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ComfortScale-v1.1(2021EN) - Bewerkingsoverzicht
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{{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.12.12(EN)|1|ComfortScale-v1.1(2021EN)}}<br />
<!-- Tot hier de transclude page --><br />
==General information<!--hdGeneralInformation-->==<br />
Name<!--hdName-->: '''nl.zorg.ComfortScale''' [[Bestand:NL.png|link=ComfortScore-v1.1(2021NL)]]<BR><br />
Version<!--hdVersion-->: '''1.1''' <br><br />
HCIM Status<!--hdStatus-->:Final<br><br />
Release<!--hdPublication-->: '''2021''' <br><br />
Release status<!--hdPublicationStatus-->: Prepublished<br><br />
Release date<!--hdPublicationDate-->: 01-12-2021<br />
<!-- Aanroep Errata transclude page --><br />
{{ErrataEN<!--hdErrata-->|2021|{{PAGENAME}}}}<br />
<!-- tot hier --><br />
-----<br />
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2021(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2021(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div><br />
<br />
==Metadata==<br />
{| class="wikitable" style="font-size:90%; width: 750px"<br />
|- <br />
|style="width:250px; "|DCM::CoderList||Werkgroep RadB Verpleegkundige Gegevens<br />
|- <br />
|style="width:250px; "|DCM::ContactInformation.Address||*<br />
|- <br />
|style="width:250px; "|DCM::ContactInformation.Name||*<br />
|- <br />
|style="width:250px; "|DCM::ContactInformation.Telecom||*<br />
|- <br />
|style="width:250px; "|DCM::ContentAuthorList||Werkgroep RadB Verpleegkundige Gegevens<br />
|- <br />
|style="width:250px; "|DCM::CreationDate||1-8-2016<br />
|- <br />
|style="width:250px; "|DCM::DeprecatedDate||<br />
|- <br />
|style="width:250px; "|DCM::DescriptionLanguage||nl<br />
|- <br />
|style="width:250px; "|DCM::EndorsingAuthority.Address||<br />
|- <br />
|style="width:250px; "|DCM::EndorsingAuthority.Name||zorg<br />
|- <br />
|style="width:250px; "|DCM::EndorsingAuthority.Telecom||<br />
|- <br />
|style="width:250px; "|DCM::Id||2.16.840.1.113883.2.4.3.11.60.40.3.12.12<br />
|- <br />
|style="width:250px; "|DCM::KeywordList||Pijnscore, assessment, comfort, comfortneo<br />
|- <br />
|style="width:250px; "|DCM::LifecycleStatus||Final<br />
|- <br />
|style="width:250px; "|DCM::ModelerList||Werkgroep RadB Verpleegkundige Gegevens<br />
|- <br />
|style="width:250px; "|DCM::Name||nl.zorg.ComfortScore<br />
|- <br />
|style="width:250px; "|DCM::PublicationDate||01-12-2021<br />
|- <br />
|style="width:250px; "|DCM::PublicationStatus||Prepublished<br />
|- <br />
|style="width:250px; "|DCM::ReviewerList||Projectgroep RadB Verpleegkundige Gegevens & Kerngroep Registratie aan de Bron<br />
|- <br />
|style="width:250px; "|DCM::RevisionDate||09-01-2020<br />
|- <br />
|style="width:250px; "|DCM::Supersedes||nl.zorg.ComfortScore-v1.0<br />
|- <br />
|style="width:250px; "|DCM::Version||1.1<br />
|- <br />
|style="width:250px; "|HCIM::PublicationLanguage||EN<br />
|}<br />
<br />
==Revision History==<br />
<div class="mw-collapsible mw-collapsed"><br />
'' Only available in Dutch<!--noTranslation-->''<br />
<br />
<u>Publicatieversie 1.0</u> (04-09-2017)<br />
<br />
Publicatieversie <u>1.1</u> (31-01-2020)<br />
{|<br />
|-<br />
|style="width:75px; "|[[ZIBIssues#ZIB-925 | ZIB-925 ]]<br />
|DefinitionCodes zib nl.ComfortScore<br />
|}<br />
</div><br />
<br />
==Concept==<br />
The Comfort Behaviour scale /Comfortneo scale is an assessment tool, that is used to assess the pain behaviour of neonates (new born).<BR><br />
The Comfort Behaviour scale has 7 observation points that that need to be addressed. For each on observation is value is assigned from a 5-point scale, the final score indicates whether the observed child suffers pain and 'how much'. The score is combined with an NRS score that is completed by the nurses on basis of clinical experience.<br />
<br />
==Purpose==<br />
