Probleem
- ZIB
- Probleem-v4.4
- Status
- mapping:Ontwikkelen template:Ontwikkelen vertaling:Inrichten codelijst:Inrichten globaal:Ontwikkelen
- Labels
- clinical impression, concern, condition, diagnosen, diagnosis, injury, issue, klachten, problem, en problemen
- Informatiestandaard
- BgZ en Klinische context
- Auteurs
- Sebastian Iancu (Code24)
- Versie
- 0.1
- Laatste wijziging
- 22-01-2021
Mapping
- Templates
- Probleem-v4.4(2020NL) (local)
- Archetypes
- openEHR-EHR-EVALUATION.problem_diagnosis.v1 CKM
Valuesets
ProbleemTypeCodelijst
| ZIB_Conceptnaam | ZIB_Conceptcode | ZIB_Conceptwaarde | ZIB_Codestelselnaam | ZIB_Codesysteem_OID | ZIB_Omschrijving | openEHR_Code | openEHR_Text | Commentaar |
|---|---|---|---|---|---|---|---|---|
| Interpretatie van diagnose | 282291009 | SNOMED CT | 2.16.840.1.113883.6.96 | Diagnose | ||||
| Symptoom gerapporteerd door patiënt of andere bron van voorgeschiedenis | 418799008 | SNOMED CT | 2.16.840.1.113883.6.96 | Symptoom | ||||
| Klinische bevinding | 404684003 | SNOMED CT | 2.16.840.1.113883.6.96 | Bevinding | ||||
| Klacht | 409586006 | SNOMED CT | 2.16.840.1.113883.6.96 | Klacht | ||||
| Bevinding van functionele prestatie en activiteit | 248536006 | SNOMED CT | 2.16.840.1.113883.6.96 | Functionele Beperking | ||||
| Complicatie | 116223007 | SNOMED CT | 2.16.840.1.113883.6.96 | Complicatie |
ProbleemNaamCodelijst
| ZIB_Conceptnaam | ZIB_Conceptcode | ZIB_Conceptwaarde | ZIB_Codestelselnaam | ZIB_Codesysteem_OID | ZIB_Omschrijving | openEHR_Code | openEHR_Text | Commentaar |
|---|---|---|---|---|---|---|---|---|
| Alle waarden [DEPRECATED] | Omaha Systems [DEPRECATED] | 2.16.840.1.113883.6.98 | ||||||
| Alle waarden [DEPRECATED] | G-Standaard Contra Indicaties (Tabel 40) [DEPRECATED] | 2.16.840.1.113883.2.4.4.1.902.40 | ||||||
| Alle waarden | DHD Diagnosethesaurus | 2.16.840.1.113883.2.4.3.120.5.1 | ||||||
| Alle waarden | ICD-10, dutch translation | 2.16.840.1.113883.6.3.2 | ||||||
| 11721000146100|Nationale kernset patiëntproblemen| | SNOMED CT | 2.16.840.1.113883.6.96 | ||||||
| Alle waarden | NANDA-I | 2.16.840.1.113883.6.20 | ||||||
| Alle waarden | ICF | 2.16.840.1.113883.6.254 | ||||||
| Alle waarden | ICPC-1 NL | 2.16.840.1.113883.2.4.4.31.1 | ||||||
| Alle waarden | DSM-IV | 2.16.840.1.113883.6.126 | ||||||
| Alle waarden | DSM-5 | 2.16.840.1.113883.6.344 | ||||||
| Alle waarden | GGZ Diagnoselijst | 2.16.840.1.113883.3.3210.14.2.2.35 |
ProbleemStatusCodelijst
| ZIB_Conceptnaam | ZIB_Conceptcode | ZIB_Conceptwaarde | ZIB_Codestelselnaam | ZIB_Codesysteem_OID | ZIB_Omschrijving | openEHR_Code | openEHR_Text | Commentaar |
|---|---|---|---|---|---|---|---|---|
| Actief | 55561003 | SNOMED CT | 2.16.840.1.113883.6.96 | Actueel | ||||
| Inactief | 73425007 | SNOMED CT | 2.16.840.1.113883.6.96 | Niet actueel |
VerificatieStatusCodelijst
| ZIB_Conceptnaam | ZIB_Conceptcode | ZIB_Conceptwaarde | ZIB_Codestelselnaam | ZIB_Codesysteem_OID | ZIB_Omschrijving | openEHR_Code | openEHR_Text | Commentaar |
|---|---|---|---|---|---|---|---|---|
| Vermoedelijk | 415684004 | SNOMED CT | 2.16.840.1.113883.6.96 | Werk | ||||
| Mogelijk | 410590009 | SNOMED CT | 2.16.840.1.113883.6.96 | Differentiaal | ||||
| Aanwezigheid bevestigd | 410605003 | SNOMED CT | 2.16.840.1.113883.6.96 | Bevestigd | ||||
| Afwezigheid bekend | 410516002 | SNOMED CT | 2.16.840.1.113883.6.96 | Uitgesloten | ||||
| Unknown | UNK | NullFlavor | 2.16.840.1.113883.5.1008 | Onbekend |
Web template: Probleem-v4.4(2020NL)
| Node | Beschrijving | Invoer |
|---|---|---|
