TextResult-v4.4(2022EN)
General information
Name: nl.zorg.TextResult 
Version: 4.4
HCIM Status:Final
Release: 2022
Release status: Prepublished
Release date: 15-10-2023
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 | 14-12-2012 |
| DCM::DeprecatedDate | |
| DCM::DescriptionLanguage | nl |
| DCM::EndorsingAuthority.Address | |
| DCM::EndorsingAuthority.Name | PM |
| DCM::EndorsingAuthority.Telecom | |
| DCM::Id | 2.16.840.1.113883.2.4.3.11.60.40.3.13.2 |
| DCM::KeywordList | laboratorium uitslagen, verslagen |
| DCM::LifecycleStatus | Final |
| DCM::ModelerList | Kerngroep Registratie aan de Bron |
| DCM::Name | nl.zorg.TekstUitslag |
| DCM::PublicationDate | 15-10-2023 |
| DCM::PublicationStatus | Prepublished |
| DCM::ReviewerList | Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron |
| DCM::RevisionDate | 17-07-2020 |
| DCM::Supersedes | nl.zorg.TekstUitslag-v4.3 |
| DCM::Version | 4.4 |
| HCIM::PublicationLanguage | EN |
Revision History
Only available in Dutch
Publicatieversie 1.0 (15-02-2013)
Publicatieversie 1.1 (01-07-2013)
Publicatieversie 1.2 (01-04-2015)
Issue summaries niet beschikbaarBevat: ZIB-76, ZIB-130, ZIB-274, ZIB-275, ZIB-322, ZIB-323, ZIB-370.
Incl. algemene wijzigingsverzoeken: ZIB-94, ZIB-154, ZIB-200, ZIB-201, ZIB-309, ZIB-324, ZIB-326.
Publicatieversie 3.0 (01-05-2016) Bevat: ZIB-423, ZIB-453.
Publicatieversie 4.0 (04-09-2017) Bevat: ZIB-549, ZIB-576.
Publicatieversie 4.1 (31-12-2017) Bevat: ZIB-646.
Publicatieversie 4.2 (01-10-2018) Bevat: ZIB-630.
Publicatieversie 4.3 (31-01-2020) Bevat: ZIB-955.
Publicatieversie 4.4 (01-09-2020) Bevat: ZIB-631, ZIB-1187.
Concept
Textual results describe the findings and interpretation of diagnostic or therapeutic procedures carried out on patients or on specimens from the patient.
Purpose
Recording the results of diagnostic procedures for the purpose of communicating these with the person requesting the procedure and documenting the findings resulting from therapeutic procedures.
Evidence Base
Most results of procedures and some laboratory test results are descriptive by nature. This includes reports from radiology, pathology, scopies, ultrasounds, etc. and laboratory tests such as cultures, in which results, interpretation and advice form integral parts of the result. This information model can be used for these (mainly unstructured) results.
For laboratory test results, it is difficult to clearly indicate exactly when to use this information model and when to use the LaboratoryTestResult information model.
In general, laboratory tests resulting in a value (7.1 mmol/L), ordinal number (++ from series to ++++) or a quantitative result (Low) can best be transferred using the LaboratoryTestResult, whereas this information model is better suited for textual results containing more than just a few words.
Both types of tests occur in almost all laboratories.
Applicability is not determined by the kind of lab but by the kind of result.
Information Model
| Type | Id | Concept | Card. | Definition | DefinitionCode | Reference | ||||||||
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NL-CM:13.2.1 |  TextResult
|
Root concept of the TextResult information model. This root concept contains all data elements of the TextResult information model. |
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NL-CM:13.2.3 |  TextResultDateTime
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0..1 | Date and if possible time of the result report. |
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NL-CM:13.2.5 | Procedure
|
0..1 | Reference to the Procedure information model including the date of the procedure, requesting and executive specialty. |
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NL-CM:13.2.6 | TextResultStatus
|
0..1 | The status of the result. |
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NL-CM:13.2.2 | TextResultReport
|
1 | The text report detailing the actual results of the test or procedure. |
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NL-CM:13.2.7 | VisualResult
|
0..* | Visual examination results that are the starting point and reason for the textual report. These results include visual material - e.g. radiological images, scopy images, medical photos and videos - as well as graphic recordings - e.g. ECGs, EEGs etc. |
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NL-CM:13.2.4 | TextResultType
|
1 | The type of result. |
| |||||||||
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
Voorbeeld file fout: Unable to find the specified file. : nl.zorg.TekstUitslag-v4.4(NL)_Voorbeeld.docx
Valuesets
TextResultStatusCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.2.2 | Binding: Extensible |
| Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
| Pending | pending | ResultaatStatus | 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 | Uitslag volgt |
| Preliminary | preliminary | ResultaatStatus | 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 | Voorlopig |
| Final | final | ResultaatStatus | 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 | Definitief |
| Appended | appended | ResultaatStatus | 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 | Aanvullend |
| Corrected | corrected | ResultaatStatus | 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 | Gecorrigeerd |
TextResultTypeCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1 | Binding: Extensible |
| Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
| Microbiology procedure | 19851009 | SNOMED CT | 2.16.840.1.113883.6.96 | microbiologie |
| Imaging | 363679005 | SNOMED CT | 2.16.840.1.113883.6.96 | overige beeld vormende techniek |
| Radiographic imaging procedure | 363680008 | SNOMED CT | 2.16.840.1.113883.6.96 | röntgen |
| Ultrasonography | 16310003 | SNOMED CT | 2.16.840.1.113883.6.96 | echografie |
| Computed tomography | 77477000 | SNOMED CT | 2.16.840.1.113883.6.96 | CT |
| Magnetic resonance imaging | 113091000 | SNOMED CT | 2.16.840.1.113883.6.96 | MRI |
| Angiography | 77343006 | SNOMED CT | 2.16.840.1.113883.6.96 | angiografie |
| Echocardiography | 40701008 | SNOMED CT | 2.16.840.1.113883.6.96 | echocardiografie |
| Nuclear medicine procedure | 371572003 | SNOMED CT | 2.16.840.1.113883.6.96 | nucleaire geneeskunde |
| Anatomic pathology procedure | 108257001 | SNOMED CT | 2.16.840.1.113883.6.96 | pathologie |
| Procedure | 71388002 | SNOMED CT | 2.16.840.1.113883.6.96 | procedure |
| Positron emission tomography with computed tomography | 450436003 | SNOMED CT | 2.16.840.1.113883.6.96 | PET CT |
This information model in other releases
- Release 2015, (Version 1.2)
- Release 2016, (Version 3.0)
- Release 2017, (Version 4.1)
- Prerelease 2018-2, (Version 4.2)
- Prerelease 2019-2, (Version 4.3)
- Release 2020, (Version 4.4)
- Prerelease 2021-2, (Version 4.4)
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.<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
Downloads
This information model is also available as pdf file 
or as spreadsheet 
About this information
The information in this wikipage is based on Pre-release 2022-1
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 27/03/2024 11:11:21 with ZibExtraction v. 9.3.8851.20230