Be.en.hd.TransferConcern.Review

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General

Name: be.en.hd.TransferConcern
Version: 0.0.1
Status: Draft

Metadata

DCM::CoderList healthdata.be
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList Clinical Building Blocks Expert Group & healthdata.be
DCM::CreationDate 11-6-2012
DCM::DeprecatedDate
DCM::DescriptionLanguage en
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name healthdata.be
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.5.1
DCM::KeywordList problemen, klachten, diagnosen, episode
DCM::LifecycleStatus Draft
DCM::ModelerList Clinical Building Blocks Expert Group & healthdata.be
DCM::Name be.en.hd.TransferConcern
DCM::PublicationDate
DCM::PublicationStatus
DCM::ReviewerList Clinical Building Blocks Expert Group & healthdata.be
DCM::RevisionDate 05-01-2016
DCM::Superseeds
DCM::Version 0.0.1

Revision History

Concept

Determining relevant health issues of the patient involves two important aspects: observing the problem itself on the one hand (complaints, symptoms, diagnosis, etc.) and evaluation of whether or not an active policy is required on the other. This evaluation by the healthcare provider is documented in the ‘Concern’, the point of attention. Multiple, linked Problems can be subsumed under a single Concern. The difference between recorded problems and the attention they require enables an indication of which issues medical or nursing policy applies to, or in which issues policy is necessary. An example is well-managed diabetes; this requires no active policy of the healthcare provider.

A problem describes a situation with regard to an individual’s health and/or welfare. This situation can be described by the person involved (the patient) themselves (in the form of a complaint), or by their healthcare provider (in the form of a diagnosis, for example). The situation can form cause for diagnostic or therapeutic policy. A problem includes all kinds of medical or nursing information that represents a health problem. A problem can represent various types of health problems:

  • A complaint, finding by patient: a subjective, negatively experienced observation of the patient’s health. Examples: stomach ache, amnesia
  • A symptom: an observation by or about the patient which may indicate a certain disease. Examples: fever, blood in stool, white spots on the roof of the mouth;
  • A finding: a healthcare provider’s observation of a patient’s health. Examples: enlarged liver, pathological plantar reflex, deviating Minimal Mental State, missing teeth.
  • A condition: a description of a (deviating) bodily state, which may or may not be seen as a disease. Examples: pregnancy, circulatory disorder, poisoning.
  • A diagnosis: medical interpretation of complaints and findings. Examples: Diabetes Mellitus type II, pneumonia, hemolytic-uremic syndrome.
  • A functional limitation: a reduction of functional options. Examples: reduced mobility, help required for dressing.
  • A complication: Every diagnosis seen by the healthcare provider as an unforeseen and undesired result of medical action. Examples: post-operative wound infections, loss of hearing through the use of antibiotics.
  • A problem: any circumstance that is relevant to the medical treatment, but does not fit into one of the categories listed. Examples: Patient resides in the Netherlands without a legal status and is not insured; patient is not able to check their own blood sugar levels.

In first-line care the Episode concept fills the role of Concern.

Purpose

An overview of a patient’s health problems has the purpose of informing all healthcare providers involved in the patient’s care on the patient’s current and past health condition. It provides insight into which problems require medical action, which are under control and which are no longer current. The problem overview also directly provides medical context for medication administered and procedures carried out. The overview promotes an efficient, targeted continuation of the patient’s care. A complete list of problems is of importance for automated decision support and determining contraindications.

Information model

Be.en.hd.TransferConcernModel.png
Refer to the legend page for more information about the used types and data types

rootconcept Concern
Definition Root concept of the ConcernTransfer building block. This root concept contains all data elements of the ConcernTransfer building block.
Type Zib.png
DCM::DefinitionCode NL-CM:5.1.1
data ConcernLabel
Definition If needed, a short, written description of the concern. Mainly in first-line care this will be used for the episode name.
Datatype ST.png
DCM::DefinitionCode NL-CM:5.1.9
container Problem
Definition Container of the Problem concept. This container contains all data elements of the Problem concept.

A problem describes a situation with regard to an individual’s health and/or welfare. This situation can be described by the person involved (the patient) themselves (in the form of a complaint) or by their healthcare provider (in the form of a diagnosis, for example).

