Precondition: Reference Postcondition: a contact is scheduled
Pre-condition: (preliminary/work) diagnosis has been made
Post-condition: the treatment plan has been drawn up and activities and resources have been planned.
WP "Prepare treatment" precedes any specific WP ""Run *"!
This is specifically described in the pre-conditions.
""Treat"" is actually ""Execute treatment plan"""
Pre-condition: information is available.Post-condition: information reviewed and review processed.
Pre-condition: Prepared (other) medical treatment
Post-condition: Performed/completed (other) medical treatment"
Pre-conditie: Voorbereide (geplande) therapie
Post-conditie: Uitgevoerde therapie
Post-condition: that you know what you are going to do with the referral.
Pre-condition: a (provisional/work) diagnosis has been determined
Post-condition: a (specific) treatment plan has been determined
After determining treatment options (MDO?) for diagnosis,
an option is chosen together with the patient (informing the patient) and concent is asked for it and then the details are filled in (treatment plan).
Pre-condition: Performed Treatment
Post-condition: Evaluated Treatment
Pre-condition: Prepared (planned) care.
Post-condition: Care performed.
Pre-condition: Prepared (planned) nursing care
Post-condition: Nursing care performed.
Pre condition: there is a question to make an appointment, for example from a referral, but that is not necessary.
Post condition: of this work process is an appointment for a patient with persons (care provider) at a location and possibly resources.
An appointment is an intended contact.
You need the referral information to determine which care providers, but that has been done in the current WPs! Granting a care provider is another BA.
So ""Planning persons"" is more than just caregivers.
In Schedule appointment, the patient and healthcare provider are determined whether this has already been done when processing the referral.
Process Steps Planning people, resources and location can also be executed simultaneously.
"Pre-condition: Treatment plan = including planned (treatment) activities
Post-condition: Prepared treatment (location, resources, patient)"
"Ensuring that the supplies are prepared, e.g. preparing medication for administration, ensuring that the correct nets are present in the OR, etc
Receiving and processing a request (digital and/or paper) from a patient or healthcare provider for service(s) within a hospital.
BA Release result is still missing between Drafting report and Notifying applicant.
pre-condition: treatment plan consists of activities that must be ordered
post-condition: an order for the activity has been created
Taking note of the nature and background of a request for advice, assessing whether the requested care is appropriate and can also be provided.
Receiving and administrative processing of the referral.
Start of the treatment relationship as a hospital.
To be accountable for social topics such as sustainability, mobility, aging.
To be accountable for the extent to which performance goals are met.
Providing and/or introducing medication to be taken at a specific time, according to agreement and route of administration (oral, injection, anal, etc.). May also concern the administration of nutrition via an IV or tube and the use of self-administered medication.
Includes personnel registration, time, absenteeism and leave registration, HR costs and return.
Preparing, planning, and supervising new construction, rebuilding, and renovation.
Providing advice to the patient on how to deal with his/her complaints.
If unanticipated, but relevant findings are made during the research these are reported to the patient or his practitioner.
If necessary, external funding is requested.
Permits are applied for if necessary.
Assessing the request for additional diagnostic testing.
Taking note of the nature and background of a referral by the (assigned) healthcare provider
Reading and interpreting the results of diagnostic testing.
Taking note of the results of additional diagnostic tests or results of the examinations carried out by care provider himself and including these in the diagnosis and treatment plan.
Taking note of and assessing the findings made during a consultation with a fellow healthcare provider, and including these in the diagnosis and treatment plans.
Receiving and processing information (eg., measurements, diary and findings) from the patient about their own care process, both digitally and on paper.
Assigning a healthcare provider of a (sub)specialty to the patient (as primary).
Assigning a healthcare provider of a (sub)specialty to the patient (as primary).
Request in advance and record a desired service administratively.
Performing treatment including final check, stabilization.
Receiving and verifying material data.
Data required for the research is collected and, if necessary, research material is also collected from the patient.
Collecting human material (blood, urine, tissue, etc.) required for diagnostic testing.
Collecting information on the treatment provided based on clinical and patient reported measures.
Drawing up curriculum and study programming for regular (including medicine, nursing, paramedical) and further education (medical and nursing specializations).
Comprehensively handling the care request.
Completing the treatment (final check-up, stabilization, transfer to another healthcare provider and cleaning up the treatment room).
To be accountable for compliance with applicable legislation and regulations.
Obtaining information about the physical or mental condition of patient in a systematic manner, according to a specific method or technique. Collecting human material/specimen(s) and collecting visual material.
Examining factors that determine or influence supply and demand.
Observing/measuring certain bodily functions such as breathing, blood pressure, heart rate, temperature, fluid balance, reflexes or other aspects of bodily functioning. Also, examination by the care provider as part of the diagnostic consultation.
Carrying out treatment by various therapeutic disciplines (that deal with the treatment or cure of diseases or the alleviation of symptoms) as part of the treatment plan, for example radiotherapy, physiotherapy, speech therapy.
Individual assessment of the quality of education (sometimes quantity) based on established criteria.
Dispensing by a pharmacy of a specific drug to a person. Dispensing is the supply of a quantity of a medicinal product to the patient, his administering party or his representative.