> A pain observation instrument is a tool in determining the intensity of pain and can be useful in order to determine the effectiveness of pain treatment interventions (pharmacological or non-pharmacological). For new born it is nevertheless difficult to differentiate between pain or distress/anxiety. This is relevant in determining the treatment. The score on a pain measurement instrument remains a snapshot in time.<br />
<br />
==Evidence Base==<br />
For determining the degree of pain in children with difficulty expressing themselves there are divers pain observation instruments available<BR><br />
<ul><br />
<li>CPB</li><br />
<li>Comfort behaviour scale/ Comfortneo scale</li><br />
<li>Flacc</li><br />
</ul><br />
<br />
==Patient Population==<br />
The COMFORT assessment scale is validated for young children up to the age of 4.<BR><br />
The COMFORT and COMFORTneo assessment score is validated for preterm neonates<br />
<br />
==Information Model==<br />
<BR><br />
<imagemap> Bestand:ComfortScale-v1.1Model(2021EN).png | center <br />
rect 617 91 736 161 [[#11394]]<br />
rect 617 489 785 539 [[#BodyMovementCodelist]]<br />
rect 426 59 544 161 [[#11401]]<br />
rect 425 489 545 539 [[#CryingCodelist]]<br />
rect 243 91 362 161 [[#11399]]<br />
rect 425 227 545 307 [[#11402]]<br />
rect 242 190 362 260 [[#11406]]<br />
rect 242 290 362 360 [[#11407]]<br />
rect 242 391 362 461 [[#11408]]<br />
rect 425 392 545 462 [[#11409]]<br />
rect 617 391 737 461 [[#11410]]<br />
rect 617 291 737 361 [[#11411]]<br />
rect 617 191 737 261 [[#11412]]<br />
rect 75 201 191 251 [[#AlertnessCodelist]]<br />
rect 35 301 190 351 [[#Calmness_AgitationCodelist]]<br />
rect 192 489 362 539 [[#RespiratoryResponseCodelist]]<br />
rect 782 201 925 251 [[#BodyMuscleToneCodelist]]<br />
rect 782 301 936 351 [[#FacialToneCodelist]]<br />
desc none<br />
</imagemap><br />
<BR><br />
{| border= "1" width="1500px" style = "font-size: 9.5pt; border: solid 1px silver; border-collapse:collapse;" cellpadding = "3px" cellspacing ="0px" <br />
|-style="background-color: #1F497D; color: white; font-weight: bold; font-variant: small-caps; "<br />
|style="width:30px;"|Type<!--imType-->||style="width:100px;"|Id<!--imId-->||colspan="6 " style="width:140px;"|Concept<!--imConcept-->||Card.<!--imCard-->||style="width: 600px;"|Definition<!--imDefinition-->||style="width:200px;"|DefinitionCode<!--imDefinitionCode-->||style="width:200px;"|Reference<!--imReference--><br />
|-style="vertical-align:top; background-color: #E3E3E3; "<br />
|style = "text-align:center" |[[Bestand: block.png| 20px | link=]]<br />
||NL-CM:12.12.1<br />
|colspan ="6" style ="padding-left: 0px"|<span Id=11402 Title="NL: ComfortScore">[[Bestand: arrowdown.png | 10px | link=]]ComfortScale</span><br />
|<br />
|Rootconcept of the ComfortScale information model. This root concept contains all data elements of the ComfortScale information model.<br />
|<br />
{|<br />
|-<br />
|<span title = "Codesystem: SNOMED CT (assessment scale)" >[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=108301000146109 108301000146109] COMFORT scale</span><br />
|}<br />
|<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: INT.png| 16px | link=]]<br />
||NL-CM:12.12.2<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="5" style ="padding-left: 0px"|<span Id=11401 Title="NL: TotaalScore">[[Bestand: arrowright.png | 10px | link=]]TotalScore</span><br />
|0..1<br />
|The total score is the sum of all the individual scores. The total score has a range from 0 - 35.<br />
|<br />
{|<br />
|-<br />
|<span title = "Codesystem: SNOMED CT; COMFORT-score (observable entity)" >[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=48961000146108 48961000146108] COMFORT behavior scale score</span><br />
|}<br />
|<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: CO.png| 16px | link=]]<br />
||NL-CM:12.12.3<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="5" style ="padding-left: 0px"|<span Id=11406 Title="NL: Alertheid">[[Bestand: arrowright.png | 10px | link=]]Alertness</span><br />
