Condition-v1.0(2024EN)
Inhoud
- 1 General information
- 2 Metadata
- 3 Revision History
- 4 Concept
- 5 Purpose
- 6 Evidence Base
- 7 Patient Population
- 8 Information Model
- 9 Example Instances
- 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.Condition 
Version: 1.0
HCIM Status:Final
Release: 2024
Release status: Prepublished
Release date: 15-04-2024
Metadata
| DCM::CoderList | Zib-centrum |
| DCM::ContactInformation.Address | * |
| DCM::ContactInformation.Name | * |
| DCM::ContactInformation.Telecom | * |
| DCM::ContentAuthorList | Zib-centrum |
| DCM::CreationDate | 26-04-2023 |
| DCM::DeprecatedDate | |
| DCM::DescriptionLanguage | nl |
| DCM::EndorsingAuthority.Address | |
| DCM::EndorsingAuthority.Name | * |
| DCM::EndorsingAuthority.Telecom | |
| DCM::Id | 2.16.840.1.113883.2.4.3.11.60.40.3.5.4 |
| DCM::KeywordList | |
| DCM::LifecycleStatus | Final |
| DCM::ModelerList | * |
| DCM::Name | nl.zorg.AandoeningOfGesteldheid |
| DCM::PublicationDate | 15-04-2024 |
| DCM::PublicationStatus | Prepublished |
| DCM::ReviewerList | Zib-centrum |
| DCM::RevisionDate | |
| DCM::Supersedes | * |
| DCM::Version | 1.0 |
| HCIM::PublicationLanguage | EN |
Revision History
Only available in Dutch
Publicatieversie 1.0 (15-04-2024)
| ZIB-1146 | nieuwe datums toevoegen aan zib Probleem ivm onderliggend lijden |
| ZIB-1295 | correctie en toevoegen SNOMED CT termen in de zib probleem |
| ZIB-1370 | Verschillende waardenlijsten voor status in zib-problem en zib-allergyintolerance |
| ZIB-1394 | Codelijst ProbleemType in zib Probleem |
| ZIB-2170 | ZIB Probleem Diagnosedatum |
Concept
A condition is pathological or non-pathological state of the patient that generally presents with symptoms. It is 'that what the patient has'. A care professional can assign a (differential) diagnosis to the condition. The symptoms as well as the diagnostic insight with respect to the same condition may change over time.
Purpose
A clear representation of the symptoms and diagnostic insight per condition. This contributes to the insight of the health care professionals involved into the patient's health status. It helps evaluate the effect of the care provided and determine follow-up policy.
Evidence Base
Note on zib Condition
This zib describes the characteristics of a patient's condition: the period during which the condition is present, its severity and course. The designation of the condition is not a characteristic, but an interpretation by the health professional. The zib DiagnosticInsight represents this interpretation. The condition presents itself with symptoms for which there is the zib Symptom.
Both the interpretation of the condition and the symptoms, with which it presents itself, can change independently over time.
If possible, a health professional will communicate about a condition by its interpretation in the form of a (differential) diagnosis. If there is not yet a (differential) diagnosis, he/she will communicate about it on the basis of ≥ 1 major symptoms that he/she thinks belong together and can probably be explained by one condition.
Relationship between (differential) diagnosis and symptoms The zibs DiagnosticInsight for the (differential) diagnosis and the zib Symptom each refer to the zib Condition. Via this reference it is clear to which condition the (differential) diagnosis and symptoms refer. This makes it clear at any moment in time what the diagnostic insight is and what the status of the symptoms is.
Functionality (informative) If the patient presents with a new request for care or problem, the health professional will register this using a (differential) diagnosis and/or ≥ 1 symptoms.
To do this, the EHR must create an instance of a Condition with the corresponding fields for PeriodPresent, Severity, Course, and a StatusDate indicating the time from which the values entered apply. In addition, the EHR must support the representation of the (differential) diagnosis and/or symptoms entered by the health professional, with a reference to the corresponding Condition.
In the EHR, the content of the fields StartDate, EndDate, Severity and Course will be recorded with the Condition.
Patient Population
The entire patient population.
