BgZ CDA Implementation Guide

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

4 Metadata

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

4.2 HCIM (zib) metadata

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

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

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