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

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Regel 33: Regel 33:
 
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 (Id)
 
* IdentificationNumber (Id)
* InformationSource (Source)
+
* DateTime (DateTime)
 
* Author (Author)
 
* Author (Author)
 
* Subject (Subject)
 
* Subject (Subject)
* DateTime (DateTime)
+
* InformationSource (Source)
 +
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 Basiuc Elements against the HCIMs.
 +
{| class="wikitable" style="horizontal-align: right"
 +
!style="background-color: #1F497D; color: white; font-weight: bold; text-align:left;  background-color: #E3E3E3 width:10px"  | HCIM
 +
!style="background-color: #1F497D; color: white; font-weight: bold; text-align:left;  background-color: #E3E3E3 width:100px" | Id
 +
!style="background-color: #1F497D; color: white; font-weight: bold; text-align:left;  background-color: #E3E3E3 width:400px" | DateTime
 +
!style="background-color: #1F497D; color: white; font-weight: bold; text-align:left;  background-color: #E3E3E3 width:400px" | Author
 +
!style="background-color: #1F497D; color: white; font-weight: bold; text-align:left;  background-color: #E3E3E3 width:400px" | Subject
 +
!style="background-color: #1F497D; color: white; font-weight: bold; text-align:left;  background-color: #E3E3E3 width:100px" | Source
 +
|-
 +
| '''Patient'''
 +
| Test
 +
| Test
 +
| Test
 +
| Test
 +
| Test
 +
|}
  
 
==Persistent identifiers==
 
==Persistent identifiers==

Versie van 3 dec 2021 08:36


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

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

  • IdentificationNumber (Id)
  • DateTime (DateTime)
  • Author (Author)
  • Subject (Subject)
  • InformationSource (Source)

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 Basiuc Elements against the HCIMs.

HCIM Id DateTime Author Subject Source
Patient Test Test Test Test Test

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