ComfortScale-v1.0(2017EN): verschil tussen versies

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Regel 1: Regel 1:
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==General information==
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<!-- Hieronder wordt een transclude page aangeroepen -->
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Name: '''nl.zorg.ComfortScale''' [[Bestand:NL.png|link=ComfortScore-v1.0(2017NL)]]<BR>
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{{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.12.12(EN)|1|ComfortScale-v1.0(2017EN)}}
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Version: '''1.0''' <br>
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<!-- Tot hier de transclude page -->
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HCIM Status:Final<br>
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==General information<!--hdGeneralInformation-->==
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Release: '''2017''' <br>
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Name<!--hdName-->: '''nl.zorg.ComfortScale''' [[Bestand:NL.png|link=ComfortScore-v1.0(2017NL)]]<BR>
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Release status: Published<br>
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Version<!--hdVersion-->: '''1.0''' <br>
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Release date: 31-12-2017
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HCIM Status<!--hdStatus-->:Final<br>
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Release<!--hdPublication-->: '''2017''' <br>
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Release status<!--hdPublicationStatus-->: Published<br>
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Release date<!--hdPublicationDate-->: 31-12-2017
 
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<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release_2017(EN)]] [[HCIM_Release_2017(EN) |Back to HCIM list ]]</div>
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<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2017(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2017(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div>
  
 
==Metadata==
 
==Metadata==
Regel 61: Regel 64:
 
==Revision History==
 
==Revision History==
 
<div class="mw-collapsible mw-collapsed">
 
<div class="mw-collapsible mw-collapsed">
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''Only available in Dutch''
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''Only available in Dutch<!--noTranslation-->''
  
 
<u>Publicatieversie 1.0</u> (04-09-2017).
 
<u>Publicatieversie 1.0</u> (04-09-2017).
Regel 87: Regel 90:
 
==Information Model==
 
==Information Model==
 
<BR>
 
<BR>
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{|
 
{|
 
|-
 
|-
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|<span Title="Codesystem: LOINC"> 48767-8 Annotation comment</span>
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|<span title = "Codesystem: LOINC>[https://terminologie.nictiz.nl/art-decor/loinc?conceptId=48767-8 48767-8] Annotation comment</span>
 
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Columns Concept and DefinitionCode: hover over the values for more information<BR>
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Columns Concept and DefinitionCode: hover over the values for more information<!--imHover--><BR>
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For explanation of the symbols, please see the legend page<!--imLegend--> [[Bestand:list2.png|link=Legend<!--wikiLegend-->]]
  
 
==Example Instances==
 
==Example Instances==
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''Only available in Dutch''
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''Only available in Dutch<!--noTranslation-->''
  
 
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|Deeply asleep
 
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Regel 369: Regel 373:
 
|Wakker en hyper-alert (overdreven reactie op veranderingen)
 
|Wakker en hyper-alert (overdreven reactie op veranderingen)
 
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=== BodyMovementCodelist===
 
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|No movement
 
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Regel 418: Regel 422:
 
|Heftige bewegingen ook met romp en hoofd
 
|Heftige bewegingen ook met romp en hoofd
 
|}
 
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=== BodyMuscleToneCodelist===
 
=== BodyMuscleToneCodelist===
 
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|Description
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|Description<!--vsDescription-->
 
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|-style="vertical-align:top; "
 
|Muscles fully relaxed
 
|Muscles fully relaxed
Regel 467: Regel 471:
 
|Extreme spierstijfheid en buiging van vingers en tenen
 
|Extreme spierstijfheid en buiging van vingers en tenen
 
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=== Calmness_AgitationCodelist===
 
=== Calmness_AgitationCodelist===
 
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|Description
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|Calm
 
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|Paniekerig (ernstige onrust met verlies van beheersing)
 
|Paniekerig (ernstige onrust met verlies van beheersing)
 
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|}
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=== CryingCodelist===
 
=== CryingCodelist===
 
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|Description
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|Description<!--vsDescription-->
 
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|-style="vertical-align:top; "
 
|Quiet breathing
 
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Regel 563: Regel 567:
 
|CN_Huilen
 
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|2.16.840.1.113883.2.4.3.11.60.40.4.20.4
 
|2.16.840.1.113883.2.4.3.11.60.40.4.20.4
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|Schreewen of krijsen
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|Schreeuwen of krijsen
 
