EncounterReport-v1.0(2022EN)

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General information

Name: nl.zorg.EncounterReport 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 Projectgroep VIPP GGZ
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList Projectgroep VIPP GGZ
DCM::CreationDate 30-3-2022
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name *
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.15.3
DCM::KeywordList
DCM::LifecycleStatus Final
DCM::ModelerList Projectgroep VIPP GGZ
DCM::Name nl.zorg.ContactVerslag
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).

Concept

The contact report is a textual report of a (partial) consult between the care provider and the patient.

Purpose

A contact report offers a care provider the possibility to record information in a structured manner in free text about a contact with a patient.

Information Model


#15092Encounter-v5.0(2022EN)HealthProfessional-v3.5.2(2022EN)#15090#15089EncounterReport-v1.0Model(2022EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:15.3.1 Arrowdown.pngEncounterReport Root concept of the EncounterReport information model.This root concept contains all data elements of the EncounterReport information model.
11591000146107 Patient encounter report
Verwijzing.png NL-CM:15.3.2 Arrowright.pngAuthor::HealthProfessional 1 The healthcare provider who prepared the report and who is responsible for its content.
Block.png HealthProfessional
Verwijzing.png NL-CM:15.3.3 Arrowright.pngEncounter 1 The encounter the report is about.
308335008 Patient encounter procedure
Block.png Encounter
TS.png NL-CM:15.3.4 Arrowright.pngEncounterReportDateTime 1 Date and, if applicable, the time the report was made.
ST.png NL-CM:15.3.5 Arrowright.pngEncounterReportText 1 The actual content of the contact as free text.
422813005 Document section

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

ContactVerslag
ContactVerslagDatumTijd 21-11-2020
Auteur
Medewerkerscode 01299
AGBCode 01999999
Initialen G.L.
Geslachtsnaam Klaassen
ZorgverlenersRol Psychiater
ContactVerslagTekst Goed verzorgde man, normaal contact, wanhopige klachtenpresentatie, onrustige motoriek (grimasseren, oor vastgrijpen). Bewustzijn helder, oriëntatie intact, geheugen en zelfwaarneming ongestoord, bovengemiddeld intelligent, geen psychotische kenmerken, denken normaal van tempo en vorm, inhoudelijk preoccupatie met oorsuizen, stemming somber (er kan een lachje af), rationaliseren, isoleren van het affect, niet actief suïcidaal.

This information model in other releases

Information model references

This information model refers to

This information model is used in

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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 version: 20220131 [R] (January 2022 Release)
  • LOINC version 2.67

Conditions for use are located on the mainpage List2.png
This page is generated on 10/06/2022 12:40:07 with ZibExtraction v. 8.0.8196.20371


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