TreatmentDirective-v3.1(2018EN)

Attention!! This is not the most recent version of this information model. You can find the most recent version here.

General information

Name: nl.zorg.TreatmentDirective
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	25-10-2012
DCM::DeprecatedDate
DCM::DescriptionLanguage	nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name	PM
DCM::EndorsingAuthority.Telecom
DCM::Id	2.16.840.1.113883.2.4.3.11.60.40.3.2.1
DCM::KeywordList	advance directives, behandel aanwijzing, wilsverklaring, behandelbeperking
DCM::LifecycleStatus	Final
DCM::ModelerList	Kerngroep Registratie aan de Bron
DCM::Name	nl.zorg.BehandelAanwijzing
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.nfu.BehandelAanwijzing-v1.0.1
DCM::Version	3.1
HCIM::PublicationLanguage	EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (01-04-2015)

ZIB-82	OverdrachtBehandelAanwijzing v1.1
ZIB-91	Opsplitsen OverdrachtBehandelAanwijzing in OverdrachtWilsverklaring en OverdrachtBehandelAanwijzing, incl. uitbreiding WilsverklaringTypeCodelijst.
ZIB-133	Aanpassingen in SNOMED CT codes en omschrijvingen voor codelijst BehandelingCodelijst n.a.v. review terminologie expert.
ZIB-134	Aanpassingen in SNOMED CT codes en omschrijvingen voor codelijst GeverifieerdBijCodelijst n.a.v. review terminologie expert.
ZIB-213	In klinische bouwsteen OverdrachtBehandelAanwijzing de waarde van DCM::Name aanpassen van <<DCM>> nl.nfu. ... naar nl.nfu. ....
ZIB-215	De naam van gekoppelde waardenlijst BehandelingToegestaan is onjuist in de bouwsteen OverdrachtBehandelAanwijzing, dit zou BehandelingToegestaanCodelijst moeten zijn.
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 1.0.1 (22-05-2015)

ZIB-386

De GeverifeerdBijCodelijst heeft geen "OID: " aanduiding in de onderliggende codelijst.

Publicatieversie 3.0 (01-05-2016)

Publicatieversie 3.1 (04-09-2017)

ZIB-549

De Engelse naam van de bouwsteen en het rootconcept zijn niet correct

.

Concept

A treatment instruction includes an agreed constraint in the treatment based on the oral or written living will of the patient.

Purpose

A good overview of treatment instructions based on the wishes of the patient or their authorized representative on (un)desired treatments is important in a patient’s care. A concise, orderly list is of particular importance in acute care situations. Due to the large variety of symptoms, the situation concerns not only a CPR setting, but also cases in which the patient’s condition rapidly worsens as a result of existing symptoms.
A healthcare provider consulting this information can discuss these existing treatment instructions with the patient, the patient’s family or the patient’s authorized representative and possibly include the instructions in their policy.

Evidence Base

Explanation for TreatmentCodeList:
In discussions on constraints in the therapeutic treatment of patients with a chronic neurological or respiratory condition, respiration is sometimes included as a separate restriction. The ‘Respiration’ item is to be seen separately from the decisions on CPR.

