DiagnosticInsight-v1.0(2024EN)

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General information

Name: nl.zorg.DiagnosticInsight NL.png
Version: 1.0
HCIM Status:Final
Release: 2024
Release status: Prepublished
Release date: 15-04-2024

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Metadata

DCM::CoderList *
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList *
DCM::CreationDate 15-5-2023
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name *
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.5.6
DCM::KeywordList
DCM::LifecycleStatus Final
DCM::ModelerList *
DCM::Name nl.zorg.DiagnostischInzicht
DCM::PublicationDate 15-04-2024
DCM::PublicationStatus Prepublished
DCM::ReviewerList
DCM::RevisionDate
DCM::Supersedes *
DCM::Version 1.0
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (15-04-2024)

ZIB-628 Hoe complicaties te relateren aan veroorzakende factor?
ZIB-1146 nieuwe datums toevoegen aan zib Probleem ivm onderliggend lijden
ZIB-1286 Auteur toevoegen bij zib Probleem
ZIB-1394 Codelijst ProbleemType in zib Probleem
ZIB-1520 missende qualifier voor verificationStatusCodeList
ZIB-1795 ZIB Probleem: veld 'PROBLEEM_TYPE' optioneel?
ZIB-1916 ZIB Probleem - verficatiestatus NL vertaling Snomed 415684004
ZIB-1934 ProbleemType moet ProbleemCategorie worden
ZIB-2087 vervangen ggz diagnoselijst uit probleemNaam codelijst door een refset
ZIB-2170 ZIB Probleem Diagnosedatum

Concept

Diagnostic insight is the interpretation of the condition by the care provider. This is based on known combinations of conditions and the symptoms with which these present themselves. It may involve a single diagnosis or a differential diagnosis with conditions that are under consideration.

Purpose

Diagnostic insight is the basis for the care plan and the activities of the health care providers that are involved in the patient's care. It is important for the application of evidence-based care and the evaluation of care provided, also in the form of comparative research on the basis of patients with similar conditions.

Evidence Base

Note on zib DiagnosticInsight The diagnostic insight is the interpretation of a condition in the form of a (differential) diagnosis by the health professional. The DiagnosticInsightDate indicates the moment when the health professional acquired the insight. In the case of a differential diagnosis, the health professional specifies ≥ 2 diagnoses that he/she is currently considering. For all diagnoses within one differential diagnosis, CertaintyStatus has the value 'possible'.
At any given time, only one instance of DiagnosticInsight applies to a Condition. The presentation of advancing diagnostic insight then consists of a series of instances of DiagnosticInsight, all of which refer to the same Condition, and where the value of DiagnosticInsightDate represents the chronology. An instance of DiagnosticInsight with a more recent DiagnosticInsightDate therefore replaces the previous diagnostic insight.
 
A health professional may wish to record a reason for a diagnosis. You can argue that in fact the condition has a cause, but the specification of the cause is based on the insight into what kind of condition it is. That is why we see the reason as part of the diagnostic insight.
The reason for a diagnosis can be an incident (e.g. a hip fracture due to a fall), a procedure (e.g. a bowel perforation due to a colonoscopy) or another diagnosis (e.g. neuropathy due to diabetes).
Regardless of the diagnostic insight as specification of the nature of the condition, one may come to the conclusion that it is a complication. This can be represented separately using the IsComplication element. Whether there is a complication generally depends on the reason, but there are of course also reasons for which there is no complication in the sense of unintentional damage due to medical treatment or decisions.
 
The cardinality of the reference to Condition is 0..1, because when a diagnosis is denied there is no condition to which that diagnosis relates. To represent that a patient is not known to have, for example, diabetes type II or that diabetes type II has been excluded, one should use the Zib Exclusion with a reference to DiagnosticInsight. In this case, the instance of DiagnosticInsight does not refer to a Condition.