|0..1<br />
|Observation of: Alertness<br />
|<br />
{|<br />
|-<br />
|<span title = "Codesystem: ScoreObservaties>12012003 ComfortScale Alertness</span><br />
|}<br />
|<br />
{|<br />
|-<br />
|[[Bestand: List2.png | link=#AlertnessCodelist]]||[[#AlertnessCodelist|AlertnessCodelist]]<br />
|}<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: CO.png| 16px | link=]]<br />
||NL-CM:12.12.4<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="5" style ="padding-left: 0px"|<span Id=11407 Title="NL: Kalmte_Agitatie">[[Bestand: arrowright.png | 10px | link=]]Calmness_Agitation</span><br />
|0..1<br />
| Observation: Calmness/ agitation<br />
|<br />
{|<br />
|-<br />
|<span title = "Codesystem: ScoreObservaties>12012004 ComfortScale Calmness_Agitation</span><br />
|}<br />
|<br />
{|<br />
|-<br />
|[[Bestand: List2.png | link=#Calmness_AgitationCodelist]]||[[#Calmness_AgitationCodelist|Calmness_AgitationCodelist]]<br />
|}<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: CO.png| 16px | link=]]<br />
||NL-CM:12.12.5<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="5" style ="padding-left: 0px"|<span Id=11408 Title="NL: Ademhalingsreactie">[[Bestand: arrowright.png | 10px | link=]]RespiratoryResponse</span><br />
|0..1<br />
|Observation Respiratory response (only in mechanically ventilated children)<br />
|<br />
{|<br />
|-<br />
|<span title = "Codesystem: ScoreObservaties>12012005 ComfortScale RespiratoryResponse</span><br />
|}<br />
|<br />
{|<br />
|-<br />
|[[Bestand: List2.png | link=#RespiratoryResponseCodelist]]||[[#RespiratoryResponseCodelist|RespiratoryResponseCodelist]]<br />
|}<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: CO.png| 16px | link=]]<br />
||NL-CM:12.12.6<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="5" style ="padding-left: 0px"|<span Id=11409 Title="NL: Huilen">[[Bestand: arrowright.png | 10px | link=]]Crying</span><br />
|0..1<br />
|Observation Crying (only in spontaneously breathing children)<br />
|<br />
{|<br />
|-<br />
|<span title = "Codesystem: ScoreObservaties>12012006 ComfortScale Crying</span><br />
|}<br />
|<br />
{|<br />
|-<br />
|[[Bestand: List2.png | link=#CryingCodelist]]||[[#CryingCodelist|CryingCodelist]]<br />
|}<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: CO.png| 16px | link=]]<br />
||NL-CM:12.12.8<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="5" style ="padding-left: 0px"|<span Id=11410 Title="NL: Lichaamsbeweging">[[Bestand: arrowright.png | 10px | link=]]BodyMovement</span><br />
|0..1<br />
|Observation Physical movement<br />
|<br />
{|<br />
|-<br />
|<span title = "Codesystem: ScoreObservaties>12012008 ComfortScale BodyMovement</span><br />
|}<br />
|<br />
{|<br />
|-<br />
|[[Bestand: List2.png | link=#BodyMovementCodelist]]||[[#BodyMovementCodelist|BodyMovementCodelist]]<br />
|}<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: CO.png| 16px | link=]]<br />
||NL-CM:12.12.9<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="5" style ="padding-left: 0px"|<span Id=11411 Title="NL: Gezichtsspanning">[[Bestand: arrowright.png | 10px | link=]]FacialTone</span><br />
|0..1<br />
|Observation Facial tension<br />
|<br />
{|<br />
|-<br />
|<span title = "Codesystem: ScoreObservaties>12012009 ComfortScale FacialTone</span><br />
|}<br />
|<br />
{|<br />
|-<br />
|[[Bestand: List2.png | link=#FacialToneCodelist]]||[[#FacialToneCodelist|FacialToneCodelist]]<br />
|}<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: CO.png| 16px | link=]]<br />
||NL-CM:12.12.10<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="5" style ="padding-left: 0px"|<span Id=11412 Title="NL: Spierspanning">[[Bestand: arrowright.png | 10px | link=]]BodyMuscleTone</span><br />
|0..1<br />
|Observation Muscle tone<br />
|<br />
{|<br />
|-<br />
|<span title = "Codesystem: ScoreObservaties>12012010 ComfortScale BodyMuscleTone</span><br />
|}<br />
|<br />
{|<br />
|-<br />
