Procedure-v4.1(2017EN)

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General information

Name: nl.zorg.Procedure
Version: 4.1
HCIM Status:Final
Release: 2017
Release status: Published
Release date: 31-12-2017


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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 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 31-12-2017
DCM::PublicationStatus Published
DCM::ReviewerList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 31-12-2017
DCM::Superseeds nl.zorg.Verrichting-v4.0
DCM::Version 4.1
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


#ProcedureMethodCodelist#13108#ProcedureLateralityCodelist#13095#ProcedureAnatomicalLocationCodelist#ProcedureTypeCodelistHealthProfessional-v3.2(2017EN)Problem-v4.1(2017EN)#13106#13097HealthcareProvider-v3.1.1(2017EN)MedicalDevice-v3.1(2017EN)#13094HealthProfessional-v3.2(2017EN)#13096#13100


Type Id Concept Card. Definition DefinitionCode Reference
NL-CM:14.1.1 Procedure Root concept of the Procedure information model. This root concept contains all data elements of the Procedure information model.
71388002 Verrichting
NL-CM:14.1.2 ProcedureStartDate 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.

NL-CM:14.1.3 ProcedureEndDate 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.

NL-CM:14.1.8 ProcedureAnatomicalLocation 0..1 Anatomical location which is the focus of the procedure.
405813007 Procedure site - Direct
ProcedureAnatomicalLocationCodelist
NL-CM:14.1.11 ProcedureLaterality 0..1 Laterality adds information about body side to the anatomic location, e.g. left
272741003 Laterality
ProcedureLateralityCodelist
NL-CM:14.1.9 Indication::Problem 0..* The indication is the reason for the procedure.
363702006 Has focus
Problem
NL-CM:14.1.4 ProcedureType 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.

ProcedureTypeCodelist
NL-CM:14.1.12 ProcedureMethod 0..* the method or technique that was used to perform the procedure, e.g. approach, lavage, pressuring, ets
260686004 Method
ProcedureMethodCodelist
NL-CM:14.1.7 MedicalDevice 0..* The product, the placing of which in or on the body is the purpose of the procedure, for example placing an implant.
405815000 Procedure device
MedicalDevice
NL-CM:14.1.5 Location::HealthcareProvider 0..1 The healthcare center where the procedure was or is carried out.
HealthcareProvider
NL-CM:14.1.6 Performer::HealthProfessional 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.
HealthProfessional
NL-CM:14.1.10 Requester::HealthProfessional 0..* The healthcare provider who requested the procedure.
HealthProfessional

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 Binding:
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 Binding:
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 Binding:
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 Binding:
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

Information model references

This information model refers to

This information model is used in

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

Downloads

This information model is also available as pdf file or as spreadsheet

About this information

The information in this wikipage is based on Release 2017
Conditions for use are located on the mainpage
This page is generated on 21/12/2018 14:11:50 with ZibExtraction v. 3.0.6929.24609


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