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{{DISPLAYTITLE:eOverdracht FHIR Implementation Guide}}
 
{{DISPLAYTITLE:eOverdracht FHIR Implementation Guide}}
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__NUMBEREDHEADINGS__
 
=Introduction=
 
=Introduction=
  

Versie van 21 jan 2021 09:24


1 Introduction

This implementation guide assumes that the reader is familiar with FHIR(STU3).

1.1 Overarching FHIR principles

TODO: This implementation guide does not provide information on finding the right XIS, nor does it provide information about security. It is assumed that the sending XIS is able to make a connection with the receiving XIS.

{TODO: referentie naar overarching principles}


1.2 CapabilityStatements

Information standards may have a CapabilityStatement that is informative in nature and does not represent the minimum or maximum set of capabilities the client or server should support. Nictiz will strive to provide CapabilityStatements that are as complete as possible, however for the exact set of capabilities the implementation guide of the corresponding information standard should be consulted.

1.3 Referring other resources when sending information

When the client creates/updates a resource on a server, it often needs to reference "secondary" resources which are not the primary focus of the interaction -- e.g. an Observation must indicate its subject using a reference to a Patient resource. The client may refer to existing resources on the server for this, but this is not always possible (for example, the client doesn't know about the existing resource or the server doesn't support the read operation for it). In this case, the client needs to send the secondary resources along with the primary resource in a Bundle, and the server should align these new resources with the ones it already has.

A data conflict may arise if these secondary resources carry details that are not of interest within the particular context of the information standard. For example, the client posts an Observation and sends along a Patient resource containing a different telephone number than the one that is on record at the server side. This change in telephone number is not relevant in this particular context, since the interaction is about creating the Observation.

Unless more specific guidance is given by the information standard, the following guidance applies:

  • Sending secondary resources SHALL only be done when the information standard specifies that a batch or transaction operation is to be used.
  • If so, the client MAY send a bare-bones instance as the secondary resource containing just minimal information, but this SHOULD include the information necessary for the server to match its own copy. The information standard MAY specify which information is minimally needed for such a secondary resource and MAY also restrict the information that is sent in the secondary resource.
  • The client MUST include a Bundle.entry.request for each of the resources in the Bundle, including the secondary resources that are only there for referencing purposes[1]. .request SHOULD be a POST to the appropriate endpoint. As an alternative, PUT MAY be used, but is strongly discouraged; if the client has knowledge on the id of the resource on the server, an absolute URL is strongly preferred.
  • If the server can unequivocally de-duplicate this secondary resource (for example, because the patient is already known from the security context or the healthcare provider is recognized by the UZI number), it MAY choose to ignore the differences of this resource or it MAY incorporate them (see the the section on transactional integity in the FHIR specification). Please note that absence of information should not result in deletion of information on the server, as the client could send a bare-bones instance.
    • If a transaction operation is used and the server chooses to ignore the differences, it SHOULD do so silently by responding with a 200 OK status code for the corresponding Bundle.entry.response.status in the response Bundle.
    • If a batch operation is used and the server chooses to ignore the differences, it SHOULD do so either silently using the mechanism described above, or explicitly by responding with a 422 Unprocessable Entity status code Bundle.entry.response.status to indicate that a business rule prevented the resource from being created (in combination with an OperationOutcome resource).
  • The server SHALL rewrite the references in the primary resource to the resource it already has.

2 FHIR Packages

The information standards maintained by Nictiz adopt the FHIR Packaging mechanism to support consistent versioning of profiles and related conformance resources such as OperationDefinitions. FHIR Packaging is based on the NPM Packaging mechanism and offers developers a convenient way to include the conformance resources in their favorite IDE. The relevant package version is indicated and linked in the information standards technical design page.

Please note that every effort has been made to ensure that the examples contained in the packages are correct and useful, but they are not a normative part of any information standard.

For even more background information:


{TODO}: link naar versie

3 Actors involved

Actors Systems FHIR Capability Statements
Name Description Name Description Name Description
Sending organization The organization or health care professional(?) at the organization that wants to transfer the care of a patient Sending XIS Healthcare information system of the sending organization CapabilityStatement: Sending XIS FHIR requirements for sending XIS
Receiving organization The organization or health care professional(?) at the organization that the sending organization wants to transfer the care of a patient to Receiving XIS Healthcare information system of the receiving organization CapabilityStatement: Receiving XIS FHIR requirements for receiving XIS

4 Workflow and message structure

4.1 Overview

The use cases within eOverdracht are not isolated, but form a workflow that may include the negotiation of the transfer of the patient, and ends with the transfer of the medical record. In FHIR, this is handled by using a Task resource. This resource tracks the worflow (see #Workflow) and acts as the entry point for all data exchanges (see #Use of the Composition resource) for the transfer of care for a patient.