Providing data to external parties, such as those involved in the continuum of care, insurers, registries, and governmental entities with jurisdiction.
The strategy describes how the vision will be achieved and indicates a coherent set of policy lines for maintaining continuity in the longer term.
Assessing the patient's care needs and determining how they can be delivered. This includes triage in specific contexts.
To the greatest extent possible, making an unambiguous determination of the nature and cause of the patient's complaints.
Determining which innovations should take place to support product and service development.
A mission defines the raison d'être of an organization and answers the question: Why do we do what we do? The mission is timeless. A vision is a consistent view of the future and indicates the desired situation.
Deciding a diagnosis that is pertinent to nursing treatment.
Determining the nursing goal.
Determining a formal process that includes six components: assessment, diagnosis, expected outcomes, interventions, rationale, and evaluation. Documenting these steps ensures effective communication between doctors, nurses, and other healthcare professionals over multiple shifts.
Determining hospital and/or division policy and specific policy plans such as medical, nursing, department, safety, labor, quality, and environment at strategic, tactical, and operational level.
Coordinating production capacity with health insurers.
Provide the diagnosis.
Working with the patient to determine the aim of the therapy.
Deciding on a nursing plan and recording it so that it can be used in communication with the patient and other caregivers.
Determining the activities and the necessary information provision for the transfer of patient to home or transfer of patient to another institution.
Determining and establishing a treatment recommendation.
Determining which treatments are possible for the patient's care needs on the basis of all available data.
Developing and refining business, solutions, information, and technology architecture based on desired innovations.
Develop and test services based on customer requirements, so that the customer gets what he needs. This activity includes change management, engineering and IT projects.
Developing new healthcare products and services as well as product management.
If clinical data must be collected for the research, researchers and data managers jointly develop the required dataset.
Determining and establishing a treatment plan (including requests for authorizations from the insurer)).
Inventory of supply and demand, from forecast to normative space requirement, multi-year housing plan, efficient and flexible use of space, real estate and land.
Drafting legal policy such as privacy policy and ensuring compliance with the policy on the basis of existing legislation.
The researcher or research group draws up a definitive research proposal.
Developing a protocol/design for the purpose of conducting a research project.
Termination or transfer of care from one healthcare provider to another healthcare provider (including discharge/referral/transfer/death).
Planning implementation of the care request.
Providing the patient with medical and healthcare information regarding their complaints or conditions.
Evaluating the care provided (the result of all treatments) with respect to treatment goals.
Evaluation of education and implementation of improvement actions.
Evaluating the nursing outcome.
Evaluating the outcome of the therapy.
Acquire additional funds and maintain sponsorship relationships.
Guiding, coaching, counseling, including informal means of imparting knowledge and experience.
Identifying, can lead to changes in patient data.
Implementing the nursing plan.
Completed publications are included in a publication list.
Compiling, collecting and providing information about and to patients, visitors, healthcare professionals, students, researchers, employees, press, etc.
Informing and advising on, for example, the nature, approach and risk of further examination, treatment options, or surgery that the patient undergoes.
Processing transactions and other required data into care products and an invoice.
Maintaining contact with partners and stakeholders with the aim of promoting existing services and obtaining feedback on the services offered.
Technical management (preventive and corrective maintenance) of medical technology such as medical equipment, medical devices including software.
Providing or sending medical information about a patient to external healthcare providers/key stakeholders in digital or paper format.
Sending the report of the result of the requested diagnostic test to othe applicant.
Using key performance indicators (KPI) to manage performance with the ultimate aim of realizing the strategy of the organization.
Making existing IT facilities fully functional (including infrastructure, applications, functional management, helpdesk, user support. IT services include presentation aggregation (portals), search engine, business intelligence (BI), identity management, web content management, knowledge creation and social media, e-mail and calendar, telephone and video, speech recognition.
Activities aimed at maintaining capital and achieving the desired result. Includes preparing the liquidity forecast, aligning the long-term housing plan, and attracting (required) funds, managing working capital, determining the interest result and managing the financing ratio on the balance sheet.
The (business) activity for managing data (data governance). Includes all activities that ensure that important data is formally managed with the premise that data represents (business) value.
Recording and maintaining administrative data of these organizations.
Establishing and maintaining administrative data of healthcare providers.
Recording and maintaining administrative data of health insurers.
Making knowledge available and keeping it up to date (publications, professional literature, etc.).
Managing all vehicles and other means of transport (eg service bicycle) in lease or ownership.
Collecting, analyzing, and using student data to improve current and future educational efforts.
Recording and maintaining administrative data, such as insurance, personal identification number, etc.
Processing (medical) patient information in the patient file.
The salary administration takes place on the basis of the personnel administration. Includes gross-net calculations, checking pay slips and processing adjustments and seizures of individual staff members.
Organizing the management of the hospital (division of tasks, powers and responsibilities) that is necessary to make good decisions, including supervision of its functioning (accurate and demonstrable). Also realizing, optimizing and maintaining the (including financial) planning and control cycle. Drawing up budget and monitoring budgets and providing solicited and unsolicited advice to board and management. Also includes administrative organization/internal control, process management, information management and knowledge management.