|[[Bestand: List2.png | link=#BodyMuscleToneCodelist]]||[[#BodyMuscleToneCodelist|BodyMuscleToneCodelist]]<br />
|}<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: TS.png| 16px | link=]]<br />
||NL-CM:12.12.11<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="5" style ="padding-left: 0px"|<span Id=11394 Title="NL: ScoreDatumTijd">[[Bestand: arrowright.png | 10px | link=]]ScoreDateTime</span><br />
|1<br />
|The date and time at which the Comfort Behaviour scale/ComfortNeo scale was determined.<br />
|<br />
|<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: ST.png| 16px | link=]]<br />
||NL-CM:12.12.12<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="5" style ="padding-left: 0px"|<span Id=11399 Title="NL: Toelichting">[[Bestand: arrowright.png | 10px | link=]]Comment</span><br />
|0..1<br />
|A comment on the circumstances during the measurement.<br />
|<br />
{|<br />
|-<br />
|<span title = "Codesystem: LOINC (Nar)" >[https://terminologie.nictiz.nl/art-decor/loinc?conceptId=48767-8 48767-8] Annotation comment [Interpretation] Narrative</span><br />
|}<br />
|<br />
|}<br />
Columns Concept and DefinitionCode: hover over the values for more information<!--imHover--><BR><br />
For explanation of the symbols, please see the legend page<!--imLegend--> [[Bestand:list2.png|link=Legend<!--wikiLegend-->]]<br />
<br />
==Example Instances==<br />
''Only available in Dutch<!--noTranslation-->''<br />
<br />
{|class="wikitable" width="564px" style= "font-size: 9.5pt;"<br />
|-style=vertical-align:top;<br />
|colspan="2" style="background-color: #1F497D; width: 100%; "|<font color=#FFFFFF><b>Comfort</b></font><font color=#FFFFFF><b>Score</b></font><br />
|-style=vertical-align:top;<br />
| style="width: 44%; "|ScoreDatumTijd<br />
| style="width: 56%; "|21-12-2016 12:05<br />
|-style=vertical-align:top;<br />
| style="width: 44%; "|Alertheid<br />
| style="width: 56%; "|4 (wakker en alert)<br />
|-style=vertical-align:top;<br />
| style="width: 44%; "|Kalmte_Agitatie<br />
| style="width: 56%; "|2 (licht angstig)<br />
|-style=vertical-align:top;<br />
| style="width: 44%; "|Huilen<br />
| style="width: 56%; "|2 (af en toe snikken of kreunen)<br />
|-style=vertical-align:top;<br />
| style="width: 44%; "|Lichaamsbeweging<br />
| style="width: 56%; "|2 (incidentele beweging)<br />
|-style=vertical-align:top;<br />
| style="width: 44%; "|Gezichtsspanning<br />
| style="width: 56%; "|2 (normale spanning van het gelaat)<br />
|-style=vertical-align:top;<br />
| style="width: 44%; "|Spierspanning<br />
| style="width: 56%; "|2 (verminderde spierspanning)<br />
|-style=vertical-align:top;<br />
| style="width: 44%; "|Totaalscore<br />
| style="width: 56%; "|14<br />
|-style=vertical-align:top;<br />
| style="width: 44%; "|Toelichting<br />
| style="width: 56%; "|Controle na verhogen pijnmedicatie.<br />
|}<br />
{|class="wikitable" width="564px" style= "font-size: 9.5pt;"<br />
|-style=vertical-align:top;<br />
|colspan="2" style="background-color: #1F497D; width: 100%; "|<font color=#FFFFFF><b>ComfortNeoScore</b></font><br />
|-style=vertical-align:top;<br />
| style="width: 44%; "|ScoreDatumTijd<br />
| style="width: 56%; "|21-12-2016 12:05<br />
|-style=vertical-align:top;<br />
| style="width: 44%; "|Alertheid<br />
| style="width: 56%; "|4 (wakker en alert)<br />
|-style=vertical-align:top;<br />
| style="width: 44%; "|Kalmte_Agitatie<br />
| style="width: 56%; "|2 (licht angstig)<br />
|-style=vertical-align:top;<br />
| style="width: 44%; "|Ademhalingsreactie<br />
| style="width: 56%; "|3 (af en toe hoesten of verzet tegen de ventilator)<br />
|-style=vertical-align:top;<br />
| style="width: 44%; "|Lichaamsbeweging<br />
| style="width: 56%; "|2 (incidentele beweging)<br />
|-style=vertical-align:top;<br />
| style="width: 44%; "|Gezichtsspanning<br />
| style="width: 56%; "|2 (normale spanning van het gelaat)<br />
|-style=vertical-align:top;<br />
| style="width: 44%; "|Spierspanning<br />
