Patient-v4.2(2023EN): verschil tussen versies
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Regel 26: | Regel 26: | ||
|style="width:250px; "|DCM::ContactInformation.Telecom||* | |style="width:250px; "|DCM::ContactInformation.Telecom||* | ||
|- | |- | ||
− | |style="width:250px; "|DCM::ContentAuthorList||Projectgroep Generieke Overdrachtsgegevens & | + | |style="width:250px; "|DCM::ContentAuthorList||Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron |
|- | |- | ||
|style="width:250px; "|DCM::CreationDate||14-6-2012 | |style="width:250px; "|DCM::CreationDate||14-6-2012 | ||
Regel 54: | Regel 54: | ||
|style="width:250px; "|DCM::PublicationStatus||Prepublished | |style="width:250px; "|DCM::PublicationStatus||Prepublished | ||
|- | |- | ||
− | |style="width:250px; "|DCM::ReviewerList||Projectgroep Generieke Overdrachtsgegevens & | + | |style="width:250px; "|DCM::ReviewerList||Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron |
|- | |- | ||
|style="width:250px; "|DCM::RevisionDate||11-09-2023 | |style="width:250px; "|DCM::RevisionDate||11-09-2023 | ||
Regel 150: | Regel 150: | ||
|- | |- | ||
|style="width:75px; "|[[ZIBIssues500_0#ZIB-94 | ZIB-94 ]] | |style="width:75px; "|[[ZIBIssues500_0#ZIB-94 | ZIB-94 ]] | ||
− | |Aanpassen tekst van Disclaimer, Terms of Use & | + | |Aanpassen tekst van Disclaimer, Terms of Use & Copyrights |
|- | |- | ||
|style="width:75px; "|[[ZIBIssues500_0#ZIB-154 | ZIB-154 ]] | |style="width:75px; "|[[ZIBIssues500_0#ZIB-154 | ZIB-154 ]] | ||
Regel 185: | Regel 185: | ||
|- | |- | ||
|style="width:75px; "|[[ZIBIssues500_0#ZIB-453 | ZIB-453 ]] | |style="width:75px; "|[[ZIBIssues500_0#ZIB-453 | ZIB-453 ]] | ||
− | |Wijziging naamgeving ZIB | + | |Wijziging naamgeving ZIB's en logo's door andere opzet van beheer |
|} | |} | ||
Regel 201: | Regel 201: | ||
|- | |- | ||
|style="width:75px; "|[[ZIBIssues500_0#ZIB-471 | ZIB-471 ]] | |style="width:75px; "|[[ZIBIssues500_0#ZIB-471 | ZIB-471 ]] | ||
− | |Terminologiekoppeling | + | |Terminologiekoppeling Patiënt |
|- | |- | ||
|style="width:75px; "|[[ZIBIssues500_0#ZIB-491 | ZIB-491 ]] | |style="width:75px; "|[[ZIBIssues500_0#ZIB-491 | ZIB-491 ]] | ||
− | |Bij telefoonnummer staat | + | |Bij telefoonnummer staat "het telefoonnummer van de patiënt", ook als het om een zorgverlener of zorgaanbieder gaat |
|- | |- | ||
|style="width:75px; "|[[ZIBIssues500_1#ZIB-564 | ZIB-564 ]] | |style="width:75px; "|[[ZIBIssues500_1#ZIB-564 | ZIB-564 ]] | ||
Regel 303: | Regel 303: | ||
{| | {| | ||
|- | |- | ||
− | |<span title = "Codesystem: SNOMED CT; | + | |<span title = "Codesystem: SNOMED CT; Patiënt (person)" >[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=116154003 116154003] Patient</span> |
|} | |} | ||
| | | | ||
Regel 312: | Regel 312: | ||
|colspan ="5" style ="padding-left: 0px"|<span Id=1068 Title="NL: Naamgegevens">[[Bestand: arrowright.png | 10px | link=]]NameInformation</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=1068 Title="NL: Naamgegevens">[[Bestand: arrowright.png | 10px | link=]]NameInformation</span> | ||
|1 | |1 | ||
− | |Patient | + | |Patient's full name. |
| | | | ||
| | | | ||
Regel 325: | Regel 325: | ||
|colspan ="5" style ="padding-left: 0px"|<span Id=1069 Title="NL: Adresgegevens">[[Bestand: arrowright.png | 10px | link=]]AddressInformation</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=1069 Title="NL: Adresgegevens">[[Bestand: arrowright.png | 10px | link=]]AddressInformation</span> | ||
|0..* | |0..* | ||
− | |Patient | + | |Patient's address information. |
| | | | ||
