RegistrationData-v1.1(2023EN)

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Attention!! This is not the most recent version of this information model. You can find the most recent version ''here''.

General information

Name: nl.zorg.process.RegistrationData NL.png
Version: 1.1
HCIM Status:Final
Release: 2023
Release status: Prepublished
Release date: 15-10-2023


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Metadata

DCM::CoderList
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList
DCM::CreationDate 10-12-2024
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name PM
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.22.1
DCM::KeywordList
DCM::LifecycleStatus Final
DCM::ModelerList
DCM::Name nl.zorg.process.RegistratieGegevens
DCM::PublicationDate 15-10-2023
DCM::PublicationStatus Prepublished
DCM::ReviewerList
DCM::RevisionDate 04-09-2023
DCM::Supersedes nl.zorg.process.RegistratieGegevens-v1.0
DCM::Version 1.1
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (10-06-2022)

Publicatieversie 1.1 (15-10-2023)

ZIB-1774 Definitie RedenAfwezigheidGegevens

Concept

When recording information on a medical concept about a patient in a healthprofessional's patient record, additional information arises which does not so much contain data about the concept itself but relates to the registering process, such as e.g. when and by whom the information was registered.

Purpose

Registration data mainly provides an administrative overview of who has registered information in the EPR and when. In addition to a timeline with the information available in the EPR, this data also offers the posibility of logging.

Information Model


#2738#2732#ReasonDataAbsentCodelist#2741#2742#2737#2740#2730#2735#2731#2733HealthProfessional-v4.0(2023EN)#2745HealthProfessional-v4.0(2023EN)ContactPerson-v4.0(2023EN)Patient-v4.2(2023EN)RegistrationData-v1.1Model(2023EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:22.1.1 Arrowdown.pngRegistrationData Root concept of the RegistrationData process data information model. This root concept contains all data elements of the RegistrationData process data information model.
II.png NL-CM:22.1.12 Arrowright.pngIdentificationNumber 0..1 Globally unique number that identifies the instantiation of the information model. The number is composed of an identification of the issuer organization and a unique number assigned by this organization.
396278008 Identification number
AA2.png AssigningAuthority
Verwijzing.png NL-CM:22.1.2 Arrowright.pngAuthor::HealthProfessional 1 The person who has is responsible for entering the information in de patient's record. It concerns not only own observations, but also information received from third parties. The author has decided to include the information in the file if necessary with source reference.
Block.png HealthProfessional
TS.png NL-CM:22.1.3 Arrowright.pngRegistrationDataTime 1 Date and time when the information was recorded in the patient record.
ST.png NL-CM:22.1.4 Arrowright.pngRegistrationReason 0..1 Description of the reason for including the information in the patient record.
TS.png NL-CM:22.1.5 Arrowright.pngDatTimeOfClosure 0..1 Date and time at which it is recorded in the patient record that the information is no longer relevant, for example because the information is outdated, no longer requires attention, etc.
ST.png NL-CM:22.1.6 Arrowright.pngReasonForClosing 0..1 Reason why updating the information, or following changes in the the concept in question is no longer considered relevant. For example, in the case of a condition, this does not mean that the disease is no longer present, but merely that the holder of the patients record no longer considers the condition as an aspect to be taken into account during care provision.
ST.png NL-CM:22.1.8 Arrowright.pngAcquisitionMethod 1 The way in which the information is obtained by the patient record holder.
TS.png NL-CM:22.1.9 Arrowright.pngAcquisitionDateTime 0..1 Date and when relevant time when the information became available. This may be an earlier time than the date/time when the information was entered in the patient record.
CD.png NL-CM:22.1.10 Arrowright.pngReasonDataAbsent 0..1 Reason why no data is available for the value of a concept. This includes, for example, all 'Unknown' variants, but also 'Indeterminate', 'Specimen unsatisfactory', etc.
List2.png ReasonDataAbsentCodelist
BL.png NL-CM:22.1.11 Arrowright.pngCopyIndicator 1 Indication that the data has been obtained from the EPR of another healthcare professional/healthcare provider.
Folder.png NL-CM:22.1.13 Arrowdown.pngInformationSource 0..1 Container of the InformationSource concept.This container contains all data elements of the InformationSource concept.

If the recorded information has not been assessed by the attending physician, the source of the information can be recorded.

Verwijzing.png NL-CM:22.1.14 Arrowright.pngHealthProfessional (0..1) The health professional who is the source of the information.
Block.png HealthProfessional
Verwijzing.png NL-CM:22.1.15 Arrowright.pngContactPerson (0..1) The contact person who is the source of the information.
Block.png ContactPerson
Verwijzing.png NL-CM:22.1.16 Arrowright.pngPatient (0..1) The patient as information source
Block.png Patient

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

RegistratieGegevens
Identificatienummer 01229993999444
RegistratieDatumTijd 16-05-2016 13:15
DatumVanVerkrijgen 14-05-2016
WijzeVanVerkrijgen Brief
KopieIndicator Waar
Informatiebron : Zorgverlener
ZorgverlenerIdentificatieNummer 21870932
ZorgverlenerRol Hoofdbehandelaar
Specialisme Neuroloog
ZorgverlenerNaam
Initialen J.H.R.
Geslachtsnaam Peters
Adres
Straat Simon Smitweg
Huisnummer 1
Woonplaats Leiderdorp
Postcode 2353 GA
AdresSoort Werkadres
Land Nederland
Auteur : Zorgverlener
ZorgverlenerIdentificatieNummer 88844558
Zorgverlener Rol Verwijzer
Specialisme Huisarts
Zorgverlener Naam
Initialen G.J.
Geslachtsnaam de Vries

Assigning authorities

The identifying numbers are issued by the following authorities

AssigningAuthority

Identifying number ID system OID
AssigningAuthority OID: OID: AssigningAuthorityOID

Valuesets

ReasonDataAbsentCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.22.1.1 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Unknown UNK NullFlavor 2.16.840.1.113883.5.1008 Onbekend
Asked but unknown ASKU NullFlavor 2.16.840.1.113883.5.1008 Gevraagd, maar onbekend
Not asked NASK NullFlavor 2.16.840.1.113883.5.1008 Niet gevraagd
Indeterminate 82334004 SNOMED CT 2.16.840.1.113883.6.96 Niet bepaald
Specimen unsatisfactory 142251000146108 SNOMED CT 2.16.840.1.113883.6.96 Monster ongeschikt

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 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 List2.png
This page is generated on 31/10/2023 18:28:00 with ZibExtraction v. 9.3.8704.31782


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