Admission-v1.0(2022EN)

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General information

Name: nl.zorg.Admission NL.png
Version: 1.0
HCIM Status:Final
Release: 2022
Release status: Prepublished
Release date: 10-06-2022


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Metadata

DCM::CoderList Zib-centrum
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList *
DCM::CreationDate 1-12-2021
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name *
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.15.4
DCM::KeywordList Opname, Deelopname, Ziekenhuisopname
DCM::LifecycleStatus Final
DCM::ModelerList Zib-centrum
DCM::Name nl.zorg.Opname
DCM::PublicationDate 10-06-2022
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 (10-06-2022) Bevat: .

Concept

A (partial) admission describes the entire stay or a part of the stay of a patient or client in a ward equipped for nursing in a healthcare institution, for example a clinical ward, day care ward or observatory. This information model can therefore be used for the entire admission as well as for parts of the admission. It concerns both historical and future (partial) admissions.

Purpose

Admissions take place internally in a healthcare institution with the aim of treating, observing or examining a patient or client.

Evidence Base

The codelists for Origin and Destination generally correspond to the ‘Landelijke Basisregistratie Ziekenhuiszorg’ (National Basic Registration Hospital Care)

Information Model


#TiggerForAdmissionCodelist#15031Problem-v4.6(2022EN)#15024#15023#OriginCodelist#DestinationCodelist#15028#15034#15027HealthcareProvider-v3.5(2022EN)#15039#15038HealthProfessional-v3.5.2(2022EN)#AdmissionScopeCodelist#CareTypeCodelist#15033#15037Admission-v1.0Model(2022EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:15.4.1 Arrowdown.pngAdmission Root concept of the Admission information model.This root concept contains all data elements of the Admission information model.
CD.png NL-CM:15.4.2 Arrowright.pngCareType 1 The type of care that has been or will be provided to the patient during the (partial) admission. This is related, among other things, to the severity category of the care.
List2.png CareTypeCodelist
TS.png NL-CM:15.4.3 Arrowright.pngStartDateTime 1 Date and time when the (partial) admission will start or was started.
TS.png NL-CM:15.4.4 Arrowright.pngEndDateTime 0..1 Date and time on which the (partial) admission ended. For a future or ongoing admission, the end date can be empty.
Folder.png NL-CM:15.4.5 Arrowdown.pngReasonAdmission 1 Container of the ReasonAdmission concept.This container contains all data elements of the ReasonAdmission concept.
Verwijzing.png NL-CM:15.4.6 Arrowright.pngProblem 1 The main problem to which the (partial) admission relates.
Block.png Problem
CD.png NL-CM:15.4.7 Arrowright.pngTiggerForAdmission 1 The specific reason for the admission in relation to the diagnosis and/or treatment of the problem.
59021000146108 Reason for admission
List2.png TiggerForAdmissionCodelist
ST.png NL-CM:15.4.8 Arrowright.pngCommentAdmissionReason 0..1 Comment on the reason for the (partial) admission, insofar as this cannot be sufficiently expressed in the other elements.
48767-8 Annotation comment [Interpretation] Narrative
CD.png NL-CM:15.4.9 Arrowright.pngOrigin 1 Location where the patient comes from prior to the (partial) admission. This will mainly be used at the start of hospitalisation.
List2.png OriginCodelist
CD.png NL-CM:15.4.10 Arrowright.pngDestination 1 Location where the patient will go after the (partial) admission. This will mainly be used at the end of hospitalization.
List2.png DestinationCodelist
CD.png NL-CM:15.4.11 Arrowright.pngAdmissionScope 1 AdmissionScope indicates whether it is a overall admission or a partial admission.
List2.png AdmissionScopeCodelist
Verwijzing.png NL-CM:15.4.12 Arrowright.pngResponsibleHealthProfessional::HealthProfessional 1 The health professional who is responsible during the (partial) admission. The information about the health professional can also include the specialism and role of the health professional.
Block.png HealthProfessional
Verwijzing.png NL-CM:15.4.13 Arrowright.pngCareFacility::HealthcareProvider 1 The physical location of the healthcare provider where the (partial) admission has taken place or will take place.
Block.png HealthcareProvider

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

Herkomst Begin
Datum
Tijd
RedenOpname Verantwoordelijk
Behandelaar
ZorgType Zorginstelling
Probleem Aanleiding
Opname
Zorgverlener
Naam
Zorgaanbieder
Naam
Eigen woonomgeving 16-05-2022 Gebroken been Uitvoeren verrichting J.H.R. Peters Reguliere verpleging Universitair Medisch Centrum Groningen

References

1. Landelijke Basisregistratie Ziekenhuiszorg [Online] Beschikbaar op: https://www.dhd.nl/klanten/klantenservice/handleidingen_formulieren/Documents/Handleiding%20LBZ.pdf [Geraadpleegd: 29 juni2017].