| | | | ||
Regel 368: | Regel 368: | ||
{| | {| | ||
|- | |- | ||
− | |<span title = "Codesystem: LOINC; Geboortedatum [tijdstempel] in ^ | + | |<span title = "Codesystem: LOINC; Geboortedatum [tijdstempel] in ^patiënt (Qn)" >[https://terminologie.nictiz.nl/art-decor/loinc?conceptId=21112-8 21112-8] Birth date</span> |
|} | |} | ||
| | | | ||
Regel 381: | Regel 381: | ||
{| | {| | ||
|- | |- | ||
− | |<span title = "Codesystem: LOINC; Geslacht [type] in ^ | + | |<span title = "Codesystem: LOINC; Geslacht [type] in ^patiënt (Nom)" >[https://terminologie.nictiz.nl/art-decor/loinc?conceptId=46098-0 46098-0] Sex</span> |
|} | |} | ||
| | | | ||
Regel 677: | Regel 677: | ||
*[[TreatmentDirective2-v2.0.1(2023EN)|TreatmentDirective2-v2.0.1]] | *[[TreatmentDirective2-v2.0.1(2023EN)|TreatmentDirective2-v2.0.1]] | ||
==Technical specifications in HL7v3 CDA and HL7 FHIR<!--ftHeader-->== | ==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. | + | 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:<!--ftReferenceIntro--> | Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:<!--ftReferenceIntro--> | ||
<ul> | <ul> | ||
− | <li> | + | <li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment<!--ftArtDecorReference--> {{ArtDecorLinks|2023|0.1}}</li> |
− | <li> | + | <li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR<!--ftSimplifierReference--> {{SimplefierLinks|2023|Patient}}</li> |
</ul> | </ul> | ||
==Downloads<!--ftDownloadTitle-->== | ==Downloads<!--ftDownloadTitle-->== | ||
Regel 693: | Regel 693: | ||
</ul> | </ul> | ||
Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR> | Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR> | ||
− | This page is generated on | + | This page is generated on 31/10/2023 18:35:47 with ZibExtraction v. 9.3.8704.31782<!--ftDate--> <BR> |
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Huidige versie van 31 okt 2023 om 20:41
Inhoud
- 1 General information
- 2 Metadata
- 3 Revision History
- 4 Concept
- 5 Purpose
- 6 Evidence Base
- 7 Information Model
- 8 Example Instances
- 9 Instructions
- 10 References
- 11 Assigning authorities
- 12 Valuesets
- 13 This information model in other releases
- 14 Information model references
- 15 Technical specifications in HL7v3 CDA and HL7 FHIR
- 16 Downloads
- 17 About this information
General information
Name: nl.zorg.Patient
Version: 4.2
HCIM Status:Final
Release: 2023
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 | 14-6-2012 |
DCM::DeprecatedDate | |
DCM::DescriptionLanguage | nl |
DCM::EndorsingAuthority.Address | |
DCM::EndorsingAuthority.Name | PM |
DCM::EndorsingAuthority.Telecom | |
DCM::Id | 2.16.840.1.113883.2.4.3.11.60.40.3.0.1 |
DCM::KeywordList | Patient, zorgverlener, contact |
DCM::LifecycleStatus | Final |
DCM::ModelerList | Kerngroep Registratie aan de Bron |
DCM::Name | nl.zorg.Patient |
DCM::PublicationDate | 15-10-2023 |
DCM::PublicationStatus | Prepublished |
DCM::ReviewerList | Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron |
DCM::RevisionDate | 11-09-2023 |
DCM::Supersedes | nl.zorg.Patient-v4.1 |
DCM::Version | 4.2 |
HCIM::PublicationLanguage | EN |
Revision History
Only available in Dutch
Publicatieversie 1.0 (15-02-2013) -
Publicatieversie 1.1 (01-07-2013)
ZIB-33 | Wijzigingsverzoek betreffende Generieke Overdrachtsgegevens |
Publicatieversie 2.0 (01-04-2015)
ZIB-62 | commentaar op bouwsteen: nl.nfu.OverdrachtPatient?v1.1: dubbel id 0.1.33 |
ZIB-67 | Wijzigingsverzoek Klinische Bouwsteen Patient document |
ZIB-96 | Cardinaliteit PatientIdentificatienummer in OverdrachtPatient anapassen naar 0..* |