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=== FacialToneCodelist===
 
=== FacialToneCodelist===
 
{| class="wikitable" width="60%"  
 
{| class="wikitable" width="60%"  
 
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|Facial muscles totally relaxed
 
|Facial muscles totally relaxed
Regel 614: Regel 618:
 
|Gezichtsspieren verwrongen en in een grimas
 
|Gezichtsspieren verwrongen en in een grimas
 
|}
 
|}
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=== RespiratoryResponseCodelist===
 
=== RespiratoryResponseCodelist===
 
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|No spontaneous respiration
 
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Regel 664: Regel 668:
 
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==This information model in other releases<!--ftOtherReleases-->==
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==This information model in other releases==
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<!-- Hieronder wordt een transclude page aangeroepen -->
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---
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{{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.12.12(EN)|2|2017}}
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==More on this information model==
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<!-- Tot hier de transclude page -->
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==Information model references<!--ftReferences-->==
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====This information model refers to<!--ftRefersTo-->====
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:--
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====This information model is used in<!--ftReferredBy-->====
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:--
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==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.<BR>
 
To exchange information based on health and care information models, additional, more technical specifications are required.<BR>
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Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:
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Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:<!--ftReferenceIntro-->
 
<ul>
 
<ul>
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<li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment [http://decor.nictiz.nl/art-decor/decor-scenarios--zib2017bbr-?id=2.16.840.1.113883.2.4.3.11.60.7.4.2.12.12&effectiveDate=2017-12-31T00:00:00&language=en-US&scenariotree=false [[File:artdecor.jpg|16px|link=]]]</li>
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<li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment<!--ftArtDecorReference--> [http://decor.nictiz.nl/art-decor/decor-scenarios--zib2017bbr-?id=2.16.840.1.113883.2.4.3.11.60.7.4.2.12.12&effectiveDate=2017-12-31T00:00:00&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 [https://simplifier.net/NictizSTU3/~resources?text=zib&category=StructureDefinition [[File:fhir.png|link=]]]</li>
+
<li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR<!--ftSimplifierReference--> {{SimplefierLinks|2017}}</li>
 
</ul>
 
</ul>
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This information model is also available as [[Media:nl.zorg.ComfortScale-v1.0(2017EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.ComfortScale-v1.0(2017EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]]
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==Downloads<!--ftDownloadTitle-->==
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==About this information==
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This information model is also available as [[Media:nl.zorg.ComfortScale-v1.0(2017EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.ComfortScale-v1.0(2017EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]]<!--ftDownloads-->
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The information in this wikipage is based on Release 2017 <BR>
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==About this information<!--ftHeader2-->==
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Conditions for use are located on the mainpage [[Bestand:list2.png|link=HCIM_Mainpage]]<BR>
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The information in this wikipage is based on<!--ftInfoBase--> Release 2017 <BR>
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This page is generated on 24/01/2018 16:09:13 <BR>
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Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR>
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This page is generated on 21/12/2018 14:46:54 with ZibExtraction v. 3.0.6929.24609<!--ftDate--> <BR>
 
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<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release_2017(EN)]] [[HCIM_Release_2017(EN) |Back to HCIM list ]]</div>
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<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2017(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2017(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div>

Huidige versie van 24 dec 2018 om 11:03


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.ComfortScale NL.png
Version: 1.0
HCIM Status:Final
Release: 2017
Release status: Published
Release date: 31-12-2017

Back 16.png Back to HCIM list

Metadata

DCM::CoderList Werkgroep RadB Verpleegkundige Gegevens
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList Werkgroep RadB Verpleegkundige Gegevens
DCM::CreationDate 1-8-2016
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name zorg
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.12.12
DCM::KeywordList Pijnscore, assessment, comfort, comfortneo
DCM::LifecycleStatus Final
DCM::ModelerList Werkgroep RadB Verpleegkundige Gegevens
DCM::Name nl.zorg.ComfortScore
DCM::PublicationDate 31-12-2017
DCM::PublicationStatus Published
DCM::ReviewerList Projectgroep RadB Verpleegkundige Gegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 31-12-2017
DCM::Superseeds
DCM::Version 1.0
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (04-09-2017).