| style="width: 56%; "|2 (verminderde spierspanning)<br />
|-style=vertical-align:top;<br />
| style="width: 44%; "|Totaalscore<br />
| style="width: 56%; "|15<br />
|-style=vertical-align:top;<br />
| style="width: 44%; "|Toelichting<br />
| style="width: 56%; "|Controle na verhogen pijnmedicatie.<br />
|}<br />
<br />
==Instructions==<br />
In the ComfortNeo scale the item crying is replaced by respiratory reaction.<BR><br />
In the Comfort scale the item respiratory reaction is replaced by crying.<br />
<br />
==References==<br />
1. Comfort assessment [Online] Beschikbaar op:<font color="#0000ff"><u>http://www.comfortassessment.nl/</u></font> [Geraadpleegd: 2 augustus 2016]<br />
2. Richtlijn Pijnmeting en Behandeling van pijn bij kinderen, NVK, 2007 [Online] Beschikbaar op:<font color="#0000ff"><u>https://www.nvk.nl/Kwaliteit/Richtlijnenoverzicht/Details/tabid/1558/articleType/ArticleView/articleId/760/Pijn-meting-en-behandeling-van.aspx</u></font> [Geraadpleegd: 21 december 2016]<br />
<br />
== Valuesets ==<br />
=== AlertnessCodelist===<br />
{| class="wikitable" width="60%" <br />
|-style='vertical-align:top; background-color: #E8D7BE;'<br />
|Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.1<br />
|Binding<!--vsBindingTag-->: Required<br />
|}<br />
{| class="wikitable" width="60% "<br />
|-style="background-color: #1F497D; color: white; font-weight: bold; "<br />
|Conceptname<!--vsConceptName--><br />
|Conceptcode<!--vsConceptCode--><br />
|Conceptvalue<!--vsConceptValue--><br />
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--><br />
|Description<!--vsDescription--><br />
|-style="vertical-align:top; "<br />
|<span title = "Diep in slaap">Deeply asleep</span><br />
|Alert1<br />
|1<br />
|CN_Alertheid<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.1<br />
|Diep in slaap (ogen dicht, geen reactie op omgeving)<br />
|-style="vertical-align:top; "<br />
|<span title = "Licht in slaap">Lightly asleep</span><br />
|Alert2<br />
|2<br />
|CN_Alertheid<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.1<br />
|Licht in slaap (ogen grotendeels gesloten, af en toe reactie)<br />
|-style="vertical-align:top; "<br />
|<span title = "Slaperig">Drowsy</span><br />
|Alert3<br />
|3<br />
|CN_Alertheid<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.1<br />
|Slaperig (kind sluit vaak zijn ogen, reageert minder op omgeving)<br />
|-style="vertical-align:top; "<br />
|<span title = "Wakker en alert">Awake and alert</span><br />
|Alert4<br />
|4<br />
|CN_Alertheid<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.1<br />
|Wakker en alert (kind reageert op omgeving)<br />
|-style="vertical-align:top; "<br />
|<span title = "Wakker en hyper-alert">Awake and hyperalert</span><br />
|Alert5<br />
|5<br />
|CN_Alertheid<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.1<br />
|Wakker en hyper-alert (overdreven reactie op veranderingen)<br />
|}<br />
=== BodyMovementCodelist===<br />
{| class="wikitable" width="60%" <br />
|-style='vertical-align:top; background-color: #E8D7BE;'<br />
|Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.5<br />
|Binding<!--vsBindingTag-->: Required<br />
|}<br />
{| class="wikitable" width="60% "<br />
|-style="background-color: #1F497D; color: white; font-weight: bold; "<br />
|Conceptname<!--vsConceptName--><br />
|Conceptcode<!--vsConceptCode--><br />
|Conceptvalue<!--vsConceptValue--><br />
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--><br />
|Description<!--vsDescription--><br />
|-style="vertical-align:top; "<br />
|<span title = "Geen beweging">No movement</span><br />
|Mov1<br />
|1<br />
|CN_Lichaamsbeweging<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.5<br />
|Geen beweging<br />
|-style="vertical-align:top; "<br />
|<span title = "Incidentele, kleine bewegingen">Occasional, slight movements</span><br />
|Mov2<br />
|2<br />
|CN_Lichaamsbeweging<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.5<br />
