SurveillanceDecision-v1.0(2024EN)

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General information

Name: nl.zorg.SurveillanceDecision 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 Zib-centrum
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList Zib-centrum
DCM::CreationDate 07-06-2023
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name *
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.8.5
DCM::KeywordList
DCM::LifecycleStatus Final
DCM::ModelerList *
DCM::Name nl.zorg.BewakingBesluit
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-1340 Ontkenning van een overgevoeligheid In AllergieIntolerantie
ZIB-1440 Omschrijving BeginDatum verbeteren, +bijkomende verbeteringen elementen
ZIB-1986 Zib Overgevoeligheid- naam Stof wijzigen in TeBewakenStof

Concept

The decision to initiate or terminate surveillance for a substance or group of substances that may cause an adverse reaction in the patient.

Purpose

Specifying a surveillance decision with an effective date makes it clear on which substance or group of substances surveillance has started or stopped. An overview of surveillance decisions provides insight into which substances are subject to surveillance and options for managing surveillance decisions.

Evidence Base

Note on zib SurveillanceDecision The zib SurveillanceDecision represents the health professional’s decision to start or end surveillance of a substance or group of substances. Initiating surveillance means that the health professional wants to receive a warning if an unsafe substance is prescribed. The DecisionEffectiveDateTime represents the moment at which surveillance should start or end, depending on the DecisionType (started or discontinued).
The user can indicate the reason for starting a surveillance decision with one of the three following options:
-          A hypersensitivity or intolerance: to be indicated via a reference to HypersensitivityIntolerance
-          A reaction: to be indicated via a reference to Reaction
-          Specify a decision reason via a selection from the StartReasonCodelist
The user can specify the reason for stopping a surveillance decision by selecting from the StopReasonCodelist.
 
The SafeWithinUnsafeGroup element makes it possible to make exceptions within a (large) group of unsafe substances. Suppose that 78 of a group of substances are unsafe and 2 are safe, then one does not need to record a surveillance decision for each of the 78 unsafe substances. Instead, it will suffice to record one surveillance decision in which the entire group of 80 substances is declared as unsafe and 2 substances that are safe within that group.
 
Where a reaction is related to a (component of) a substance actually administered, the health professional may decide to start surveillance for a broader collection of substances. The substance(s) indicated in a surveillance decision may therefore differ from the substance to which the patient has actually developed a reaction.
 
A hypersensitivity or intolerance involves a diagnosis in which it has been demonstrated or assumed that the patient has a tendency to develop an adverse reaction when exposed to a certain substance or group of substances. In most cases, a surveillance decision related to this hypersensitivity or intolerance will concern the same substances, but not necessarily. Additional diagnostiscs may reveal an allergy based on a limited number of actually tested substances, and it may then be decided to start surveillance for the entire group to which those substances belong. 
Even if no additional diagnostics are possible, but an intolerance is suspected due to side effects based on a pharmacological property of a medicine, the specification of the substance(s) for which the health professional decides to start surveillance may deviate from the substance(s) that are recorded for the hypersensitivity or intolerance.

Functionality (informative) It is desirable that an EHR supports the specification of a surveillance decision as efficiently as possible. If the health professional specifies a reaction or hypersensitivity or intolerance as the reason for a surveillance decision, the EHR can first propose the substance(s) to which that reaction or hypersensitivity or intolerance is related. The user then only needs to change the proposed substance(s) if he wishes.
The EHR must be able to show the user an overview of surveillance decisions that are active and offer the option to select a surveillance decision from this overview and then change or terminate it.
In general, a user will modify a surveillance decision if the reason for the surveillance decision remains the same, but he/she wants to adjust the specification of the substance(s) and/or the comment. The EHR then presents the selected surveillance decision with the data in the fields that the user can subsequently adjust. Changing a surveillance decision essentially means that the selected surveillance decision is terminated and replaced by the surveillance decision with the modified field values.
It is important that the EHR keeps track of the history of each surveillance decision, so that it is clear how the decisions follow each other.

