TreatmentDirective-v3.1(2018EN)

Uit Zorginformatiebouwstenen
Ga naar: navigatie, zoeken



General information

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


Back 16.png Back to HCIM list

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 25-10-2012
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name PM
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.2.1
DCM::KeywordList advance directives, behandel aanwijzing, wilsverklaring, behandelbeperking
DCM::LifecycleStatus Final
DCM::ModelerList Kerngroep Registratie aan de Bron
DCM::Name nl.zorg.BehandelAanwijzing
DCM::PublicationDate 01-10-2018
DCM::PublicationStatus Prepublished
DCM::ReviewerList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 31-12-2017
DCM::Superseeds nl.nfu.BehandelAanwijzing-v1.0.1
DCM::Version 3.1
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (01-04-2015)

ZIB-82 OverdrachtBehandelAanwijzing v1.1
ZIB-91 Opsplitsen OverdrachtBehandelAanwijzing in OverdrachtWilsverklaring en OverdrachtBehandelAanwijzing, incl. uitbreiding WilsverklaringTypeCodelijst.
ZIB-133 Aanpassingen in SNOMED CT codes en omschrijvingen voor codelijst BehandelingCodelijst n.a.v. review terminologie expert.
ZIB-134 Aanpassingen in SNOMED CT codes en omschrijvingen voor codelijst GeverifieerdBijCodelijst n.a.v. review terminologie expert.
ZIB-213 In klinische bouwsteen OverdrachtBehandelAanwijzing de waarde van DCM::Name aanpassen van <<DCM>> nl.nfu. ... naar nl.nfu. ....
ZIB-215 De naam van gekoppelde waardenlijst BehandelingToegestaan is onjuist in de bouwsteen OverdrachtBehandelAanwijzing, dit zou BehandelingToegestaanCodelijst moeten zijn.
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 1.0.1 (22-05-2015)

ZIB-386 De GeverifeerdBijCodelijst heeft geen "OID: " aanduiding in de onderliggende codelijst.

Publicatieversie 3.0 (01-05-2016)

Publicatieversie 3.1 (04-09-2017)

ZIB-549 De Engelse naam van de bouwsteen en het rootconcept zijn niet correct

.

Concept

A treatment instruction includes an agreed constraint in the treatment based on the oral or written living will of the patient.

Purpose

A good overview of treatment instructions based on the wishes of the patient or their authorized representative on (un)desired treatments is important in a patient’s care. A concise, orderly list is of particular importance in acute care situations. Due to the large variety of symptoms, the situation concerns not only a CPR setting, but also cases in which the patient’s condition rapidly worsens as a result of existing symptoms.
A healthcare provider consulting this information can discuss these existing treatment instructions with the patient, the patient’s family or the patient’s authorized representative and possibly include the instructions in their policy.

Evidence Base

Explanation for TreatmentCodeList:
In discussions on constraints in the therapeutic treatment of patients with a chronic neurological or respiratory condition, respiration is sometimes included as a separate restriction. The ‘Respiration’ item is to be seen separately from the decisions on CPR.

Information Model


AdvanceDirective-v3.1(2018EN)#TreatmentCodelist#TreatmentPermittedCodelist#VerifiedWithCodelist#9189#9190#9192#9197#9195#9196#9194#9191#9188#9193#11754TreatmentDirective-v3.1Model(EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:2.1.1 Arrowdown.pngTreatmentDirective Root concept of the TreatmentInstruction information model. This concept contains all data elements of the TreatmentInstruction information model.
Folder.png NL-CM:2.1.8 Arrowdown.pngVerification 0..* Container of the Verification concept. This container contains all data elements of the Verification concept.
BL.png NL-CM:2.1.9 Arrowright.pngVerified 1 Indication of the fact that the treatment instruction has been verified with the patient, the patient’s family and/or the patient's authorized representative.
CD.png NL-CM:2.1.11 Arrowright.pngVerifiedWith 0..* The person with whom the treatment instruction was discussed and verified.
List2.png VerifiedWithCodelist
TS.png NL-CM:2.1.10 Arrowright.pngVerificationDate 0..1 Date on which the verification with the patient, the patient’s family and/or the patient's authorized representative took place.
CD.png NL-CM:2.1.3 Arrowright.pngTreatment 0..1 The medical treatment to which the treatment instruction applies.
50731006 Medical procedure
List2.png TreatmentCodelist
CD.png NL-CM:2.1.4 Arrowright.pngTreatmentPermitted 1 Indication of permission for the treatment, no permission for the treatment, or permission for the treatment with constraints.
List2.png TreatmentPermittedCodelist
ST.png NL-CM:2.1.5 Arrowright.pngRestrictions 0..1 The restrictions or specific circumstances that apply to a certain treatment.
TS.png NL-CM:2.1.6 Arrowright.pngStartDate 0..1 Date on which the treatment instruction went into effect. A ‘vague’ date, such as only the year, is permitted.
TS.png NL-CM:2.1.7 Arrowright.pngEndDate 0..1 Date on which the treatment instruction ends. A ‘vague’ date, such as only the year, is permitted.