|Incidentele (3 of minder) kleine bewegingen<br />
|-style="vertical-align:top; "<br />
|<span title = "Frequente, kleine bewegingen">Frequent, slight movements</span><br />
|Mov3<br />
|3<br />
|CN_Lichaamsbeweging<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.5<br />
|Frequente (3 of meer) kleine bewegingen<br />
|-style="vertical-align:top; "<br />
|<span title = "Heftige bewegingen met arrmen en benen">Vigorous movements limited to extremities</span><br />
|Mov4<br />
|4<br />
|CN_Lichaamsbeweging<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.5<br />
|Heftige bewegingen met armen en benen<br />
|-style="vertical-align:top; "<br />
|<span title = "Heftige bewegingen ook met romp en hoofd">Vigorous movements including torso and head</span><br />
|Mov5<br />
|5<br />
|CN_Lichaamsbeweging<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.5<br />
|Heftige bewegingen ook met romp en hoofd<br />
|}<br />
=== BodyMuscleToneCodelist===<br />
{| class="wikitable" width="60%" <br />
|-style='vertical-align:top; background-color: #E8D7BE;'<br />
|Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.7<br />
|Binding<!--vsBindingTag-->: Required<br />
|}<br />
{| class="wikitable" width="60% "<br />
|-style="background-color: #1F497D; color: white; font-weight: bold; "<br />
|Conceptname<!--vsConceptName--><br />
|Conceptcode<!--vsConceptCode--><br />
|Conceptvalue<!--vsConceptValue--><br />
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--><br />
|Description<!--vsDescription--><br />
|-style="vertical-align:top; "<br />
|<span title = "Spieren volledig ontspannen">Muscles fully relaxed</span><br />
|Musc1<br />
|1<br />
|CN_Spierspanning<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.7<br />
|Spieren volledig ontspannen; geen spierspanning<br />
|-style="vertical-align:top; "<br />
|<span title = "Verminderde spierspanning">Reduced muscle tone</span><br />
|Musc2<br />
|2<br />
|CN_Spierspanning<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.7<br />
|Verminderde spierspanning; minder weerstand dan normaal<br />
|-style="vertical-align:top; "<br />
|<span title = "Normale spierspanning">Normal muscle tone</span><br />
|Musc3<br />
|3<br />
|CN_Spierspanning<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.7<br />
|Normale spierspanning<br />
|-style="vertical-align:top; "<br />
|<span title = "Toegenomen spierspanning">Increased muscle tone</span><br />
|Musc4<br />
|4<br />
|CN_Spierspanning<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.7<br />
|Toegenomen spierspanning en buiging van vingers en tenen<br />
|-style="vertical-align:top; "<br />
|<span title = "Extreme spierstijfheid">Extreme muscle rigidity</span><br />
|Musc5<br />
|5<br />
|CN_Spierspanning<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.7<br />
|Extreme spierstijfheid en buiging van vingers en tenen<br />
|}<br />
=== Calmness_AgitationCodelist===<br />
{| class="wikitable" width="60%" <br />
|-style='vertical-align:top; background-color: #E8D7BE;'<br />
|Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.2<br />
|Binding<!--vsBindingTag-->: Required<br />
|}<br />
{| class="wikitable" width="60% "<br />
|-style="background-color: #1F497D; color: white; font-weight: bold; "<br />
|Conceptname<!--vsConceptName--><br />
|Conceptcode<!--vsConceptCode--><br />
|Conceptvalue<!--vsConceptValue--><br />
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--><br />
|Description<!--vsDescription--><br />
|-style="vertical-align:top; "<br />
|<span title = "Kalm">Calm</span><br />
|Calm1<br />
|1<br />
|CN_Kalmte_Agitatie<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.2<br />
|Kalm (kind helder en rustig)<br />
|-style="vertical-align:top; "<br />
|<span title = "Licht angstig">Slightly anxious</span><br />
|Calm2<br />
|2<br />
|CN_Kalmte_Agitatie<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.2<br />
|Licht angstig (kind toont lichte onrust)<br />
|-style="vertical-align:top; "<br />