Information Model


#DecisionTypeCodelist#StopReasonCodelist#StartReasonCodelistHypersensitivityIntolerance-v1.0(2024EN)#4939Reaction-v2.0(2024EN)#4940#4947#4942#AgentHPKCodelist#AgentSNKCodelist#AgentSSKCodelist#4952#4938#4948#AgentHPKCodelist#AgentAllergicAgentCodelist#AgentThesaurus122Codelist#AgentSNKCodelist#AgentSSKCodelist#4935HealthProfessional-v4.0(2024EN)#4944SurveillanceDecision-v1.0Model(2024EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:8.5.1 Arrowdown.pngSurveillanceDecision This is a reference to the root concept of information model SurveillanceDecision.
225419007 Surveillance
CD.png NL-CM:8.5.2 Arrowright.pngDecisionType 1 The kind of decision: to start or stop the surveillance.
408730004 Procedure context
List2.png DecisionTypeCodelist
TS.png NL-CM:8.5.3 Arrowright.pngDecisionEffectiveDateTime 1 Moment (date and time) when the decision should take effect.
330421000146108 Date of effectuation
Folder.png NL-CM:8.5.4 Arrowdown.pngDecisionBasis 1 Container of the DecisionBasis concept.This container contains all data elements of the DecisionBasis concept.

This concerns the basis for the surveillance decision to start or end the surveillance.

Verwijzing.png NL-CM:8.5.5 Arrowright.pngHypersensitivity::HypersensitivityIntolerance (0..1) Hypersensitivity in the patient as reason for the surveillance decision.
420134006 Propensity to adverse reaction
Block.png HypersensitivityIntolerance
Verwijzing.png NL-CM:8.5.6 Arrowright.pngReaction (0..1) Reaction in the patient as reason for the surveillance decision.
281647001 Adverse reaction
Block.png Reaction
CD.png NL-CM:8.5.7 Arrowright.pngSurveillanceDecision (0..1) Reason for the surveillance decision: to start or end the surveillance.
330431000146105 Reason for surveillance
List2.png StartReasonCodelist
List2.png StopReasonCodelist
Folder.png NL-CM:8.5.8 Arrowdown.pngSubstanceForSurveillance 1 Container of the SubstanceForSurveillance concept. This container contains all data elements of the SubstanceForSurveillance concept.

Substance or group of substances that must be monitored in the sense that prescription will trigger a message.

105590001 Substance
CD.png NL-CM:8.5.9 Arrowright.pngUnsafeSubstance 1 The substance or group of substances that must be monitored completely or with exceptions.
350221000146108 Substance hazardous to patient
List2.png AgentAllergicAgentCodelist
List2.png AgentHPKCodelist
List2.png AgentSNKCodelist
List2.png AgentSSKCodelist
List2.png AgentThesaurus122Codelist
CD.png NL-CM:8.5.10 Arrowright.pngSafeWithinUnsafeGroup 0..* Exception within the group of substances to be monitored that do not require monitoring.
350211000146103 Substance safe for patient
List2.png AgentHPKCodelist
List2.png AgentSNKCodelist
List2.png AgentSSKCodelist
Verwijzing.png NL-CM:8.5.12 Arrowright.pngDecisionMaker::HealthProfessional 1 The health professional who made the surveillance decision.
PRF performer
Block.png HealthProfessional
ST.png NL-CM:8.5.13 Arrowright.pngComment 0..1 Textual explanation of the surveillance decision which cannot be expressed in any of the other fields.
48767-8 Annotation comment [Interpretation] Narrative

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

BewakingBesluit
BesluitType Bewaking gestart
BesluitIngangsDatumTijd 02-07-2023
TeBewakenStof
OnveiligeStof Valproïnezuur
VeiligBinnenOnveiligeGroep
Toelichting Gegevens in verwijsbrief van huisarts.
Besluitgrond
BesluitReden Stof heeft (mogelijk) een nadelige reactie veroorzaakt.
Beslisser::Zorgverlener
Naam R. Verhagen-De Leeuw
Specialisme Huisarts
BewakingBesluit
BesluitType Bewaking gestart
BesluitIngangsDatumTijd 12-09-2023 14:30
TeBewakenStof
OnveiligeStof Heparine
VeiligBinnenOnveiligeGroep
Toelichting Antistolling na CABG
Reactie
ReactieNaam Heparine-geïnduceerde trombocytopenie
Beslisser::Zorgverlener
Naam J. Gielissen
Specialisme Apotheker
BewakingBesluit
BesluitType Bewaking gestart Bewaking gestopt Bewaking gestart
BesluitIngangsDatumTijd 17-03-2018 02-01-2024 02-01-2024
TeBewakenStof
OnveiligeStof Penicillines Penicillines Amoxicilline/clavulaanzuur
VeiligBinnenOnveiligeGroep
Besluitgrond
BesluitReden Stof heeft (mogelijk) een nadelige reactie veroorzaakt. De groep waarop wordt bewaakt, is groter of kleiner dan nodig. Stof heeft (mogelijk) een nadelige reactie veroorzaakt.
Toelichting Patiënte werd erg misselijk en had extreme diarree. Wil het middel nooit meer gebruiken. Ceftriaxon werd goed verdragen, waarschijnlijk reactie gehad op amoxiclav.
Beslisser::Zorgverlener
Naam F. Zegers G.J. Zaal G.J. Zaal
Specialisme Huisartsgeneeskunde SEH-arts SEH-arts

