EncounterReport-v1.0(2022EN) - Bewerkingsoverzicht

https://zibs.nl/index.php?action=history&feed=atom&title=EncounterReport-v1.0%282022EN%29 EncounterReport-v1.0(2022EN) - Bewerkingsoverzicht 2026-04-24T06:47:50Z Bewerkingsoverzicht voor deze pagina op de wiki MediaWiki 1.31.16 https://zibs.nl/index.php?title=EncounterReport-v1.0(2022EN)&diff=23964&oldid=prev Update bot: Nieuwe pagina aangemaakt met ' {{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.15.3(EN)|1|EncounterReport-v1.0(2022EN)}} <!-- Tot hier de...' 2022-06-10T20:17:44Z

<p>Nieuwe pagina aangemaakt met ' {{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.15.3(EN)|1|EncounterReport-v1.0(2022EN)}} <br /> {{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.15.3(EN)|1|EncounterReport-v1.0(2022EN)}}<br /> <br /> ==General information==<br /> Name: '''nl.zorg.EncounterReport''' [[Bestand:NL.png|link=ContactVerslag-v1.0(2022NL)]]<BR><br /> Version: '''1.0''' <br><br /> HCIM Status:Final<br><br /> Release: '''2022''' <br><br /> Release status: Prepublished<br><br /> Release date: 10-06-2022<br /> <br /> {{ErrataEN|2022|{{PAGENAME}}}}<br /> <br /> -----<br /> <div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release_2022(EN)]] [[HCIM_Release_2022(EN) |Back to HCIM list ]]</div><br /> <br /> ==Metadata==<br /> {| class="wikitable" style="font-size:90%; width: 750px"<br /> |- <br /> |style="width:250px; "|DCM::CoderList||Projectgroep VIPP GGZ<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||Projectgroep VIPP GGZ<br /> |- <br /> |style="width:250px; "|DCM::CreationDate||30-3-2022<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||*<br /> |- <br /> |style="width:250px; "|DCM::EndorsingAuthority.Telecom||<br /> |- <br /> |style="width:250px; "|DCM::Id||2.16.840.1.113883.2.4.3.11.60.40.3.15.3<br /> |- <br /> |style="width:250px; "|DCM::KeywordList||<br /> |- <br /> |style="width:250px; "|DCM::LifecycleStatus||Final<br /> |- <br /> |style="width:250px; "|DCM::ModelerList||Projectgroep VIPP GGZ<br /> |- <br /> |style="width:250px; "|DCM::Name||nl.zorg.ContactVerslag<br /> |- <br /> |style="width:250px; "|DCM::PublicationDate||10-06-2022<br /> |- <br /> |style="width:250px; "|DCM::PublicationStatus||Prepublished<br /> |- <br /> |style="width:250px; "|DCM::ReviewerList||<br /> |- <br /> |style="width:250px; "|DCM::RevisionDate||<br /> |- <br /> |style="width:250px; "|DCM::Supersedes||*<br /> |- <br /> |style="width:250px; "|DCM::Version||1.0<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''<br /> <br /> <u>Publicatieversie 1.0</u> (10-06-2022).<br /> </div><br /> <br /> ==Concept==<br /> <font color="#172b4d">The contact report is a textual report of a (partial) consult between the care provider and the patient.</font><br /> <br /> ==Purpose==<br /> <font color="#222222">A contact report offers a care provider the possibility to record information in a structured manner in free text about a contact with a patient.</font><br /> <br /> ==Information Model==<br /> <BR><br /> <imagemap> Bestand:EncounterReport-v1.0Model(2022EN).png | center <br /> rect 496 151 586 221 [[#15092]]<br /> rect 184 151 274 221 [[Encounter-v5.0(2022EN)]]<br /> rect 327 267 417 337 [[HealthProfessional-v3.5.2(2022EN)]]<br /> rect 318 43 429 113 [[#15090]]<br /> rect 328 151 418 221 [[#15089]]<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||style="width:100px;"|Id||colspan="6 " style="width:140px;"|Concept||Card.||style="width: 600px;"|Definition||style="width:200px;"|DefinitionCode||style="width:200px;"|Reference<br /> |-style="vertical-align:top; background-color: #E3E3E3; "<br /> |style = "text-align:center" |[[Bestand: block.png| 20px | link=]]<br /> ||NL-CM:15.3.1<br /> |colspan ="6" style ="padding-left: 0px"|<span Id=15089 Title="NL: ContactVerslag">[[Bestand: arrowdown.png | 10px | link=]]EncounterReport</span><br /> |<br /> |Root concept of the EncounterReport information model.This root concept contains all data elements of the EncounterReport information model.<br /> |<br /> {|<br /> |-<br /> |<span title = "Codesystem: SNOMED CT; Patiëntcontactverslag (record artifact)" >[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=11591000146107 11591000146107] Patient encounter report</span><br /> |}<br /> |<br /> |-style="vertical-align:top; background-color: transparent; "<br /> |style = "text-align:center" |[[Bestand: Verwijzing.png| 20px | link=]]<br /> ||NL-CM:15.3.2<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=15093 Title="NL: Auteur::Zorgverlener">[[Bestand: arrowright.png | 10px | link=]]Author::HealthProfessional</span><br /> |1<br /> |The healthcare provider who prepared the report and who is responsible for its content.<br /> |<br /> |<br /> {|<br /> |-<br /> |[[Bestand: block.png | link=HealthProfessional-v3.5.2(2022EN)]]||[[HealthProfessional-v3.5.2(2022EN) |HealthProfessional]]<br /> |}<br /> |-style="vertical-align:top; background-color: transparent; "<br /> |style = "text-align:center" |[[Bestand: Verwijzing.png| 20px | link=]]<br /> ||NL-CM:15.3.3<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=15094 Title="NL: Contact">[[Bestand: arrowright.png | 10px | link=]]Encounter</span><br /> |1<br /> |The encounter the report is about.