Functionality (informative) EHRs already offer the option to distinguish between recording a new diagnosis or changing a diagnosis. When recording a new (differential) diagnosis, the EHR must create a new Condition and have the new instance of DiagnosticInsight refer to it. When changing a diagnosis, the EHR must have the new instance of DiagnosticInsight refer to the same Condition as the previous instance of DiagnosticInsight.
It is highly desirable for the EHR to provide functionality to maintain the order of diagnoses within a differential diagnosis, as many health professionals then record diagnoses in order of descending probability.

Information Model


#IncidentCodelist#4990DiagnosticInsight-v1.0(2024EN)Procedure-v5.4.1(2024EN)#5002Condition-v1.0(2024EN)#ProblemNameCodelist#MethodOfConfirmationCodelist#DegreeOfCertaintyCodelist#4979#4992#4998#4985HealthProfessional-v4.0(2024EN)#4983#4981AnatomicalLocation-v1.0.3(2024EN)#4988#5000#4986DiagnosticInsight-v1.0Model(2024EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:5.6.1 Arrowdown.pngDiagnosticInsight Root concept of the DiagnosticInsight information model.This root concept contains all data elements of the DiagnosticInsight information model.
404684003 Clinical finding
Verwijzing.png NL-CM:5.6.2 Arrowright.pngDiagnostician::HealthProfessional 1 The care professional that acquired the diagnostic insight. This can be a different individual than the person who recorded the diagnostic insight.
PRF performer
Block.png HealthProfessional
TS.png NL-CM:5.6.3 Arrowright.pngDiagnosticInsightDate 1 Date (and time) at which the care professional obtained the diagnostic insight.
432213005 Date of diagnosis
CD.png NL-CM:5.6.4 Arrowright.pngDegreeOfCertainty 1 Indicates the conviction of the care professional with respect to the diagnostic insight as interpretation of the condition.
List2.png DegreeOfCertaintyCodelist
CD.png NL-CM:5.6.5 Arrowright.pngMethodOfConfirmation 1 The method that the care professional used to diagnose the condition, such as history taking only, history taking and physical examination, additional diagnostic examination or information from other care professionals.
418775008 Finding method
List2.png MethodOfConfirmationCodelist
Folder.png NL-CM:5.6.6 Arrowdown.pngDiagnosis 1..* Container of the Diagnosis concept. This container contains all data elements of the Diagnosis concept.

Represents a disease or physiological condition as part of the diagnostic insight.

CD.png NL-CM:5.6.7 Arrowright.pngDiagnosisName 1 The term with associated code that the care professional selects from the used code system with conditions.
439401001 Diagnosis
List2.png ProblemNameCodelist
ST.png NL-CM:5.6.8 Arrowright.pngFurtherSpecificationDiagnosisName 0..1 A more detailed description of the DiagnosisName in free text, when this detail is not available in the used code list.
330341000146107 Narrative comments on diagnosis
Verwijzing.png NL-CM:5.6.9 Arrowright.pngAnatomicalLocation 0..* The location(s) on and/or in the body that is/are affected by the condition, conform the diagnostics. 
123037004 Body structure
Block.png AnatomicalLocation
Verwijzing.png NL-CM:5.6.10 Arrowright.pngCondition 0..1 The Condition to which the DiagnosticInsight applies.
365860008 General clinical state finding
Block.png Condition
ST.png NL-CM:5.6.11 Arrowright.pngComment 0..1 A comment in free text with respect to the diagnostic insight, that is not represented by the other data elements in the information model.
48767-8 Annotation comment [Interpretation] Narrative
BL.png NL-CM:5.6.12 Arrowright.pngIsComplication 0..1 Indicates whether or not the diagnostic insight involves a complication.
Folder.png NL-CM:5.6.13 Arrowdown.pngReason 0..1 Container of the Reason concept.This container contains all data elements of the Reason concept.
CD.png NL-CM:5.6.14 Arrowright.pngIncident (0..1) The unintended event during the care process that has led, could have led or could (still) lead to harm to the patient.
418019003 Accidental event
List2.png IncidentCodelist
Verwijzing.png NL-CM:5.6.15 Arrowright.pngProcedure (0..1) The procedure that gave rise to the condition to which the diagnostic insight relates.
71388002 Procedure
Block.png Procedure
Verwijzing.png NL-CM:5.6.16 Arrowright.pngDiagnosticInsight (0..1) The diagnostic insight with regard to another condition that, based on that diagnostic insight, is seen as a reason for the condition with the current diagnostic insight.
404684003 Clinical finding
Block.png DiagnosticInsight

