General information
Name: nl.zorg.Symptom 
Version: 2.0
HCIM Status:Final
Release: 2024
Release status: Published
Release date: 24-04-2024
Metadata
| DCM::CoderList |
Zib-centrum
|
| DCM::ContactInformation.Address |
*
|
| DCM::ContactInformation.Name |
*
|
| DCM::ContactInformation.Telecom |
*
|
| DCM::ContentAuthorList |
Zib-centrum
|
| DCM::CreationDate |
01-05-2023
|
| DCM::DeprecatedDate |
|
| DCM::DescriptionLanguage |
nl
|
| DCM::EndorsingAuthority.Address |
|
| DCM::EndorsingAuthority.Name |
*
|
| DCM::EndorsingAuthority.Telecom |
|
| DCM::Id |
2.16.840.1.113883.2.4.3.11.60.40.3.5.5
|
| DCM::KeywordList |
|
| DCM::LifecycleStatus |
Final
|
| DCM::ModelerList |
*
|
| DCM::Name |
nl.zorg.Symptoom
|
| DCM::PublicationDate |
24-04-2024
|
| DCM::PublicationStatus |
Published
|
| DCM::ReviewerList |
Zib-centrum
|
| DCM::RevisionDate |
03-04-2025
|
| DCM::Supersedes |
nl.zorg.Symptoom-v1.0
|
| DCM::Version |
2.0
|
| HCIM::PublicationLanguage |
EN
|
Revision History
Only available in Dutch
Publicatieversie 1.0 (15-04-2024)
| ZIB-1934
|
ProbleemType moet ProbleemCategorie worden
|
Publicatieversie 2.0 (24-04-2024)
| ZIB-2404
|
Verzoek voor zib Symptoom: Definitiecode voor TijdPatroon verwijderen
|
| ZIB-2409
|
Verzoek Aanscherpen Definitietekst bij SymptoomPeriode
|
| ZIB-2636
|
Symptoom - Tekst aanpassen in Evidence Base
|
| ZIB-2654
|
Symptoom - Element IsVerpleegkundigeDiagnose verwijderen
|
| ZIB-2678
|
Symptoom - Evidence base: Functionaliteit (informatief) verwijderen
|
Concept
A phenomenon with which a condition in the patient presents itself. This also includes a complaint or a finding, but not additional research, such as laboratory tests, function tests and imaging studies.
Purpose
Symptoms are an important basis for interpreting the condition (making the diagnosis) and for assessing the severity of the condition and the need for further examination or treatment. Symptoms and their course are also essential for evaluating the effectiveness of treatment.
Evidence Base
Note on zib Symptom
A symptom refers to a phenomenon in a broad sense (including complaint and finding) with which a condition presents itself, but limited to symptoms that the patient notices himself or that a health professional can observe, if necessary with simple instruments.
Multiple symptoms may refer to the same condition, as a disorder or condition may present with > 1 symptom.
If a symptom changes, a new instance of zib Symptom with the same Symptom Name and a more recent SymptomStatusDate indicates how the symptom presented itself at that more recent date(time). A series of instances of Symptom with the same SymptomName then represents the course of the symptom by means of an increasing value for SymptomStatusDate.
The cardinality of the reference to Condition is 0..*. The cardinality “0” is used because, when a symptom is negated, there is no condition or state of which the symptom is a manifestation. To exclude a symptom on its own (outside the context of a condition), one should use questionnaires or checklists. If a Symptom needs to be excluded in the context of a specific condition—for example, no fever in the case of diverticulitis—the Zib Exclusion should be used. The cardinality ”*” indicates that a symptom can be a manifestation of more than one condition.