4.2 Task

The requirements for the Task resource in the eOverdracht context are specified using the the profile {TODO}. This profile SHALL be used for the eOverdracht workflow.

The Task will be hosted on the server of the sending XIS. Both the sending and the receiving XIS need to be able to update the Task. Both the sending and the receiving XIS SHALL monitor the Task resource for changes. It is generally assumed that the sending XIS will use a notification mechanism to inform the receiving XIS of creation or updates of the Task (see #Notifications), but the receiving XIS could use a polling mechanism as well.

For each combination of sending and receiving XIS, a dedicated instance of the Task resource SHALL be used for each transfer situation. This is true even when the sending XIS wants to send the same request to multiple parties. The reason for this is that the Task status is used to negotiate the transfer of care, so it cannot be used simultaneously for multiple recipients.

4.3 Notifications

It is generally assumed that the sending XIS will notify the receiving XIS when a new Task is created or when an existing Task is updated. Although the notification mechanism is out of scope for the eOverdracht information standard, it is assumed that the notification does not contain a Task resource id. Rather, it signals that the receiving server should perform a search at the sending server to look for additions or changes in the eOverdracht Task resources.

A straightforward implementation for this notification mechanism is for the notifying party to make an empty POST request on a pre-determined endpoint at the party that should be notified. This could be arranged using the FHIR subscriptions mechanism, but the endpoints could also be arranged by other means.

4.4 Workflow

The eOverdracht transactions are mapped to FHIR in the following way:

eOverdracht transaction Task
Send Aanmeldbericht
  • sending XIS creates Aanmeldbericht Composition
  • sending XIS creates Task:
    • Task.status = requested
    • Task.input:aanmeldBericht contains reference to the Aanmeldbericht Composition resource
  • (sending XIS sends notification to receiving XIS)
Send Antwoordbericht
Accept transfer
  • receiving xis updates Task:
    • Task.status = accepted
Reject transfer
  • receiving xis updates Task:
    • Task.status = rejected
Propose alternate date
  • receiving xis updates Task:
    • Task.status = on-hold
    • Task.input:alternatieveDatum contains alternate proposed date
Respond to alternate proposed date
Accept alternate proposed date:
  • sending XIS updates Aanmeldbericht
    • new date/time for overdracht
  • sending xis updates Task:
    • Task.status = ???
  • (sending XIS sends notification to receiving XIS)
Reject alternate proposed date:
  • sending xis updates Task:
    • Task.status = ???
  • (sending XIS sends notification to receiving XIS)
Send Overdrachtbericht
  • Sending XIS creates Overdrachtbericht Composition
  • Sending XIS updates Task:
    • Task.input:overdrachtBericht contains reference to the Overdrachtbericht Composition resource
  • (sending XIS sends notification to receiving XIS)

4.5 Use of the Compostion resource

The Aanmeldbericht and the (three variants of) the Overdrachtbericht are mainly built up of individual FHIR resources, selected by the sending organization to form a coherent set of information relevant to the receiving organization. The bulk of these resources are not referenced directly from the Task. Instead, the Task references a Composition resource which in turn assembles the references to all individual FHIR resources.

The receiving XIS MAY use either of the following mechanism for retrieving the individual FHIR resources referenced in the Compostion resource (also see the section on interactions.

As a Document
The receiving XIS uses the $document operation to retrieve both the Composition and all referenced resources as a single document Bundle.
Individual requests
The receiving XIS first retrieves the Composition resource, and then retrieves the necessary other resources referenced here.

The sending XIS SHALL support both mechanisms.

5 Invocations

5.1 New Tasks and changes to known Tasks

The Task is the main entry point for the eOverdracht transactions. The eOverdracht workflow starts with the retrieval of a new Task instance by the receiving XIS, and all subsequent steps in the worflow are mediated by updates to this Task instance.

