TextResult-v4.1(2017EN): verschil tussen versies
(Een tussenliggende versie door dezelfde gebruiker niet weergegeven) | |||
Regel 1: | Regel 1: | ||
− | ==General information== | + | <!-- Hieronder wordt een transclude page aangeroepen --> |
− | Name: '''nl.zorg.TextResult''' [[Bestand:NL.png|link=TekstUitslag-v4.1(2017NL)]]<BR> | + | {{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.13.2(EN)|1|TextResult-v4.1(2017EN)}} |
− | Version: '''4.1''' <br> | + | <!-- Tot hier de transclude page --> |
− | HCIM Status:Final<br> | + | ==General information<!--hdGeneralInformation-->== |
− | Release: '''2017''' <br> | + | Name<!--hdName-->: '''nl.zorg.TextResult''' [[Bestand:NL.png|link=TekstUitslag-v4.1(2017NL)]]<BR> |
− | Release status: Published<br> | + | Version<!--hdVersion-->: '''4.1''' <br> |
− | Release date: 31-12-2017 | + | HCIM Status<!--hdStatus-->:Final<br> |
+ | Release<!--hdPublication-->: '''2017''' <br> | ||
+ | Release status<!--hdPublicationStatus-->: Published<br> | ||
+ | Release date<!--hdPublicationDate-->: 31-12-2017 | ||
----- | ----- | ||
− | <div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= | + | <div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2017(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2017(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div> |
==Metadata== | ==Metadata== | ||
Regel 61: | Regel 64: | ||
==Revision History== | ==Revision History== | ||
<div class="mw-collapsible mw-collapsed"> | <div class="mw-collapsible mw-collapsed"> | ||
− | ''Only available in Dutch'' | + | ''Only available in Dutch<!--noTranslation-->'' |
<u>Publicatieversie 1.0</u> (15-02-2013) | <u>Publicatieversie 1.0</u> (15-02-2013) | ||
Regel 162: | Regel 165: | ||
==Information Model== | ==Information Model== | ||
<BR> | <BR> | ||
− | <imagemap> Bestand:TextResult-v4.1Model( | + | <imagemap> Bestand:TextResult-v4.1Model(2017EN).png | center |
− | rect | + | rect 174 67 290 137 [[#13063]] |
− | rect | + | rect 555 68 671 138 [[Procedure-v4.1(2017EN)]] |
− | rect | + | rect 371 210 461 280 [[#13066]] |
− | rect | + | rect 173 327 302 377 [[#TextResultStatusCodelist]] |
− | rect | + | rect 513 327 677 377 [[#TextResultTypeCodelist]] |
− | rect | + | rect 358 67 476 137 [[#13065]] |
− | rect | + | rect 183 210 281 280 [[#13062]] |
− | rect | + | rect 543 210 645 280 [[#13068]] |
desc none | desc none | ||
</imagemap> | </imagemap> | ||
Regel 176: | Regel 179: | ||
{| border= "1" width="1500px" style = "font-size: 9.5pt; border: solid 1px silver; border-collapse:collapse;" cellpadding = "3px" cellspacing ="0px" | {| border= "1" width="1500px" style = "font-size: 9.5pt; border: solid 1px silver; border-collapse:collapse;" cellpadding = "3px" cellspacing ="0px" | ||
|-style="background-color: #1F497D; color: white; font-weight: bold; font-variant: small-caps; " | |-style="background-color: #1F497D; color: white; font-weight: bold; font-variant: small-caps; " | ||
− | |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 | + | |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--> |
|-style="vertical-align:top; background-color: #E3E3E3; " | |-style="vertical-align:top; background-color: #E3E3E3; " | ||
|style = "text-align:center" |[[Bestand: block.png| 20px | link=]] | |style = "text-align:center" |[[Bestand: block.png| 20px | link=]] | ||
Regel 206: | Regel 209: | ||
{| | {| | ||
|- | |- | ||
− | |<span | + | |<span title = "Codesystem: SNOMED CT>[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=363714003 363714003] Interprets</span> |
|} | |} | ||
| | | | ||
Regel 249: | Regel 252: | ||
|} | |} | ||
|} | |} | ||
− | Columns Concept and DefinitionCode: hover over the values for more information<BR> | + | Columns Concept and DefinitionCode: hover over the values for more information<!--imHover--><BR> |
− | For explanation of the symbols, please see the legend page [[Bestand:list2.png|link=Legend]] | + | For explanation of the symbols, please see the legend page<!--imLegend--> [[Bestand:list2.png|link=Legend<!--wikiLegend-->]] |
==Example Instances== | ==Example Instances== | ||
− | ''Only available in Dutch'' | + | ''Only available in Dutch<!--noTranslation-->'' |
{|class="wikitable" width="655px" style= "font-size: 9.5pt;" | {|class="wikitable" width="655px" style= "font-size: 9.5pt;" | ||
Regel 320: | Regel 323: | ||
{| class="wikitable" width="60%" | {| class="wikitable" width="60%" | ||
|-style='vertical-align:top; background-color: #E8D7BE;' | |-style='vertical-align:top; background-color: #E8D7BE;' | ||
− | |Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.13.2.2 | + | |Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.13.2.2 |
+ | |Binding<!--vsBindingTag-->: | ||
|} | |} | ||
{| class="wikitable" width="60% " | {| class="wikitable" width="60% " | ||
|-style="background-color: #1F497D; color: white; font-weight: bold; " | |-style="background-color: #1F497D; color: white; font-weight: bold; " | ||
