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General information
Name: nl.zorg.Procedure 
Version: 4.2
HCIM Status:Final
Release: 2018
Release status: Prepublished
Release date: 26-02-2019
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 |
26-02-2019
|
| DCM::PublicationStatus |
Prepublished
|
| DCM::ReviewerList |
Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
|
| DCM::RevisionDate |
31-12-2017
|
| DCM::Superseeds |
nl.zorg.Verrichting-v4.1
|
| DCM::Version |
4.2
|
| HCIM::PublicationLanguage |
EN
|
Revision History
Only available in Dutch
Publicatieversie 1.0 (15-02-2013)
-
Publicatieversie 1.1 (01-07-2013)
| ZIB-55
|
RFC Bouwsteen Procedure
|
| ZIB-24
|
Diagnostische verrichtingen onderdeel van Results
|
Publicatieversie 1.2 (01-04-2015)
| ZIB-84
|
Klinische bouwsteen nl.nfu.OverdrachtProcedure uitbreiden met Aanvrager (n.a.v. issue #077)
|
| ZIB-93
|
Bouwsteennaam Procedure wijzigen in Verrichting
|
| ZIB-95
|
Elementen in Example of the Instrument OverdrachtProcedure komen niet terug in model
|
| ZIB-122
|
De definitie van de sectie Concept van de bouwsteen OverdrachtProcedure aanpassen.
|
| ZIB-270
|
Aanpassen DCM::DefinitionCode van rootconcept Verrichting van NL-CM-14.1.1 naar NL-CM:14.1.1.
|
| ZIB-271
|
In de klinische bouwsteen OverdrachtProcedure DCM::ValueSet SNOMED CT aangepast van concept AnatomischeLokalisatie naar tagged value DCM::ContentExpression.
|
| ZIB-272
|
In klinische bouwsteen OverdrachtProcedure DCM::ValueSet CBV verrichtingen van concept VerrichtingType aangepast naar tagged value DCM::CodeSystem.
|
| ZIB-273
|
Tagged value DCM::ReferencedDefinitionCode is onjuist voor classes UitgevoerdDoor::Zorgverlener en AangevraagdDoor::Zorgverlener, dit zou NL-CM:17.1.1 moeten zijn i.p.v. NL-CM:17.1.2.
|
| ZIB-308
|
Prefix Overdracht weggehaald bij de generieke bouwstenen
|
| ZIB-325
|
AnatomischeLokaisatie wijzigen in AnatomischeLocatie
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| ZIB-353
|
Tagged values DCM::CodeSystem aanpassen naar DCM::ValueSet incl. gekoppelde codelijst.
|
Incl. algemene wijzigingsverzoeken:
| ZIB-94
|
Aanpassen tekst van Disclaimer, Terms of Use & Copyrights
|
| ZIB-154
|
Consequenties opsplitsing Medicatie bouwstenen voor overige bouwstenen.
|
| ZIB-200
|
Naamgeving SNOMED CT in tagged values klinische bouwstenen gelijk getrokken.
|
| ZIB-201
|
Naamgeving OID: in tagged value notes van klinische bouwstenen gelijk getrokken.
|
| ZIB-309
|
EOI aangepast
|
| ZIB-324
|
Codelijsten Name en Description beginnen met een Hoofdletter
|
| ZIB-326
|
Tekstuele aanpassingen conform de kwaliteitsreview kerngroep 2015
|
Publicatieversie 3.0 (01-05-2016)
| ZIB-401
|
CBV Verrichtingen mist geldig OID
|
| ZIB-453
|
Wijziging naamgeving ZIB's en logo's door andere opzet van beheer
|
Publicatieversie 3.1 (04-09-2017)
| ZIB-475
|
Terminologiekoppeling Drugsgebruik
|
| ZIB-549
|
De Engelse naam van de bouwsteen en het rootconcept zijn niet correct
|
| ZIB-564
|
Aanpassing/harmonisatie Engelse conceptnamen
|
| ZIB-576
|
Aanpassen bouwstenen die nog de prefix overdracht hebben, zodat de prefix kan vervallen.