If the validity duration of the treatment instruction cannot be expressed as a date, such as “until discharge from hospital”, it can be included in the Comment concept.

ST.png NL-CM:2.1.15 Arrowright.pngComment 0..1 Comments on the treatment instruction such as a written description of an end date which can be indicated as a date (“until discharge from hospital”).
48767-8 Annotation comment [Interpretation] Narrative
Verwijzing.png NL-CM:2.1.14 Arrowright.pngAdvanceDirective 0..* A (written) statement in which a person indicates wishes concerning future medical action, in the event that this person is at that point no longer (deemed) capable of taking decisions on the matter.
Block.png AdvanceDirective

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

Behandeling Behandeling Toegestaan Beperkingen GeverifieerdBij Verificatie Datum
Opname op Intensive Care Ja gevolmachtigde 11-9-2012
Behandeling Behandeling Toegestaan Beperkingen GeverifieerdBij Verificatie Datum
Cardiopulmonaire resuscitatie Ja, maar met beperkingen eerst overleg met echtgenote patiënt 11-9-2012

Valuesets

TreatmentCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.2.1.1 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Admission to intensive care unit 305351004 SNOMED CT 2.16.840.1.113883.6.96 Opname op intensive care
Cardiopulmonary resuscitation 89666000 SNOMED CT 2.16.840.1.113883.6.96 Cardiopulmonaire resuscitatie
Artificial respiration 40617009 SNOMED CT 2.16.840.1.113883.6.96 Kunstmatige beademing
Administration of blood product 116762002 SNOMED CT 2.16.840.1.113883.6.96 Toediening van een bloedproduct
Other OTH NullFlavor 2.16.840.1.113883.5.1008 Overige behandelingen, namelijk (in vrije tekst meegeven)

TreatmentPermittedCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.2.1.2 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Ja JA NL-CM-CS 2.16.840.1.113883.2.4.3.11.60.40.4 Behandeling is toegestaan en/of wenselijk.
Ja, maar met beperkingen JA_MAAR NL-CM-CS 2.16.840.1.113883.2.4.3.11.60.40.4 Behandeling toegestaan en/of wenselijk maar met beperkingen die dan ook vermeld moeten worden
Nee NEE NL-CM-CS 2.16.840.1.113883.2.4.3.11.60.40.4 Behandeling niet toegestaan en/of wenselijk

VerifiedWithCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.2.1.4 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Patient 116154003 SNOMED CT 2.16.840.1.113883.6.96 Patiënt
Parent 40683002 SNOMED CT 2.16.840.1.113883.6.96 Ouder
Guardian 394619001 SNOMED CT 2.16.840.1.113883.6.96 Voogd
Holder of enduring power of attorney 8601000146109 SNOMED CT 2.16.840.1.113883.6.96 Gevolmachtigde
Other OTH NullFlavor 2.16.840.1.113883.5.1008 Anders, namelijk (in vrije tekst meegeven)

This information model in other releases

Information model references

This information model refers to

This inforation 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 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 17:34:20 with ZibExtraction v. 2.0.6879.31307


Back 16.png Back to HCIM list