TextResult-v4.4(2022EN)

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Attention!! This is not the most recent version of this information model. You can find the most recent version ''here''.

General information

Name: nl.zorg.TextResult NL.png
Version: 4.4
HCIM Status:Final
Release: 2022
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 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 beschikbaar
Bevat: 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


#1221Procedure-v5.4(2022EN)#1224#TextResultStatusCodelist#TextResultTypeCodelist#1223#1220#1226#1922TextResult-v4.4Model(2022EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:13.2.1 Arrowdown.pngTextResult Root concept of the TextResult information model. This root concept contains all data elements of the TextResult information model.
371525003 Clinical procedure report
TS.png NL-CM:13.2.3 Arrowright.pngTextResultDateTime 0..1 Date and if possible time of the result report. 
399651003 Date of report
Verwijzing.png NL-CM:13.2.5 Arrowright.pngProcedure 0..1 Reference to the Procedure information model including the date of the procedure, requesting and executive specialty.
71388002 Procedure
Block.png Procedure
CD.png NL-CM:13.2.6 Arrowright.pngTextResultStatus 0..1 The status of the result.
308552006 Report status
List2.png TextResultStatusCodelist
ST.png NL-CM:13.2.2 Arrowright.pngTextResultReport 1 The text report detailing the actual results of the test or procedure.
423100009 Results section
ED.png NL-CM:13.2.7 Arrowright.pngVisualResult 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.
9841000146101 Image
CD.png NL-CM:13.2.4 Arrowright.pngTextResultType 1 The type of result.
List2.png TextResultTypeCodelist

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

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

Information model references

This information model refers to

This information model is used in

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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 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 List2.png
This page is generated on 27/03/2024 11:11:21 with ZibExtraction v. 9.3.8851.20230


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