|<span title = "Angstig">Anxious</span><br />
|Calm3<br />
|3<br />
|CN_Kalmte_Agitatie<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.2<br />
|Angstig (kind lijkt onrustig, kan zich beheersen)<br />
|-style="vertical-align:top; "<br />
|<span title = "Zeer angstig">Very anxious</span><br />
|Calm4<br />
|4<br />
|CN_Kalmte_Agitatie<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.2<br />
|Zeer angstig (kind lijkt zeer onrustig, kan zich nog net beheersen)<br />
|-style="vertical-align:top; "<br />
|<span title = "Paniekerig">Panicky</span><br />
|Calm5<br />
|5<br />
|CN_Kalmte_Agitatie<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.2<br />
|Paniekerig (ernstige onrust met verlies van beheersing)<br />
|}<br />
=== CryingCodelist===<br />
{| class="wikitable" width="60%" <br />
|-style='vertical-align:top; background-color: #E8D7BE;'<br />
|Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.4<br />
|Binding<!--vsBindingTag-->: Required<br />
|}<br />
{| class="wikitable" width="60% "<br />
|-style="background-color: #1F497D; color: white; font-weight: bold; "<br />
|Conceptname<!--vsConceptName--><br />
|Conceptcode<!--vsConceptCode--><br />
|Conceptvalue<!--vsConceptValue--><br />
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--><br />
|Description<!--vsDescription--><br />
|-style="vertical-align:top; "<br />
|<span title = "Geen huilgeluiden">Quiet breathing</span><br />
|Cry1<br />
|1<br />
|CN_Huilen<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.4<br />
|Geen huilgeluiden<br />
|-style="vertical-align:top; "<br />
|<span title = "Af en toe snikken of kreunen">Occasional sobbing or moaning</span><br />
|Cry2<br />
|2<br />
|CN_Huilen<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.4<br />
|Af en toe snikken of kreunen (nasnikken)<br />
|-style="vertical-align:top; "<br />
|<span title = "Jengelen">Whining</span><br />
|Cry3<br />
|3<br />
|CN_Huilen<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.4<br />
|Jengelen of dreinen (monotoon geluid)<br />
|-style="vertical-align:top; "<br />
|<span title = "Huilen">Crying</span><br />
|Cry4<br />
|4<br />
|CN_Huilen<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.4<br />
|Huilen<br />
|-style="vertical-align:top; "<br />
|<span title = "Schreeuwen of krijsen">Screaming or shrieking</span><br />
|Cry5<br />
|5<br />
|CN_Huilen<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.4<br />
|Schreeuwen of krijsen<br />
|}<br />
=== FacialToneCodelist===<br />
{| class="wikitable" width="60%" <br />
|-style='vertical-align:top; background-color: #E8D7BE;'<br />
|Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.6<br />
|Binding<!--vsBindingTag-->: Required<br />
|}<br />
{| class="wikitable" width="60% "<br />
|-style="background-color: #1F497D; color: white; font-weight: bold; "<br />
|Conceptname<!--vsConceptName--><br />
|Conceptcode<!--vsConceptCode--><br />
|Conceptvalue<!--vsConceptValue--><br />
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--><br />
|Description<!--vsDescription--><br />
|-style="vertical-align:top; "<br />
|<span title = "Gezichtsspieren volkomen ontspannen">Facial muscles totally relaxed</span><br />
|Face1<br />
|1<br />
|CN_Gezichtsspanning<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.6<br />
|Gezichtsspieren volkomen ontspannen<br />
|-style="vertical-align:top; "<br />
|<span title = "Normale spanning van het gelaat">Normal facial tone</span><br />
|Face2<br />
|2<br />
|CN_Gezichtsspanning<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.6<br />
|Normale spanning van het gezicht<br />
|-style="vertical-align:top; "<br />
|<span title = "Spanning duidelijk in sommige gelaatsspieren">Tension evident in some facial muscles</span><br />
|Face3<br />
|3<br />
|CN_Gezichtsspanning<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.6<br />
|Spanning duidelijk in sommige gelaatsspieren (niet aanhoudend)<br />
|-style="vertical-align:top; "<br />
