NursingIntervention-v3.2(2020EN): verschil tussen versies
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| Regel 443: | Regel 443: | ||
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>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment<!--ftArtDecorReference--> [http://decor.nictiz.nl/art-decor/decor-scenarios--zib2020bbr-?id=2.16.840.1.113883.2.4.3.11.60. | + | <li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment<!--ftArtDecorReference--> [http://decor.nictiz.nl/art-decor/decor-scenarios--zib2020bbr-?id=2.16.840.1.113883.2.4.3.11.60.121.4.2.14.2&effectiveDate=2020-09-01T00:00:00&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<!--ftSimplifierReference--> {{SimplefierLinks|2020}}</li> | <li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR<!--ftSimplifierReference--> {{SimplefierLinks|2020}}</li> | ||
</ul> | </ul> | ||
| Regel 452: | Regel 452: | ||
SNOMED CT and LOINC codes are based on: | SNOMED CT and LOINC codes are based on: | ||
<ul> | <ul> | ||
| − | <li>SNOMED Clinical Terms version: | + | <li>SNOMED Clinical Terms version: 20200731 [R] (July 2020 Release)</li> |
<li>LOINC version 2.67</li> | <li>LOINC version 2.67</li> | ||
</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 29/09/2020 21:09:10 with ZibExtraction v. 4.0.7577.31095<!--ftDate--> <BR> |
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Versie van 29 sep 2020 om 21:19
Inhoud
- 1 General information
- 2 Metadata
- 3 Revision History
- 4 Concept
- 5 Purpose
- 6 Information Model
- 7 Example Instances
- 8 Instructions
- 9 References
- 10 Valuesets
- 11 This information model in other releases
- 12 Information model references
- 13 Technical specifications in HL7v3 CDA and HL7 FHIR
- 14 Downloads
- 15 About this information
General information
Name: nl.zorg.NursingIntervention 
Version: 3.2
HCIM Status:Final
Release: 2020
Release status: Published
Release date: 01-09-2020
Metadata
| DCM::CoderList | Werkgroep RadB Verpleegkundige Gegevens |
| DCM::ContactInformation.Address | * |
| DCM::ContactInformation.Name | * |
| DCM::ContactInformation.Telecom | * |
| DCM::ContentAuthorList | Werkgroep RadB Verpleegkundige Gegevens |
| DCM::CreationDate | 7-7-2014 |
| DCM::DeprecatedDate | |
| DCM::DescriptionLanguage | nl |
| DCM::EndorsingAuthority.Address | |
| DCM::EndorsingAuthority.Name | PM |
| DCM::EndorsingAuthority.Telecom | |
| DCM::Id | 2.16.840.1.113883.2.4.3.11.60.40.3.14.2 |
| DCM::KeywordList | Interventie, verpleegkundige actie |
| DCM::LifecycleStatus | Final |
| DCM::ModelerList | Werkgroep RadB Verpleegkundige Gegevens |
| DCM::Name | nl.zorg.VerpleegkundigeInterventie |
| DCM::PublicationDate | 01-09-2020 |
| DCM::PublicationStatus | Published |
| DCM::ReviewerList | Projectgroep RadB Verpleegkundige Gegevens & Kerngroep Registratie aan de Bron |
| DCM::RevisionDate | 10-10-2018 |
| DCM::Supersedes | nl.zorg.VerpleegkundigeInterventie-v3.1 |
| DCM::Version | 3.2 |
| HCIM::PublicationLanguage | EN |
Revision History
Only available in Dutch
Publicatieversie 1.0 (01-07-2015)
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-542 | Verwijderen verwijzingen naar codesystemen ICF, Omaha System, NANDA,,NIC en NOC |
Publicatieversie 3.2 (nn-nn-nnn)
| ZIB-728 | aanpassing zib verpleegkundige interventie |
Concept
A nursing intervention is the care and/or treatment carried out by a nurse based on an expert opinion and clinical knowledge. It is part of the nursing process; interventions are determined as a result of indexed healthcare problems (nursing diagnoses) and based on treatment goals. Following the NEN-EN-ISO 18104 norm, it is possible to structure nursing interventions (or actions) in a hierarchy, where one intervention can be part of another intervention.
In a home care situation some actions can also be performed by the patient or a caregiver after a relevant instruction
Purpose
The nursing interventions are an essential part of the nursing process. A nursing intervention is recorded to document the nursing policy and to update other health professionals on the intervention. The documentation of nursing interventions offers the option to determine whether the interventions outlined in the treatment plan have been carried out. This way, we can facilitate optimal nursing and continuity of care.
Information Model
| Type | Id | Concept | Card. | Definition | DefinitionCode | Reference | |||||||||
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NL-CM:14.2.1 |  NursingIntervention
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Root concept of the NursingIntervention information model. This root concept contains all data elements of the NursingIntervention information model. |
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NL-CM:14.2.2 |  Intervention
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1 | A nursing intervention is a treatment carried out by a nurse based on an expert opinion and clinical knowledge for the benefit of the person requesting healthcare. The intervention is targeted towards a certain problem (diagnosis) and has a predetermined healthcare result. It is possible to build a hierarchy of nursing interventions (where one intervention is part of another). |
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NL-CM:14.2.6 | Indication::Problem
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0..1 | The nursing-related problem (indication) providing cause for the intervention. |
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NL-CM:14.2.14 | TreatmentObjective
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0..1 | The description of the treatment goal that the intervention decision is based on. |
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NL-CM:14.2.3 | Interval
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0..1 | Interval indicates the time between planned procedures.
