Encounter-v3.1(2018EN)

Uit Zorginformatiebouwstenen
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General information

Name: nl.zorg.Encounter NL.png
Version: 3.1
HCIM Status:Final
Release: 2018
Release status: Prepublished
Release date: 01-10-2018

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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 19-4-2012
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name PM
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.15.1
DCM::KeywordList Contacten, contact, patiëntcontact
DCM::LifecycleStatus Final
DCM::ModelerList Kerngroep Registratie aan de Bron
DCM::Name nl.zorg.Contact
DCM::PublicationDate 01-10-2018
DCM::PublicationStatus Prepublished
DCM::ReviewerList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 31-12-2017
DCM::Superseeds nl.zorg.Contact-v3.0
DCM::Version 3.1
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-163 Naamgeving concept Probleem::Probleem uit OverdrachtContact aanpassen.
ZIB-164 Het concept Locatie::Zorgaanbieder uit bouwsteen OverdrachtContact niet verplicht maken, maar als cardinaliteit 0..1 opgeven.
ZIB-165 Het concept Procedure in OverdrachtContact dient referentie naar bouwsteen te zijn.
ZIB-306 Aanpassen modellering keuzebox, boundary en cardinaliteit
ZIB-308 Prefix Overdracht weggehaald bij de generieke bouwstenen

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-453 Wijziging naamgeving ZIB's en logo's door andere opzet van beheer

Publicatieversie 3.1 (04-09-2017)

ZIB-463 Toevoegen IC aan ContactTypeCodelijst
ZIB-465 Uitbreiding met datacontainers "Herkomst" en "Ontslagbestemming"
ZIB-553 Example Instances Contact Type komt niet overeen met ContactTypeCodelijst
ZIB-563 Engelse vertaling van Contact is Encounter
ZIB-564 Aanpassing/harmonisatie Engelse conceptnamen
ZIB-565 ContactTypeCodelijst niet compleet
ZIB-574 Alleen verwijzen naar het rootconcept van de ZIB.

Concept

A contact is any interaction, regardless of the situation, between a patient and the healthcare provider, in which the healthcare provider has primary responsibility for diagnosing, evaluating and treating the patient’s condition and informing the patient. These can be visits, appointments or non face-to-face interactions.

Contacts can be visits to the general practitioner or other practices, home visits, admissions (in hospitals, nursing homes or care homes, psychiatric institutions or convalescent homes) or other relevant contacts. This only includes past contacts. Future contacts can be documented in the PlannedCareActivity information model.

Purpose

Contacts can be recorded to provide insight on the interactions that have taken place between the patient and healthcare professional and in which context these took place.

Evidence Base

The codelists for Origin and Destination generally correspond to the ‘Landelijke Basisregistratie Ziekenhuiszorg’ (National Basic Registration Hospital Care)

Information Model


#DestinationCodelist#OriginCodelist#12807#12817#12811HealthcareProvider-v3.2(2018EN)#ContactTypeCodelist#12806Procedure-v4.1(2018EN)#12815Problem-v4.1.1(2018EN)HealthProfessional-v3.2(2018EN)#12809#12818#12813Encounter-v3.1Model(EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:15.1.1 Arrowdown.pngEncounter Root concept of the Contact information model. This concept contains all data elements of the Contact information model.
CD.png NL-CM:15.1.2 Arrowright.pngContactType 1 The type of contact.
List2.png ContactTypeCodelist
Verwijzing.png NL-CM:15.1.7 Arrowright.pngContactWith::HealthProfessional 0..* The health professional with whom the contact took place. The specialty and role of the health professional can be entered in the HealthProfessional information model.
Block.png HealthProfessional
Verwijzing.png NL-CM:15.1.8 Arrowright.pngLocation::HealthcareProvider 0..1 The physical location at which the contact took place.
Block.png HealthcareProvider
TS.png NL-CM:15.1.3 Arrowright.pngStartDateTime 1 The date and time at which the contact took place.
TS.png NL-CM:15.1.4 Arrowright.pngEndDateTime 0..1 The date and time at which the contact ended. If the contact takes place over a period of time, this indicates the end of the period, in the case of an admission, for example.
Folder.png NL-CM:15.1.13 Arrowdown.pngContactReason 1 Container of the ContactReason concept. This container contains all data elements of the ContactReason concept.
Verwijzing.png NL-CM:15.1.6 Arrowright.pngProblem (0..1) The problem that led to the contact.
Block.png Problem
Verwijzing.png NL-CM:15.1.11 Arrowright.pngProcedure (0..1) The procedure carried out during the contact.
Block.png Procedure
ST.png NL-CM:15.1.12 Arrowright.pngDeviatingResult (0..1) A deviating result which serves as the reason for the contact.
CD.png NL-CM:15.1.14 Arrowright.pngOrigin 0..1 Location from which the patient came before the encounter. In most cases this will only be used when the patient is admitted.
List2.png OriginCodelist
CD.png NL-CM:15.1.16 Arrowright.pngDestination 0..1 Location to which the patient will go after the encounter. In most cases this will only be used when the patient is discharged.
List2.png DestinationCodelist

