Zandbak/eOverdracht TO: verschil tussen versies
| Regel 77: | Regel 77: | ||
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. | 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. | ||
| + | |||
| + | ==Use of the Composition 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 [[#Task|the Task]]. Instead, the Task references a Composition resource which in turn assembles the references to all individual FHIR resources. For this purpose, the Composition profiles described in [[#FHIR profiles]] SHALL be used. | ||
| + | |||
| + | ===Composition invocations=== | ||
| + | The receiving XIS MAY use either of the following mechanism for retrieving the individual FHIR resources referenced in the Compostion resource. | ||
| + | ; As a Document: The receiving XIS uses the {{fhir|$document}} operation to retrieve both the Composition ''and'' all referenced resources as a single document Bundle.<br/><pre>GET [base]/Composition/[id]/$document</pre> | ||
| + | ; Individual requests: The receiving XIS first retrieves the Composition resource<br/><pre>GET [base]/Compositon/[id]</pre>Then the necessary other resources referenced can be fetched using a <code>GET</code> interaction. | ||
| + | |||
| + | The sending XIS SHALL support both mechanisms. | ||
| + | |||
==Mapping the workflow to the Task== | ==Mapping the workflow to the Task== | ||
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. | 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. | ||
| Regel 139: | Regel 151: | ||
* (sending XIS sends notification to receiving XIS) | * (sending XIS sends notification to receiving XIS) | ||
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=FHIR profiles= | =FHIR profiles= | ||
Versie van 25 jan 2021 14:59
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
batchortransactionoperation 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.requestfor each of the resources in the Bundle, including the secondary resources that are only there for referencing purposes[1]..requestSHOULD be aPOSTto the appropriate endpoint. As an alternative,PUTMAY 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
transactionoperation 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 correspondingBundle.entry.response.statusin the response Bundle. - If a
batchoperation 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 codeBundle.entry.response.statusto indicate that a business rule prevented the resource from being created (in combination with an OperationOutcome resource).
- If a
- 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:
- The HL7 base specification for FHIR packages
- What is the problem that packaging could address
- Introducing the Simplifier FHIR Package Server (includes what problem packaging addresses)
- Firely Torinox introduction (this is one of the tools that's useful for working with FHIR packages)
|
|
It is not required to implement FHIR based information standards using the packaging mechanism. It is still possible to download all or selected resources from Simplifier on as-needed basis. You are however encouraged to invest in dealing with packages. |
{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
4.2.1 Task requirements
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 instance SHALL be hosted on the server of the sending XIS. Both the sending and the receiving XIS need to be able to update the Task. The sending XIS MAY use business rules to reject an update, for example if invalid status change is used.
Both the sending and the receiving XIS SHALL monitor the Task resource for changes. It is expected 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.
4.2.2 Task invocations
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.
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]
4.2.3 Notifications
It is expected 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.
4.3 Use of the Composition 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. For this purpose, the Composition profiles described in #FHIR profiles SHALL be used.
4.3.1 Composition invocations
The receiving XIS MAY use either of the following mechanism for retrieving the individual FHIR resources referenced in the Compostion resource.
- As a Document
- The receiving XIS uses the
$documentoperation to retrieve both the Composition and all referenced resources as a single document Bundle.GET [base]/Composition/[id]/$document
- Individual requests
- The receiving XIS first retrieves the Composition resource
GET [base]/Compositon/[id]
Then the necessary other resources referenced can be fetched using aGETinteraction.
The sending XIS SHALL support both mechanisms.
4.4 Mapping the workflow to the Task
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.
The eOverdracht transactions are mapped to FHIR in the following way:
| eOverdracht transaction | Task | |
|---|---|---|
| Send Aanmeldbericht |
| |
| Send Antwoordbericht | ||
| Accept transfer |
| |
| Reject transfer |
| |
| Propose alternate date |
| |
| Respond to alternate proposed date | ||
| Accept alternate proposed date: |
| |
| Reject alternate proposed date: |
| |
| Send Overdrachtbericht |
| |
5 FHIR profiles
5.1 eOverdracht Task
5.2 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) | - |
5.3 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 | 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) | - | |
5.4 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 |
5.5 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 |
- ↑ Although
Bundle.entry.requestis not formally required in FHIR STU3, it is made clear in FHIR R4 that the expected behavior actually is to include it.