ZIB-97 | Concept Voornamen opsplitsen in Voornamen en Initialen in OverdrachtPatient |
ZIB-98 | Achternaam en voorvoegsel als losse concepten uitwerken in OverdrachtPatient |
ZIB-99 | Example of the Instrument in OverdrachtPatient aanpassen qua naam Soort adres |
ZIB-100 | VIP indicator in OverdrachtPatient laten vervallen |
ZIB-102 | DCM::ExampleValue toevoegne bij concept MeerlingIndicator in OverdrachtPatient |
ZIB-121 | In de bouwsteen OverdrachtPatient het concept Aanhef laten vervallen. |
ZIB-257 | In de klinische bouwsteen OverdrachtPatient DCM::ValueSet Postcodetabel van concept Postcode aangepast naar tagged value DCM::CodeSystem. |
ZIB-258 | In de klinische bouwsteen OverdrachtPatient DCM::ValueSet GBA tabel 33 van concept Gemeente aangepast naar tagged value DCM::CodeSystem. |
ZIB-259 | In de klinische bouwsteen OverdrachtPatient DCM::ValueSet GBA Tabel 34 van concept Land aangepast naar tagged value DCM::CodeSystem GBA tabel 34 (Landentabel). |
ZIB-260 | In de klinische bouwsteen OverdrachtPatient DCM::ValueSet ISO 3166-2 van concept Land aangepast naar tagged value DCM::CodeSystem. |
ZIB-261 | In de klinische bouwsteen OverdrachtPatient DCM::ValueSet Burger Service Nummer van concept PatientIdentificatienummer aangepast naar tagged value DMC::AssigningAuthority. |
ZIB-262 | AdressoortCodelijst bevatte hoofdletter L, dit aangepast naar Codelijst. |
ZIB-303 | foutje in bouwsteen patient |
ZIB-308 | Prefix Overdracht weggehaald bij de generieke bouwstenen |
ZIB-349 | VIPIndicator uit bouwsteen OverdrachtPatient verwijderd |
ZIB-350 | Aanpassing concept namen in container Naamgegevens |
ZIB-351 | NaamgebruikCodelijst aangevuld met descriptions |
ZIB-353 | Tagged values DCM::CodeSystem aanpassen naar DCM::ValueSet incl. gekoppelde codelijst. |
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 2.0.1 (22-05-2015)
ZIB-385 | Inconsistent gebruik van de naam AdresSoortCodelijst. |
ZIB-374 | Het concept AanduidingBijHuisnummer is afgeleid van ST, maar heeft een valueset; dit zou CD moeten zijn. |
Publicatieversie 3.0 (01-05-2016)
ZIB-453 | Wijziging naamgeving ZIB's en logo's door andere opzet van beheer |
Publicatieversie 3.1 (04-09-2017)
ZIB-429 | Opsplitsen bouwsteen Patient zodat Naamgegevens, Adresgegevens en Contactgegevens aparte bouwstenen worden. |
ZIB-430 | Aanpassen naamgeving concept PatientIdentificatienummer |
ZIB-442 | Tweetal tekstuele aanpassingen in AdresSoortCodeLijst |
ZIB-471 | Terminologiekoppeling Patiënt |
ZIB-491 | Bij telefoonnummer staat "het telefoonnummer van de patiënt", ook als het om een zorgverlener of zorgaanbieder gaat |
ZIB-564 | Aanpassing/harmonisatie Engelse conceptnamen |
Publicatieversie 3.1.1 (01-10-2018)
ZIB-647 | Wijziging naam concept Patient? |
Publicatieversie 3.2 (01-09-2020)
ZIB-961 | Kardinaliteit naamgegevens bij patient, 1..1 is te strikt ivm kwaliteitsregistraties |
ZIB-1029 | Patient Geboortedatum en Geslacht verplichting onterecht |
ZIB-1189 | DefinitionCodes alle administratieve zibs |
Publicatieversie 4.0 (01-12-2021)
ZIB-1239 | Geslacht uitbreiden o.a. met X |
ZIB-1465 | Meldingen terminology report bij overlijdensIndicator en BronMonster |
Publicatieversie 4.1 (10-06-2022)
ZIB-1650 | tekst over verplichting geboortedatum bij Patient publicatie 2020 wijzigen |
Publicatieversie 4.2 (15-10-2023)
ZIB-1693 | Geslacht in zib Patient |
Concept
A person who receives medical, psychological, paramedical or nursing care. In some care settings, the term client or participant is used instead of the term patient.