When entering an interval, the focus is on the time between the consecutive procedures, such as in the treatment of a wound, for example. The exact times are of lesser importance. |
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NL-CM:14.2.4 | Frequency
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0..1 | The frequency describes how often and in which period certain procedures are carried out, e.g. 3x a day. | |||||||||||
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NL-CM:14.2.11 | ProcedureStartDateTime
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0..1 | The start date (and if possible start time) of the procedure. The concept offers the option to indicate the start of the period of a series of repeating procedures. | |||||||||||
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NL-CM:14.2.12 | ProcedureEndDateTime
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0..1 | The end date (and if possible end time) of the procedure. The concept offers the option to indicate the end of the period of a series of repeating procedures. | |||||||||||
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NL-CM:14.2.13 | MedicalDevice
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0..* | Description of the materials used for the nursing procedure, such as bandages. |
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NL-CM:14.2.18 | Instruction
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0..1 | Instructions for performing the nursing action. This is particularly at issue when the action is performed by the patient himself or by a caregiver. | |||||||||||
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NL-CM:14.2.15 | Performer
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0..1 | The person carrying out the nursing procedure. | |||||||||||
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NL-CM:14.2.7 | HealthcareProvider
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(0..1) | The health professional carrying out the nursing procedure. |
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NL-CM:14.2.16 | Caregiver::ContactPerson
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(0..1) | The caregiver carrying out the nursing procedure. |
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NL-CM:14.2.17 | Patient
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(0..1) | The patient carrying out the nursing procedure. |
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NL-CM:14.2.8 | Requester::HealthProfessional
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0..* | The health professional who requested the nursing intervention. If desired, only the requester’s specialty can be entered. |
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NL-CM:14.2.5 | Comment
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0..1 | Comment on the nursing intervention. |
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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
| VerpleegkundigeInterventie | |
| Interventie | Pijnmanagement |
| Indicatie | |
| ProbleemNaam | Pijn |
| Behandeldoel | |
| Streefwaarde | |
| MetingNaam | Pijnscore |
| UitslagWaarde | <4 |
| UitslagDatumTijd | 10-09-2015 |
| VerpleegkundigeActie | |
| Activiteit | Ondersteuning van de wond bij hoesten. |
| ActieStartDatumTijd | 10-08-2015 |
| ActieEindDatumTijd | 15-08-2015 |
| VerpleegkundigeActie | |
| Activiteit | Toedienen medicatie volgens voorschrift bij pijnscore > 4. |
| ActieStartDatumTijd | 10-08-2015 |
| Toelichting | - |
Instructions
For the nursing domain: when two parties use different classification systems, the SNOMED CT based Dutch nursing problem list is used for exchange of information, so that data becomes comparable and interchangeable. A mapping table is available from the Dutch nursing problem list to Omaha System, NANDA-I and ICF.
References
1. Richtlijn Verpleegkundige en verzorgende verslaglegging (V&VN, 2011) [Online] Beschikbaar op:http://www.diliguide.nl/document/4060/file/pdf/ [Geraadpleegd: 13 februari 2015]
2. Vreeke E, Klein Wolterink G. Classificatie- en terminologiestelsels voor verpleegkundige informatie. Nictiz & NFU (2014). [Geraadpleegd: 13 februari 2015]
3. The Omaha System [Online] Beschikbaar op:http://www.omahasystem.org/ [Geraadpleegd: 13 februari 2015]
4. Nursing Intervention Classification (NIC) [Online] Beschikbaar op:http://www.nursing.uiowa.edu/center-for-nursing-classification-and-clinical-effectiveness [Geraadpleegd: 13 februari 2015]
5. Nursing Outcome Classification (NOC) [Online] Beschikbaar op:http://www.nursing.uiowa.edu/center-for-nursing-classification-and-clinical-effectiveness [Geraadpleegd: 13 februari 2015]
6. North American Nursing Diagnosis Association (NANDA) [Online] Beschikbaar op:http://www.nanda.org/ [Geraadpleegd: 13 februari 2015]
7. International Classification for Nursing Practice (ICNP) [Online] Beschikbaar op:www.icn.ch[Geraadpleegd: 13 februari 2015]
8. International Classification of Functioning, Disability and Health (ICF) [Online] Beschikbaar op:http://www.rivm.nl/who-fic/icf.htm [Geraadpleegd: 13 februari 2015]
Valuesets
InterventionNICCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.2.2 | Binding: Required |
| Conceptname | Codesystem name | Codesystem OID |
| Alle waarden | NIC | 2.16.840.1.113883.6.15 |
InterventionSnomedCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.2.4 | Binding: Required |
| Conceptname | Codesystem name | Codesystem OID |
| SNOMED CT: <<71388002|Procedure| | SNOMED CT | 2.16.840.1.113883.6.96 |
This information model in other releases
- Release 2015, (Version 1.0)
- Release 2016, (Version 3.0)
- Release 2017, (Version 3.1)
- Prerelease 2018-2, (Version 3.2)
- Prerelease 2019-2, (Version 3.2)
- Prerelease 2021-2, (Version 4.0)
- Prerelease 2022-1, (Version 4.0)
- Prerelease 2023-1, (Version 4.0.1)
- Prerelease 2024-1, (Version 4.1)
Information model references
This information model refers to
- ContactPerson-v3.4
- HealthProfessional-v3.5
- MedicalDevice-v3.3.1
- Patient-v3.2
- Problem-v4.4
- TreatmentObjective-v3.2
This information model is used in
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 Release 2020
SNOMED CT and LOINC codes are based on:
- SNOMED Clinical Terms version: 20200731 [R] (July 2020 Release)
- LOINC version 2.67
Conditions for use are located on the mainpage
This page is generated on 29/09/2020 21:09:10 with ZibExtraction v. 4.0.7577.31095