Datatype Container.png
DCM::DefinitionCode NL-CM:5.1.2
data ProblemStartDate
Definition Start of the disorder to which the problem applies. Especially in symptoms in which it takes longer for the final diagnosis, it is important to know not only the date of the diagnosis, but also how long the patient has had the disorder. A ‘vague’ date, such as only the year or the month and the year, is permitted.
Datatype TS.png
DCM::DefinitionCode NL-CM:5.1.6
DCM::ExampleValue 12-05-2011
data ProblemStatusDate
Definition Date from when the current value of the ProblemStatus applies: since when is the problem current, under control or non-current.
Datatype TS.png
DCM::DefinitionCode NL-CM:5.1.7
DCM::ExampleValue 03-2012
data Explanation
Definition Explanation by the one who determined or updated the Problem.
Datatype ST.png
DCM::DefinitionCode LOINC: 48767-8 Annotation comment
DCM::DefinitionCode NL-CM:5.1.5
data ProblemType
Definition The type of problem; see the concept description.
Datatype CD.png
DCM::DefinitionCode NL-CM:5.1.8
DCM::ExampleValue Symptoom
DCM::ValueSet File:List.png ProblemTypeCodeList OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.1.1
data ProblemName
Definition The problem name defines the problem.

Depending on the setting, one or more of the code systems below can be used:

  • Structured terms: SNOMED CT
  • Medical diagnoses: national DHD list
  • Nurse diagnoses: NANDA
  • Paramedic diagnoses: DHD and NANDA (partially offer solutions for this)
  • For functional constraints: ICF
  • For first-line care: ICPC-1 NL
Datatype CD.png
DCM::DefinitionCode NL-CM:5.1.3
DCM::ExampleValue Nausea
DCM::ValueSet File:List.png ProblemNameCodeList OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.1.3
data ProblemStatus
Definition The problem status describes the condition of the problem:
  1. Current problems are the focus of the current medical policy.
  2. Non-current (historic) problems are part of the case history.
  3. Problems with the status 'Under control' refer to problems that still exist, but which currently do not require specific medical policy (such as well-managed diabetes).
Datatype CD.png
DCM::DefinitionCode NL-CM:5.1.4
DCM::ExampleValue Actueel
DCM::ValueSet File:List.png ProblemStatusCodeList OID: 2.16.840.1.113883.2.4.3.11.60.40.2.5.1.2

Code Lists

ProblemNameCodeList

OID:2.16.840.1.113883.2.4.3.11.60.40.2.5.1.3

Codes Coding Syst. Name Coding System OID
Alle waarden ICPC-1 NL 2.16.840.1.113883.2.4.4.31.1
Clinical Finding|SNOMED CT 2.16.840.1.113883.6.96
Alle waarden NANDA 2.16.840.1.113883.6.20
Alle waarden ICF 2.16.840.1.113883.6.254
Alle waarden ICD-10 2.16.840.1.113883.6.90
Alle waarden G-Standaard Contra Indicaties (Tabel 40) 2.16.840.1.113883.2.4.4.1.902.40
Alle waarden Diagnosethesaurus DHD 9999

ProblemTypeCodeList

OID:2.16.840.1.113883.2.4.3.11.60.40.2.5.1.1

Concept Name Concept Code Codesystem Codesystem OID Description
Problem 55607006 SNOMED CT 2.16.840.1.113883.6.96 Probleem
Condition 64572001 SNOMED CT 2.16.840.1.113883.6.96 Conditie
Diagnosis 282291009 SNOMED CT 2.16.840.1.113883.6.96 Diagnose
Symptom 418799008 SNOMED CT 2.16.840.1.113883.6.96 Symptoom
Finding 404684003 SNOMED CT 2.16.840.1.113883.6.96 Bevinding
Complaint 409586006 SNOMED CT 2.16.840.1.113883.6.96 Klacht
Functional Limitation 248536006 SNOMED CT 2.16.840.1.113883.6.96 Functionele Beperking
Complication 116223007 SNOMED CT 2.16.840.1.113883.6.96 Complicatie

ProblemStatusCodeList

OID:2.16.840.1.113883.2.4.3.11.60.40.2.5.1.2

Concept Name Concept Code Codesystem Codesystem OID Description
Active 55561003 SNOMED CT 2.16.840.1.113883.6.96 Actueel
Inactive 73425007 SNOMED CT 2.16.840.1.113883.6.96 Niet actueel
Resolved 413322009 SNOMED CT 2.16.840.1.113883.6.96 Onder controle

References

1. openEHR-EHR-EVALUATION.problem.v1 [Online] Beschikbaar op: http://www.openehr.org/knowledge/ [Geraadpleegd: 23 juli 2014].

2. North American Nursing Diagnosis Association [Online] Beschikbaar op: http://www.nanda.org [Geraadpleegd: 23 juli 2014].

3. Diagnosethesaurus. Dutch Hospital Data [Online] Beschikbaar op: http://www.dutchhospitaldata.nl [Geraadpleegd: 23 juli 2014].

4. Health Level Seven International EHR Technical Committee (February 2007) Electronic Health Record–System Functional Model, Release 1. Chapter Three: Direct Care Functions.

5. HL7 (April 2007) HL7 Implementation Guide: CDA Release 2 – Continuity of Care Document (CCD)

6. Nederlands Huisartsen Genootschap (2013) HIS-Referentiemodel 2013