Links | 05-06-2012 | Orthopedic surgical implants | (01)05050474530799 (17)160131 (21)1148130801 |
Implantant, Gen 2 Tibia Insert 5/6-9mm | Artrose | Beperking bij het bewegen van het gewricht, drukpijn door slijtage van twee compartimenten van de linker knie. | Orthopedie | UMCG |
Instructions
Only the procedures are described in this information model, not the results of the procedures. The LaboratoryResult and TextResult information models can be used to document the results.
Issues
Voor een succesvolle implementatie is een meer specifieke vulling van de VerrichtingMethodeCodelijst noodzakelijk
References
1. GS1 Global Traceability Standard for Healthcare 1.2.0 (2013) [Online] Beschikbaar op: http://www.gs1.org/traceability/healthcare-traceability/1-2-0 [Geraadpleegd: 19 juni 2014].
2. Vektis Zorgverlenersspecificatie (subberoepsgroep) [Online] Beschikbaar op: http://ei.vektis.nl/WespCodelijstenDetail.aspx?Co_Ge_Code=COD016&Co_Or_Code=VEKT [Geraadpleegd: 19 juni 2014].
3. AZR-AGB-codelijst [Online] Beschikbaar op: http://www.agbcode.nl/MainPage/opzoeken.aspx?soort=IS [Geraadpleegd: 19 juni 2014].
Valuesets
ProcedureAnatomicalLocationCodelist
| Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.14.1.1 |
| Conceptname | Codesystem name | Codesystem OID |
| SNOMED CT: < 442083009 |Anatomical or acquired body structure| | SNOMED CT | 2.16.840.1.113883.6.96 |
ProcedureLateralityCodelist
| Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.14.1.3 |
| Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
| Left | 7771000 | SNOMED CT | 2.16.840.1.113883.6.96 | Links |
| Right | 24028007 | SNOMED CT | 2.16.840.1.113883.6.96 | Rechts |
| Right and left | 51440002 | SNOMED CT | 2.16.840.1.113883.6.96 | Rechts en links |
ProcedureMethodCodelist
| Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.14.1.4 |
| Conceptname | Codesystem name | Codesystem OID |
| SNOMED CT: < 129264002 |Action (qualifier value)| | SNOMED CT | 2.16.840.1.113883.6.96 |
ProcedureTypeCodelist
| Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.14.1.2 |
| Conceptname | Codesystem name | Codesystem OID |
| Alle waarden | Verrichtingenthesaurus DHD | 2.16.840.1.113883.2.4.3.120.5.2 |
This information model in other releases
More on this information model
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
This information model is also available as pdf file 
or as spreadsheet 
About this information
The information in this wikipage is based on Prerelease 2017 #1
Conditions for use are located on the mainpage
This page is generated on 30/11/2017 13:38:27