|
Publicatieversie 4.0 (04-09-2017)
| ZIB-457
|
Uitbreiding AnatomischeLocatieCodelijst met Snomed qualifiers
|
| ZIB-458
|
Uitbreiding met dataelement "werkwijze"
|
| ZIB-515
|
Geen informatie
|
| ZIB-518
|
Geen informatie
|
| ZIB-549
|
De Engelse naam van de bouwsteen en het rootconcept zijn niet correct
|
| ZIB-564
|
Aanpassing/harmonisatie Engelse conceptnamen
|
| ZIB-574
|
Alleen verwijzen naar het rootconcept van de ZIB.
|
| ZIB-576
|
Aanpassen bouwstenen die nog de prefix overdracht hebben, zodat de prefix kan vervallen.
|
| ZIB-578
|
Aan het concept anatomische locatie moet een concept Laterariteit toegevoegd worden.
|
| ZIB-581
|
Geen informatie
|
| ZIB-585
|
Toevoegen concept Lateraliteit aan het concept Anatomische Locatie
|
Publicatieversie 4.1 (31-12-2017)
Publicatieversie 4.2 (26-02-2019)
| ZIB-624
|
Waardelijsten met DHD en Nationale Kernset Patiëntproblemen V&VN niet implementeerbaar
|
| ZIB-633
|
Toevoegen SNOMED CT als codelijst aan VerrichtingType, naast de DHD Verrichtingenthesaurus
|
| ZIB-625
|
Verrichting: uitbreiden VerrichtingTypeCodelijst met codestelsel NZa
|
| ZIB-675
|
toevoegen CBV codelijst aan verrichtingtype
|
.
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
|
|
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.
|
|
|
|
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.
|
|
|
|
|
NL-CM:14.1.11
|
|
ProcedureLaterality
|
0..1
|
Laterality adds information about body side to the anatomic location, e.g. left
|
|
|
|
NL-CM:14.1.9
|
|
Indication::Problem
|
0..*
|
The indication is the reason for the procedure.
|
|
|
|
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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.
|
|
|
|
|
NL-CM:14.1.12
|
|
ProcedureMethod
|
0..*
|
the method or technique that was used to perform the procedure, e.g. approach, lavage, pressuring, ets
|
|
|
|
|
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.
|
|
|
|
|
NL-CM:14.1.5
|
|
Location::HealthcareProvider
|
0..1
|
The healthcare center where the procedure was or is carried out.
|
|
|
|
|
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.
|
|
|
|
|
NL-CM:14.1.10
|
|
Requester::HealthProfessional
|
0..*
|
The healthcare provider who requested the procedure.
|
|
|
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
We allow multiple, current code systems (SNOMED, NZa and CBV) with the preference of using SNOMED (using DHD-Verrichtingenthesaurus) as soon as available.
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.
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: Extensible
|
| 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: Extensible
|
| 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: Extensible
|
| Conceptname
|
Codesystem name |
Codesystem OID
|
| SNOMED CT: <129264002|Action|
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
ProcedureTypeCBVCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.1.6
|
Binding: Preferred
|
| Conceptname
|
Codesystem name |
Codesystem OID
|
| Alle waarden
|
CBV
|
??
|
ProcedureTypeDHDCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.1.2
|
Binding: Extensible
|
| Conceptname
|
Codesystem name |
Codesystem OID
|
| SNOMED CT: ^tbd| RefSet Verrichtingenthesaurus DHD|
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
ProcedureTypeNZaCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.1.5
|
Binding: Preferred
|
| Conceptname
|
Codesystem name |
Codesystem OID
|
| Alle waarden
|
NZa
|
??
|
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 Prerelease 2018-2
SNOMED CT and LOINC codes are based on:
- SNOMED Clinical Terms version: 20180731 [R] (July 2018 Release)
- LOINC version 2.64
Conditions for use are located on the mainpage
This page is generated on 12/03/2019 17:31:45 with ZibExtraction v. 3.0.7010.25883