<br /> |<br /> {|<br /> |-<br /> |<span title = "Codesystem: SNOMED CT; Patiëntcontact (procedure)" >[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=308335008 308335008] Patient encounter procedure</span><br /> |}<br /> |<br /> {|<br /> |-<br /> |[[Bestand: block.png | link=Encounter-v5.0(2022EN)]]||[[Encounter-v5.0(2022EN) |Encounter]]<br /> |}<br /> |-style="vertical-align:top; background-color: transparent; "<br /> |style = "text-align:center" |[[Bestand: TS.png| 16px | link=]]<br /> ||NL-CM:15.3.4<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=15090 Title="NL: ContactVerslagDatumTijd">[[Bestand: arrowright.png | 10px | link=]]EncounterReportDateTime</span><br /> |1<br /> |Date and, if applicable, the time the report was made.<br /> |<br /> |<br /> |-style="vertical-align:top; background-color: transparent; "<br /> |style = "text-align:center" |[[Bestand: ST.png| 16px | link=]]<br /> ||NL-CM:15.3.5<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=15092 Title="NL: ContactVerslagTekst">[[Bestand: arrowright.png | 10px | link=]]EncounterReportText</span><br /> |1<br /> |The actual content of the contact as free text.<br /> |<br /> {|<br /> |-<br /> |<span title = "Codesystem: SNOMED CT; Gedeelte in status (record artifact)" >[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=422813005 422813005] Document section</span><br /> |}<br /> |<br /> |}<br /> Columns Concept and DefinitionCode: hover over the values for more information<BR><br /> For explanation of the symbols, please see the legend page [[Bestand:list2.png|link=Legend]]<br /> <br /> ==Example Instances==<br /> ''Only available in Dutch''<br /> <br /> {|class="wikitable" width="590px" style= "font-size: 9.5pt;"<br /> |-style=vertical-align:top;<br /> |colspan="2" style="background-color: #1F497D; width: 100%; "|<font color=#FFFFFF><b>ContactVerslag</b></font><br /> |-style=vertical-align:top;<br /> | style="width: 30%; "|ContactVerslagDatumTijd<br /> | style="width: 70%; "|21-11-2020<br /> |-style=vertical-align:top;<br /> |colspan="2" style="background-color: #BFBFBF; width: 100%; "|Auteur<br /> |-style=vertical-align:top;<br /> | style="width: 30%; "|Medewerkerscode<br /> | style="width: 70%; "|01299<br /> |-style=vertical-align:top;<br /> | style="width: 30%; "|AGBCode<br /> | style="width: 70%; "|01999999<br /> |-style=vertical-align:top;<br /> | style="width: 30%; "|Initialen<br /> | style="width: 70%; "|G.L.<br /> |-style=vertical-align:top;<br /> | style="width: 30%; "|Geslachtsnaam<br /> | style="width: 70%; "|Klaassen<br /> |-style=vertical-align:top;<br /> | style="width: 30%; "|ZorgverlenersRol<br /> | style="width: 70%; "|Psychiater<br /> |-style=vertical-align:top;<br /> |colspan="2" style="background-color: #4F81BD; width: 100%; "|<br /> |-style=vertical-align:top;<br /> | style="width: 30%; "|ContactVerslagTekst<br /> | style="width: 70%; "|Goed verzorgde man, normaal contact, wanhopige klachtenpresentatie, onrustige motoriek (grimasseren, oor vastgrijpen). Bewustzijn helder, oriëntatie intact, geheugen en zelfwaarneming ongestoord, bovengemiddeld intelligent, geen psychotische kenmerken, denken normaal van tempo en vorm, inhoudelijk preoccupatie met oorsuizen, stemming somber (er kan een lachje af), rationaliseren, isoleren van het affect, niet actief suïcidaal.<br /> |}<br /> <br /> ==This information model in other releases==<br /> <br /> {{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.15.3(EN)|2|2022}}<br /> <br /> ==Information model references==<br /> ====This information model refers to====<br /> *[[Encounter-v5.0(2022EN)|Encounter-v5.0]]<br /> *[[HealthProfessional-v3.5.2(2022EN)|HealthProfessional-v3.5.2]]<br /> ====This information model is used in====<br /> :--<br /> ==Technical specifications in HL7v3 CDA and HL7 FHIR==<br /> To exchange information based on health and care information models, additional, more technical specifications are required.<BR><br /> Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:<br /> <ul><br /> <li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment {{ArtDecorLinks|2022|15.3}}</li><br /> <li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR {{SimplefierLinks|2022}}</li><br /> </ul><br /> ==Downloads==<br /> This information model is also available as [[Media:nl.zorg.EncounterReport-v1.0(2022EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.EncounterReport-v1.0(2022EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]]<br /> ==About this information==<br /> The information in this wikipage is based on Pre-release 2022-1 <BR><br /> SNOMED CT and LOINC codes are based on:<br /> <ul><br /> <li>SNOMED Clinical Terms version: 20220131 [R] (January 2022 Release)</li><br /> <li>LOINC version 2.67</li><br /> </ul><br /> Conditions for use are located on the mainpage [[Bestand:list2.png|link=HCIM_Mainpage]]<BR><br /> This page is generated on 10/06/2022 12:40:07 with ZibExtraction v. 8.0.8196.20371 <BR><br /> -----<br /> <div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release_2022(EN)]] [[HCIM_Release_2022(EN) |Back to HCIM list ]]</div></div>

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