− | |Conceptname | + | |Conceptname<!--vsConceptName--> |
− | |Conceptcode | + | |Conceptcode<!--vsConceptCode--> |
− | |Codesystem name||Codesystem OID | + | |Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--> |
− | |Description | + | |Description<!--vsDescription--> |
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Pending | |Pending | ||
Regel 359: | Regel 363: | ||
|Gecorrigeerd | |Gecorrigeerd | ||
|} | |} | ||
− | |||
=== TextResultTypeCodelist=== | === TextResultTypeCodelist=== | ||
{| class="wikitable" width="60%" | {| class="wikitable" width="60%" | ||
|-style='vertical-align:top; background-color: #E8D7BE;' | |-style='vertical-align:top; background-color: #E8D7BE;' | ||
− | |Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1 | + | |Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.13.2.1 |
+ | |Binding<!--vsBindingTag-->: | ||
|} | |} | ||
{| class="wikitable" width="60% " | {| class="wikitable" width="60% " | ||
|-style="background-color: #1F497D; color: white; font-weight: bold; " | |-style="background-color: #1F497D; color: white; font-weight: bold; " | ||
− | |Conceptname | + | |Conceptname<!--vsConceptName--> |
− | |Conceptcode | + | |Conceptcode<!--vsConceptCode--> |
− | |Codesystem name||Codesystem OID | + | |Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--> |
− | |Description | + | |Description<!--vsDescription--> |
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Microbiology | |Microbiology | ||
− | |19851009 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=19851009 19851009] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 379: | Regel 383: | ||
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Imaging | |Imaging | ||
− | |363679005 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=363679005 363679005] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 385: | Regel 389: | ||
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|X-ray | |X-ray | ||
− | |363680008 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=363680008 363680008] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 391: | Regel 395: | ||
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Ultrasound | |Ultrasound | ||
− | |16310003 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=16310003 16310003] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 397: | Regel 401: | ||
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|CT | |CT | ||
− | |77477000 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=77477000 77477000] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 403: | Regel 407: | ||
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|MRI | |MRI | ||
− | |113091000 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=113091000 113091000] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 409: | Regel 413: | ||
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Angiography | |Angiography | ||
− | |77343006 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=77343006 77343006] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 415: | Regel 419: | ||
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Cardiac Echo | |Cardiac Echo | ||
− | |40701008 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=40701008 40701008] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 421: | Regel 425: | ||
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Nuclear Medicine | |Nuclear Medicine | ||
− | |371572003 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=371572003 371572003] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 427: | Regel 431: | ||
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Pathology | |Pathology | ||
− | |108257001 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=108257001 108257001] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 433: | Regel 437: | ||
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Procedure | |Procedure | ||
− | |71388002 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=71388002 71388002] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 439: | Regel 443: | ||
|} | |} | ||
− | + | ==This information model in other releases<!--ftOtherReleases-->== | |
− | ==This information model in other releases== | + | <!-- Hieronder wordt een transclude page aangeroepen --> |
− | < | + | {{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.13.2(EN)|2|2017}} |
− | + | <!-- Tot hier de transclude page --> | |
− | < | + | ==Information model references<!--ftReferences-->== |
− | + | ====This information model refers to<!--ftRefersTo-->==== | |
− | == | + | *[[Procedure-v4.1(2017EN)|Procedure-v4.1]] |
+ | ====This information model is used in<!--ftReferredBy-->==== | ||
+ | :-- | ||
+ | ==Technical specifications in HL7v3 CDA and HL7 FHIR<!--ftHeader-->== | ||