Notifications to the receiving XIS are not expected to contain a logical id to the Task. Hence, the receiving XIS should use a combination of a search interaction and the _lastUpdated search parameter to retrieve the eOverdracht Tasks that have been added are changed since the last invoation:

 GET base/Task?code=[TODO]&_lastUpdated=[time of last request]

Note 1: More than one result can be returned, for example when an additional Task can have been modified before the notification has been sent, when the receiving XIS choose to batch search interactions, etc.

Note 2: It is up to the receiving XIS to detect if a result is a new Task instance or a change to an exising instance, and if so, what has been changed since the last invocation.

5.2 Updating a Task

The receiving XIS can update a Task hosted by the sending XIS using a PUT operation:

 PUT base/Task/[id]

The body should be the original Task with the needed modifications.

[TODO: uitleggen hoe de sending XIS reageert]

It is up to the sending XIS to determine what has been changed. The sending XIS MAY use business rules to reject an update, for example if invalid status change is used.

5.3 Compositions and referenced resources

The bulk of the Aanmeldbericht and of the Overdrachtbericht is specified using Composition resources, which are referenced from the eOverdracht Task. This Composition may be used to request a FHIR Document or as a base for individual requests (see #Use of the Compostion resource), at the discretion of the receiving XIS.

When the receiving XIS requests the Compostion as a Document, it should use the $document operation:

 GET [base]/Composition/[id]/$document

When the receiving XIS wants to use individual requests, it should first obtain the Composition resource:

 GET [base]/Compositon/[id]

Then it can use a GET interaction to obtain the required FHIR resources referenced in the Composition.

6 FHIR profiles

6.1 eOverdracht Task

6.2 Aanmeldbericht

Section FHIR profile FHIR resource HCIM name HCIM version Remarks
- eOverdracht aanmeldbericht Composition - - Declaration of the Send Aanmeldbericht transaction.
Datum overplaatsing eOverdracht-TransferDate - - - DateTime extension used in eOverdracht composition profiles
Persoonsgegevens nl-core-patient Patient Patient v3.1(2017NL) -
zib-Payer Coverage Betaler v3.1(2017NL) -
nl-core-relatedperson RelatedPerson Contactpersoon v3.1(2017NL) -
Sturende organisatie nl-core-organization Organization Zorgaanbieder v3.1.1(2017NL) -
Ontvangende organisatie nl-core-organization
Medische diagnose zib-Problem Condition Probleem v4.1(2017NL -
Voorgeschiedenis zib-Problem Condition Probleem v4.1(2017NL -
Let op zib-Alert Flag Alert v3.2(2017NL) -
Vrijheidsbeperking zib-FreedomRestrictingMeasures Procedure VrijheidsBeperkendeMaatregelen v3.1(2017NL) -
Actuele patiëntenproblemen zib-Problem Condition Probleem v4.1(2017NL) -
Afspraken patiënt zib-ProcedureRequest ProcedureRequest OverdrachtGeplandeZorgActiviteit v3.1(2017NL) -
Wensen en behoeften patiënt en/of naasten - - - - Declared as a text section. See eOverdracht aanmeldbericht profile.
Voeding/vocht zib-FeedingTubeSystem DeviceUseStatement SondeSysteem v3.2(2017NL) -
zib-Infusion DeviceUseStatement Infuus v3.2(2017NL) -
Uitscheiding zib-Stoma Observation Stoma v3.2(2017NL) -

