BgZ:V1.0 BgZ 2017 Technical IG: verschil tussen versies

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Regel 31: Regel 31:
 
==Document metadata==
 
==Document metadata==
 
==HCIM (zib) metadata==
 
==HCIM (zib) metadata==
 +
===Metadata===
 
The 2017 HCIM all have the following implicit Basic Elements which provide metadata:
 
The 2017 HCIM all have the following implicit Basic Elements which provide metadata:
 
* IdentificationNumber
 
* IdentificationNumber
Regel 38: Regel 39:
 
* InformationSource
 
* InformationSource
 
Metadata are often already present in the HCIMs themselves: in that case there is no need to add them to the HCIM again. In other cases, the metadata is not relevant. The table below lists the various Basic Elements against the HCIMs.
 
Metadata are often already present in the HCIMs themselves: in that case there is no need to add them to the HCIM again. In other cases, the metadata is not relevant. The table below lists the various Basic Elements against the HCIMs.
 +
 +
Legend:
 +
{| class="wikitable" style="horizontal-align: right"
 +
! Required |
 +
! Optional |
 +
|}
 +
===Metadata table===
 
{| class="wikitable" style="horizontal-align: right"  
 
{| class="wikitable" style="horizontal-align: right"  
 
! Id
 
! Id

Versie van 3 dec 2021 14:13


1 Introduction

TODO

2 Actors involved

Persons Systems
Name Description Name Description
Referring medical specialist Medical specialist who sends a BgZ along with a referral EHR Electronic health record
Receiving medical specialist Medical specialist receives a BgZ along with a referral EHR Electronic health record

3 Use cases

4 Metadata

The functional description requires metadata for the BgZ. This chapter outlines the technical implementation of those metadata.

4.1 Document metadata

4.2 HCIM (zib) metadata

4.2.1 Metadata

The 2017 HCIM all have the following implicit Basic Elements which provide metadata:

  • IdentificationNumber
  • DateTime
  • Author
  • Subject
  • InformationSource

Metadata are often already present in the HCIMs themselves: in that case there is no need to add them to the HCIM again. In other cases, the metadata is not relevant. The table below lists the various Basic Elements against the HCIMs.

Legend:

4.2.2 Metadata table

Id Zib HCIM IdentificationNumber DateTime Author Subject InformationSource
NL-CM:0.1.1 Patient Patient PatientIdentificationNumber DateOfBirth Not Relevant Patient Not Relevant
NL-CM:1.1.1 Betaler Payer BankCode+AccountNumber OR IdentificationNumber+InsurantNumber StartDateTime+EndDateTime Not Relevant Patient Not Relevant
NL-CM:2.1.1 BehandelAanwijzing TreatmentDirective Required VerificationDate Patient OR patient's authorized representative Patient Patient OR patient's authorized representative
NL-CM:7.15.1 Wilsverklaring AdvanceDirective Required LivingWillDate Patient OR patient's authorized representative Patient Patient OR patient's authorized representative
NL-CM:3.1.1 Contactpersoon Contactperson Not Relevant Not Relevant Not Relevant Contactpersoon Not Relevant
NL-CM:4.26.1 FunctioneleOfMentaleStatus FunctionalOrMentalStatus Required StatusDate Required Patient ?
NL-CM:5.1.1 Probleem Problem Required ProblemStartDate Required Patient Optional
NL-CM:7.8.1 Woonsituatie LivingSituation Optional Not Relevant Not Relevant Patient Not Relevant
NL-CM:7.4.1 DrugsGebruik DrugUse Required StartDate empty OR equal to Source Patient Required
NL-CM:7.3.1 AlcoholGebruik AlcoholUse Required StartDate empty OR equal to Source Patient Required
NL-CM:7.2.1 TabakGebruik TobaccoUse Required StartDate empty OR equal to Source Patient Required
NL-CM:7.11.1 Voedingsadvies NutritionAdvice Required Not Relevant Optional Patient Required
NL-CM:8.3.1 Alert Alert Required StartDateTime empty OR equal to Source Patient Required
NL-CM:8.2.1 AllergieIntolerantie AllergyIntolerance Required StartDateTime empty OR equal to Source Patient Required
NL-CM:9.6.9580 Medicatieafspraak MedicationAgreement Required MedicationAgreementDateTime Prescriber::HealthProfessional Patient Optional
NL-CM:9.8.20132 Toedieningsafspraak AdministrationAgreement Required AdministrationAgreementDateTime Supplier::HealthProfessional Patient Optional
NL-CM:9.11.21338 MedicatieGebruik MedicationUse2 Required MedicationUseDateTime Prescriber::HealthProfessional Patient Required
NL-CM:10.1.1 MedischHulpmiddel MedicalDevice ProductID StartDate HealthProfessional Patient Optional
NL-CM:11.1.1 Vaccinatie Vaccination ProductCode+VaccinationDate VaccinationDate Administrator::Healthprofessional Patient Optional
NL-CM:12.4.1 Bloeddruk BloodPressure BloodPressureDateTime BloodPressureDateTime Required Patient Optional
NL-CM:12.1.1 Lichaamsgewicht BodyWeight WeightDateTime WeightDateTime Required Patient Optional
NL-CM:12.2.1 Lichaamslengte BodyHeight HeightValue OR HeightDateTime HeightDateTime Required Patient Optional
NL-CM:14.1.1 Verrichting Procedure Required ProcedureStartDate Performer::HealthProfessional Patient Requireduired when performer is not known
NL-CM:15.1.1 Contact Encounter ContactType + StartDateTime StartDateTime ContactWith::HealthProfessional Patient Not Relevant
NL-CM:17.1.1 Zorgverlener HealthProfessional HealthProfessionalIdentificationNumber Not Relevant Not Relevant HealthProfessional Not Relevant

