Symptom-v1.0(2024EN)

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General information

Name: nl.zorg.Symptom NL.png
Version: 1.0
HCIM Status:Final
Release: 2024
Release status: Prepublished
Release date: 15-04-2024


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Metadata

DCM::CoderList Zib-centrum
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList Zib-centrum
DCM::CreationDate 01-05-2023
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name *
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.5.5
DCM::KeywordList
DCM::LifecycleStatus Final
DCM::ModelerList *
DCM::Name nl.zorg.Symptoom
DCM::PublicationDate 15-04-2024
DCM::PublicationStatus Prepublished
DCM::ReviewerList Zib-centrum
DCM::RevisionDate
DCM::Supersedes *
DCM::Version 1.0
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (15-04-2024)

ZIB-1934 ProbleemType moet ProbleemCategorie worden

Concept

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


#SymptomNameCodelist#5092TimeInterval-v1.3(2024EN)#5082Range-v1.0.1(2024EN)#OnsetCodelist#5094#SymptomSeverityCodelist#SymptomCourseCodelist#TemporalPatternCodelist#5089#5085#5093#5087#5081Condition-v1.0(2024EN)#5083AnatomicalLocation-v1.0.3(2024EN)#5088#5095Symptom-v1.0Model(2024EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:5.5.1 Arrowdown.pngSymptom This is a reference to the rootconcept of information model Symptom.
162408000 General symptom description
Verwijzing.png NL-CM:5.5.16 Arrowright.pngSymptomPeriod::TimeInterval 1 The period in which the symptom is (was) present.
408731000 Temporal context
Block.png TimeInterval
TS.png NL-CM:5.5.3 Arrowright.pngSymptomStatusDate 1 Date from which the specification of the symptom applies.
162499001 Symptom has changed
BL.png NL-CM:5.5.17 Arrowright.pngIsNursingDiagnosis 1 Indicates whether the symptom serves as a nursing diagnosis.
86644006 Nursing diagnosis
CD.png NL-CM:5.5.5 Arrowright.pngOnset 1 Indication how fast the symptom presented at first.
List2.png OnsetCodelist
CD.png NL-CM:5.5.6 Arrowright.pngTemporalPattern 0..1 The temporal pattern with which the symptom presents itself, such as continuous or intermittent.
288524001 Courses
List2.png TemporalPatternCodelist
CD.png NL-CM:5.5.7 Arrowright.pngSymptomCourse 0..1 The course of the intensity of the symptom over time, such as increased, unchanged.
List2.png SymptomCourseCodelist
CD.png NL-CM:5.5.8 Arrowright.pngSymptomSeverity 1 Indicates the degree of severity of the symptom at the moment of the SymptomStatusDate.
246112005 Severity
List2.png SymptomSeverityCodelist
Verwijzing.png NL-CM:5.5.9 Arrowright.pngDurationWhenPresent::Range 0..1 Duration of an intermittent or paroxysmal symptom while it presents.
162442009 Time symptom lasts
Block.png Range
CD.png NL-CM:5.5.10 Arrowright.pngSymptomName 1 Name and code of the symptom via selection from a code list, based on a standardised coding system.
List2.png SymptomNameCodelist
ST.png NL-CM:5.5.11 Arrowright.pngFurtherSpecificationSymptomName 0..1 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.
Verwijzing.png NL-CM:5.5.12 Arrowright.pngAnatomicalLocation 0..* The location(s) on or in the body where the symptom presents itself.
363698007 Finding site
Block.png AnatomicalLocation
ST.png NL-CM:5.5.13 Arrowright.pngInfluencingFactors 0..1 Actions, events or circumstances that influence the presentation of the symptom. Generally, this pertains to factors that aggravate or alleviate the symptom.
Verwijzing.png NL-CM:5.5.14 Arrowright.pngCondition 0..* The condition of which the symptom is a manifestation.
64572001 Disease
Block.png Condition
ST.png NL-CM:5.5.15 Arrowright.pngComment 0..1 A comment in free text with respect to the symptom, that is not represented by the other data elements in the information model.

Columns Concept and DefinitionCode: hover over the values for more information
For explanation of the symbols, please see the legend page List2.png