| Problem/Diagnosis name DV_TEXT 1..1 | Identification of the problem or diagnosis, by name. | Coding of the name of the problem or diagnosis with a terminology is preferred, where possible. TEXT field |
| Clinical description DV_TEXT 0..1 | Narrative description about the problem or diagnosis. | Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis. TEXT field |
| AnatomischeLocatie-v1.0(2020NL) CLUSTER 0..1 | A physical site on or within the human body. | |
| Body site name DV_TEXT 1..1 | Identification of a single physical site either on, or within, the human body. | This data element is the only mandated data point in this archetype and should be used as the primary data point to record an anatomical location with a commonly used name. It is strongly recommended that 'Body site name' be recorded as specifically as is anatomically possible. For example: record 'upper eyelid' rather than recording 'eyelid' with 'upper' as a qualifier; 'fifth rib' rather than 'rib' with a numeric qualifier. Use the other data elements for laterality, aspect, region and anatomical line to provide more detail. This data element should be coded with a terminology capable of triggering decision support, where possible - an appropriate termset for use here could comprise individual concepts or a list of precoordinated terms. Free text should be used only if there is no appropriate terminology available. If body site name is already identified in the parent archetype, then this data element may be redundant. Alternatively, a use case has been identified where the value may be duplicated into this element to support semantic querying using this archetype, rather than the data element within the parent. TEXT field |
| Laterality DV_CODED_TEXT 0..1 [SNOMED-CT::272741003] | The side of the body on which the identified body site is located. | If the identified body site has no laterality, this data element should not have a value. If the 'Body site name' data element uses pre-coordinated terms that include laterality, then this data element is redundant. code :: label(description)at0003 :: () at0004 :: () |
| Datum/tijd van aanvang DV_DATE_TIME 0..1 | Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed. | Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth. DATETIME field |
| *Date/time of resolution(en) DV_DATE_TIME 0..1 | Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional. | Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth. DATETIME field |
| Problem/Diagnosis qualifier CLUSTER 0..1 | Contextual or temporal qualifier for a specified problem or diagnosis. | |
| Active/Inactive? DV_CODED_TEXT 1..1 | Category that supports division of problems and diagnoses into Active or Inactive problem lists. | The Active/Inactive and Current/Past data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If a Current/Past qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms. code :: label(description)at0026 :: () at0027 :: () |
| Diagnostic category DV_CODED_TEXT 0..1 | Category of the problem or diagnosis within a specified episode of care and/or local care context. | This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG. In addition, the free text choice permits use of other local value sets, as required. code :: label(description)at0064 :: () at0066 :: () at0076 :: () other: TEXT field |
| *Diagnostic certainty(en) DV_CODED_TEXT 0..1 | The level of confidence in the identification of the diagnosis. | code :: label(description) at0074 :: () at0075 :: () at0076 :: () |
| Comment DV_TEXT 0..1 | Additional narrative about the problem or diagnosis not captured in other fields. | TEXT field |
| Language CODE_PHRASE 0..1 | ||
| Encoding CODE_PHRASE 0..1 | ||
| Subject PARTY_PROXY 0..1 |