Encounter-v6.0(2023EN)
Inhoud
- 1 General information
- 2 Metadata
- 3 Revision History
- 4 Concept
- 5 Purpose
- 6 Information Model
- 7 Example Instances
- 8 Instructions
- 9 Valuesets
- 10 This information model in other releases
- 11 Information model references
- 12 Technical specifications in HL7v3 CDA and HL7 FHIR
- 13 Downloads
- 14 About this information
General information
Name: nl.zorg.Encounter
Version: 6.0
HCIM Status:Final
Release: 2023
Release status: Prepublished
Release date: 15-10-2023
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, afspraak |
DCM::LifecycleStatus | Final |
DCM::ModelerList | Kerngroep Registratie aan de Bron |
DCM::Name | nl.zorg.Contact |
DCM::PublicationDate | 15-10-2023 |
DCM::PublicationStatus | Prepublished |
DCM::ReviewerList | Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron |
DCM::RevisionDate | 04-09-2023 |
DCM::Supersedes | nl.zorg.Contact-v5.0 |
DCM::Version | 6.0 |
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. |
Publicatieversie 4.0 (06-07-2019)
ZIB-701 | AfwijkendeUitslag algemenere naam geven |
ZIB-819 | aanpassen kardinaliteit RedenContact naar 1..* |
ZIB-821 | OverdrachtGeplandeZorgactiviteit laten vervallen en onderliggende zibs aanpassen |
ZIB-822 | Mapping reden van opname in HCIM Encounter |
Publicatieversie 4.0.1 (01-09-2020)
ZIB-1089 | Kardinaliteit reden contact losser maken naar 0..* |
ZIB-1189 | DefinitionCodes alle administratieve zibs |
Publicatieversie 4.0.2 (01-12-2021)
ZIB-1334 | Incorrecte vertaling 'Ambulatory' in ZIB Contact |
ZIB-1428 | "Contact" is niet consistent vertaald naar "Encounter" |
Publicatieversie 5.0 (10-06-2022)
ZIB-622 | ContactTypeCodelijst uitbreiden |
ZIB-938 | Zib Contact: ContactType moeizaam voor eerstelijn |
ZIB-1104 | Contact versus opname |
ZIB-1306 | Toevoegen IC en MC aan Contactypecodelijst |
ZIB-1632 | Contact.Locatie kardinaliteit |
Publicatieversie 6.0 (15-10-2023)
ZIB-1772 | Typefout in waardelijst AanleidingContactCodelijst |
ZIB-1824 | Zibs Contact en Opname |
ZIB-1890 | In waardenlijst ContactVormCodelijst van de zib Contact ontbreekt de Snomed code voor concept Fysiek |
ZIB-1906 | Nieuwe en verbeterde SNOMED codes voor de zib Contact |
Concept
A contact is an interaction between a patient and health care provider(s) in the context of a problem. These can be visits or online interactions.
Encounters can be visits to the general practitioner or other practices, home visits or other relevant encounters. This includes past and future encounters.
In the case of encounters where the main purpose is to perform a procedure, the encounter is considered an implicit part of this procedure and not additionally described as encounter.
