NursingIntervention-v3.1(2018EN)

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General information

Name: nl.zorg.NursingIntervention NL.png
Version: 3.1
HCIM Status:Final
Release: 2018
Release status: Prepublished
Release date: 01-10-2018


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Metadata

DCM::CoderList Werkgroep RadB Verpleegkundige Gegevens
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList Werkgroep RadB Verpleegkundige Gegevens
DCM::CreationDate 7-7-2014
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name PM
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.14.2
DCM::KeywordList Interventie, verpleegkundige actie
DCM::LifecycleStatus Final
DCM::ModelerList Werkgroep RadB Verpleegkundige Gegevens
DCM::Name nl.zorg.VerpleegkundigeInterventie
DCM::PublicationDate 01-10-2018
DCM::PublicationStatus Prepublished
DCM::ReviewerList Projectgroep RadB Verpleegkundige Gegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 31-12-2017
DCM::Superseeds nl.zorg.VerpleegkundigeInterventie-v3.0
DCM::Version 3.1
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (01-07-2015)

Publicatieversie 3.0 (01-05-2016)

Publicatieversie 3.1 (04-09-2017)

ZIB-542 Verwijderen verwijzingen naar codesystemen ICF, Omaha System, NANDA,,NIC en NOC

Concept

A nursing intervention is the care and/or treatment carried out by a nurse based on an expert opinion and clinical knowledge. It is part of the nursing process; interventions are determined as a result of indexed healthcare problems (nursing diagnoses) and based on treatment goals. The interventions are outlined in the nursing procedures.
In a home care situation some actions can also be performed by the patient or a caregiver after a relevant instruction

Purpose

The nursing interventions are an essential part of the nursing process. A nursing intervention is recorded to document the nursing policy and to update other health professionals on the intervention. The documentation of nursing interventions offers the option to determine whether the interventions outlined in the treatment plan have been carried out. This way, we can facilitate optimal nursing and continuity of care.

Information Model


#InterventionSnomedCodelistPatient-v3.1.1(2018EN)ContactPerson-v3.2(2018EN)#12363#12366TreatmentObjective-v3.1(2018EN)MedicalDevice-v3.1.1(2018EN)#12358#12365#12361#12354#12370HealthProfessional-v3.2(2018EN)Problem-v4.1.1(2018EN)#12357#12359#12356HealthProfessional-v3.2(2018EN)#12371#InterventionNICCodelistNursingIntervention-v3.1Model(EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:14.2.1 Arrowdown.pngNursingIntervention Root concept of the NursingIntervention information model. This root concept contains all data elements of the NursingIntervention information model.
CD.png NL-CM:14.2.2 Arrowright.pngIntervention 1 A nursing intervention is a treatment carried out by a nurse based on an expert opinion and clinical knowledge for the benefit of the person requesting healthcare. The intervention is targeted towards a certain problem (diagnosis) and has a predetermined healthcare result.
List2.png InterventionNICCodelist
List2.png InterventionSnomedCodelist
Verwijzing.png NL-CM:14.2.6 Arrowright.pngIndication::Problem 0..1 The nursing-related problem (indication) providing cause for the intervention.
Block.png Problem
Verwijzing.png NL-CM:14.2.14 Arrowright.pngTreatmentObjective 0..1 The description of the treatment goal that the intervention decision is based on.
Block.png TreatmentObjective
Folder.png NL-CM:14.2.9 Arrowdown.pngNursingProcedure 1..* Container of the NursingProcedure concept. This container contains all data elements of the NursingProcedure concept.
9632001 Nursing procedure
PQ.png NL-CM:14.2.3 Arrowright.pngInterval 0..1 Interval indicates the time between planned procedures.

When entering an interval, the focus is on the time between the consecutive procedures, such as in the treatment of a wound, for example. The exact times are of lesser importance.

