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General information
Name: nl.zorg.Symptom 
Version: 1.0
HCIM Status:Final
Release: 2024
Release status: Prepublished
Release date: 15-04-2024
Metadata
| DCM::CoderList |
Zib-centrum
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| DCM::ContactInformation.Address |
*
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| DCM::ContactInformation.Name |
*
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| DCM::ContactInformation.Telecom |
*
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| DCM::ContentAuthorList |
Zib-centrum
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| DCM::CreationDate |
01-05-2023
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| DCM::DeprecatedDate |
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| DCM::DescriptionLanguage |
nl
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| DCM::EndorsingAuthority.Address |
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| DCM::EndorsingAuthority.Name |
*
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| DCM::EndorsingAuthority.Telecom |
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| DCM::Id |
2.16.840.1.113883.2.4.3.11.60.40.3.5.5
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| DCM::KeywordList |
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| DCM::LifecycleStatus |
Final
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| DCM::ModelerList |
*
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| DCM::Name |
nl.zorg.Symptoom
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| DCM::PublicationDate |
15-04-2024
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| DCM::PublicationStatus |
Prepublished
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| DCM::ReviewerList |
Zib-centrum
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| DCM::RevisionDate |
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| DCM::Supersedes |
*
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| DCM::Version |
1.0
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| HCIM::PublicationLanguage |
EN
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Revision History
Only available in Dutch
Publicatieversie 1.0 (15-04-2024)
| ZIB-1934
|
ProbleemType moet ProbleemCategorie worden
|
Concept
A phenomenon with which a condition in the patient presents itself. This also includes a complaint or a finding, but not additional research, such as laboratory tests, function tests and imaging studies.
Purpose
Symptoms are an important basis for interpreting the condition (making the diagnosis) and for assessing the severity of the condition and the need for further examination or treatment. Symptoms and their course are also essential for evaluating the effectiveness of treatment.
Evidence Base
Note on zib Symptom A symptom refers to a phenomenon in a broad sense (including complaint and finding) with which a condition presents itself, but limited to symptoms that the patient notices himself or that a health professional can observe, if necessary with simple instruments.
Multiple symptoms may refer to the same condition, as a disorder or condition may present with > 1 symptom.
If a symptom changes, a new instance of zib Symptom with the same Symptom Name and a more recent SymptomStatusDate indicates how the symptom presented itself at that more recent date(time). A series of instances of Symptom with the same SymptomName then represents the course of the symptom by means of an increasing value for SymptomStatusDate.
The cardinality of the reference to Condition is 0..1, because a denial of a symptom does not necessarily involve a condition or state to which that denial refers. To represent that a patient does not have a fever, one should use the zib Exclusion with a reference to Symptom. If the denial of fever stands alone, the instance of Symptom does not refer to a Condition. If the denial of fever explicitly refers to a certain condition, then the instance of Symptom does have a reference to the relevant Condition.
Example: in case a patient has a condition diagnosed with diverticulitis, the health professional may want to explicitly record that there is no fever, because fever is an indication for admission. In that case, the excluded symptom 'fever' will refer to the same condition as to which the diagnostic insight 'diverticulitis' refers.
Functionality (informative) It may happen that a health professional cannot yet make a (differential) diagnosis for a patient and can only indicate ≥ 1 important symptoms that he/she thinks belong together and can probably be explained by one condition. In this case, the EHR must create a new Condition and have the new instance(s) of Symptom refer to it. The EHR must also support that the health professional records ≥ 1 symptoms for a condition with an associated (differential) diagnosis. These symptoms then refer to the same condition.
When modifying an existing symptom, the EHR must have the new Symptom instance refer to the same Condition as the previous Symptom instance with the same SymptomName.
Information Model
| Type |
Id |
Concept |
Card. |
Definition |
DefinitionCode |
Reference
|
|
NL-CM:5.5.1
|
 Symptom
|
|
This is a reference to the rootconcept of information model Symptom.
|
|
|
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NL-CM:5.5.16
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|
 SymptomPeriod::TimeInterval
|
1
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The period in which the symptom is (was) present.
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|
|
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NL-CM:5.5.3
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SymptomStatusDate
|
1
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Date from which the specification of the symptom applies.
|
|
|
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NL-CM:5.5.17
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|
IsNursingDiagnosis
|
1
|
Indicates whether the symptom serves as a nursing diagnosis.
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|
|
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NL-CM:5.5.5
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Onset
|
1
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Indication how fast the symptom presented at first.
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|
|
|
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NL-CM:5.5.6
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|
TemporalPattern
|
0..1
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The temporal pattern with which the symptom presents itself, such as continuous or intermittent.
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|
|
|
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NL-CM:5.5.7
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|
SymptomCourse
|
0..1
|
The course of the intensity of the symptom over time, such as increased, unchanged.
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|
|
|
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NL-CM:5.5.8
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SymptomSeverity
|
1
|
Indicates the degree of severity of the symptom at the moment of the SymptomStatusDate.
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|
|
|
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NL-CM:5.5.9
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DurationWhenPresent::Range
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0..1
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Duration of an intermittent or paroxysmal symptom while it presents.
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|
|
|
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NL-CM:5.5.10
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|
SymptomName
|
1
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Name and code of the symptom via selection from a code list, based on a standardised coding system.