4.3 Persistent identifiers

5 CDA templates

Section Titel Title CDA Template
0 BgZ Template CDA Basisgegevensset Zorg 2017 (BgZ)
1. Demografie en identificatie Demographics and identification CDArecordTargetSDTC-NL
Patient Patient
2. Financiële informatie Financial information BgZ2017Betaler
Betaler Payer
3. Behandelrestricties Treatment Directives BgZ2017TreatmentDirectives
BehandelAanwijzing TreatmentDirective
Wilsverklaring AdvanceDirective
4. Contactpersonen Contact persons CDArecordTargetSDTC-NL
Contactpersoon ContactPerson
5. Functionele status Functional Status BgZ2017FunctionalStatus
Funct. OfMentaleStatus FunctionalOrMentalStatus
6. Klachten en diagnoses Complaints and diagnoses BgZ2017ComplaintsAndDiagnoses
Probleem Problem
7. Sociale anamnese Social anamnesis BgZ2017SocialAnamesis
Woonsituatie LivingSituation
DrugsGebruik DrugUse
AlcoholGebruik AlcoholUse
TabakGebruik TobaccoUse
Voedingsadvies NutritionAdvice
8. Waarschuwingen Alerts BgZ2017Alerts
Alert Alert
9. Allergieën Allergies BgZ2017Allergies
AllergieIntolerantie AllergyIntolerance
10. Medicatie Medication BgZ2017Medication
MedicatieGebruik2 MedicationUse2
Medicatieafspraak MedicationAgreement
Toedieningsafspraak AdministrationAgreement
11. Medische hulpmiddelen Medical devices BgZ2017MedicalDevices
MedischHulpmiddel MedicalDevice
12. Vaccinaties Immunizations BgZ2017Immunizations
Vaccinatie Vaccination
13. Vitale functies Vital signs BgZ2017VitalSigns
Bloeddruk BloodPressure
LichaamsGewicht BodyWeight
LichaamsLengte BodyHeight
14. Uitslagen Results Laboratoryspecialtysection
LaboratoriumUitslag LaboratoryTestResult
15. Verrichtingen Procedures BgZ2017Procedures
Verrichting Procedure
16. Contacten Encounters BgZ2017Encounters
Contact Encounter
17. Zorgplan Care plan BgZ2017CarePlan
OverdrachtGeplandeZorgActiviteit PlannedCareActivityForTransfer
18. Zorgverleners Health professionals
Zorgverlener HealthProfessional
Zorgaanbieder HealthcareProvider

6 Release notes