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

DiagnostischInzicht
DiagnostischInzichtDatum 01-03-2023 05-03-2023
ZekerheidsStatus In Overweging Bevestigd
WijzeVanVaststellen Vastgesteld op basis van het klinisch beeld Vastgesteld op basis van het klinisch beeld en aanvullend onderzoek
IsComplicatie Nee Nee
Toelichting
Diagnose
DiagnoseNaam Bronchitis Longontsteking
Diagnosesteller::Zorgverlener
Naam Drs. L.J. Verhagen Drs. L.J. Verhagen
Specialisme Huisarts Huisarts
AnatomischeLocatie
Locatie Long
Lateraliteit Links
AandoeningOfGesteldheid
PeriodeAanwezig
StartDatumTijd 22-02-2023 22-02-2023
StatusDatum 01-03-2023 05-03-2023
Beloop Verslechterd
Ernst Mild Matig
DiagnostischInzicht
DiagnostischInzichtDatum 15-01-2023
ZekerheidsStatus Bevestigd
WijzeVanVaststellen Vastgesteld op basis van het klinisch beeld en aanvullend onderzoek
IsComplicatie Nee
Toelichting Val van fiets na aanrijding
Diagnose
DiagnoseNaam Radiusfractuur
NadereSpecificatieDiagnoseNaam Distale radiusfractuur
Diagnosesteller::Zorgverlener
Naam C.A. van der Kamp
Specialisme Algemene heelkunde
AnatomischeLocatie
Locatie Radius
Lateraliteit Links
Aanleiding
Incident Val
AandoeningOfGesteldheid
PeriodeAanwezig
StartDatumTijd 15-01-2023
StatusDatum 15-01-2023
Beloop
DiagnostischInzicht
DiagnostischInzichtDatum 03-04-2023 03-04-2023 20-04-2023
ZekerheidsStatus Mogelijk Mogelijk Bevestigd
WijzeVanVaststellen Vastgesteld op basis van anamnese en klinisch beeld Vastgesteld op basis van het klinisch beeld en aanvullend onderzoek Vastgesteld op basis van het klinisch beeld en aanvullend onderzoek
IsComplicatie Nee
Toelichting
Diagnose
Diagnose 1
DiagnoseNaam Angina pectoris Angina pectoris Slokdarmspasme
Diagnose 2
DiagnoseNaam Longembolie Slokdarmspasme
Diagnose 3
DiagnoseNaam Slokdarmspasme
Diagnosesteller::Zorgverlener
Naam Drs. L.J. Verhagen H. verhoeven G.A. de Jong
Specialisme Huisarts Inwendige geneeskunde Inwendige geneeskunde
AnatomischeLocatie
Locatie Thorax Thorax Slokdarm
Lateraliteit
AandoeningOfGesteldheid
PeriodeAanwezig
StartDatumTijd 03-04-2023 03-04-2023 03-04-2023
StatusDatum 03-04-2023 03-04-2023 20-04-2023
Beloop Onveranderd Verbeterd
Ernst Matig
DiagnostischInzicht
DiagnostischInzichtDatum 08-09-2023 08-09-2023 09-09-2023
ZekerheidsStatus Mogelijk Uitgesloten Bevestigd
WijzeVanVaststellen Vastgesteld op basis van anamnese en klinisch beeld Vastgesteld op basis van het klinisch beeld en aanvullend onderzoek Vastgesteld op basis van het klinisch beeld en aanvullend onderzoek
IsComplicatie Nee Ja
Toelichting
Diagnose
DiagnoseNaam Pneumothorax Pneumothorax Longembolie
Diagnosesteller::Zorgverlener
Naam Drs. L.J. Verhagen H. verhoeven G.A. de Jong
Specialisme Huisarts SEH-arts Inwendige geneeskunde
AnatomischeLocatie
Locatie Thorax Thorax Long
Lateraliteit links links links
AandoeningOfGesteldheid
PeriodeAanwezig
StartDatumTijd 08-09-2023 08-09-2023 08-09-2023
StatusDatum 08-09-2023 08-09-2023 09-09-2023
Beloop Onveranderd Onveranderd
Ernst Ernstig