To exchange information based on health and care information models, additional, more technical specifications are required.<BR> | 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: | + | Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:<!--ftReferenceIntro--> |
<ul> | <ul> | ||
− | <li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment [http://decor.nictiz.nl/art-decor/decor-scenarios--zib2017bbr-?id=2.16.840.1.113883.2.4.3.11.60.7.4.2.13.2&effectiveDate=2017-12-31T00:00:00&language=en-US&scenariotree=false [[File:artdecor.jpg|16px|link=]]]</li> | + | <li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment<!--ftArtDecorReference--> [http://decor.nictiz.nl/art-decor/decor-scenarios--zib2017bbr-?id=2.16.840.1.113883.2.4.3.11.60.7.4.2.13.2&effectiveDate=2017-12-31T00:00:00&language=en-US&scenariotree=false [[File:artdecor.jpg|16px|link=]]]</li> |
− | <li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR | + | <li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR<!--ftSimplifierReference--> {{SimplefierLinks|2017}}</li> |
</ul> | </ul> | ||
− | This information model is also available as [[Media:nl.zorg.TextResult-v4.1(2017EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.TextResult-v4.1(2017EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]] | + | ==Downloads<!--ftDownloadTitle-->== |
− | ==About this information== | + | This information model is also available as [[Media:nl.zorg.TextResult-v4.1(2017EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.TextResult-v4.1(2017EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]]<!--ftDownloads--> |
− | The information in this wikipage is based on Release 2017 <BR> | + | ==About this information<!--ftHeader2-->== |
− | Conditions for use are located on the mainpage [[Bestand:list2.png|link=HCIM_Mainpage]]<BR> | + | The information in this wikipage is based on<!--ftInfoBase--> Release 2017 <BR> |
− | This page is generated on | + | Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR> |
+ | This page is generated on 21/12/2018 14:11:33 with ZibExtraction v. 3.0.6929.24609<!--ftDate--> <BR> | ||
----- | ----- | ||
− | <div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= | + | <div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2017(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2017(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div> |
Huidige versie van 24 dec 2018 om 11:04
Inhoud
- 1 General information
- 2 Metadata
- 3 Revision History
- 4 Concept
- 5 Purpose
- 6 Evidence Base
- 7 Information Model
- 8 Example Instances
- 9 Valuesets
- 10 This information model in other releases
- 11 Information model references
- 12 Technical specifications in HL7v3 CDA and HL7 FHIR
- 13 Downloads
- 14 About this information
General information
Name: nl.zorg.TextResult
Version: 4.1
HCIM Status:Final
Release: 2017
Release status: Published
Release date: 31-12-2017
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 | 31-12-2017 |
DCM::PublicationStatus | Published |
DCM::ReviewerList | Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron |
DCM::RevisionDate | 31-12-2017 |
DCM::Superseeds | nl.zorg.TekstUitslag-v4.0 |
DCM::Version | 4.1 |
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)
ZIB-76 | OverdrachtTekstUitslag Omschrijving |
ZIB-130 | Samenvoegen bouwstenen OverdrachtLabuitslag en OverdrachtTekstuitslag tot een bouwsteen. |
ZIB-274 | In de klinische bouwsteen OverdrachtTekstUitslag kwam de naam van de gekoppelde waardenlijst van concept TekstUitslagStatus niet overeen met de tagged value van het concept. |
ZIB-275 | In de klinische bouwsteen OverdrachtTekstUitslag kwam de naam van de gekoppelde waardenlijst van concept TekstUitslagType niet overeen met de tagged value van het concept. |
ZIB-322 | Wijziging paragraaf concept |
ZIB-323 | Wijzing paragraaf Purpose |
ZIB-370 | ResultaatStatusCodelijst en TekstUitslagCodelijst codes aanpassen |
Incl. algemene wijzigingsverzoeken:
ZIB-94 | Aanpassen tekst van Disclaimer, Terms of Use & Copyrights |
ZIB-154 | Consequenties opsplitsing Medicatie bouwstenen voor overige bouwstenen. |
ZIB-200 | Naamgeving SNOMED CT in tagged values klinische bouwstenen gelijk getrokken. |
ZIB-201 | Naamgeving OID: in tagged value notes van klinische bouwstenen gelijk getrokken. |
ZIB-309 | EOI aangepast |
ZIB-324 | Codelijsten Name en Description beginnen met een Hoofdletter |
ZIB-326 | Tekstuele aanpassingen conform de kwaliteitsreview kerngroep 2015 |
Publicatieversie 3.0 (01-05-2016)
ZIB-423 | Verkeerd bron-codestelsel gekoppeld aan de 'TestStatusCodelijst'. |
ZIB-453 | Wijziging naamgeving ZIB's en logo's door andere opzet van beheer |
Publicatieversie 4.0 (04-09-2017)
ZIB-549 | De Engelse naam van de bouwsteen en het rootconcept zijn niet correct |
ZIB-576 | Aanpassen bouwstenen die nog de prefix overdracht hebben, zodat de prefix kan vervallen. |
Publicatieversie 4.1 (31-12-2017)
ZIB-646 | Aanpassing SNOMED codes |
.