Purpose
Recording relevant information to identify the patient for administrative purposes and process support.
Evidence Base
Although the term Patient is not used in all care settings, it has been decided not to change the name of the zib to Person as the overall name for Patient, Client, Participant, etc. because the concept Person is broader than the concept referred to here. Healthprofessionals and contact persons are ultimately also Persons.
The name and address information is based on the information set of the Municipal Personal Records Database (GBA) and on the Dutch Implementation Guide: HL7v3 Basic Components.
The information for the legally required verification of a social security number provided by the SBV-Z also follows GBA specifications.
Furthermore, the AZR (AWBZ-wide healthcare registration) data set used in AWBZ healthcare served as a base in determining the set.
Use of patient and personal details must follow the Personal Data Protection Act. This law prohibits processing non-essential personal data and mandates decent and reasonable processing of obtained personal data (Kohnstamm, 2006). Patient data recorded in (electronic) patient records or in digital messages must be handled in the context of the Personal Data Protection Act. Furthermore, healthcare centers must meet the Information Security NEN 7510 standard. Observance of the PDPA is monitored by the Dutch Data Protection Authority (CBP). The CBP and the Healthcare Inspectorate (IGZ) are jointly responsible for monitoring information security in healthcare (CBP, IGZ, 2008).
For those reasons, some personal data, seen in some countries as administrative data, are not included in this information model but in the information models for the Social Anamnesis.
Information Model
Type | Id | Concept | Card. | Definition | DefinitionCode | Reference | ||||||||
NL-CM:0.1.1 | Patient | Root concept of the Patient information model. This root concept contains all data elements of the Patient information model. |
|
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NL-CM:0.1.6 | NameInformation | 1 | Patient's full name. |
| ||||||||||
NL-CM:0.1.4 | AddressInformation | 0..* | Patient's address information. |
| ||||||||||
NL-CM:0.1.5 | ContactInformation | 0..1 | Patient’s telephone number(s) or e-mail address(es). |
| ||||||||||
NL-CM:0.1.7 | PatientIdentificationNumber | 0..* | The patient’s identification number. In transfer situations, use of the social security number (BSN) must comply with the Use of Social Security Numbers in Healthcare Act (Wbsn-z). In other situations, other number systems can be used, such as internal hospital patient numbers for example. |
| ||||||||||
NL-CM:0.1.10 | DateOfBirth | 1 | Patient’s date of birth. The date of birth is mandatory for a patient. A vague date (such as only the year) is permitted. |
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NL-CM:0.1.9 | Gender | 1 | Patient’s administrative gender. |
|
| |||||||||
NL-CM:0.1.34 | GenderIdentity | 0..1 | The gender with which the person identifies. |
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| |||||||||
NL-CM:0.1.31 | MultipleBirthIndicator | 1 | An indication stating whether the patient is of a multiple birth. | |||||||||||
NL-CM:0.1.32 | DeathIndicator | 1 | An indication stating whether the patient has died. |
|
||||||||||
NL-CM:0.1.33 | DateOfDeath | 0..1 | The date on which the patient died. A ‘vague’ date, such as only the year, is permitted. |
|
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
Patiënt | |
Naamgegevens | |
PatiëntIdentificatienummer | 111222333 |
Achternaam | Putten |
Voorvoegsels | van |
AchternaamPartner | Giessen |
VoorvoegselsPartner | van der |
Voornamen | Johanna Petronella Maria |
Initialen | J.P.M. |
Roepnaam | Jo |
Geslacht | Vrouw |
Genderidentiteit | Identificeert zich als non-binair |
Geboortedatum | 28-04-1994 |
MeerlingIndicator | Ja |
OverlijdensIndicator | Nee |
DatumOverlijden | |
Adresgegevens* | |
Straat | 1e Jacob van Campenstr |
Huisnummer | 15 |
Woonplaats | Hoogmade |
Gemeente | Kaag en Braassem |
Postcode | 1012 NX |
AdresSoort | Woon-/verblijfadres |
Land | Nederland |
Adresgegevens* | |
Straat | Stationsstraat |
Huisnummer | 11 |
Woonplaats | Alphen aan den Rijn |
Gemeente | |
Postcode | 2406 AB |
AdresSoort | Officieel adres |
Land | |
Telefoonnummers* | |
Telefoonnummer | +31611234567 |
NummerSoort | Mobiel telefoonnummer |
EmailAdressen* | |
EmailAdres | giesput@myweb.nl |
EmailSoort | Privé e-mailadres |
Instructions
If both a name and an identification number are given, the name must match the name registered under that identification number, for verification purposes.