PQ.png NL-CM:14.2.4 Arrowright.pngFrequency 0..1 The frequency describes how often and in which period certain procedures are carried out, e.g. 3x a day.
ST.png NL-CM:14.2.10 Arrowright.pngActivity 1 The description of nursing procedures carried out in the care for a patient. A nursing intervention consists of a set of patient-related nursing procedures.
TS.png NL-CM:14.2.11 Arrowright.pngProcedureStartDateTime 0..1 The start date (and if possible start time) of the procedure. The concept offers the option to indicate the start of the period of a series of repeating procedures.
TS.png NL-CM:14.2.12 Arrowright.pngProcedureEndDateTime 0..1 The end date (and if possible end time) of the procedure. The concept offers the option to indicate the end of the period of a series of repeating procedures.
Verwijzing.png NL-CM:14.2.13 Arrowright.pngMedicalDevice 0..* Description of the materials used for the nursing procedure, such as bandages.
Block.png MedicalDevice
ST.png NL-CM:14.2.18 Arrowright.pngInstruction 0..1 Instructions for performing the nursing action. This is particularly at issue when the action is performed by the patient himself or by a caregiver.
Folder.png NL-CM:14.2.15 Arrowdown.pngPerformer 0..1 The person carrying out the nursing procedure.
Verwijzing.png NL-CM:14.2.7 Arrowright.pngHealthcareProvider (0..1) The health professional carrying out the nursing procedure.
Block.png HealthProfessional
Verwijzing.png NL-CM:14.2.16 Arrowright.pngCaregiver::ContactPerson (0..1) The caregiver carrying out the nursing procedure.
Block.png ContactPerson
Verwijzing.png NL-CM:14.2.17 Arrowright.pngPatient (0..1) The patient carrying out the nursing procedure.
Block.png Patient
Verwijzing.png NL-CM:14.2.8 Arrowright.pngRequester::HealthProfessional 0..* The health professional who requested the nursing intervention. If desired, only the requester’s specialty can be entered.
Block.png HealthProfessional
ST.png NL-CM:14.2.5 Arrowright.pngComment 0..1 Comment on the nursing intervention.
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

VerpleegkundigeInterventie
Interventie Pijnmanagement
Indicatie
ProbleemNaam Pijn
Behandeldoel
Streefwaarde
MetingNaam Pijnscore
UitslagWaarde <4
UitslagDatumTijd 10-09-2015
VerpleegkundigeActie
Activiteit Ondersteuning van de wond bij hoesten.
ActieStartDatumTijd 10-08-2015
ActieEindDatumTijd 15-08-2015
VerpleegkundigeActie
Activiteit Toedienen medicatie volgens voorschrift bij pijnscore > 4.
ActieStartDatumTijd 10-08-2015
Toelichting -

References

1. Richtlijn Verpleegkundige en verzorgende verslaglegging (V&VN, 2011) [Online] Beschikbaar op:http://www.diliguide.nl/document/4060/file/pdf/ [Geraadpleegd: 13 februari 2015]

2. Vreeke E, Klein Wolterink G. Classificatie- en terminologiestelsels voor verpleegkundige informatie. Nictiz & NFU (2014). [Geraadpleegd: 13 februari 2015]

3. The Omaha System [Online] Beschikbaar op:http://www.omahasystem.org/ [Geraadpleegd: 13 februari 2015]

4. Nursing Intervention Classification (NIC) [Online] Beschikbaar op:http://www.nursing.uiowa.edu/center-for-nursing-classification-and-clinical-effectiveness [Geraadpleegd: 13 februari 2015]

5. Nursing Outcome Classification (NOC) [Online] Beschikbaar op:http://www.nursing.uiowa.edu/center-for-nursing-classification-and-clinical-effectiveness [Geraadpleegd: 13 februari 2015]

6. North American Nursing Diagnosis Association (NANDA) [Online] Beschikbaar op:http://www.nanda.org/ [Geraadpleegd: 13 februari 2015]

7. International Classification for Nursing Practice (ICNP) [Online] Beschikbaar op:www.icn.ch[Geraadpleegd: 13 februari 2015]

8. International Classification of Functioning, Disability and Health (ICF) [Online] Beschikbaar op:http://www.rivm.nl/who-fic/icf.htm [Geraadpleegd: 13 februari 2015]

Valuesets

InterventionNICCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.2.2 Binding: Preferred
Conceptname Codesystem name Codesystem OID
Alle waarden NIC 2.16.840.1.113883.6.15

InterventionSnomedCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.14.2.4 Binding: Preferred
Conceptname Codesystem name Codesystem OID
SNOMED CT: << 71388002|Procedure| SNOMED CT 2.16.840.1.113883.6.96

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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 Prerelease 2018 #1
SNOMED CT and LOINC codes are based on:

  • SNOMED Clinical Terms version: 20180731 [R] (July 2018 Release)
  • LOINC version 2.64

Conditions for use are located on the mainpage List2.png
This page is generated on 01/11/2018 22:25:09 with ZibExtraction v. 2.0.6879.31307


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