Concept

The Comfort Behaviour scale /Comfortneo scale is an assessment tool, that is used to assess the pain behaviour of neonates (new born).
The Comfort Behaviour scale has 7 observation points that that need to be addressed. For each on observation is value is assigned from a 5-point scale, the final score indicates whether the observed child suffers pain and 'how much'. The score is combined with an NRS score that is completed by the nurses on basis of clinical experience.

Purpose

> A pain observation instrument is a tool in determining the intensity of pain and can be useful in order to determine the effectiveness of pain treatment interventions (pharmacological or non-pharmacological). For new born it is nevertheless difficult to differentiate between pain or distress/anxiety. This is relevant in determining the treatment. The score on a pain measurement instrument remains a snapshot in time.

Evidence Base

For determining the degree of pain in children with difficulty expressing themselves there are divers pain observation instruments available

  • CPB
  • Comfort behaviour scale/ Comfortneo scale
  • Flacc

Patient Population

The COMFORT assessment scale is validated for young children up to the age of 4.
The COMFORT and COMFORTneo assessment score is validated for preterm neonates

Information Model


#11394#BodyMovementCodelist#11406#11407#11401#CryingCodelist#11399#11402#11408#11409#11410#11411#11412#AlertnessCodelist#Calmness AgitationCodelist#RespiratoryResponseCodelist#BodyMuscleToneCodelist#FacialToneCodelistComfortScale-v1.0Model(2017EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:12.12.1 Arrowdown.pngComfortScale Rootconcept of the ComfortScale information model. This root concept contains all data elements of the ComfortScale information model.
INT.png NL-CM:12.12.2 Arrowright.pngTotalScore 0..1 The total score is the sum of all the individual scores. The total score has a range from 0 - 35.
CO.png NL-CM:12.12.3 Arrowright.pngAlertness 0..1 Observation of: Alertness
List2.png AlertnessCodelist
CO.png NL-CM:12.12.4 Arrowright.pngCalmness_Agitation 0..1 Observation: Calmness/ agitation
List2.png Calmness_AgitationCodelist
CO.png NL-CM:12.12.5 Arrowright.pngRespiratoryResponse 0..1 Observation Respiratory response (only in mechanically ventilated children)
List2.png RespiratoryResponseCodelist
CO.png NL-CM:12.12.6 Arrowright.pngCrying 0..1 Observation Crying (only in spontaneously breathing children)
List2.png CryingCodelist
CO.png NL-CM:12.12.8 Arrowright.pngBodyMovement 0..1 Observation Physical movement
List2.png BodyMovementCodelist
CO.png NL-CM:12.12.9 Arrowright.pngFacialTone 0..1 Observation Facial tension
List2.png FacialToneCodelist
CO.png NL-CM:12.12.10 Arrowright.pngBodyMuscleTone 0..1 Observation Muscle tone
List2.png BodyMuscleToneCodelist
TS.png NL-CM:12.12.11 Arrowright.pngScoreDateTime 1 The date and time at which the Comfort Behaviour scale/ComfortNeo scale was determined.
ST.png NL-CM:12.12.12 Arrowright.pngComment 0..1 A comment on the circumstances during the measurement.
48767-8 Annotation comment

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

ComfortScore
ScoreDatumTijd 21-12-2016 12:05
Alertheid 4 (wakker en alert)
Kalmte_Agitatie 2 (licht angstig)
Huilen 2 (af en toe snikken of kreunen)
Lichaamsbeweging 2 (incidentele beweging)
Gezichtsspanning 2 (normale spanning van het gelaat)
Spierspanning 2 (verminderde spierspanning)
Totaalscore 14
Toelichting Controle na verhogen pijnmedicatie.
ComfortNeoScore
ScoreDatumTijd 21-12-2016 12:05
Alertheid 4 (wakker en alert)
Kalmte_Agitatie 2 (licht angstig)
Ademhalingsreactie 3 (af en toe hoesten of verzet tegen de ventilator)
Lichaamsbeweging 2 (incidentele beweging)
Gezichtsspanning 2 (normale spanning van het gelaat)
Spierspanning 2 (verminderde spierspanning)
Totaalscore 15
Toelichting Controle na verhogen pijnmedicatie.