Information Model
| Type |
Id |
Concept |
Card. |
Definition |
DefinitionCode |
Reference
|
|
NL-CM:5.5.1
|
 Symptom
|
|
This is a reference to the rootconcept of information model Symptom.
|
|
|
|
NL-CM:5.5.16
|
|
 SymptomPeriod::TimeInterval
|
1
|
Indication of when the symptom is or was present. A vague date, e.g. only a year or a month and a year, is allowed.
|
|
|
|
NL-CM:5.5.3
|
|
SymptomStatusDate
|
1
|
Date from which the specification of the symptom applies.
|
|
|
|
NL-CM:5.5.5
|
|
Onset
|
1
|
Indication how fast the symptom presented at first.
|
|
|
|
|
NL-CM:5.5.6
|
|
TemporalPattern
|
0..1
|
The temporal pattern with which the symptom presents itself, such as continuous or intermittent.
|
|
|
|
|
NL-CM:5.5.7
|
|
SymptomCourse
|
0..1
|
The course of the intensity of the symptom over time, such as increased, unchanged.
|
|
|
|
|
NL-CM:5.5.8
|
|
SymptomSeverity
|
1
|
Indicates the degree of severity of the symptom at the moment of the SymptomStatusDate.
|
|
|
|
|
NL-CM:5.5.9
|
|
DurationWhenPresent::Range
|
0..1
|
Duration of an intermittent or paroxysmal symptom while it presents.
|
|
|
|
|
NL-CM:5.5.10
|
|
SymptomName
|
1
|
Name and code of the symptom via selection from a code list, based on a standardised coding system.
|
|
|
|
NL-CM:5.5.11
|
|
FurtherSpecificationSymptomName
|
0..1
|
More detailed specification of the symptomName that has been selected from the code list, because that list does not (yet) contain the required level of detail.
|
|
|
|
|
NL-CM:5.5.12
|
|
AnatomicalLocation
|
0..*
|
The location(s) on or in the body where the symptom presents itself.
|
|
|
|
|
NL-CM:5.5.13
|
|
InfluencingFactors
|
0..1
|
Actions, events or circumstances that influence the presentation of the symptom. Generally, this pertains to factors that aggravate or alleviate the symptom.
|
|
|
|
|
NL-CM:5.5.14
|
|
Condition
|
0..*
|
The condition of which the symptom is a manifestation.
|
|
|
|
|
NL-CM:5.5.15
|
|
Comment
|
0..1
|
A comment in free text with respect to the symptom, that is not represented by the other data elements in the information model.
|
|
|
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
| Symptoom
|
|
|
|
| SymptoomPeriode
|
|
|
|
| StartDatumTijd
|
22-02-2023
|
22-02-2023
|
22-02-2023
|
| EindDatumTijd
|
|
|
|
| TijdsDuur
|
|
|
|
| SymptoomStatusDatum
|
01-03-2023
|
05-03-2023
|
20-03-2023
|
| SymptoomType
|
Symptoom
|
Symptoom
|
Symptoom
|
| SymptoomNaam
|
Hoest
|
Hoest
|
Hoest
|
| NadereSpecificatieSymptoomNaam
|
Droge hoest
|
Productieve hoest
|
Productieve hoest
|
| Ontstaanswijze
|
Subacuut
|
|
|
| TijdsPatroon
|
Aanvalsgewijs
|
Aanvalsgewijs
|
|
| Beloop
|
|
Verslechterd
|
Verbeterd
|
| Ernst
|
Mild
|
Matig
|
Mild
|
| DuurBijOptreden
|
|
|
|
| minimumWaarde
|
30 min
|
5 min
|
|
| maximumWaarde
|
1,5 u
|
10 min
|
|
| nominaleWaarde
|
|
|
|
| BeïnvloedendeFactoren
|
Erger bij liggen
|
|
|
| Toelichting
|
|
|
|
| AnatomischeLocatie
|
|
|
|
| Locatie
|
|
|
|
| Lateraliteit
|
|
|
|
| AandoeningOfGesteldheid
|
|
|
|
| PeriodeAanwezig
|
|
|
|
| StartDatumTijd
|
22-02-2023
|
22-02-2023
|
22-02-2023
|
| EindDatumTijd
|
|
|
|
| StatusDatum
|
01-03-2023
|
05-03-2023
|
20-03-2023
|
| Beloop
|
|
Verslechterd
|
Verbeterd
|
| Ernst
|
Mild
|
Matig
|
Mild
|
| Symptoom
|
|
|
| SymptoomPeriode
|
|
|
| StartDatumTijd
|
15-01-2023 10:30
|
15-01-2023 10:30
|
| EindDatumTijd
|
|
26-02-2023
|
| TijdsDuur
|
|
|
| SymptoomStatusDatum
|
15-01-2023
|
26-02-2023
|
| SymptoomType
|
Symptoom
|
Symptoom
|
| SymptoomNaam
|
Zwelling
|
Zwelling
|
| NadereSpecificatieSymptoomNaam
|
|
|
| Ontstaanswijze
|
Acuut
|
|
| TijdsPatroon
|
|
|
| Beloop
|
|
Niet meer aanwezig
|
| Ernst
|
Ernstig
|
|
| Beïnvloedende actoren
|
Neemt toe bij beweging en neemt af in rust.
