A phenomenon with which a condition in the patient presents itself. This also includes a complaint or a finding, but not additional research, such as laboratory tests, function tests and imaging studies.
Purpose
Symptoms are an important basis for interpreting the condition (making the diagnosis) and for assessing the severity of the condition and the need for further examination or treatment. Symptoms and their course are also essential for evaluating the effectiveness of treatment.
Evidence Base
Note on zib Symptom A symptom refers to a phenomenon in a broad sense (including complaint and finding) with which a condition presents itself, but limited to symptoms that the patient notices himself or that a health professional can observe, if necessary with simple instruments.
Multiple symptoms may refer to the same condition, as a disorder or condition may present with > 1 symptom.
If a symptom changes, a new instance of zib Symptom with the same Symptom Name and a more recent SymptomStatusDate indicates how the symptom presented itself at that more recent date(time). A series of instances of Symptom with the same SymptomName then represents the course of the symptom by means of an increasing value for SymptomStatusDate.
The cardinality of the reference to Condition is 0..1, because a denial of a symptom does not necessarily involve a condition or state to which that denial refers. To represent that a patient does not have a fever, one should use the zib Exclusion with a reference to Symptom. If the denial of fever stands alone, the instance of Symptom does not refer to a Condition. If the denial of fever explicitly refers to a certain condition, then the instance of Symptom does have a reference to the relevant Condition.
Example: in case a patient has a condition diagnosed with diverticulitis, the health professional may want to explicitly record that there is no fever, because fever is an indication for admission. In that case, the excluded symptom 'fever' will refer to the same condition as to which the diagnostic insight 'diverticulitis' refers. Functionality (informative) It may happen that a health professional cannot yet make a (differential) diagnosis for a patient and can only indicate ≥ 1 important symptoms that he/she thinks belong together and can probably be explained by one condition. In this case, the EHR must create a new Condition and have the new instance(s) of Symptom refer to it. The EHR must also support that the health professional records ≥ 1 symptoms for a condition with an associated (differential) diagnosis. These symptoms then refer to the same condition.
When modifying an existing symptom, the EHR must have the new Symptom instance refer to the same Condition as the previous Symptom instance with the same SymptomName.
Information Model
Type
Id
Concept
Card.
Definition
DefinitionCode
Reference
NL-CM:5.5.1
Symptom
This is a reference to the rootconcept of information model Symptom.
More detailed specification of the symptomName that has been selected from the code list, because that list does not (yet) contain the required level of detail.
NL-CM:5.5.12
AnatomicalLocation
0..*
The location(s) on or in the body where the symptom presents itself.
Actions, events or circumstances that influence the presentation of the symptom. Generally, this pertains to factors that aggravate or alleviate the symptom.
NL-CM:5.5.14
Condition
0..*
The condition of which the symptom is a manifestation.
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
HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR
Symptom
SymptomPeriod::TimeInterval
or as spreadsheet 