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Regel 163: Regel 163:
 
'''Note''': any other version with the same ''major''.''minor'' version is compatible. See [https://semver.org/ Semantic Versioning] for more information.}}
 
'''Note''': any other version with the same ''major''.''minor'' version is compatible. See [https://semver.org/ Semantic Versioning] for more information.}}
 
==Infrastructure==
 
==Infrastructure==
 +
The following table lists the FHIR profiles that should be used for the infrastructural parts of the eOverdracht information standard.
 
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!style="background-color: #4AB8A7; color: white; font-weight: bold; text-align:left;  background-color: #E3E3E3 width:400px" | HCIM Name
 
!style="background-color: #4AB8A7; color: white; font-weight: bold; text-align:left;  background-color: #E3E3E3 width:400px" | HCIM Name

Versie van 1 feb 2021 16:27


1 Introduction

This is the implementation guide for the information standard eOverdracht, version . This standard is described in this functional specification (TODO) and implemented here using FHIR(STU3) HL7 FHIR, STU3. This implementation guide assumes that the reader is familiar with this FHIR version.

Apart from this document, the guidelines as specified in general FHIR Implementation Guide apply. In particular, the reader should take note of the Use case overarching principles and the use of FHIR packages.

2 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

3 Workflow and message structure

3.1 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.

3.2 Task

3.2.1 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.

3.2.2 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 existing 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. The sending XIS SHOULD check the update for errors and inconsistencies. If the update is rejected, the sending XIS SHALL response with a HTTP 422 status code and an OperationOutcome detailing the problem.

3.2.3 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.

3.3 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.

3.3.1 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 $document operation to retrieve both the Composition and all referenced resources as a single document Bundle.
GET [base]/Composition/[id]/$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 a GET interaction.

The sending XIS SHALL support both mechanisms.

3.4 Using Task to manage the workflow

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
  • 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
    • optionally: Task.owner set to receiving organization. See #Brokers.
Reject transfer
  • receiving xis updates Task:
    • Task.status = rejected
Propose alternate date
  • receiving xis updates Task:
    • Task.status = on-hold
    • Task.output: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 = requested
  • (sending XIS sends notification to receiving XIS)
Reject alternate proposed date:
  • sending xis updates Task:
    • Task.status = cancelled
  • (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)
Send confirmation of Overdrachtbericht
  • Recieving XIS updates Task:
    • Task.status = completed

3.4.1 Partial workflow

When the transfer has to be carried out without the negotiation phase, the sending XIS will create the Task instance with Task.status already set to accepted and Task.input:overdrachtbericht populated.

3.4.2 Brokers

The use of a broker to find an available healthcare provider for the patient transfer fall outside the scope of the eOverdracht information standard. However, it is possible to start the workflow without knowing the receiving organization, which allows for the use of a broker. In this situation, for the sending XIS the broker acts as a receiving XIS, and for the receiving XIS the broker acts as a sending XIS.

When Task.input:overdrachtbericht is populated with the Overdrachtbericht Composition, Task.owner MUST be populated with the receiving organization.

4 FHIR profiles

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eOverdracht uses the FHIR Packaging mechanism. This conveniently bundles all profiles, terminology, example material and other conformance resources you need into a single archive, which can be downloaded or installed using the appropriate FHIR tooling. This version of the information standard uses the following packages:

Note: any other version with the same major.minor version is compatible. See Semantic Versioning for more information.

4.1 Infrastructure

The following table lists the FHIR profiles that should be used for the infrastructural parts of the eOverdracht information standard.

HCIM Name FHIR profile
eOverdracht Task TODO
Composition for Aanmeldbericht http://nictiz.nl/fhir/StructureDefinition/eOverdracht-aanmeldbericht
Composition for Overdrachtbericht volwassenen http://nictiz.nl/fhir/StructureDefinition/eOverdracht-overdrachtsbericht-volwassenen-phase-one
Composition for Overdrachtbericht pasgeborenen http://nictiz.nl/fhir/StructureDefinition/eOverdracht-overdrachtsbericht-kinderen-0-1-jaar
Composition for Overdrachtbericht jeugdzorg http://nictiz.nl/fhir/StructureDefinition/eOverdracht-overdrachtsbericht-kinderen-1-18-jaar
Datum overdracht http://nictiz.nl/fhir/StructureDefinition/eOverdracht-TransferDate

4.2 HCIMs

The following table lists the FHIR profiles that implement the HCIMs from which the eOverdracht is built up.

