Procedure-v5.4.1(2023EN)

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General information

Name: nl.zorg.Procedure
Version: 5.4.1
HCIM Status:Final
Release: 2023
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 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 15-10-2023
DCM::PublicationStatus Prepublished
DCM::ReviewerList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 01-09-2023
DCM::Supersedes nl.zorg.Verrichting-v5.4
DCM::Version 5.4.1
HCIM::PublicationLanguage EN

Revision History

Concept

The concept Procedure describes therapeutic or diagnostic procedure undergone by the patient or which the patient will undergo. The concept can describe in the right context historical, future as well as advised procedures.
A procedure can be a simple blood pressure measurement, but also a complex heart surgery.
In some care settings, the term treatment is used instead of the term procedure.

Purpose

A procedure is carried out or planned 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#1292#ProcedureTypeDHDCodelistProblem-v4.6.1(2023EN)#1290#1285HealthcareProvider-v3.6(2023EN)MedicalDevice-v4.0(2023EN)#1283HealthProfessional-v4.0(2023EN)#1284#ProcedureTypeNZaCodelist#ProcedureTypeCBVCodelist#ProcedureTypeGGZCodelist#ProcedureTypeCodelistAnatomicalLocation-v1.0.3(2023EN)#ProcedureTypeMaternityCareCodelist


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 Procedure
NL-CM:14.1.2 ProcedureStartDate 0..1 The (desired) 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. The end date element is only used for a procedures that takes some time and is then always applied. If the procedure still continues, the value is left empty. For instantaneous or very short lasting procedures the element is omitted.

NL-CM:14.1.4 ProcedureType 1 The name of the procedure.
Choices are the DHD procedure thesaurus,  the procedures file (CBV), the Care activities file (NZa), the Dutch Mental Health and Addiction Care procedures list (GGZ) and the procedures list of the Dutch College of General Practitioners (NHG).
ProcedureTypeCBVCodelist
ProcedureTypeCodelist
ProcedureTypeDHDCodelist
ProcedureTypeGGZCodelist
ProcedureTypeMaternityCareCodelist
ProcedureTypeNZaCodelist
NL-CM:14.1.12 ProcedureMethod 0..* The method or technique that is going to be or was used to perform the procedure, e.g. approach, lavage, pressuring, etc.
260686004 Method
ProcedureMethodCodelist
NL-CM:14.1.13 ProcedureAnatomicalLocation::AnatomicalLocation 0..1 Anatomical location that is the focus of the procedure.
405813007 Procedure site - Direct
AnatomicalLocation
NL-CM:14.1.9 Indication::Problem 0..* The indication is the reason for the procedure.
363702006 Has focus
Problem
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 provider where the procedure was, is or will be carried out.
HealthcareProvider
NL-CM:14.1.6 Performer::HealthProfessional 0..* The healthcare professional who carried out or will carry out the procedure. In most cases, only the medical specialty is entered, and not the name of the healthcare professional.
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

References

1. Waardelijst GGZ-Verrichtingen [Online] Beschikbaar op: http://https://www.vippggz.nl/waardelijst-ggz-verrichtingen.html [Geraadpleegd: 03-08-2020].

Valuesets

ProcedureMethodCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.1.4 Binding: Required
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: Required
Conceptname Codesystem name Codesystem OID
All values CBV codes 2.16.840.1.113883.2.4.3.120.5.3

ProcedureTypeCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.1.8 Binding: Required
Conceptname Codesystem name Codesystem OID
All values NHG tabel 49 Ingrepen en behandelingen 2.16.840.1.113883.2.4.4.30.49

ProcedureTypeDHDCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.1.2 Binding: Required
Conceptname Codesystem name Codesystem OID
All values DHD Verrichtingenthesaurus 2.16.840.1.113883.2.4.3.120.5.2

ProcedureTypeGGZCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.1.7 Binding: Required
Conceptname Codesystem name Codesystem OID
All values GGZ Verrichtingenijst 2.16.840.1.113883.3.3210.14.2.2.15

ProcedureTypeMaternityCareCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.1.9 Binding: Required
Conceptname Codesystem name Codesystem OID
SNOMED CT: ^146481000146103|Dutch obstetric procedures simple reference set| 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: Required
Conceptname Codesystem name Codesystem OID
All values NZa codes 2.16.840.1.113883.2.4.3.27.15.5

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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
  • 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 2023-1
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
This page is generated on 31/10/2023 18:37:19 with ZibExtraction v. 9.3.8704.31782

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