Instructions

In the ComfortNeo scale the item crying is replaced by respiratory reaction.
In the Comfort scale the item respiratory reaction is replaced by crying.

References

1. Comfort assessment [Online] Beschikbaar op:http://www.comfortassessment.nl/ [Geraadpleegd: 2 augustus 2016] 2. Richtlijn Pijnmeting en Behandeling van pijn bij kinderen, NVK, 2007 [Online] Beschikbaar op:https://www.nvk.nl/Kwaliteit/Richtlijnenoverzicht/Details/tabid/1558/articleType/ArticleView/articleId/760/Pijn-meting-en-behandeling-van.aspx [Geraadpleegd: 21 december 2016]

Valuesets

AlertnessCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.1 Binding:
Conceptname Conceptcode Conceptvalue Codesystem name Codesystem OID Description
Deeply asleep Alert1 1 CN_Alertheid 2.16.840.1.113883.2.4.3.11.60.40.4.20.1 Diep in slaap (ogen dicht, geen reactie op omgeving)
Lightly asleep Alert2 2 CN_Alertheid 2.16.840.1.113883.2.4.3.11.60.40.4.20.1 Licht in slaap (ogen grotendeels gesloten, af en toe reactie)
Drowsy Alert3 3 CN_Alertheid 2.16.840.1.113883.2.4.3.11.60.40.4.20.1 Slaperig (kind sluit vaak zijn ogen, reageert minder op omgeving)
Awake and alert Alert4 4 CN_Alertheid 2.16.840.1.113883.2.4.3.11.60.40.4.20.1 Wakker en alert (kind reageert op omgeving)
Awake and hyperalert Alert5 5 CN_Alertheid 2.16.840.1.113883.2.4.3.11.60.40.4.20.1 Wakker en hyper-alert (overdreven reactie op veranderingen)

BodyMovementCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.5 Binding:
Conceptname Conceptcode Conceptvalue Codesystem name Codesystem OID Description
No movement Mov1 1 CN_Lichaamsbeweging 2.16.840.1.113883.2.4.3.11.60.40.4.20.5 Geen beweging
Occasional, slight movements Mov2 2 CN_Lichaamsbeweging 2.16.840.1.113883.2.4.3.11.60.40.4.20.5 Incidentele (3 of minder) kleine bewegingen
Frequent, slight movements Mov3 3 CN_Lichaamsbeweging 2.16.840.1.113883.2.4.3.11.60.40.4.20.5 Frequente (3 of meer) kleine bewegingen
Vigorous movements limited to extremities Mov4 4 CN_Lichaamsbeweging 2.16.840.1.113883.2.4.3.11.60.40.4.20.5 Heftige bewegingen met armen en benen
Vigorous movements including torso and head Mov5 5 CN_Lichaamsbeweging 2.16.840.1.113883.2.4.3.11.60.40.4.20.5 Heftige bewegingen ook met romp en hoofd

BodyMuscleToneCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.7 Binding:
Conceptname Conceptcode Conceptvalue Codesystem name Codesystem OID Description
Muscles fully relaxed Musc1 1 CN_Spierspanning 2.16.840.1.113883.2.4.3.11.60.40.4.20.7 Spieren volledig ontspannen; geen spierspanning
Reduced muscle tone Musc2 2 CN_Spierspanning 2.16.840.1.113883.2.4.3.11.60.40.4.20.7 Verminderde spierspanning; minder weerstand dan normaal
Normal muscle tone Musc3 3 CN_Spierspanning 2.16.840.1.113883.2.4.3.11.60.40.4.20.7 Normale spierspanning
Increased muscle tone Musc4 4 CN_Spierspanning 2.16.840.1.113883.2.4.3.11.60.40.4.20.7 Toegenomen spierspanning en buiging van vingers en tenen
Extreme muscle rigidity Musc5 5 CN_Spierspanning 2.16.840.1.113883.2.4.3.11.60.40.4.20.7 Extreme spierstijfheid en buiging van vingers en tenen

