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
• 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 Basiuc Elements against the HCIMs.

Id	Zib	HCIM	IdentificationNumber	DateTime	Author	Subject	InformationSource
Patient	Patient	Patient	PatientIdentificationNumber	DateOfBirth	Not Relevant	Patient	Not Relevant
Betaler	Betaler	Payer	BankCode+AccountNumber OR IdentificationNumber+InsurantNumber	StartDateTime+EndDateTime	Not Relevant	Patient	Not Relevant
BehandelAanwijzing	BehandelAanwijzing	TreatmentDirective	Required	VerificationDate	Patient OR patient's authorized representative	Patient	Patient OR patient's authorized representative
Wilsverklaring	Wilsverklaring	AdvanceDirective	Required	LivingWillDate	Patient OR patient's authorized representative	Patient	Patient OR patient's authorized representative
Contactpersoon	Contactpersoon	Contactperson	Not Relevant	Not Relevant	Not Relevant	Contactpersoon	Not Relevant
FunctioneleOfMentaleStatus	FunctioneleOfMentaleStatus	FunctionalOrMentalStatus	Required	StatusDate	Required	Patient	?
Probleem	Probleem	Problem	Required	ProblemStartDate	Required	Patient	Optional
Woonsituatie	Woonsituatie	LivingSituation	Optional	Not Relevant	Not Relevant	Patient	Not Relevant
DrugsGebruik	DrugsGebruik	DrugUse	Required	StartDate	empty OR equal to Source	Patient	Required
AlcoholGebruik	AlcoholGebruik	AlcoholUse	Required	StartDate	empty OR equal to Source	Patient	Required
TabakGebruik	TabakGebruik	TobaccoUse	Required	StartDate	empty OR equal to Source	Patient	Required
Voedingsadvies	Voedingsadvies	NutritionAdvice	Required	Not Relevant	Optional	Patient	Required
Alert	Alert	Alert	Required	StartDateTime	empty OR equal to Source	Patient	Required
AllergieIntolerantie	AllergieIntolerantie	AllergyIntolerance	Required	StartDateTime	empty OR equal to Source	Patient	Required
Medicatieafspraak	Medicatieafspraak	MedicationAgreement	Required	MedicationAgreementDateTime	Prescriber::HealthProfessional	Patient	Optional
Toedieningsafspraak	Toedieningsafspraak	AdministrationAgreement	Required	AdministrationAgreementDateTime	Supplier::HealthProfessional	Patient	Optional
MedicatieGebruik	MedicatieGebruik	MedicationUse2	Required	MedicationUseDateTime	Prescriber::HealthProfessional	Patient	Required
MedischHulpmiddel	MedischHulpmiddel	MedicalDevice	ProductID	StartDate	HealthProfessional	Patient	Optional
Vaccinatie	Vaccinatie	Vaccination	ProductCode+VaccinationDate	VaccinationDate	Administrator::Healthprofessional	Patient	Optional
Bloeddruk	Bloeddruk	BloodPressure	BloodPressureDateTime	BloodPressureDateTime	Required	Patient	Optional
Lichaamsgewicht	Lichaamsgewicht	BodyWeight	WeightDateTime	WeightDateTime	Required	Patient	Optional
Lichaamslengte	Lichaamslengte	BodyHeight	HeightValue OR HeightDateTime	HeightDateTime	Required	Patient	Optional
Verrichting	Verrichting	Procedure	Required	ProcedureStartDate	Performer::HealthProfessional	Patient	Requireduired when performer is not known
Contact	Contact	Encounter	ContactType + StartDateTime	StartDateTime	ContactWith::HealthProfessional	Patient	Not Relevant
Zorgverlener	Zorgverlener	HealthProfessional	HealthProfessionalIdentificationNumber	Not Relevant	Not Relevant	HealthProfessional	Not Relevant

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