6.3 Overdrachtsbericht volwassenen

Section FHIR profile FHIR resource HCIM name HCIM version Remarks
Administratieve gegevens
- eOverdracht aanmeldbericht Composition - - Declaration of the Send Aanmeldbericht transaction.
Datum overplaatsing eOverdracht-TransferDate - - - DateTime extension used in eOverdracht composition profiles
Persoonsgegevens nl-core-patient Patient Patient v3.1(2017NL) -
zib-Payer Coverage Betaler v3.1(2017NL) -
nl-core-relatedperson RelatedPerson Contactpersoon v3.1(2017NL) -
nl-core-patient Patient v3.1(2017NL) -
Sturende organisatie nl-core-organization Organization Zorgaanbieder v3.1.1(2017NL) -
Ontvangende organisatie nl-core-organization Organization Zorgaanbieder v3.1.1(2017NL) -
Zorgverlener sturende organisatie nl-core-practitioner Practitioner Zorgverlener v3.1.1(2017NL) -
nl-core-practitionerrole PractitionerRole
Zorgverlener ontvangende organisatie nl-core-practitioner Practitioner Zorgverlener v3.1.1(2017NL) -
nl-core-practitionerrole PractitionerRole
Algemene patiënten context
Gezinssituatie zib-FamilySituation FamilySituation Gezinssituatie v3.1(2017NL) -
Woonomgeving zib-LivingSituation Woonsituatie LivingSituation v3.1 (2017NL) -
Levensovertuiging zib-LifeStance Levensovertuiging LifeStance v3.1 (2017NL) -
zib-AdvanceDirective Wilsverklaring AdvanceDirective v3.1 (2017NL) -
Sociale omgeving zib-ParticipationInSociety ParticipatieInMaatschappij ParticipationInSociety v3.1 (2017NL) -
zib-HelpFromOthers HulpVanAnderen HelpFromOthers v3.0 (2017NL) -
Communicatie patient-proficiency Taalvaardigheid LanguageProfeciency v3.1(2017NL)
Medische context
Medische diagnose zib-Problem Condition Probleem v4.1(2017NL -
Voorgeschiedenis zib-Problem Condition Probleem v4.1(2017NL -
Let op zib-Alert Flag Alert v3.2(2017NL) -
Vrijheidsbeperking zib-FreedomRestrictingMeasures Procedure VrijheidsBeperkendeMaatregelen v3.1(2017NL) -
Meetwaarden zib-BloodPressure Observation Bloeddruk v3.1(2017NL) -
zib-PulseRate Observation PolsFrequentie v3.1(2017NL) -
zib-BodyTemperature Observation Lichaamstemperatuur v3.1(2017NL) -
zib-Respiration Observation Ademhaling v3.1(2017NL) -
zib-BodyWeight Observation Lichaamsgewicht v3.1(2017NL) -
zib-BodyHeight Observation Lichaamslengte v3.1(2017NL) -
AlgemeneMeting Observation AlgemeneMeting v3.0(2017NL) No FHIR profile is available yet for this HCIM.
Pijnscore zib-PainScore Observation Pijnscore v3.1(2017NL) -
Verpleegkundige context: zorgplan
Actuele patiëntenproblemen zib-Problem Condition Probleem v4.1(2017NL) -
zib-TreatmentObjective Goal Behandeldoel v3.1(2017NL) -
zib-NursingIntervention Procedure VerpleegkundigeInterventie v3.2(2018NL) -
Zorgresultaat zib-OutcomeOfCare DiagnisticReport UitkomstVanZorg v3.1(2017NL) -
Afspraken patiënt zib-ProcedureRequest ProcedureRequest OverdrachtGeplandeZorgActiviteit v3.1(2017NL) -
eAfspraak-Appointment Appointment v3.1(2017NL) -
zib-VaccinationRecommendation ImmunizationRecommendation v3.1(2017NL) -
Wensen en behoeften patiënt en/of naasten - - - - Declared as a text section. See eOverdracht aanmeldbericht profile.
Verpleegkundige context: specificatie gezondheidstoestand
Zelfzorg zib-AbilityToDrink Observation VermogenTotDrinken v3.1(2017NL) -
zib-AbilityToEat Observation VermogenTotEten v3.1(2017NL) -
zib-AbilityToPerformMouthcareActivities Observation VermogenTotMondverzorging v3.1(2017NL) -
zib-AbilityToPerformMouthcareActivities-MedicalDevice DeviceUseStatement v3.1(2017NL) -
zib-AbilityToPerformMouthcareActivities-MedicalDeviceProduct Device v3.1(2017NL) -
zib-AbilityToWashOneSelf Observation VermogenTotZichWassen v3.1(2017NL) -
zib-AbilityToDressOneself Observation VermogenTotZichKleden v3.1(2017NL) -
zib-AbilityToGroome Observation VermogenTotUiterlijkeVerzorging v1.0(2017NL) -
zib-AbilityToUseToilet Observation VermogenTotToiletgang v1.0(2017NL) -
zib-AbilityToManageMedication Observation VermogenTotZelfstandigMedicatiegebruik v1.0(2017NL) -
zib-AbilityToPerformNursingActivities Observation VermogenTotVerpleegtechnischeHandelingen v1.0(2017NL) -
toelichting zelfzorg - Explanation selfcare - Free text
Mobiliteit zib-Mobility Observation Mobiliteit v3.1(2017NL) -
Voeding/vocht zib-NutritionAdvice NutritionOrder Voedingsadvies v3.2(2017NL) -
zib-SNAQScore

zib-SNAQrcScore

zib-SNAQ65+Score

zib-MUSTScore

Observation SNAQScore

SNAQrcScore

SNAQ65+Score

MUSTScore

v3.1(2017NL)

v1.0(2017NL)

v1.0(2017NL)

v3.1(2017NL)