Purpose
Encounters take place between a health professional and patient with the aim of assessing the patient's health condition or discuss a health problem, treatment outcome or follow-up policy with the patient
Information Model
Type | Id | Concept | Card. | Definition | DefinitionCode | Reference | |||||||
NL-CM:15.1.1 | Encounter | Root concept of the Encounter information model. This concept contains all data elements of the Encounter information model. |
|
||||||||||
NL-CM:15.1.2 | EncounterType | 1 | The type of encounter is based on the setting of the encounter and the participants present. |
| |||||||||
NL-CM:15.1.19 | EncounterSetting | 1 | EncounterSetting describes the manner and setting in which the contact takes place |
| |||||||||
NL-CM:15.1.13 | EncounterReason | 1 | Container of the EncounterReason concept.This container contains all data elements of the EncounterReason concept. | ||||||||||
NL-CM:15.1.6 | Problem | 1 | The main problem to which the encounter relates. |
| |||||||||
NL-CM:15.1.20 | Reason | 1 | Main reason for the encounter within the context of the health problem. |
| |||||||||
NL-CM:15.1.17 | CommentEncounterReason | 0..1 | Comment on the reason for the encounter, insofar as this cannot be sufficiently expressed in the other elements. |
|
|||||||||
NL-CM:15.1.3 | DateTime | 1 | The date and time at which the encounter took or will take place. | ||||||||||
NL-CM:15.1.18 | ResponsableHealthProfessional::HealthProfessional | 1 | The health professional who is responsible at the time of the encounter for the treatment of the patient's stated health problem. |
| |||||||||
NL-CM:15.1.7 | HealthProfessional | 1..* | The health professional with whom the encounter took or will take place. The specialty and role of the health professional can be entered in the HealthProfessional information model. |
| |||||||||
NL-CM:15.1.8 | Location::HealthcareProvider | 1 | The physical location at which the encountert ook or will take place. |
|
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
Contact Type |
Datum Tijd |
RedenContact | Verantwoordelijk Zorgverlener |
Contact Vorm |
Locatie | |
Probleem | Aanleiding Contact |
Zorgverlener Naam |
Organisatie Naam | |||
SEH | 16-05-2022 | Gebroken been | Acuut Probleem | J.H.R. Peters | Fysiek | Universitair Medisch Centrum Groningen |
Instructions
If a patient has contact with different specialities for different problems then a separate HCIM instantiation of Contact should be created for each problem. For example, someone seen in the ER by an ophthalmologist for eye injury, a surgeon for knee injury and an internist for loss of consciousness.
Valuesets
EncounterSettingCodelist
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 |
Physical face-to-face encounter | 180231000146108 | SNOMED CT | 2.16.840.1.113883.6.96 | Fysiek |
Indirect encounter | 185316007 | SNOMED CT | 2.16.840.1.113883.6.96 | Op afstand |
Telephone encounter | 185317003 | SNOMED CT | 2.16.840.1.113883.6.96 | Telefonisch |
Consultation via video conference | 719410009 | SNOMED CT | 2.16.840.1.113883.6.96 | Video |
Telemedicine consultation with patient | 448337001 | SNOMED CT | 2.16.840.1.113883.6.96 | Digitaal tekstueel |
EncounterTypeCodelist
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, Ambulant [DEPRECATED] |
Emergency | EMER | ActCode | 2.16.840.1.113883.5.4 | SEH [DEPRECATED] |
Field | FLD | ActCode | 2.16.840.1.113883.5.4 | Op lokatie [DEPRECATED] |
Home | HH | ActCode | 2.16.840.1.113883.5.4 | Thuis [DEPRECATED] |
Inpatient | IMP | ActCode | 2.16.840.1.113883.5.4 | Klinisch [DEPRECATED] |
Short Stay | SS | ActCode | 2.16.840.1.113883.5.4 | Dagopname [DEPRECATED] |
Virtual | VR | ActCode | 2.16.840.1.113883.5.4 | Virtueel [DEPRECATED] |
Triage | 225390008 | SNOMED CT | 2.16.840.1.113883.6.96 | Triage |