Example Instances

Only available in Dutch

Symptoom
SymptoomPeriode
StartDatumTijd 22-02-2023 22-02-2023 22-02-2023
EindDatumTijd
TijdsDuur
SymptoomStatusDatum 01-03-2023 05-03-2023 20-03-2023
SymptoomType Symptoom Symptoom Symptoom
SymptoomNaam Hoest Hoest Hoest
NadereSpecificatieSymptoomNaam Droge hoest Productieve hoest Productieve hoest
Ontstaanswijze Subacuut
TijdsPatroon Aanvalsgewijs Aanvalsgewijs
Beloop Verslechterd Verbeterd
Ernst Mild Matig Mild
DuurBijOptreden
minimumWaarde 30 min 5 min
maximumWaarde 1,5 u 10 min
nominaleWaarde
BeïnvloedendeFactoren Erger bij liggen
Toelichting
AnatomischeLocatie
Locatie
Lateraliteit
AandoeningOfGesteldheid
PeriodeAanwezig
StartDatumTijd 22-02-2023 22-02-2023 22-02-2023
EindDatumTijd
StatusDatum 01-03-2023 05-03-2023 20-03-2023
Beloop Verslechterd Verbeterd
Ernst Mild Matig Mild
Symptoom
SymptoomPeriode
StartDatumTijd 15-01-2023 10:30 15-01-2023 10:30
EindDatumTijd 26-02-2023
TijdsDuur
SymptoomStatusDatum 15-01-2023 26-02-2023
SymptoomType Symptoom Symptoom
SymptoomNaam Zwelling Zwelling
NadereSpecificatieSymptoomNaam
Ontstaanswijze Acuut
TijdsPatroon
Beloop Niet meer aanwezig
Ernst Ernstig
Beïnvloedende actoren Neemt toe bij beweging en neemt af in rust.
Toelichting
AnatomischeLocatie
Locatie Pols Pols
Lateraliteit Links Links
AandoeningOfGesteldheid
PeriodeAanwezig
StartDatumTijd 15-01-2023 15-01-2023
EindDatumTijd
StatusDatum 15-01-2023 26-02-2023
Beloop Herstellend
Ernst

Instructions

A symptom always refers to a condition of which it is an expression. Multiple symptoms may refer to the same condition or condition.

Valuesets

OnsetCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.5.2 Binding: Required
Conceptname Conceptcode Codesystem name Codesystem OID Description
Gradual onset 61751001 SNOMED CT 2.16.840.1.113883.6.96 Geleidelijk ontstaan
Subacute onset 373935005 SNOMED CT 2.16.840.1.113883.6.96 Subacuut ontstaan
Sudden onset 385315009 SNOMED CT 2.16.840.1.113883.6.96 Acuut onstaan

SymptomCourseCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.5.4 Binding: Required
Conceptname Conceptcode Codesystem name Codesystem OID Description
No status change 260388006 SNOMED CT 2.16.840.1.113883.6.96 Onveranderd
Worse 231877006 SNOMED CT 2.16.840.1.113883.6.96 Verslechterd
Improved 385425000 SNOMED CT 2.16.840.1.113883.6.96 Verbeterd
Fluctuating 255341006 SNOMED CT 2.16.840.1.113883.6.96 Fluctuerend
No longer present 350361000146109 SNOMED CT 2.16.840.1.113883.6.96 Niet meer aanwezig
Other OTH NullFlavor 2.16.840.1.113883.5.1008 Anders

SymptomNameCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.5.8 Binding: Required
Conceptname Codesystem name Codesystem OID
SNOMED CT: <404684003|Clinical finding| SNOMED CT 2.16.840.1.113883.6.96

SymptomSeverityCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.5.5 Binding: Required
Conceptname Conceptcode Codesystem name Codesystem OID Description
Mild 255604002 SNOMED CT 2.16.840.1.113883.6.96 Mild
Mild to moderate 371923003 SNOMED CT 2.16.840.1.113883.6.96 Mild tot matig
Moderate severity 6736007 SNOMED CT 2.16.840.1.113883.6.96 Matig
Moderate to severe 371924009 SNOMED CT 2.16.840.1.113883.6.96 Matig tot ernstig
Severe 24484000 SNOMED CT 2.16.840.1.113883.6.96 Ernstig
Life threatening severity 442452003 SNOMED CT 2.16.840.1.113883.6.96 Levensbedreigend

TemporalPatternCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.5.3 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Continual 263730007 SNOMED CT 2.16.840.1.113883.6.96 Continu
Intermittent 7087005 SNOMED CT 2.16.840.1.113883.6.96 Intermitterend
Paroxysmal 26593000 SNOMED CT 2.16.840.1.113883.6.96 Aanvalsgewijs
Cyclic 44180009 SNOMED CT 2.16.840.1.113883.6.96 Cyclisch
Other OTH NullFlavor 2.16.840.1.113883.5.1008 Anders

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Information model references

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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.<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 Artdecor.jpg
  • HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR Fhir.png

Downloads

This information model is also available as pdf file PDF.png or as spreadsheet Xlsx.png

About this information

The information in this wikipage is based on Prerelease 2024-1
SNOMED CT and LOINC codes are based on:

  • SNOMED Clinical Terms versie: 20240331 [R] (maart 2024-editie)
  • LOINC version 2.77

Conditions for use are located on the mainpage List2.png
This page is generated on 25/04/2024 12:42:42 with ZibExtraction v. 9.3.8880.19756


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