Valuesets

AdmissionScopeCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.15.4.4 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Total admission TA OpnameScope 2.16.840.1.113883.2.4.3.11.60.40.4.29.1 Gehele opname
Admission part PA OpnameScope 2.16.840.1.113883.2.4.3.11.60.40.4.29.1 Opnamedeel

CareTypeCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.15.4.5 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Regular nursing care 180121000146103 SNOMED CT 2.16.840.1.113883.6.96 Reguliere verpleging
Medium care 180141000146109 SNOMED CT 2.16.840.1.113883.6.96 Medium Care
High care 180151000146107 SNOMED CT 2.16.840.1.113883.6.96 High Care
Intensive care 180131000146101 SNOMED CT 2.16.840.1.113883.6.96 IC-zorg

DestinationCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.15.4.2 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Home 264362003 SNOMED CT 2.16.840.1.113883.6.96 Eigen woonomgeving, niet zijnde een instelling
Left against medical advice 445060000 SNOMED CT 2.16.840.1.113883.6.96 Tegen advies in vertrokken [DEPRECATED]
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 [DEPRECATED]
Morgue 225737007 SNOMED CT 2.16.840.1.113883.6.96 Mortuarium
Hospice 284546000 SNOMED CT 2.16.840.1.113883.6.96 Hospice
Hospital abroad 155621000146109 SNOMED CT 2.16.840.1.113883.6.96 Ziekenhuis buitenland
Site of care 43741000 SNOMED CT 2.16.840.1.113883.6.96 Instelling (anders)
Discharge to other location within hospital premises 115841000146105 SNOMED CT 2.16.840.1.113883.6.96 Afdeling binnen zelfde instelling

OriginCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.15.4.3 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Home 264362003 SNOMED CT 2.16.840.1.113883.6.96 Eigen woonomgeving, niet zijnde een instelling
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
Newborn nursery unit 427695007 SNOMED CT 2.16.840.1.113883.6.96 In dit ziekenhuis geboren
Liveborn born in hospital 442311008 SNOMED CT 2.16.840.1.113883.6.96 In dit ziekenhuis geboren [DEPRECATED]
Hospice 284546000 SNOMED CT 2.16.840.1.113883.6.96 Hospice
Hospital abroad 155621000146109 SNOMED CT 2.16.840.1.113883.6.96 Ziekenhuis buitenland
Site of care 43741000 SNOMED CT 2.16.840.1.113883.6.96 Instelling (anders)
Accident and Emergency department 225728007 SNOMED CT 2.16.840.1.113883.6.96 SEH
Outpatient environment 440655000 SNOMED CT 2.16.840.1.113883.6.96 Poliklinische afdeling
Discharge to other location within hospital premises 115841000146105 SNOMED CT 2.16.840.1.113883.6.96 Afdeling binnen zelfde instelling

TiggerForAdmissionCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.15.4.1 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Procedure 71388002 SNOMED CT 2.16.840.1.113883.6.96 Uitvoeren verrichting
Administration of medication 18629005 SNOMED CT 2.16.840.1.113883.6.96 Medicatietoediening
Observation regime 225308005 SNOMED CT 2.16.840.1.113883.6.96 Observatie
Rehabilitation therapy 52052004 SNOMED CT 2.16.840.1.113883.6.96 Revalidatie
Safety procedure 370886002 SNOMED CT 2.16.840.1.113883.6.96 Veiligheid patiënt en/of omgeving
Respite care of patient 105386004 SNOMED CT 2.16.840.1.113883.6.96 Respijtzorg

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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.
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 Pre-release 2022-1
SNOMED CT and LOINC codes are based on:

  • SNOMED Clinical Terms versie: 20220930 [R] (september 2022-editie)
  • LOINC version 2.72

Conditions for use are located on the mainpage List2.png
This page is generated on 17/10/2022 23:20:28 with ZibExtraction v. 8.1.8325.41206


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