Calmness_AgitationCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.2 Binding:
Conceptname Conceptcode Conceptvalue Codesystem name Codesystem OID Description
Calm Calm1 1 CN_Kalmte_Agitatie 2.16.840.1.113883.2.4.3.11.60.40.4.20.2 Kalm (kind helder en rustig)
Slightly anxious Calm2 2 CN_Kalmte_Agitatie 2.16.840.1.113883.2.4.3.11.60.40.4.20.2 Licht angstig (kind toont lichte onrust)
Anxious Calm3 3 CN_Kalmte_Agitatie 2.16.840.1.113883.2.4.3.11.60.40.4.20.2 Angstig (kind lijkt onrustig, kan zich beheersen)
Very anxious Calm4 4 CN_Kalmte_Agitatie 2.16.840.1.113883.2.4.3.11.60.40.4.20.2 Zeer angstig (kind lijkt zeer onrustig, kan zich nog net beheersen)
Panicky Calm5 5 CN_Kalmte_Agitatie 2.16.840.1.113883.2.4.3.11.60.40.4.20.2 Paniekerig (ernstige onrust met verlies van beheersing)

CryingCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.4 Binding:
Conceptname Conceptcode Conceptvalue Codesystem name Codesystem OID Description
Quiet breathing Cry1 1 CN_Huilen 2.16.840.1.113883.2.4.3.11.60.40.4.20.4 Geen huilgeluiden
Occasional sobbing or moaning Cry2 2 CN_Huilen 2.16.840.1.113883.2.4.3.11.60.40.4.20.4 Af en toe snikken of kreunen (nasnikken)
Whining Cry3 3 CN_Huilen 2.16.840.1.113883.2.4.3.11.60.40.4.20.4 Jengelen of dreinen (monotoon geluid)
Crying Cry4 4 CN_Huilen 2.16.840.1.113883.2.4.3.11.60.40.4.20.4 Huilen
Screaming or shrieking Cry5 5 CN_Huilen 2.16.840.1.113883.2.4.3.11.60.40.4.20.4 Schreeuwen of krijsen

FacialToneCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.6 Binding:
Conceptname Conceptcode Conceptvalue Codesystem name Codesystem OID Description
Facial muscles totally relaxed Face1 1 CN_Gezichtsspanning 2.16.840.1.113883.2.4.3.11.60.40.4.20.6 Gezichtsspieren volkomen ontspannen
Normal facial tone Face2 2 CN_Gezichtsspanning 2.16.840.1.113883.2.4.3.11.60.40.4.20.6 Normale spanning van het gezicht
Tension evident in some facial muscles Face3 3 CN_Gezichtsspanning 2.16.840.1.113883.2.4.3.11.60.40.4.20.6 Spanning duidelijk in sommige gelaatsspieren (niet aanhoudend)
Tension evident throughout facial muscles Face4 4 CN_Gezichtsspanning 2.16.840.1.113883.2.4.3.11.60.40.4.20.6 Spanning duidelijk in alle gelaatsspieren (aanhoudend)
Facial muscles contorted and grimacing Face5 5 CN_Gezichtsspanning 2.16.840.1.113883.2.4.3.11.60.40.4.20.6 Gezichtsspieren verwrongen en in een grimas

RespiratoryResponseCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.12.12.3 Binding:
Conceptname Conceptcode Conceptvalue Codesystem name Codesystem OID Description
No spontaneous respiration Vent1 1 CN_Ademhalingsreactie 2.16.840.1.113883.2.4.3.11.60.40.4.20.3 Geen spontane ademhaling
Spontaneous respiration on ventilator Vent2 2 CN_Ademhalingsreactie 2.16.840.1.113883.2.4.3.11.60.40.4.20.3 Spontane ademhaling aan de beademing
Unrest or resistance to ventilator Vent3 3 CN_Ademhalingsreactie 2.16.840.1.113883.2.4.3.11.60.40.4.20.3 Onrust of verzet tegen de beademing
Actively breathes against ventilator or coughs regularly Vent4 4 CN_Ademhalingsreactie 2.16.840.1.113883.2.4.3.11.60.40.4.20.3 Ademt actief tegen de beademing in of hoest regelmatig
Fights ventilator Vent5 5 CN_Ademhalingsreactie 2.16.840.1.113883.2.4.3.11.60.40.4.20.3 Vecht tegen de beademing

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About this information

The information in this wikipage is based on Release 2017
Conditions for use are located on the mainpage List2.png
This page is generated on 21/12/2018 14:46:54 with ZibExtraction v. 3.0.6929.24609

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