-
zib-FluidBalance Observation Vochtbalans v1.0(2017NL) -
zib-FeedingTubeSystem DeviceUseStatement SondeSysteem v3.2(2017NL) -
zib-FeedingTubeSystem-Product Device v3.2(2017NL) -
zib-Infusion DeviceUseStatement Infuus v3.2(2017NL) -
zib-Infusion-Product Device v3.2(2017NL) -
Uitscheiding zib-BladderFunction Observation Blaasfunctie v3.1(2017NL) -
zib-BowelFunction Observation Darmfunctie v3.1(2017NL) -
zib-Stoma Observation Stoma v3.2(2017NL) -
Huid zib-Burnwound Condition Brandwond v3.2(2017NL) -
zib-PressureUlcer Condition DecubitusWond v3.2(2017NL) -
zib-SkinDisorder Condition Huidaandoening v3.2(2017NL) -
zib-Wound Condition Wond v3.1(2017NL) -
Zintuigen zib-HearingFunction Observation FunctieHoren v3.1(2017NL) -
zib-HearingFunction-HearingAid DeviceUseStatement v3.1(2017NL) -
zib-HearingFunction-HearingAid-Product Device v3.1(2017NL) -
zib-VisualFunction Observation FunctieZien v3.1(2017NL) -
zib-VisualAid DeviceUseStatement v3.1(2017NL) -
zib-VisualAid-Product Device v3.1(2017NL) -
Ziektebeleving zib-IllnessPerception Observation Ziektebeleving v3.1(2017NL) -
Mentale status zib-Problem Condition Probleem v4.1(2017NL) -
Voortplanting zib-Pregnancy Condition Zwangerschap v3.1(2017NL) -
zib-Pregnancy-PregnancyStatus Observation Zwanger v3.1(2017NL) -
zib-Pregnancy-TermDate Observation ATermDatum v3.1(2017NL) -
zib-PregnancyDuration Observation Zwangerschapsduur v3.1(2017NL) -
zib-Pregnancy-Parity Observation Pariteit v3.1(2017NL) -
zib-Pregnancy-Gravidity Observation Graviditeit v3.1(2017NL) -
zib-Pregnancy-DatelastMenstruation Observation DatumLaatsteMenstruatie v3.1(2017NL) -