Columns Concept and DefinitionCode: hover over the values for more information
For explanation of the symbols, please see the legend page List2.png

Example Instances

Only available in Dutch

Contact
Type 		BeginDatum
Tijd 		RedenContact ContactMet Locatie
ProbleemNaam Zorgverlener
Naam 		OrganisatieType Organisatie
Naam
SEH 16-08-2012 Gebroken been J.H.R. Peters Ziekenhuis Universitair Medisch Centrum Groningen
Contact
Type 		Begin
Datum
Tijd 		Eind
Datum
Tijd 		RedenContact ContactMet Locatie
VerrichtingType Zorgverlener
Naam 		OrganisatieType Organisatie
Naam
Klinisch 16-08-2012 19-08-2012 Operatie been G.Z.M. de Wit Ziekenhuis St. Lucas Andreas Ziekenhuis

Instructions

Explanation ‘Eigen woonomgeving’ (Home) from the ‘Landelijke Basisregistratie Ziekenhuiszorg’ (National Basic Registration Hospital Care) (concepts Origin and Destination)
The home environment is the environment where the patient stays regular. This distinguishes between living in a private home and living in an institution for nursing and care. This distinction is the difference between "independent living with any additional care" and "being taken care of including living". Thus, residential homes are counted as the first and stay in a nursing home to the second.

References

1. Landelijke Basisregistratie Ziekenhuiszorg [Online] Beschikbaar op: https://www.dhd.nl/klanten/klantenservice/handleidingen_formulieren/Documents/Handleiding%20LBZ.pdf [Geraadpleegd: 29 juni2017].

Valuesets

ContactTypeCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.15.1.1 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Ambulatory AMB ActCode 2.16.840.1.113883.5.4 Poliklinisch
Emergency EMER ActCode 2.16.840.1.113883.5.4 SEH
Field FLD ActCode 2.16.840.1.113883.5.4 Op lokatie
Home HH ActCode 2.16.840.1.113883.5.4 Thuis
Inpatient IMP ActCode 2.16.840.1.113883.5.4 Klinisch
Short Stay SS ActCode 2.16.840.1.113883.5.4 Dagopname
Virtual VR ActCode 2.16.840.1.113883.5.4 Virtueel
Other OTH NullFlavor 2.16.840.1.113883.5.1008 Anders

DestinationCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.15.1.3 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Home 264362003 SNOMED CT 2.16.840.1.113883.6.96 Eigen woonomgeving
Left against medical advice 445060000 SNOMED CT 2.16.840.1.113883.6.96 Tegen advies in vertrokken
Rehabilitation hospital 80522000 SNOMED CT 2.16.840.1.113883.6.96 Instelling voor revalidatie
Long term care facility 42665001 SNOMED CT 2.16.840.1.113883.6.96 Instelling voor verpleging/verzorging
Psychiatric hospital 62480006 SNOMED CT 2.16.840.1.113883.6.96 GGZ instelling
Hospital 22232009 SNOMED CT 2.16.840.1.113883.6.96 Ander ziekenhuis
Died in hospital 183676005 SNOMED CT 2.16.840.1.113883.6.96 Overleden
Hospice 284546000 SNOMED CT 2.16.840.1.113883.6.96 Hospice
Other OTH NullFlavor 2.16.840.1.113883.5.1008 Overig

OriginCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.15.1.2 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Home 264362003 SNOMED CT 2.16.840.1.113883.6.96 Eigen woonomgeving
Rehabilitation hospital 80522000 SNOMED CT 2.16.840.1.113883.6.96 Instelling voor revalidatie
Long term care facility 42665001 SNOMED CT 2.16.840.1.113883.6.96 Instelling voor verpleging/verzorging
Psychiatric hospital 62480006 SNOMED CT 2.16.840.1.113883.6.96 GGZ instelling
Hospital 22232009 SNOMED CT 2.16.840.1.113883.6.96 Ander ziekenhuis
Liveborn born in hospital 442311008 SNOMED CT 2.16.840.1.113883.6.96 In dit ziekenhuis geboren
Hospice 284546000 SNOMED CT 2.16.840.1.113883.6.96 Hospice
Other OTH NullFlavor 2.16.840.1.113883.5.1008 Overig

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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 Artdecor.jpg
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This information model is also available as pdf file PDF.png or as spreadsheet Xlsx.png

About this information

The information in this wikipage is based on Prerelease 2018 #1
SNOMED CT and LOINC codes are based on:

  • SNOMED Clinical Terms version: 20180731 [R] (July 2018 Release)
  • LOINC version 2.64

Conditions for use are located on the mainpage List2.png
This page is generated on 01/11/2018 17:34:48 with ZibExtraction v. 2.0.6879.31307

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