Instructions

Medication surveillance with regard to medication contraindication is based on the Zib Alert with AlertType 'Possible medication contraindication'

Valuesets

AgentAllergicAgentCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.8.5.4 Binding: Required
Conceptname Codesystem name Codesystem OID
SNOMED CT: ^98061000146100|Dutch total non-drug allergen simple reference set| SNOMED CT 2.16.840.1.113883.6.96

AgentHPKCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.8.5.6 Binding: Required
Conceptname Codesystem name Codesystem OID
All values G-Standaard Handels Product Kode (HPK) 2.16.840.1.113883.2.4.4.7

AgentHPKCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.8.5.5 Binding: Required
Conceptname Codesystem name Codesystem OID
All values G-Standaard Handels Product Kode (HPK) 2.16.840.1.113883.2.4.4.7

AgentSNKCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.8.5.8 Binding: Required
Conceptname Codesystem name Codesystem OID
All values G-standaard Stofnaamcode (SNK) 2.16.840.1.113883.2.4.4.1.750

AgentSNKCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.8.5.7 Binding: Required
Conceptname Codesystem name Codesystem OID
All values G-standaard Stofnaamcode (SNK) 2.16.840.1.113883.2.4.4.1.750

AgentSSKCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.8.5.9 Binding: Required
Conceptname Codesystem name Codesystem OID
All values G-standaard Stofnaamcode i.c.m. toedieningsweg (SSK) 2.16.840.1.113883.2.4.4.1.725

AgentSSKCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.8.5.10 Binding: Required
Conceptname Codesystem name Codesystem OID
All values G-standaard Stofnaamcode i.c.m. toedieningsweg (SSK) 2.16.840.1.113883.2.4.4.1.725

AgentThesaurus122Codelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.8.5.11 Binding: Required
Conceptname Codesystem name Codesystem OID
All values G-standaard Ongewenste medicatiegroepen 2.16.840.1.113883.2.4.4.1.902.122

DecisionTypeCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.8.5.1 Binding: Required
Conceptname Conceptcode Codesystem name Codesystem OID Description
Started 385652002 SNOMED CT 2.16.840.1.113883.6.96 Bewaking gestart
Discontinued 410546004 SNOMED CT 2.16.840.1.113883.6.96 Bewaking gestopt

StartReasonCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.8.5.2 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Nadelige reactie (mogelijk) veroorzaakt door de stof(fen). NTB SNOMED CT 2.16.840.1.113883.6.96 Nadelige reactie (mogelijk) veroorzaakt door de stof(fen).
Vermoeden van kruisovergevoeligheid. NTB SNOMED CT 2.16.840.1.113883.6.96 Vermoeden van kruisovergevoeligheid.
Patiënt vreest nadelige reactie. NTB SNOMED CT 2.16.840.1.113883.6.96 Patiënt vreest nadelige reactie.
Bezwaar van patiënt tegen stof vanwege persoonlijke overwegingen. NTB SNOMED CT 2.16.840.1.113883.6.96 Bezwaar van patiënt tegen stof vanwege persoonlijke overwegingen.
Other OTH NullFlavor 2.16.840.1.113883.5.1008 Anders

StopReasonCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.8.5.3 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Risico op toekomstige ernstige reactie zeer laag. NTB SNOMED CT 2.16.840.1.113883.6.96 Risico op toekomstige ernstige reactie zeer laag.
Geen reactie na hernieuwd gebruik. NTB SNOMED CT 2.16.840.1.113883.6.96 Geen reactie na hernieuwd gebruik.
Op basis van aanvullend onderzoek. NTB SNOMED CT 2.16.840.1.113883.6.96 Op basis van aanvullend onderzoek.
Bijwerking acceptabel. NTB SNOMED CT 2.16.840.1.113883.6.96 Bijwerking acceptabel.
Inzicht m.b.t. reikwijdte van te bewaken stof(fen) is gewijzigd. NTB SNOMED CT 2.16.840.1.113883.6.96 De groep waarop wordt bewaakt is breder of smaller dan nodig.
Geen reden voor bewaking gevonden. NTB SNOMED CT 2.16.840.1.113883.6.96 Geen reden voor bewaking gevonden.
Other OTH NullFlavor 2.16.840.1.113883.5.1008 Anders

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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:

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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 12:40:24 with ZibExtraction v. 9.3.8880.19756

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