|<span title = "Spanning duidelijk in alle gelaatsspieren">Tension evident throughout facial muscles</span><br />
|Face4<br />
|4<br />
|CN_Gezichtsspanning<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.6<br />
|Spanning duidelijk in alle gelaatsspieren (aanhoudend)<br />
|-style="vertical-align:top; "<br />
|<span title = "Gelaatsspieren verwrongen in een grimas">Facial muscles contorted and grimacing</span><br />
|Face5<br />
|5<br />
|CN_Gezichtsspanning<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.6<br />
|Gezichtsspieren verwrongen en in een grimas<br />
|}<br />
=== RespiratoryResponseCodelist===<br />
{| class="wikitable" width="60%" <br />
|-style='vertical-align:top; background-color: #E8D7BE;'<br />
|Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.3<br />
|Binding<!--vsBindingTag-->: Required<br />
|}<br />
{| class="wikitable" width="60% "<br />
|-style="background-color: #1F497D; color: white; font-weight: bold; "<br />
|Conceptname<!--vsConceptName--><br />
|Conceptcode<!--vsConceptCode--><br />
|Conceptvalue<!--vsConceptValue--><br />
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--><br />
|Description<!--vsDescription--><br />
|-style="vertical-align:top; "<br />
|<span title = "Geen spontane ademhaling">No spontaneous respiration</span><br />
|Vent1<br />
|1<br />
|CN_Ademhalingsreactie<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.3<br />
|Geen spontane ademhaling<br />
|-style="vertical-align:top; "<br />
|<span title = "Spontane ademhaling aan de beademing">Spontaneous respiration on ventilator</span><br />
|Vent2<br />
|2<br />
|CN_Ademhalingsreactie<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.3<br />
|Spontane ademhaling aan de beademing<br />
|-style="vertical-align:top; "<br />
|<span title = "Onrust of verzet tegen de beademing">Unrest or resistance to ventilator</span><br />
|Vent3<br />
|3<br />
|CN_Ademhalingsreactie<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.3<br />
|Onrust of verzet tegen de beademing<br />
|-style="vertical-align:top; "<br />
|<span title = "Ademt actief tegen de beademing in of hoest regelmatig">Actively breathes against ventilator or coughs regularly</span><br />
|Vent4<br />
|4<br />
|CN_Ademhalingsreactie<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.3<br />
|Ademt actief tegen de beademing in of hoest regelmatig<br />
|-style="vertical-align:top; "<br />
|<span title = "Vecht tegen de beademing">Fights ventilator</span><br />
|Vent5<br />
|5<br />
|CN_Ademhalingsreactie<br />
|2.16.840.1.113883.2.4.3.11.60.40.4.20.3<br />
|Vecht tegen de beademing<br />
|}<br />
<br />
==This information model in other releases<!--ftOtherReleases-->==<br />
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==Information model references<!--ftReferences-->==<br />
====This information model refers to<!--ftRefersTo-->====<br />
:--<br />
====This information model is used in<!--ftReferredBy-->====<br />
:--<br />
==Technical specifications in HL7v3 CDA and HL7 FHIR<!--ftHeader-->==<br />
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Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:<!--ftReferenceIntro--><br />
<ul><br />
<li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment<!--ftArtDecorReference--> [http://decor.nictiz.nl/art-decor/decor-scenarios--zib2021bbr-?id=2.16.840.1.113883.2.4.3.11.60.11.4.2.12.12&effectiveDate=2021-12-01T00:00:00&language=en-US&scenariotree=false [[File:artdecor.jpg|16px|link=]]]</li><br />
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==About this information<!--ftHeader2-->==<br />
The information in this wikipage is based on<!--ftInfoBase--> Pre-release 2021-2 <BR><br />
SNOMED CT and LOINC codes are based on:<br />
<ul><br />
<li>SNOMED Clinical Terms version: 20210731 [R] (July 2021 Release)</li><br />
<li>LOINC version 2.67</li><br />
</ul><br />
Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR><br />
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