Encounter-v3.1(2018EN): verschil tussen versies

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Regel 8: Regel 8:
 
Release<!--hdPublication-->: '''2018''' <br>
 
Release<!--hdPublication-->: '''2018''' <br>
 
Release status<!--hdPublicationStatus-->: Prepublished<br>
 
Release status<!--hdPublicationStatus-->: Prepublished<br>
Release date<!--hdPublicationDate-->: 01-10-2018
+
Release date<!--hdPublicationDate-->: 26-02-2019
 
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<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2018(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2018(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div>
 
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2018(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2018(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div>
Regel 47: Regel 47:
 
|style="width:250px; "|DCM::Name||nl.zorg.Contact
 
|style="width:250px; "|DCM::Name||nl.zorg.Contact
 
|-  
 
|-  
|style="width:250px; "|DCM::PublicationDate||01-10-2018
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|style="width:250px; "|DCM::PublicationDate||26-02-2019
 
|-  
 
|-  
 
|style="width:250px; "|DCM::PublicationStatus||Prepublished
 
|style="width:250px; "|DCM::PublicationStatus||Prepublished
Regel 161: Regel 161:
 
<BR>
 
<BR>
 
<imagemap> Bestand:Encounter-v3.1Model(2018EN).png | center  
 
<imagemap> Bestand:Encounter-v3.1Model(2018EN).png | center  
rect 720 138 857 188 [[#DestinationCodelist]]
+
rect 698 129 835 179 [[#DestinationCodelist]]
rect 213 137 350 187 [[#OriginCodelist]]
+
rect 191 128 328 178 [[#OriginCodelist]]
rect 388 127 515 197 [[#12807]]
+
rect 366 118 493 188 [[#12807]]
rect 555 125 683 195 [[#12817]]
+
rect 533 116 661 186 [[#12817]]
rect 439 368 549 438 [[#12811]]
+
rect 417 359 527 429 [[#12811]]
rect 220 326 350 399 [[HealthcareProvider-v3.2(2018EN)]]
+
rect 198 317 328 390 [[HealthcareProvider-v3.2(2018EN)]]
rect 725 515 848 565 [[#ContactTypeCodelist]]
+
rect 703 506 826 556 [[#ContactTypeCodelist]]
rect 569 512 683 585 [[#12806]]
+
rect 551 502 665 575 [[#12806]]
rect 436 512 550 585 [[Procedure-v4.1(2018EN)]]
+
rect 415 502 529 575 [[Procedure-v4.2(2018EN)]]
rect 720 326 843 399 [[#12815]]
+
rect 698 317 821 390 [[#12815]]
rect 303 512 417 585 [[Problem-v4.1.1(2018EN)]]
+
rect 281 502 395 575 [[Problem-v4.2(2018EN)]]
rect 220 238 350 311 [[HealthProfessional-v3.2(2018EN)]]
+
rect 198 229 328 302 [[HealthProfessional-v3.2(2018EN)]]
rect 720 238 843 311 [[#12809]]
+
rect 698 229 821 302 [[#12809]]
rect 439 237 549 310 [[#12818]]
+
rect 417 228 527 301 [[#12818]]
rect 720 421 843 494 [[#12813]]
+
rect 698 412 821 485 [[#12813]]
 
desc none
 
desc none
 
</imagemap>
 
</imagemap>
Regel 262: Regel 262:
 
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
 
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
 
|colspan ="4" style ="padding-left: 0px"|<span Id=12821 Title="NL: Probleem">[[Bestand: arrowright.png | 10px | link=]]Problem</span>
 
|colspan ="4" style ="padding-left: 0px"|<span Id=12821 Title="NL: Probleem">[[Bestand: arrowright.png | 10px | link=]]Problem</span>
|(0..1)
+
|
 
|The problem that led to the contact.
 
|The problem that led to the contact.
 
|
 
|
Regel 268: Regel 268:
 
{|
 
{|
 
|-
 
|-
|[[Bestand: block.png | link=Problem-v4.1.1(2018EN)]]||[[Problem-v4.1.1(2018EN) |Problem]]
+
|[[Bestand: block.png | link=Problem-v4.2(2018EN)]]||[[Problem-v4.2(2018EN) |Problem]]
 
|}
 
|}
 
|-style="vertical-align:top; background-color: transparent; "
 
|-style="vertical-align:top; background-color: transparent; "
Regel 276: Regel 276:
 
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
 
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
 
|colspan ="4" style ="padding-left: 0px"|<span Id=12819 Title="NL: Verrichting">[[Bestand: arrowright.png | 10px | link=]]Procedure</span>
 
|colspan ="4" style ="padding-left: 0px"|<span Id=12819 Title="NL: Verrichting">[[Bestand: arrowright.png | 10px | link=]]Procedure</span>
|(0..1)
+
|
 
|The procedure carried out during the contact.
 
|The procedure carried out during the contact.
 
|
 
|
Regel 282: Regel 282:
 
