Verrichting

ZIB: Verrichting-v5.2
Status: mapping:Inrichten template:Ontwikkelen vertaling:Inrichten codelijst:Inrichten globaal:Ontwikkelen
Labels: clinical, cure, diagnostic, intervention, investigation, medical, palliative, procedure, screening, surgical, therapeutic, therapy, treatment, en verrichting
Informatiestandaard: BgZ en Behandeling
Auteurs: Sebastian Iancu (Code24)
Versie: 0.1
Laatste wijziging: 12-11-2020

Mapping

Templates: Verrichting-v5.2(2020NL) (local)
Archetypes: openEHR-EHR-ACTION.procedure.v1 CKM

ZIB_Id	ZIB_Naam	ZIB_Type	ZIB_Card	ZIB_DefCode	ZIB_Verwijzing
NL-CM:14.1.1	Verrichting	rootconcept		SNOMED CT: 71388002 Verrichting
NL-CM:14.1.2	VerrichtingStartDatum	TS	0..1
NL-CM:14.1.3	VerrichtingEindDatum	TS	0..1
NL-CM:14.1.4	VerrichtingType	CD	1		VerrichtingTypeCBVCodelijst; VerrichtingTypeDHDCodelijst; VerrichtingTypeGGZCodelijst; VerrichtingTypeNHGCodelijst; VerrichtingTypeNZaCodelijst
NL-CM:14.1.12	VerrichtingMethode	CD	0..*	SNOMED CT: 260686004 Methode	VerrichtingMethodeCodelijst
NL-CM:14.1.13	VerrichtingAnatomischeLocatie::AnatomischeLocatie	data,reference	0..1	SNOMED CT: 405813007 Directe locatie van verrichting	ZIB AnatomischeLocatie
NL-CM:14.1.9	Indicatie::Probleem	data,reference	0..*	SNOMED CT: 363702006 Heeft focus	ZIB Probleem
NL-CM:14.1.7	MedischHulpmiddel	data,reference	0..*	SNOMED CT: 405815000 Hulpmiddel voor verrichting	ZIB MedischHulpmiddel
NL-CM:14.1.5	Locatie::Zorgaanbieder	context,reference	0..1		ZIB Zorgaanbieder
NL-CM:14.1.6	Uitvoerder::Zorgverlener	context,reference	0..*		ZIB Zorgverlener
NL-CM:14.1.10	Aanvrager::Zorgverlener	context,reference	0..*		ZIB Zorgverlener

Deze mapping is beschikbaar als verrichting.csv bestand.

Valuesets

VerrichtingTypeCBVCodelijst

ZIB_Conceptnaam	ZIB_Conceptcode	ZIB_Conceptwaarde	ZIB_Codestelselnaam	ZIB_Codesysteem_OID	ZIB_Omschrijving	openEHR_Code	openEHR_Text	Commentaar
Alle waarden			CBV codes	2.16.840.1.113883.2.4.3.120.5.3

Deze ValueSet is beschikbaar als verrichtingtypecbvcodelijst.csv bestand.

VerrichtingTypeDHDCodelijst

ZIB_Conceptnaam	ZIB_Conceptcode	ZIB_Conceptwaarde	ZIB_Codestelselnaam	ZIB_Codesysteem_OID	ZIB_Omschrijving	openEHR_Code	openEHR_Text	Commentaar
Alle waarden			DHD Verrichtingenthesaurus	2.16.840.1.113883.2.4.3.120.5.2

Deze ValueSet is beschikbaar als verrichtingtypedhdcodelijst.csv bestand.

VerrichtingTypeGGZCodelijst

ZIB_Conceptnaam	ZIB_Conceptcode	ZIB_Conceptwaarde	ZIB_Codestelselnaam	ZIB_Codesysteem_OID	ZIB_Omschrijving	openEHR_Code	openEHR_Text	Commentaar
Alle waarden			GGZ Verrichtingenijst	2.16.840.1.113883.3.3210.14.2.2.15

Deze ValueSet is beschikbaar als verrichtingtypeggzcodelijst.csv bestand.

VerrichtingTypeNHGCodelijst

ZIB_Conceptnaam	ZIB_Conceptcode	ZIB_Conceptwaarde	ZIB_Codestelselnaam	ZIB_Codesysteem_OID	ZIB_Omschrijving	openEHR_Code	openEHR_Text	Commentaar
Alle waarden			NHG tabel 49 Ingrepen en behandelingen	2.16.840.1.113883.2.4.4.30.49

Deze ValueSet is beschikbaar als verrichtingtypenhgcodelijst.csv bestand.

VerrichtingTypeNZaCodelijst

ZIB_Conceptnaam	ZIB_Conceptcode	ZIB_Conceptwaarde	ZIB_Codestelselnaam	ZIB_Codesysteem_OID	ZIB_Omschrijving	openEHR_Code	openEHR_Text	Commentaar
Alle waarden			NZa codes	2.16.840.1.113883.2.4.3.27.15.5

Deze ValueSet is beschikbaar als verrichtingtypenzacodelijst.csv bestand.

VerrichtingMethodeCodelijst

ZIB_Conceptnaam	ZIB_Conceptcode	ZIB_Conceptwaarde	ZIB_Codestelselnaam	ZIB_Codesysteem_OID	ZIB_Omschrijving	openEHR_Code	openEHR_Text	Commentaar
129264002\|Handeling\|			SNOMED CT	2.16.840.1.113883.6.96

Deze ValueSet is beschikbaar als verrichtingmethodecodelijst.csv bestand.