HCIM Name FHIR profile
Ademhaling http://nictiz.nl/fhir/StructureDefinition/zib-Respiration
Alert http://nictiz.nl/fhir/StructureDefinition/zib-Alert
Alert http://nictiz.nl/fhir/StructureDefinition/zib-Alert
ApgarScore http://nictiz.nl/fhir/StructureDefinition/zib-ApgarScore
Behandeldoel http://nictiz.nl/fhir/StructureDefinition/zib-TreatmentObjective
Betaler http://nictiz.nl/fhir/StructureDefinition/zib-Payer
Blaasfunctie http://nictiz.nl/fhir/StructureDefinition/zib-BladderFunction
Bloeddruk http://nictiz.nl/fhir/StructureDefinition/zib-BloodPressure
BrandWond http://nictiz.nl/fhir/StructureDefinition/zib-BurnWound
ChecklijstPijnScore http://nictiz.nl/fhir/StructureDefinition/zib-ChecklistPainBehaviour
Contactpersoon http://fhir.nl/fhir/StructureDefinition/nl-core-relatedperson
Darmfunctie http://nictiz.nl/fhir/StructureDefinition/zib-BowelFunction
Datum overplaatsing http://nictiz.nl/fhir/StructureDefinition/eOverdracht-TransferDate
DecubitusWond http://nictiz.nl/fhir/StructureDefinition/zib-PressureUlcer
FLACCPijnScore http://nictiz.nl/fhir/StructureDefinition/zib-FLACCPainScale
FunctieHoren http://nictiz.nl/fhir/StructureDefinition/zib-HearingFunction
http://nictiz.nl/fhir/StructureDefinition/zib-HearingFunction-HearingAid
http://nictiz.nl/fhir/StructureDefinition/zib-HearingFunction-HearingAid-Product
FunctieZien http://nictiz.nl/fhir/StructureDefinition/zib-VisualFunction
http://nictiz.nl/fhir/StructureDefinition/zib-VisualFunction-VisualAid
http://nictiz.nl/fhir/StructureDefinition/zib-VisualFunction-VisualAidProduct
Gezinssituatie http://nictiz.nl/fhir/StructureDefinition/zib-FamilySituation
Huidaandoening http://nictiz.nl/fhir/StructureDefinition/zib-SkinDisorder
HulpVanAnderen http://nictiz.nl/fhir/StructureDefinition/zib-HelpFromOthers
Infuus http://nictiz.nl/fhir/StructureDefinition/zib-Infusion
http://nictiz.nl/fhir/StructureDefinition/zib-Infusion-Product
Levensovertuiging http://nictiz.nl/fhir/StructureDefinition/zib-LifeStance
Lichaamsgewicht http://nictiz.nl/fhir/StructureDefinition/zib-BodyWeight
Lichaamslengte http://nictiz.nl/fhir/StructureDefinition/zib-BodyHeight
Lichaamstemperatuur http://nictiz.nl/fhir/StructureDefinition/zib-BodyTemperature
Mobiliteit http://nictiz.nl/fhir/StructureDefinition/zib-Mobility
MUSTScore http://nictiz.nl/fhir/StructureDefinition/zib-MUSTScore
Ontwikkeling kind http://nictiz.nl/fhir/StructureDefinition/zib-DevelopmentChild
OverdrachtGeplandeZorgActiviteit http://nictiz.nl/fhir/StructureDefinition/zib-ProcedureRequest
http://nictiz.nl/fhir/StructureDefinition/eAfspraak-Appointment
http://nictiz.nl/fhir/StructureDefinition/zib-VaccinationRecommendation
ParticipatieInMaatschappij http://nictiz.nl/fhir/StructureDefinition/zib-ParticipationInSociety
Patient http://fhir.nl/fhir/StructureDefinition/nl-core-patient
Pijnscore http://nictiz.nl/fhir/StructureDefinition/zib-PainScore
PolsFrequentie http://nictiz.nl/fhir/StructureDefinition/zib-PulseRate
Probleem http://nictiz.nl/fhir/StructureDefinition/zib-Problem
Schedelomvang http://nictiz.nl/fhir/StructureDefinition/zib-HeadCircumference
SNAQ65+Score http://nictiz.nl/fhir/StructureDefinition/zib-SNAQrcScore
SNAQrcScore http://nictiz.nl/fhir/StructureDefinition/zib-SNAQrcScore
SNAQScore http://nictiz.nl/fhir/StructureDefinition/zib-SNAQScore
SondeSysteem http://nictiz.nl/fhir/StructureDefinition/zib-FeedingTubeSystem
http://nictiz.nl/fhir/StructureDefinition/zib-FeedingTubeSystem-Product
Stoma http://nictiz.nl/fhir/StructureDefinition/zib-Stoma
StrongKidsScore http://nictiz.nl/fhir/StructureDefinition/zib-StrongKidsScore
Taalvaardigheid http://nictiz.nl/fhir/StructureDefinition/patient-proficiency
UitkomstVanZorg http://nictiz.nl/fhir/StructureDefinition/zib-OutcomeOfCare
VermogenTotDrinken http://nictiz.nl/fhir/StructureDefinition/zib-AbilityToDrink
VermogenTotEten http://nictiz.nl/fhir/StructureDefinition/zib-AbilityToEat
VermogenTotMondverzorging http://nictiz.nl/fhir/StructureDefinition/zib-AbilityToPerformMouthcareActivities
http://nictiz.nl/fhir/StructureDefinition/zib-AbilityToPerformMouthcareActivities-MedicalDevice
http://nictiz.nl/fhir/StructureDefinition/zib-AbilityToPerformMouthcareActivities-MedicalDeviceProduct
VermogenTotToiletgang http://nictiz.nl/fhir/StructureDefinition/zib-AbilityToUseToilet
VermogenTotUiterlijkeVerzorging http://nictiz.nl/fhir/StructureDefinition/zib-AbilityToGroome
VermogenTotVerpleegtechnischeHandelingen http://nictiz.nl/fhir/StructureDefinition/zib-AbilityToPerformNursingActivities
VermogenTotZelfstandigMedicatiegebruik http://nictiz.nl/fhir/StructureDefinition/zib-AbilityToManageMedication
VermogenTotZichKleden http://nictiz.nl/fhir/StructureDefinition/zib-AbilityToDressOneself
VermogenTotZichWassen http://nictiz.nl/fhir/StructureDefinition/zib-AbilityToWashOneSelf
VerpleegkundigeInterventie http://nictiz.nl/fhir/StructureDefinition/zib-NursingIntervention
Vochtbalans http://nictiz.nl/fhir/StructureDefinition/zib-FluidBalance
Voedingsadvies http://nictiz.nl/fhir/StructureDefinition/zib-NutritionAdvice
VoedingspatroonZuigeling http://nictiz.nl/fhir/StructureDefinition/zib-FeedingPatternInfant
VrijheidsBeperkendeMaatregelen http://nictiz.nl/fhir/StructureDefinition/zib-FreedomRestrictingMeasures
Wilsverklaring http://nictiz.nl/fhir/StructureDefinition/zib-AdvanceDirective
Wond http://nictiz.nl/fhir/StructureDefinition/zib-Wound
Woonsituatie http://nictiz.nl/fhir/StructureDefinition/zib-LivingSituation
Ziektebeleving http://nictiz.nl/fhir/StructureDefinition/zib-IllnessPerception
Zorgaanbieder http://fhir.nl/fhir/StructureDefinition/nl-core-organization
Zorgverlener http://fhir.nl/fhir/StructureDefinition/nl-core-practitioner
http://fhir.nl/fhir/StructureDefinition/nl-core-practitionerrole
Zwangerschap http://nictiz.nl/fhir/StructureDefinition/zib-Pregnancy
http://nictiz.nl/fhir/StructureDefinition/zib-Pregnancy-PregnancyStatus
http://nictiz.nl/fhir/StructureDefinition/zib-Pregnancy-TermDate
http://nictiz.nl/fhir/StructureDefinition/zib-Pregnancy-PregnancyDuration
http://nictiz.nl/fhir/StructureDefinition/zib-Pregnancy-Parity
http://nictiz.nl/fhir/StructureDefinition/zib-Pregnancy-Gravidity
http://nictiz.nl/fhir/StructureDefinition/zib-Pregnancy-DateLastMenstruation