First consultation with outpatient | 105251000146109 | SNOMED CT | 2.16.840.1.113883.6.96 | 1e poliklinisch consult |
Follow-up consultation with outpatient | 93881000146109 | SNOMED CT | 2.16.840.1.113883.6.96 | Poliklinisch vervolgconsult |
Outpatient inter-collegial consultation | 180191000146100 | SNOMED CT | 2.16.840.1.113883.6.96 | Poliklinisch intercollegiaal consult |
Multidisciplinary consultation | 155161000146105 | SNOMED CT | 2.16.840.1.113883.6.96 | Poliklinisch multidisciplinair consult |
Evaluation and management of inpatient | 86181006 | SNOMED CT | 2.16.840.1.113883.6.96 | Klinische contact |
Medical consultation on hospital inpatient | 24882007 | SNOMED CT | 2.16.840.1.113883.6.96 | Klinisch intercollegiaal consult |
Primary care encounter with consulted physician | 180211000146101 | SNOMED CT | 2.16.840.1.113883.6.96 | Meekijkconsult |
Pre-anesthetic assessment | 182770003 | SNOMED CT | 2.16.840.1.113883.6.96 | Preoperatieve screening |
Home visit | 439708006 | SNOMED CT | 2.16.840.1.113883.6.96 | Huisbezoek |
Emergency department patient visit | 4525004 | SNOMED CT | 2.16.840.1.113883.6.96 | SEH bezoek |
Transportation by emergency ambulance | 715542009 | SNOMED CT | 2.16.840.1.113883.6.96 | Ambulance contact [DEPRECATED] |
Transportation by ambulance | 715537001 | SNOMED CT | 2.16.840.1.113883.6.96 | Ambulance contact |
Transportation by helicopter air ambulance | 715540001 | SNOMED CT | 2.16.840.1.113883.6.96 | Traumaheli contact |
Office visit | 180221000146106 | SNOMED CT | 2.16.840.1.113883.6.96 | Praktijkbezoek |
ReasonCodelist
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 |
Encounter for check up | 185349003 | SNOMED CT | 2.16.840.1.113883.6.96 | Controle |
New patient consultation | 185387006 | SNOMED CT | 2.16.840.1.113883.6.96 | Intake |
Screening procedure | 20135006 | SNOMED CT | 2.16.840.1.113883.6.96 | Screening |
Counseling | 409063005 | SNOMED CT | 2.16.840.1.113883.6.96 | Adviesgesprek |
Confirmatory medical consultation | 77406008 | SNOMED CT | 2.16.840.1.113883.6.96 | Second opinion |
Discussion about options | 223487003 | SNOMED CT | 2.16.840.1.113883.6.96 | Bespreken beleid |
Encounter for sign | 185346005 | SNOMED CT | 2.16.840.1.113883.6.96 | Verandering klachten |
Follow-up consultation | 281036007 | SNOMED CT | 2.16.840.1.113883.6.96 | Follow-up |
Education | 409073007 | SNOMED CT | 2.16.840.1.113883.6.96 | Voorlichting/Instructie |
Clinical trial | 110465008 | SNOMED CT | 2.16.840.1.113883.6.96 | Wetenschappelijk onderzoek |
Physician contact assessment | 410140003 | SNOMED CT | 2.16.840.1.113883.6.96 | Nagesprek |
Encounter for acute problem | 180201000146103 | SNOMED CT | 2.16.840.1.113883.6.96 | Acuut probleem |
Care provision regime | 225351009 | SNOMED CT | 2.16.840.1.113883.6.96 | Verzorging/verpleging |
Keeping vigil of dying patient | 180311000146105 | SNOMED CT | 2.16.840.1.113883.6.96 | Waken |
Evaluation of diagnostic study results | 370851004 | SNOMED CT | 2.16.840.1.113883.6.96 | Bespreken uitslagen/metingen |
This information model in other releases
- Release 2015, (Version 1.2)
- Release 2016, (Version 3.0)
- Release 2017, (Version 3.1)
- Prerelease 2018-2, (Version 3.1)
- Prerelease 2019-2, (Version 4.0)
- Release 2020, (Version 4.0.1)
- Prerelease 2021-2, (Version 4.0.2)
- Prerelease 2022-1, (Version 5.0)
- Prerelease 2024-1, (Version 6.0)
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
- HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR
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 2023-1
SNOMED CT and LOINC codes are based on:
- SNOMED Clinical Terms versie: 20230930 [R] (september 2023-editie)
- LOINC version 2.76
Conditions for use are located on the mainpage
This page is generated on 31/10/2023 18:33:31 with ZibExtraction v. 9.3.8704.31782