Web template: Verrichting-v5.2(2020NL)

Node	Beschrijving	Invoer
Ism_transition ISM_TRANSITION 0..1
Current_state DV_CODED_TEXT 1..1		code :: label(description) 530 :: () 245 :: () 531 :: () 532 :: () 524 :: () 526 :: () 527 :: () 528 :: () 529 :: ()
Transition DV_CODED_TEXT 0..1		code :: label(description) value: TEXT field
Careflow_step DV_CODED_TEXT 0..1		code :: label(description) at0004 :: () at0034 :: () at0007 :: () at0035 :: () at0038 :: () at0039 :: () at0036 :: () at0068 :: () at0047 :: () at0040 :: () at0041 :: () at0043 :: ()
Procedure name DV_TEXT 1..1	Identification of the procedure by name.	Coding of the specific procedure with a terminology is preferred, where possible. TEXT field
Description DV_TEXT 0..1	Narrative description about the procedure, as appropriate for the pathway step.	For example: description about the performance and findings from the the procedure, the aborted attempt or the cancellation of the procedure. TEXT field
Method DV_TEXT 0..-1	Identification of specific method or technique for the procedure.	Use this data element to record simple terms or a narrative description. If the requirements for recording the method require more complex modelling then this can be represented by additional archetypes within the 'Procedure detail' SLOT in this archetype. If the method is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant. TEXT field
Urgency DV_TEXT 0..1	Urgency of the procedure.	Coding with a terminology is preferred, where possible. TEXT field
Body site DV_TEXT 0..-1	Identification of the body site for the procedure.	Occurrences for this data element are unbounded to allow for clinical scenarios such as removing multiple skin lesions in different places, but where all of the other attributes are identical. Use this data element to record simple terms or precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Procedure detail' SLOT in this archetype. If the anatomical location is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant. TEXT field
Outcome DV_TEXT 0..-1	Outcome of procedure performed.	Coding with a terminology is preferred, where possible. TEXT field
Procedural difficulty DV_TEXT 0..-1	Difficulties or issues encountered during performance of the procedure.	Examples: The patient was agitated, insufficient emptying of the stomach before gastroscopy, a tumour in the bile ducts made it impossible to pass the scope through. TEXT field
Complication DV_TEXT 0..-1	Details about any complication arising from the procedure.	Use this data element to record simple terms or precoordinated complications. If the requirements for recording complication are more complex then use of a specific CLUSTER archetype within the 'Procedure detail' SLOT in this archetype is advised and this data element becomes redundant. Examples: Hematuria after a kidney biopsy, tissue irritation after insertion of intravenous catheter. TEXT field
Scheduled date/time DV_DATE_TIME 0..1	The date and/or time on which the procedure is intended to be performed.	Only for use in association with the 'Procedure scheduled' pathway step. DATETIME field
Final end date/time DV_DATE_TIME 0..1	The date and/or time when the entire procedure, or the last component of a multicomponent procedure, was finished.	Only for use in association with the 'Procedure performed' pathway step, and in situations where the procedure is repeated on multiple occasions before being completed or there are multiple components to the whole procedure. This may be the same as the RM time attribute for the 'Procedure completed' pathway step. DATETIME field
Total duration DV_DURATION 0..1	The total amount of time taken to complete the procedure, which may include time spent during the active phase of the procedure plus time during which the procedure was suspended.	Only for use in association with the 'Procedure completed' pathway steps. year: INTEGER field month: INTEGER field day: INTEGER field week: INTEGER field hour: INTEGER field minute: INTEGER field second: INTEGER field
Procedure type DV_TEXT 0..1	The type of procedure.	This pragmatic data element may be used to support organisation within the user interface. TEXT field
Reason DV_TEXT 0..-1	Reason that the activity or care pathway step for the identified procedure was carried out.	For example: the reason for the cancellation or suspension of the procedure. TEXT field
Comment DV_TEXT 0..1	Additional narrative about the activity or care pathway step not captured in other fields.	TEXT field
Requestor order identifier ELEMENT 0..1	The local ID assigned to the order by the healthcare provider or organisation requesting the service.	This is equivalent to Placer Order Number in HL7 v2 specifications.
Requestor order identifier DV_TEXT 0..1	The local ID assigned to the order by the healthcare provider or organisation requesting the service.	TEXT field
Requestor order identifier DV_IDENTIFIER 0..1	The local ID assigned to the order by the healthcare provider or organisation requesting the service.	id: TEXT field type: TEXT field issuer: TEXT field assigner: TEXT field
Receiver order identifier ELEMENT 0..1	The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier.	This is equivalent to Filler Order Number in HL7 v2 specifications.
Receiver order identifier DV_TEXT 0..1	The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier.	TEXT field
Receiver order identifier DV_IDENTIFIER 0..1	The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier.	id: TEXT field type: TEXT field issuer: TEXT field assigner: TEXT field
Time DV_DATE_TIME 0..1		DATETIME field
Language CODE_PHRASE 0..1
Encoding CODE_PHRASE 0..1
Subject PARTY_PROXY 0..1

Deze web template is beschikbaar als Verrichting-v5.2(2020NL).json bestand.