Information Model
| Type | Id | Concept | Card. | Definition | DefinitionCode | Reference | ||||||||
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NL-CM:5.4.1 |  Condition
|
This is a reference to the root concept of information model Condition. This root concept contains all data elements of the information model Condition. |
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NL-CM:5.4.8 |  PeriodPresent::TimeInterval
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1 | The period in which the condition is (was) present. |
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NL-CM:5.4.3 | StatusDate
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1 | The moment from when the data regarding the condition apply. It may be a vague moment. |
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NL-CM:5.4.5 | Course
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0..1 | The course of the condition. This is independent of the diagnostic insight for the condition. The course indicates how the condition is developing: such as stable, progression, remission, etc.. |
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NL-CM:5.4.6 | Severity
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1 | Indication of the severity of the condition. A condition may cause few or mild symptoms and yet be serious, but the reverse is also possible. |
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NL-CM:5.4.7 | Comment
|
0..1 | A comment in free text with respect to the condition, that is not represented by the other data elements in the information model. |
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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
| AandoeningOfGesteldheid | |||
| PeriodeAanwezig | |||
| StartDatumTijd | 22-02-2023 | 22-02-2023 | 22-02-2023 |
| EindDatumTijd | |||
| StatusDatum | 01-03-2023 | 05-03-2023 | 20-03-2023 |
| Beloop | Verslechterd | Verbeterd | |
| Ernst | Mild | Matig | Mild |
| Toelichting | |||
| SymptoomNaam | Hoest | Hoest, Koorts | Hoest |
| DiagnoseNaam | Bronchitis | Longontsteking | Longontsteking |
| AandoeningOfGesteldheid | |||
| PeriodeAanwezig | |||
| StartDatumTijd | 15-01-2023 | 15-01-2023 | 15-01-2023 |
| EindDatumTijd | 08-05-2023 | ||
| StatusDatum | 15-01-2023 | 26-02-2023 | 08-05-2023 |
| Beloop | Herstellend | Niet meer aanwezig | |
| SymptoomNaam | Pijn, zwelling, standsafwijking | Stijfheid | |
| DiagnoseNaam | Radiusfractuur | Radiusfractuur | Radiusfractuur |
Valuesets
CourseCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.4.1 | Binding: Extensible |
| Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
| NTB | NTB | SNOMED CT | 2.16.840.1.113883.6.96 | Asymptomatisch |
| Improved | 385425000 | SNOMED CT | 2.16.840.1.113883.6.96 | Verbeterd |
| Worse | 231877006 | SNOMED CT | 2.16.840.1.113883.6.96 | Verslechterd |
| No status change | 260388006 | SNOMED CT | 2.16.840.1.113883.6.96 | Onveranderd |
| Progressive | 255314001 | SNOMED CT | 2.16.840.1.113883.6.96 | Progressief |
| NTB | NTB | SNOMED CT | 2.16.840.1.113883.6.96 | Opvlammend |
| No longer present | 350361000146109 | SNOMED CT | 2.16.840.1.113883.6.96 | Niet meer aanwezig |
| Other | OTH | NullFlavor | 2.16.840.1.113883.5.1008 | Anders |
SeverityCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.4.3 | Binding: Required |
| Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
| Mild | 255604002 | SNOMED CT | 2.16.840.1.113883.6.96 | Mild |
| Mild to moderate | 371923003 | SNOMED CT | 2.16.840.1.113883.6.96 | Mild tot matig |
| Moderate severity | 6736007 | SNOMED CT | 2.16.840.1.113883.6.96 | Matig |
| Moderate to severe | 371924009 | SNOMED CT | 2.16.840.1.113883.6.96 | Matig tot ernstig |
| Severe | 24484000 | SNOMED CT | 2.16.840.1.113883.6.96 | Ernstig |
| Life threatening severity | 442452003 | SNOMED CT | 2.16.840.1.113883.6.96 | Levensbedreigend |
| Fatal | 399166001 | SNOMED CT | 2.16.840.1.113883.6.96 | Fataal |
This information model in other releases
Information model references
This information model refers to
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.<BR> 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 2024-1
SNOMED CT and LOINC codes are based on:
- SNOMED Clinical Terms versie: 20240331 [R] (maart 2024-editie)
- LOINC version 2.77
Conditions for use are located on the mainpage
This page is generated on 25/04/2024 12:39:51 with ZibExtraction v. 9.3.8880.19756