Instructions

A diagnostic insight always refers to the condition of which it is the interpretation. If > 1 instance of diagnostic insight refers to the same condition, then the instantiation with the most recent diagnosis date represents the current diagnostic insight.

Valuesets

DegreeOfCertaintyCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.6.3 Binding: Required
Conceptname Conceptcode Codesystem name Codesystem OID Description
Suspected 415684004 SNOMED CT 2.16.840.1.113883.6.96 Vermoedelijk
Known possible 410590009 SNOMED CT 2.16.840.1.113883.6.96 Mogelijk
Confirmed present 410605003 SNOMED CT 2.16.840.1.113883.6.96 Bevestigd
Probably not present 410593006 SNOMED CT 2.16.840.1.113883.6.96 Onwaarschijnlijk

IncidentCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.6.1 Binding: Extensible
Conceptname Codesystem name Codesystem OID
SNOMED CT: <269691005|Medical accident to patient during surgical and medical care| SNOMED CT 2.16.840.1.113883.6.96
OTH NullFlavor 2.16.840.1.113883.5.1008

MethodOfConfirmationCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.6.2 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
History taking 84100007 SNOMED CT 2.16.840.1.113883.6.96 Vastgesteld op basis van de anamnese
History AND physical examination 63332003 SNOMED CT 2.16.840.1.113883.6.96 Vastgesteld op basis van het klinisch beeld
Patient evaluation and management 14736009 SNOMED CT 2.16.840.1.113883.6.96 Vastgesteld op basis van het klinisch beeld en aanvullend onderzoek
Vastgesteld op basis van aanvullend onderzoek NTB SNOMED CT 2.16.840.1.113883.6.96 Vastgesteld op basis van aanvullend onderzoek
Obtaining healthcare information from previous practitioner for clinical alignment 117131000146104 SNOMED CT 2.16.840.1.113883.6.96 Overgenomen uit betrouwbare rapportage
Other OTH NullFlavor 2.16.840.1.113883.5.1008 Anders

ProblemNameCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.6.4 Binding: Required
Conceptname Codesystem name Codesystem OID
All values DHD Diagnosethesaurus 2.16.840.1.113883.2.4.3.120.5.1
All values ICD-10, dutch translation 2.16.840.1.113883.6.3.2
SNOMED CT: ^11721000146100|Dutch nursing problem simple reference set| SNOMED CT 2.16.840.1.113883.6.96
All values ICF 2.16.840.1.113883.6.254
All values ICPC-1 NL 2.16.840.1.113883.2.4.4.31.1
All values DSM-IV 2.16.840.1.113883.6.126
All values DSM-5 2.16.840.1.113883.6.344
All values [DEPRECATED] GGZ Diagnoselijst 2.16.840.1.113883.3.3210.14.2.2.35
SNOMED CT: ^350401000146101|Dutch mental health diagnoses simple reference set| SNOMED CT 2.16.840.1.113883.6.96

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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.<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 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 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 List2.png
This page is generated on 25/04/2024 12:40:52 with ZibExtraction v. 9.3.8880.19756

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