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|
|
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NL-CM:5.5.11
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|
FurtherSpecificationSymptomName
|
0..1
|
More detailed specification of the symptomName that has been selected from the code list, because that list does not (yet) contain the required level of detail.
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|
|
|
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NL-CM:5.5.12
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|
AnatomicalLocation
|
0..*
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The location(s) on or in the body where the symptom presents itself.
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|
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|
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NL-CM:5.5.13
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InfluencingFactors
|
0..1
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Actions, events or circumstances that influence the presentation of the symptom. Generally, this pertains to factors that aggravate or alleviate the symptom.
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|
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NL-CM:5.5.14
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Condition
|
0..*
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The condition of which the symptom is a manifestation.
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|
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|
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NL-CM:5.5.15
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Comment
|
0..1
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A comment in free text with respect to the symptom, 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
| Symptoom
|
|
|
|
| SymptoomPeriode
|
|
|
|
| StartDatumTijd
|
22-02-2023
|
22-02-2023
|
22-02-2023
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| EindDatumTijd
|
|
|
|
| TijdsDuur
|
|
|
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| SymptoomStatusDatum
|
01-03-2023
|
05-03-2023
|
20-03-2023
|
| SymptoomType
|
Symptoom
|
Symptoom
|
Symptoom
|
| SymptoomNaam
|
Hoest
|
Hoest
|
Hoest
|
| NadereSpecificatieSymptoomNaam
|
Droge hoest
|
Productieve hoest
|
Productieve hoest
|
| Ontstaanswijze
|
Subacuut
|
|
|
| TijdsPatroon
|
Aanvalsgewijs
|
Aanvalsgewijs
|
|
| Beloop
|
|
Verslechterd
|
Verbeterd
|
| Ernst
|
Mild
|
Matig
|
Mild
|
| DuurBijOptreden
|
|
|
|
| minimumWaarde
|
30 min
|
5 min
|
|
| maximumWaarde
|
1,5 u
|
10 min
|
|
| nominaleWaarde
|
|
|
|
| BeïnvloedendeFactoren
|
Erger bij liggen
|
|
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| Toelichting
|
|
|
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| AnatomischeLocatie
|
|
|
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| Locatie
|
|
|
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| Lateraliteit
|
|
|
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| AandoeningOfGesteldheid
|
|
|
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| 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
|
| Symptoom
|
|
|
| SymptoomPeriode
|
|
|
| StartDatumTijd
|
15-01-2023 10:30
|
15-01-2023 10:30
|
| EindDatumTijd
|
|
26-02-2023
|
| TijdsDuur
|
|
|
| SymptoomStatusDatum
|
15-01-2023
|
26-02-2023
|
| SymptoomType
|
Symptoom
|
Symptoom
|
| SymptoomNaam
|
Zwelling
|
Zwelling
|
| NadereSpecificatieSymptoomNaam
|
|
|
| Ontstaanswijze
|
Acuut
|
|
| TijdsPatroon
|
|
|
| Beloop
|
|
Niet meer aanwezig
|
| Ernst
|
Ernstig
|
|
| Beïnvloedende actoren
|
Neemt toe bij beweging en neemt af in rust.
|
|
| Toelichting
|
|
|
| AnatomischeLocatie
|
|
|
| Locatie
|
Pols
|
Pols
|
| Lateraliteit
|
Links
|
Links
|
| AandoeningOfGesteldheid
|
|
|
| PeriodeAanwezig
|
|
|
| StartDatumTijd
|
15-01-2023
|
15-01-2023
|
| EindDatumTijd
|
|
|
| StatusDatum
|
15-01-2023
|
26-02-2023
|
| Beloop
|
|
Herstellend
|
| Ernst
|
|
|
Instructions
A symptom always refers to a condition of which it is an expression. Multiple symptoms may refer to the same condition or condition.
Valuesets
OnsetCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.5.2
|
Binding: Required
|
| Conceptname
|
Conceptcode
|
Codesystem name |
Codesystem OID
|
Description
|
| Gradual onset
|
61751001
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Geleidelijk ontstaan
|
| Subacute onset
|
373935005
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Subacuut ontstaan
|
| Sudden onset
|
385315009
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Acuut onstaan
|
SymptomCourseCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.5.4
|
Binding: Required
|
| Conceptname
|
Conceptcode
|
Codesystem name |
Codesystem OID
|
Description
|
| No status change
|
260388006
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Onveranderd
|
| Worse
|
231877006
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Verslechterd
|
| Improved
|
385425000
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Verbeterd
|
| Fluctuating
|
255341006
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Fluctuerend
|
| 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
|
SymptomNameCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.5.8
|
Binding: Required
|
| Conceptname
|
Codesystem name |
Codesystem OID
|
| SNOMED CT: <404684003|Clinical finding|
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
SymptomSeverityCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.5.5
|
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
|
TemporalPatternCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.5.3
|
Binding: Extensible
|
| Conceptname
|
Conceptcode
|
Codesystem name |
Codesystem OID
|
Description
|
| Continual
|
263730007
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Continu
|
| Intermittent
|
7087005
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Intermitterend
|
| Paroxysmal
|
26593000
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Aanvalsgewijs
|
| Cyclic
|
44180009
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Cyclisch
|
| Other
|
OTH
|
NullFlavor
|
2.16.840.1.113883.5.1008
|
Anders
|
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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
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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 12:42:42 with ZibExtraction v. 9.3.8880.19756