4.3 Aanmeldbericht

Section HCIM name FHIR profile Location Remarks
- - Aanmeldbericht Composition Declaration of the Send Aanmeldbericht transaction.
Datum overplaatsing - eOverdracht-TransferDate Aanmeldbericht Composition DateTime extension.
Persoonsgegevens Patient nl-core-patient Task and Aanmeldbericht Compostion -
Betaler zib-Payer Aanmeldbericht Compostion -
Contactpersoon nl-core-relatedperson Aanmeldbericht Compostion -
Sturende organisatie Zorgaanbieder nl-core-organization Task and Aanmeldbericht Compostion -
Ontvangende organisatie Task
Medische diagnose Probleem zib-Problem Aanmeldbericht Compostion -
Voorgeschiedenis Probleem zib-Problem Aanmeldbericht Compostion -
Let op Alert zib-Alert Aanmeldbericht Compostion -
Vrijheidsbeperking VrijheidsBeperkendeMaatregelen zib-FreedomRestrictingMeasures Aanmeldbericht Compostion -
Actuele patiëntenproblemen Probleem zib-Problem Aanmeldbericht Compostion -
Afspraken patiënt OverdrachtGeplandeZorgActiviteit zib-ProcedureRequest Aanmeldbericht Compostion -
Wensen en behoeften patiënt en/of naasten - - Aanmeldbericht Compostion Declared as a text section.
Voeding/vocht SondeSysteem zib-FeedingTubeSystem Aanmeldbericht Compostion -
Infuus zib-Infusion Aanmeldbericht Compostion -
Uitscheiding Stoma zib-Stoma Aanmeldbericht Compostion -

4.4 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) -

4.5 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

4.6 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
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