6.4 Overdrachtsbericht kindzorg

Section FHIR profile FHIR resource HCIM name HCIM version Remarks
Administratieve gegevens
- eOverdracht aanmeldbericht Composition - - Declaration of the Send Aanmeldbericht transaction.
Datum overplaatsing eOverdracht-TransferDate - - - DateTime extension used in eOverdracht composition profiles
Persoonsgegevens nl-core-patient Patient Patient v3.1(2017NL) -
zib-Payer Coverage Betaler v3.1(2017NL) -
nl-core-relatedperson RelatedPerson Contactpersoon v3.1(2017NL) -
nl-core-patient Patient v3.1(2017NL) -
Sturende organisatie nl-core-organization Organization Zorgaanbieder v3.1.1(2017NL) -
Ontvangende organisatie nl-core-organization Organization Zorgaanbieder v3.1.1(2017NL) -
Zorgverlener sturende organisatie nl-core-practitioner Practitioner Zorgverlener v3.1.1(2017NL) -
nl-core-practitionerrole PractitionerRole
Zorgverlener ontvangende organisatie nl-core-practitioner Practitioner Zorgverlener v3.1.1(2017NL) -
nl-core-practitionerrole PractitionerRole
Algemene patiënten contact
Gezinssituatie zib-FamilySituation FamilySituation Gezinssituatie v3.1(2017NL) -
Woonomgeving zib-LivingSituation Woonsituatie LivingSituation v3.1 (2017NL) -
Levensovertuiging zib-LifeStance Levensovertuiging LifeStance v3.1 (2017NL) -
zib-AdvanceDirective Wilsverklaring AdvanceDirective v3.1 (2017NL) -
Sociale omgeving zib-ParticipationInSociety ParticipatieInMaatschappij ParticipationInSociety v3.1 (2017NL) -
zib-HelpFromOthers HulpVanAnderen HelpFromOthers v3.0 (2017NL) -
Communicatie patient-proficiency Taalvaardigheid LanguageProfeciency v3.1(2017NL)
Medische context
Medische diagnose zib-Problem Condition Probleem v4.1(2017NL -
Voorgeschiedenis zib-Problem Condition Probleem v4.1(2017NL -
Let op zib-Alert Flag Alert v3.2(2017NL) -
Vrijheidsbeperking zib-FreedomRestrictingMeasures Procedure VrijheidsBeperkendeMaatregelen v3.1(2017NL) -
Meetwaarden zib-BloodPressure Observation Bloeddruk v3.1(2017NL) -
zib-PulseRate Observation PolsFrequentie v3.1(2017NL) -
zib-BodyTemperature Observation Lichaamstemperatuur v3.1(2017NL) -
zib-Respiration Observation Ademhaling v3.1(2017NL) -
zib-BodyWeight Observation Lichaamsgewicht v3.1(2017NL) -
zib-BodyHeight Observation Lichaamslengte v3.1(2017NL) -
zib-HeadCircumference Observation Schedelomvang v1.1(2017NL) -
zib-ApgarScore Observation ApgarScore v1.0(2017NL) -
AlgemeneMeting Observation AlgemeneMeting v3.0(2017NL) No fhir profile is available yet for this HCIM.
Pijnscore zib-PainScore Observation Pijnscore v3.1(2017NL) -
Verpleegkundige context: zorgplan
Actuele patiëntenproblemen zib-Problem Condition Probleem v4.1(2017NL) -
zib-TreatmentObjective Goal Behandeldoel v3.1(2017NL) -
zib-NursingIntervention Procedure VerpleegkundigeInterventie v3.2(2018NL) -
Zorgresultaat zib-OutcomeOfCare DiagnisticReport UitkomstVanZorg v3.1(2017NL) -
Afspraken patiënt zib-ProcedureRequest ProcedureRequest OverdrachtGeplandeZorgActiviteit v3.1(2017NL) -
eAfspraak-Appointment Appointment v3.1(2017NL) -
zib-VaccinationRecommendation ImmunizationRecommendation v3.1(2017NL) -
Wensen en behoeften patiënt en/of naasten - - - - Declared as a text section. See eOverdracht aanmeldbericht profile.
Verpleegkundige context: specificatie gezondheidstoestand
Zelfzorg zib-AbilityToPerformNursingActivities Observation VermogenTotVerpleegtechnischeHandelingen v1.0(2017NL) -
toelichting zelfzorg - Explanation selfcare - Free text
Voeding/vocht zib-NutritionAdvice NutritionOrder Voedingsadvies v3.2(2017NL) -
zib-FeedingPatternInfant Observation VoedingspatroonZuigeling v1.0(2017NL) -
zib-StrongKidsScore Observation StrongKidsScore v1.0(2017NL) -
zib-FluidBalance Observation Vochtbalans v1.0(2017NL) -
zib-FeedingTubeSystem DeviceUseStatement SondeSysteem v3.2(2017NL) -
zib-FeedingTubeSystem-Product Device v3.2(2017NL) -
zib-Infusion DeviceUseStatement Infuus v3.2(2017NL) -
zib-Infusion-Product Device v3.2(2017NL) -
Uitscheiding zib-BladderFunction Observation Blaasfunctie v3.1(2017NL) -
zib-BowelFunction Observation Darmfunctie v3.1(2017NL) -
zib-Stoma Observation Stoma v3.2(2017NL) -
Huid zib-Burnwound Condition Brandwond v3.2(2017NL) -
zib-PressureUlcer Condition DecubitusWond v3.2(2017NL) -
zib-SkinDisorder Condition Huidaandoening v3.2(2017NL) -
zib-Wound Condition Wond v3.1(2017NL) -
Zintuigen zib-HearingFunction Observation FunctieHoren v3.1(2017NL) -
zib-HearingFunction-HearingAid DeviceUseStatement v3.1(2017NL) -
zib-HearingFunction-HearingAid-Product Device v3.1(2017NL) -
zib-VisualFunction Observation FunctieZien v3.1(2017NL) -
zib-VisualAid DeviceUseStatement v3.1(2017NL) -
zib-VisualAid-Product Device v3.1(2017NL) -
Ziektebeleving zib-IllnessPerception Observation Ziektebeleving v3.1(2017NL) -
Mentale status zib-Problem Condition Probleem v4.1(2017NL) -
Ontwikkeling kind zib-DevelopmentChild Observation Ontwikkeling kind v1.1(2017NL) -
Overige bijzonderheden kind - Free text - - Free text for particularities child