{|
 
{|
 
|-
 
|-
|[[Bestand: block.png | link=Procedure-v4.1(2018EN)]]||[[Procedure-v4.1(2018EN) |Procedure]]
+
|[[Bestand: block.png | link=Procedure-v4.2(2018EN)]]||[[Procedure-v4.2(2018EN) |Procedure]]
 
|}
 
|}
 
|-style="vertical-align:top; background-color: transparent; "
 
|-style="vertical-align:top; background-color: transparent; "
Regel 290: Regel 290:
 
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
 
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
 
|colspan ="4" style ="padding-left: 0px"|<span Id=12806 Title="NL: AfwijkendeUitslag">[[Bestand: arrowright.png | 10px | link=]]DeviatingResult</span>
 
|colspan ="4" style ="padding-left: 0px"|<span Id=12806 Title="NL: AfwijkendeUitslag">[[Bestand: arrowright.png | 10px | link=]]DeviatingResult</span>
|(0..1)
+
|
 
|A deviating result which serves as the reason for the contact.
 
|A deviating result which serves as the reason for the contact.
 
|
 
|
Regel 581: Regel 581:
 
*[[HealthcareProvider-v3.2(2018EN)|HealthcareProvider-v3.2]]
 
*[[HealthcareProvider-v3.2(2018EN)|HealthcareProvider-v3.2]]
 
*[[HealthProfessional-v3.2(2018EN)|HealthProfessional-v3.2]]
 
*[[HealthProfessional-v3.2(2018EN)|HealthProfessional-v3.2]]
*[[Problem-v4.1.1(2018EN)|Problem-v4.1.1]]
+
*[[Problem-v4.2(2018EN)|Problem-v4.2]]
*[[Procedure-v4.1(2018EN)|Procedure-v4.1]]
+
*[[Procedure-v4.2(2018EN)|Procedure-v4.2]]
 
====This information model is used in<!--ftReferredBy-->====
 
====This information model is used in<!--ftReferredBy-->====
 
*[[PlannedCareActivityForTransfer-v3.1(2018EN)|PlannedCareActivityForTransfer-v3.1]]
 
*[[PlannedCareActivityForTransfer-v3.1(2018EN)|PlannedCareActivityForTransfer-v3.1]]
Regel 589: Regel 589:
 
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:<!--ftReferenceIntro-->
 
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:<!--ftReferenceIntro-->
 
<ul>
 
<ul>
<li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment<!--ftArtDecorReference--> [http://decor.nictiz.nl/art-decor/decor-scenarios--zib2018bbr-?id=2.16.840.1.113883.2.4.3.11.60.8.4.2.15.1&effectiveDate=2018-10-01T00:00:00&language=en-US&scenariotree=false [[File:artdecor.jpg|16px|link=]]]</li>
+
<li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment<!--ftArtDecorReference--> [http://decor.nictiz.nl/art-decor/decor-scenarios--zib2018bbr-?id=2.16.840.1.113883.2.4.3.11.60.8.4.2.15.1&effectiveDate=2019-02-26T00:00:00&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<!--ftSimplifierReference--> {{SimplefierLinks|2018}}</li>
 
<li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR<!--ftSimplifierReference--> {{SimplefierLinks|2018}}</li>
 
</ul>
 
</ul>
Regel 595: Regel 595:
 
This information model is also available as [[Media:nl.zorg.Encounter-v3.1(2018EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.Encounter-v3.1(2018EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]]<!--ftDownloads-->
 
This information model is also available as [[Media:nl.zorg.Encounter-v3.1(2018EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.Encounter-v3.1(2018EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]]<!--ftDownloads-->
 
==About this information<!--ftHeader2-->==
 
==About this information<!--ftHeader2-->==
The information in this wikipage is based on<!--ftInfoBase--> Prerelease 2018 #1 <BR>
+
The information in this wikipage is based on<!--ftInfoBase--> Prerelease 2018-2 <BR>
 
SNOMED CT and LOINC codes are based on:
 
SNOMED CT and LOINC codes are based on:
 
<ul>
 
<ul>
Regel 602: Regel 602:
 
</ul>
 
</ul>
 
Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR>
 
Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR>
This page is generated on 23/12/2018 01:17:10 with ZibExtraction v. 3.0.6929.24609<!--ftDate--> <BR>
+
This page is generated on 12/03/2019 17:28:51 with ZibExtraction v. 3.0.7010.25883<!--ftDate--> <BR>
 
-----
 
-----
 
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2018(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2018(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div>
 
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2018(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2018(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div>

Huidige versie van 13 mrt 2019 om 00:52


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.Encounter NL.png
Version: 3.1
HCIM Status:Final
Release: 2018
Release status: Prepublished
Release date: 26-02-2019


Back 16.png Back to HCIM list

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 26-02-2019
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-v4.2(2018EN)#12815Problem-v4.2(2018EN)HealthProfessional-v3.2(2018EN)#12809#12818#12813Encounter-v3.1Model(2018EN).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 The problem that led to the contact.
Block.png Problem
Verwijzing.png NL-CM:15.1.11 Arrowright.pngProcedure The procedure carried out during the contact.
Block.png Procedure
ST.png NL-CM:15.1.12 Arrowright.pngDeviatingResult 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

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.
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
  • HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR Fhir.png

Downloads

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 2018-2
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 12/03/2019 17:28:51 with ZibExtraction v. 3.0.7010.25883


Back 16.png Back to HCIM list