Information Model

Type	Id	Concept						Card.	Definition	DefinitionCode	Reference
	NL-CM:2.1.1	TreatmentDirective							Root concept of the TreatmentInstruction information model. This concept contains all data elements of the TreatmentInstruction information model.
	NL-CM:2.1.8		Verification					0..*	Container of the Verification concept. This container contains all data elements of the Verification concept.
	NL-CM:2.1.9			Verified				1	Indication of the fact that the treatment instruction has been verified with the patient, the patient’s family and/or the patient's authorized representative.
	NL-CM:2.1.11			VerifiedWith				0..*	The person with whom the treatment instruction was discussed and verified.		VerifiedWithCodelist
	NL-CM:2.1.10			VerificationDate				0..1	Date on which the verification with the patient, the patient’s family and/or the patient's authorized representative took place.
	NL-CM:2.1.3		Treatment					0..1	The medical treatment to which the treatment instruction applies.	50731006 Medical procedure	TreatmentCodelist
	NL-CM:2.1.4		TreatmentPermitted					1	Indication of permission for the treatment, no permission for the treatment, or permission for the treatment with constraints.		TreatmentPermittedCodelist
	NL-CM:2.1.5		Restrictions					0..1	The restrictions or specific circumstances that apply to a certain treatment.
	NL-CM:2.1.6		StartDate					0..1	Date on which the treatment instruction went into effect. A ‘vague’ date, such as only the year, is permitted.
	NL-CM:2.1.7		EndDate					0..1	Date on which the treatment instruction ends. A ‘vague’ date, such as only the year, is permitted. If the validity duration of the treatment instruction cannot be expressed as a date, such as “until discharge from hospital”, it can be included in the Comment concept.
	NL-CM:2.1.15		Comment					0..1	Comments on the treatment instruction such as a written description of an end date which can be indicated as a date (“until discharge from hospital”).	48767-8 Annotation comment [Interpretation] Narrative
	NL-CM:2.1.14		AdvanceDirective					0..*	A (written) statement in which a person indicates wishes concerning future medical action, in the event that this person is at that point no longer (deemed) capable of taking decisions on the matter.		AdvanceDirective

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

Behandeling	Behandeling Toegestaan	Beperkingen	GeverifieerdBij	Verificatie Datum
Opname op Intensive Care	Ja		gevolmachtigde	11-9-2012
Behandeling	Behandeling Toegestaan	Beperkingen	GeverifieerdBij	Verificatie Datum
Cardiopulmonaire resuscitatie	Ja, maar met beperkingen	eerst overleg met echtgenote	patiënt	11-9-2012

Valuesets

TreatmentCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.2.1.1

Binding: Extensible

Conceptname	Conceptcode	Codesystem name	Codesystem OID	Description
Admission to intensive care unit	305351004	SNOMED CT	2.16.840.1.113883.6.96	Opname op intensive care
Cardiopulmonary resuscitation	89666000	SNOMED CT	2.16.840.1.113883.6.96	Cardiopulmonaire resuscitatie
Artificial respiration	40617009	SNOMED CT	2.16.840.1.113883.6.96	Kunstmatige beademing
Administration of blood product	116762002	SNOMED CT	2.16.840.1.113883.6.96	Toediening van een bloedproduct
Other	OTH	NullFlavor	2.16.840.1.113883.5.1008	Overige behandelingen, namelijk (in vrije tekst meegeven)

TreatmentPermittedCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.2.1.2

Binding: Extensible

Conceptname	Conceptcode	Codesystem name	Codesystem OID	Description
Ja	JA	NL-CM-CS	2.16.840.1.113883.2.4.3.11.60.40.4	Behandeling is toegestaan en/of wenselijk.
Ja, maar met beperkingen	JA_MAAR	NL-CM-CS	2.16.840.1.113883.2.4.3.11.60.40.4	Behandeling toegestaan en/of wenselijk maar met beperkingen die dan ook vermeld moeten worden
Nee	NEE	NL-CM-CS	2.16.840.1.113883.2.4.3.11.60.40.4	Behandeling niet toegestaan en/of wenselijk

VerifiedWithCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.2.1.4

Binding: Extensible

Conceptname	Conceptcode	Codesystem name	Codesystem OID	Description
Patient	116154003	SNOMED CT	2.16.840.1.113883.6.96	Patiënt
Parent	40683002	SNOMED CT	2.16.840.1.113883.6.96	Ouder
Guardian	394619001	SNOMED CT	2.16.840.1.113883.6.96	Voogd
Holder of enduring power of attorney	8601000146109	SNOMED CT	2.16.840.1.113883.6.96	Gevolmachtigde
Other	OTH	NullFlavor	2.16.840.1.113883.5.1008	Anders, namelijk (in vrije tekst meegeven)

This information model in other releases

• Release 2015, (Version 1.0.1)
• Release 2016, (Version 3.0)
• Release 2017, (Version 3.1)
• Release 2019, (Version 3.2)

Information model references

This information model refers to

• AdvanceDirective-v3.1

This inforation model is used in

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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
• 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 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
This page is generated on 01/11/2018 17:34:20 with ZibExtraction v. 2.0.6879.31307

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