6.5 Overdrachtsbericht Child 1-18

Section FHIR profile FHIR resource HCIM name HCIM version Remarks
Administratieve gegevens
- eOverdracht aanmeldbericht Composition - - Declaration of the Send Aanmeldbericht transaction.
Datum overplaatsing eOverdracht-TransferDate - - - DateTime extension used in eOverdracht composition profiles
Persoonsgegevens nl-core-patient Patient Patient v3.1(2017NL) -
zib-Payer Coverage Betaler v3.1(2017NL) -
nl-core-relatedperson RelatedPerson Contactpersoon v3.1(2017NL) -
nl-core-patient Patient v3.1(2017NL) -
Sturende organisatie nl-core-organization Organization Zorgaanbieder v3.1.1(2017NL) -
Ontvangende organisatie nl-core-organization Organization Zorgaanbieder v3.1.1(2017NL) -
Zorgverlener sturende organisatie nl-core-practitioner Practitioner Zorgverlener v3.1.1(2017NL) -
nl-core-practitionerrole PractitionerRole
Zorgverlener ontvangende organisatie nl-core-practitioner Practitioner Zorgverlener v3.1.1(2017NL) -
nl-core-practitionerrole PractitionerRole
Algemene patiënten context
Gezinssituatie zib-FamilySituation FamilySituation Gezinssituatie v3.1(2017NL) -
Woonomgeving zib-LivingSituation Woonsituatie LivingSituation v3.1 (2017NL) -
Levensovertuiging zib-LifeStance Levensovertuiging LifeStance v3.1 (2017NL) -
zib-AdvanceDirective Wilsverklaring AdvanceDirective v3.1 (2017NL) -
Sociale omgeving zib-ParticipationInSociety ParticipatieInMaatschappij ParticipationInSociety v3.1 (2017NL) -
zib-HelpFromOthers HulpVanAnderen HelpFromOthers v3.0 (2017NL) -
Communicatie patient-proficiency Taalvaardigheid LanguageProfeciency v3.1(2017NL)
Medische context
Medische diagnose zib-Problem Condition Probleem v4.1(2017NL -
Voorgeschiedenis zib-Problem Condition Probleem v4.1(2017NL -
Let op zib-Alert Flag Alert v3.2(2017NL) -
Vrijheidsbeperking zib-FreedomRestrictingMeasures Procedure VrijheidsBeperkendeMaatregelen v3.1(2017NL) -
Meetwaarden zib-BloodPressure Observation Bloeddruk v3.1(2017NL) -
zib-PulseRate Observation PolsFrequentie v3.1(2017NL) -
zib-BodyTemperature Observation Lichaamstemperatuur v3.1(2017NL) -
zib-Respiration Observation Ademhaling v3.1(2017NL) -
zib-BodyWeight Observation Lichaamsgewicht v3.1(2017NL) -
zib-BodyHeight Observation Lichaamslengte v3.1(2017NL) -
AlgemeneMeting Observation AlgemeneMeting v3.0(2017NL) No fhir profile is available yet for this HCIM.
Pijnscore zib-PainScore Observation Pijnscore v3.1(2017NL) -
zib-ComfortScale Observation ComfortScore v1.0(2017NL) -
zib-FLACCPainScale Observation FLACCPijnScore v1.0(2017) -
zib-ChecklistPainBehaviour Observation ChecklijstPijnScore v1.0(2017NL) -
Verpleegkundige context: zorgplan
Actuele patiëntenproblemen zib-Problem Condition Probleem v4.1(2017NL) -
zib-TreatmentObjective Goal Behandeldoel v3.1(2017NL) -
zib-NursingIntervention Procedure VerpleegkundigeInterventie v3.2(2018NL) -
Zorgresultaat zib-OutcomeOfCare DiagnisticReport UitkomstVanZorg v3.1(2017NL) -
Afspraken patiënt zib-ProcedureRequest ProcedureRequest OverdrachtGeplandeZorgActiviteit v3.1(2017NL) -
eAfspraak-Appointment Appointment v3.1(2017NL) -
zib-VaccinationRecommendation ImmunizationRecommendation v3.1(2017NL) -
Wensen en behoeften patiënt en/of naasten - - - - Declared as a text section. See eOverdracht aanmeldbericht profile.