References
1. DCM Patientgegevens V0.91. [Online] Beschikbaar op: http://www.nictiz.nl/uploaded/FILES/htmlcontent/dcm/Nictiz/DCMPatientgegevens_V_0.91loNL.pdf [Geraadpleegd: 23 februari 2015].
2. Implementatiehandleiding HL7v3 Basiscomponenten, Stichting HL7 Nederland [Online] Beschikbaar op:http://www.hl7.nl/images/downloads/Implementatiehandleiding%20HL7v3%20Basiscomponenten%20%202.3NL_secure.pdf [Geraadpleegd: 23 februari 2015].
Assigning authorities
The identifying numbers are issued by the following authorities
Burgerservicenummer
Identifying number | ID system OID |
Burgerservicenummer | OID: 2.16.840.1.113883.2.4.6.3 |
Valuesets
GenderCodelist
Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.0.1.1 | Binding: Required |
Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
Undifferentiated | UN | AdministrativeGender | 2.16.840.1.113883.5.1 | Ongedifferentieerd |
Male | M | AdministrativeGender | 2.16.840.1.113883.5.1 | Man |
Female | F | AdministrativeGender | 2.16.840.1.113883.5.1 | Vrouw, V |
Unknown | UNK | NullFlavor | 2.16.840.1.113883.5.1008 | Onbekend, Genderneutraal, X |
GenderIdentityCodelist
Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.0.1.2 | Binding: Extensible |
Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
Identifies as male gender | 446151000124109 | SNOMED CT | 2.16.840.1.113883.6.96 | Identificeert zich als man |
Identifies as female gender | 446141000124107 | SNOMED CT | 2.16.840.1.113883.6.96 | Identificeert zich als vrouw |
Identifies as nonbinary gender | 33791000087105 | SNOMED CT | 2.16.840.1.113883.6.96 | Identificeert zich als non-binair |
Other | OTH | NullFlavor | 2.16.840.1.113883.5.1008 | Anders |
This information model in other releases
- Release 2015, (Version 2.0.1)
- Release 2016, (Version 3.0)
- Release 2017, (Version 3.1)
- Prerelease 2018-2, (Version 3.1.1)
- Prerelease 2019-2, (Version 3.1.1)
- Release 2020, (Version 3.2)
- Prerelease 2021-2, (Version 4.0)
- Prerelease 2022-1, (Version 4.1)
- Prerelease 2024-1, (Version 4.3)
Information model references
This information model refers to
This information model is used in
- CareAgreement-v1.1
- CareTeam-v1.0.1
- ComplaintPerception-v1.0
- MedicationAdministration2-v2.0.1
- MultidisciplinaryTeamMeeting-v2.0
- NursingIntervention-v4.0.1
- RegistrationData-v1.1
- TreatmentDirective2-v2.0.1
Technical specifications in HL7v3 CDA and HL7 FHIR
To exchange information based on health and care information models, additional, more technical specifications are required.
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 Prerelease 2023-1
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 31/10/2023 18:35:47 with ZibExtraction v. 9.3.8704.31782