|
|
| Toelichting
|
|
|
| AnatomischeLocatie
|
|
|
| Locatie
|
Pols
|
Pols
|
| Lateraliteit
|
Links
|
Links
|
| AandoeningOfGesteldheid
|
|
|
| PeriodeAanwezig
|
|
|
| StartDatumTijd
|
15-01-2023
|
15-01-2023
|
| EindDatumTijd
|
|
|
| StatusDatum
|
15-01-2023
|
26-02-2023
|
| Beloop
|
|
Herstellend
|
| Ernst
|
|
|
Instructions
A symptom always refers to the condition or state of which it is a manifestation. Multiple symptoms can refer to the same condition or state. When an existing symptom is updated, the new instantiation of Symptom will have the same SymptomName, refer to the same Condition, and have a more recent SymptomStatusDate.
Valuesets
OnsetCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.5.2
|
Binding: Required
|
Status: Active
|
| Conceptname
|
Conceptcode
|
Codesystem name |
Codesystem OID
|
Description
|
| Gradual onset
|
61751001
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Geleidelijk ontstaan
|
| Subacute onset
|
373935005
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Subacuut ontstaan
|
| Sudden onset
|
385315009
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Acuut onstaan
|
|
|
| Other values are not allowed
|
SymptomCourseCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.5.4
|
Binding: Required
|
Status: Active
|
| Conceptname
|
Conceptcode
|
Codesystem name |
Codesystem OID
|
Description
|
| No status change
|
260388006
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Onveranderd
|
| Worse
|
231877006
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Verslechterd
|
| Improved
|
385425000
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Verbeterd
|
| Fluctuating
|
255341006
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Fluctuerend
|
| No longer present
|
350361000146109
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Niet meer aanwezig
|
|
|
| Other values are not allowed
|
SymptomNameCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.5.8
|
Binding: Required
|
Status: Active
|
| Conceptname
|
Codesystem name |
Codesystem OID
|
| SNOMED CT: <404684003|Clinical finding|
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
|
|
| Value Other (OTH) from codesystem NullFlavor (OID: 2.16.840.1.113883.5.1008) is allowed in this valueset.
|
SymptomSeverityCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.5.5
|
Binding: Required
|
Status: Active
|
| Conceptname
|
Conceptcode
|
Codesystem name |
Codesystem OID
|
Description
|
| Mild
|
255604002
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Mild
|
| Mild to moderate
|
371923003
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Mild tot matig
|
| Moderate severity
|
6736007
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Matig
|
| Moderate to severe
|
371924009
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Matig tot ernstig
|
| Severe
|
24484000
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Ernstig
|
| Life threatening severity
|
442452003
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Levensbedreigend
|
|
|
| Other values are not allowed
|
TemporalPatternCodelist
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.5.3
|
Binding: Extensible
|
Status: Active
|
| Conceptname
|
Conceptcode
|
Codesystem name |
Codesystem OID
|
Description
|
| Continual
|
263730007
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Continu
|
| Intermittent
|
7087005
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Intermitterend
|
| Paroxysmal
|
26593000
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Aanvalsgewijs
|
| Cyclic
|
44180009
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Cyclisch
|
|
|
| Value Other (OTH) from codesystem NullFlavor (OID: 2.16.840.1.113883.5.1008) is allowed in this valueset.
|
This information model in other releases
Information model references
This information model refers to
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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
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Downloads
This information model is also available as pdf file 
or as spreadsheet 
About this information
The information in this wikipage is based on Release 2024
SNOMED CT and LOINC codes are based on:
- SNOMED Clinical Terms versie: 20250430 [R] (april 2025-editie)
- LOINC version 2.77
Conditions for use are located on the mainpage
This page is generated on 27/05/2025 14:00:48 with ZibExtraction v. 9.5.9242.40707