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
![TextResult-v4.1Model(2017EN).png](/images/7/72/TextResult-v4.1Model%282017EN%29.png)
Type | Id | Concept | Card. | Definition | DefinitionCode | Reference | ||||||||
![]() |
NL-CM:13.2.1 | ![]() |
Root concept of the TextResult information model. This root concept contains all data elements of the TextResult information model. | |||||||||||
![]() |
NL-CM:13.2.3 | ![]() |
0..1 | Date and if possible time of the result.
Date on which the procedure that TextResult documents, took place. |
||||||||||
![]() |
NL-CM:13.2.5 | ![]() |
0..1 | Reference to the Procedure information model including the date of the procedure, requesting and executive specialty. |
|
| ||||||||
![]() |
NL-CM:13.2.6 | ![]() |
0..1 | The status of the result. |
| |||||||||
![]() |
NL-CM:13.2.2 | ![]() |
1 | The text report detailing the actual results of the test or procedure. | ||||||||||
![]() |
NL-CM:13.2.4 | ![]() |
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
Tekst Uitslag Datum Tijd | 05-12-2014 17:00 uur | |
Tekst Uitslag Type | Röntgen | |
Tekst Uitslag Status | Voorlopig | |
Verrichting | ||
VerrichtingType | CR THORAX BED (085002BED) | |
Uitvoerder | Dr. A | |
Locatie | Radiologie | |
Aanvrager | Onbekende arts | |
TekstResultaat | ||
Klinische gegevens: Opname van het respiratoire insufficiëntie bij pneumonie. Vraagstelling: Afname infiltraat? Verslag: Liggende opname vergeleken met onderzoek van 31/10/2012. Hoogliggende positie van de trachea tube 7 cm boven de carina, idealiter 4-6 cm. Onveranderd goede positie van jugularislijn over rechts met tip in vena cava superior. Twee lijnstructuren te volgen over de oesophagus tot subdiafragmaal. Hoogstand van het rechter hemidiafragma conform. Pleuravocht rechts. Goede afgrensbaarheid linker diafragma en enige afname stuwingsbeeld. Iets afname van diffuse consolidatie rechter thoraxhelft. Verdichting in de fissura minor, passend bij plaatatelectase. Conclusie: Hoge ligging trachea tube. Iets afname van diffuse consolidaties rechter thoraxhelft. Afname stuwingsbeeld. |
TekstUitslagDatumTijd | 15-08-2014 11:00 uur | |
TekstUitslagType | Procedure | |
TekstUitslagStatus | Definitief | |
Verrichting | ||
VerrichtingType | Colonoscopie | |
Uitvoerder | Dr. B | |
TekstResultaat | ||
Indicatie gemetastaseerd NSCLC st IV wv chemotherapie en radiotherapie. Sinds 4 wkn persisterende diarree. radiatie proctitis? Premedicatie: Geen. Verslag Het colon is voorbereid met Klean Prep. Introductie vindt plaats tot in het coecum met identificatie van appendixopening en valvula bauhini zonder inspectie van terminale ileum. De darm is goed gereinigd. Anus Hemorrhoiden. Bij RT: geen afwijkingen voelbaar. Darm Het lumen van de dikke darm is normaal van kaliber. Linkszijdige diverticulose. Het slijmvlies van het gehele colon toont geen afwijking. Rectum bij inversie wel bekeken, hemorrhoiden. Inzending voor histologie PA I colon ascendens biopten PA II transversum biopten PA III sigmoid PA IV rectum Complicaties Geen. Indien binnen 30 dagen een mogelijke late complicatie wordt waargenomen, verzoek ik u dit aan ons te melden. Conclusie Geen afwijkingen waarneembaar bij coloscopie. Advies Expectatief tav diarree. Het verdere beleid is afhankelijk van de uitslag van het onderzoek door de patholoog-anatoom; Code: 20829 |
Valuesets
TextResultStatusCodelist
Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.2.2 | Binding: |
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: |
Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
Microbiology | 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 |
X-ray | 363680008 | SNOMED CT | 2.16.840.1.113883.6.96 | röntgen |
Ultrasound | 16310003 | SNOMED CT | 2.16.840.1.113883.6.96 | echografie |
CT | 77477000 | SNOMED CT | 2.16.840.1.113883.6.96 | CT |
MRI | 113091000 | SNOMED CT | 2.16.840.1.113883.6.96 | MRI |
Angiography | 77343006 | SNOMED CT | 2.16.840.1.113883.6.96 | angiografie |
Cardiac Echo | 40701008 | SNOMED CT | 2.16.840.1.113883.6.96 | echocardiografie |
Nuclear Medicine | 371572003 | SNOMED CT | 2.16.840.1.113883.6.96 | nucleaire geneeskunde |
Pathology | 108257001 | SNOMED CT | 2.16.840.1.113883.6.96 | pathologie |
Procedure | 71388002 | SNOMED CT | 2.16.840.1.113883.6.96 | procedure |
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