Verpleegkundige context: specificatie gezondheidstoestand
Zelfzorg zib-AbilityToDrink Observation VermogenTotDrinken v3.1(2017NL) -
zib-AbilityToEat Observation VermogenTotEten v3.1(2017NL) -
zib-AbilityToPerformMouthcareActivities Observation VermogenTotMondverzorging v3.1(2017NL) -
zib-AbilityToPerformMouthcareActivities-MedicalDevice DeviceUseStatement v3.1(2017NL) -
zib-AbilityToPerformMouthcareActivities-MedicalDeviceProduct Device v3.1(2017NL) -
zib-AbilityToWashOneSelf Observation VermogenTotZichWassen v3.1(2017NL) -
zib-AbilityToDressOneself Observation VermogenTotZichKleden v3.1(2017NL) -
zib-AbilityToGroome Observation VermogenTotUiterlijkeVerzorging v1.0(2017NL) -
zib-AbilityToUseToilet Observation VermogenTotToiletgang v1.0(2017NL) -
zib-AbilityToManageMedication Observation VermogenTotZelfstandigMedicatiegebruik v1.0(2017NL) -
zib-AbilityToPerformNursingActivities Observation VermogenTotVerpleegtechnischeHandelingen v1.0(2017NL) -
toelichting zelfzorg - Explanation selfcare - Free text
Mobiliteit zib-Mobility Observation Mobiliteit v3.1(2017NL) -
Voeding/vocht zib-NutritionAdvice NutritionOrder Voedingsadvies v3.2(2017NL) -
zib-StrongKidsScore Observation StrongKidsScore v1.0(2017NL) -
zib-FluidBalance Observation Vochtbalans v1.0(2017NL) -
zib-FeedingTubeSystem DeviceUseStatement SondeSysteem v3.2(2017NL) -
zib-FeedingTubeSystem-Product Device v3.2(2017NL) -
zib-Infusion DeviceUseStatement Infuus v3.2(2017NL) -
zib-Infusion-Product Device v3.2(2017NL) -
Uitscheiding zib-BladderFunction Observation Blaasfunctie v3.1(2017NL) -
zib-BowelFunction Observation Darmfunctie v3.1(2017NL) -
zib-Stoma Observation Stoma v3.2(2017NL) -
Huid zib-Burnwound Condition Brandwond v3.2(2017NL) -
zib-PressureUlcer Condition DecubitusWond v3.2(2017NL) -
zib-SkinDisorder Condition Huidaandoening v3.2(2017NL) -
zib-Wound Condition Wond v3.1(2017NL) -
Zintuigen zib-HearingFunction Observation FunctieHoren v3.1(2017NL) -
zib-HearingFunction-HearingAid DeviceUseStatement v3.1(2017NL) -
zib-HearingFunction-HearingAid-Product Device v3.1(2017NL) -
zib-VisualFunction Observation FunctieZien v3.1(2017NL) -
zib-VisualAid DeviceUseStatement v3.1(2017NL) -
zib-VisualAid-Product Device v3.1(2017NL) -
Ziektebeleving zib-IllnessPerception Observation Ziektebeleving v3.1(2017NL) -
Mentale status zib-Problem Condition Probleem v4.1(2017NL) -
Ontwikkeling kind zib-DevelopmentChild Observation OntwikkelingKind v1.1(2017NL) -
Voortplanting zib-Pregnancy Condition Zwangerschap v3.1(2017NL) -
zib-Pregnancy-PregnancyStatus Observation Zwanger v3.1(2017NL) -
zib-Pregnancy-TermDate Observation ATermDatum v3.1(2017NL) -
zib-PregnancyDuration Observation Zwangerschapsduur v3.1(2017NL) -
zib-Pregnancy-Parity Observation Pariteit v3.1(2017NL) -
zib-Pregnancy-Gravidity Observation Graviditeit v3.1(2017NL) -
zib-Pregnancy-DatelastMenstruation Observation DatumLaatsteMenstruatie v3.1(2017NL) -
Overige bijzonderheden kind - - free text - Free text for particularities of child
  1. Although Bundle.entry.request is not formally required in FHIR STU3, it is made clear in FHIR R4 that the expected behavior actually is to include it.