Determining, monitoring and adjusting production planning
Encouraging and supervising compliance with the agreements that have been made and recorded for the purpose of safeguarding and increasing the quality of care, research, education, and patient safety.
Creating, making available, and keeping content such as protocols, manuals, instructions, quality documents available for the purpose of safeguarding the quality of care, research, and education, and patient safety.
All activities aimed at keeping or bringing stocks to a desired level.
Managing and adjusting technical installations, infrastructural facilities, energy (savings).
Managing debtors, creditors, ledger, invoices and executing financial transactions. Also includes financial settlement with health insurers.
Matching healthcare services to demand within the hospital's region.
Receiving and administering complaints and monitoring the handling of complaints.
The Research Committee/Medical Ethics Committee assesses the research application using external and internal frameworks and its relation to current research projects.
Periodically during the research, audits are carried out on the quality and correct execution of the research, possibly by external funders.
Supervising and controling the correct use of medication (eg, correct dosage, risk of allergy, side effects, combination with pregnancy, interaction with other medication) in light of the patient's overall clinical picture.
Activity that is concerned with optimizing the quality and safety of a product, production process, service, medical equipment or hospital. Also includes advice, risk management, patient safety, information security and clinical physics.
Managing risks in working conditions (including emergency response, prevention, inspections, absenteeism counseling, and reintegration.
Moving resources such as equipment, instruments, blood products, food and beds.
The actual transport of people (usually patients in a hospital).
Notifying the applicant that a result is available.
Record whether the patient agrees to the proposed treatment and/or participation in research.
Record whether the patient agrees to participate in the study.
Providing and administrative recording of a desired service such as: parking, meals, catering, shops, (meeting) space, telecom facilities, mobility equipment, waste, repro, mail, management of work clothing and bed linen, etc. Also includes improving existing services and handling malfunctions.
Management levels, technical and functional quality, preparation of a multi-year maintenance plan and budget, monitoring and control of maintenance activities, cleaning maintenance and security.
Placing orders for well-known products and services that fall within a framework contract. The delivery time is also monitored and contact is maintained with the supplier to ensure that the ordered items are delivered at the requested time, place and quantity.
Based on research criteria, patients are selected and recruited to participate in the study.
Performing an intervention in a hospital operating room that involves incision, excision, manipulation, or suturing of tissue, and usually requires regional or general anesthesia or sedation to manage pain.
Obtaining information about the patient's condition through examination/questionnaires/conversation, weighing the necessity and risks of the planned operation and determining the desired approach and method of anaesthesia.
Planning the activity.
Recording date/time for performing a specific diagnostic test.
Determining and planning the desired use of spaces and rooms.
Determining and planning the desired deployment of people (caregivers and others).
Planning the desired deployment of resources such as equipment, instruments, blood products, food and beds.
Plan necessary resources, such as rooms, e-learning facilities, medical library, viewing rooms, etc. and registration, recruitment of students, information, etc.
Recording an intention to a clinical move (admission/discharge/transfer)
Gathering the resources necessary to respond to the care request.
Preparing the contact with the patient so it is pleasant and efficient as possible.
Full or partial manufacturing, packaging, or labeling of medicines.
Preparing a report on the progress of the operation. Usually, both the surgeon and the anesthetist report.
Making sure the patient knows what to expect using an appropriate balance of tone, empathy, and information.
Recording the results of diagnostic testing.
Receiving/obtaining/collecting the necessary resources for treatment. Ensuring that the supplies are prepared, e.g. preparing medication for administration.
Taking care of logistical preparation (including ordering blood products, prostheses, etc.) and preparing the necessary materials prior to surgery.
Preparing the treatment room for the treatment that is planned.
Determining required medication, dosage and frequency of dosing.
In the outpatient situation, a request for dispensing is made to the pharmacy. This includes medication verification and checking for contraindications.
When necessary, the collected research data is processed (extraction, conversion, cleaning, ordering, etc.), after which the data is suitable for analysis.
Receiving a request and checking for completeness and correctness. Providing feedback that the application has been received in good order.
Receiving and understanding the request for care.
Processing a medication agreement by the pharmacy into a medication order (in a clinical setting) or delivery of medication (in an outpatient setting). Processing can consist of substituting the medication, applying medication monitoring, etc.
Developing and maintaining the hospital program to achieve the strategic objectives.
Enforcement (advice, inspection) of permits and legislation and regulations with regard to the environment. Also includes registration of hazardous substances, noise and thermal environment.
Giving different forms of education: e-learning, giving lectures, practicum, teaching in a simulated setting (simulating medical procedures), enabling practical experience, evaluation of practical experience.
Advising on the application of legal policy, for example with regard to medical ethical matters and providing legal support in the settlement of complaints and objections.
The results from registrations and analysis during the execution of the project are processed into a final report (publication, dissertation or presentation).
Received various forms of education.
Receiving the patient.
Register or derive or assign and recording one or more procedures following a patient contact / treatment.
Selecting students on the basis of transparent criteria.
Sending a request (digital and/or paper) for a patient/care provider to engage a healthcare provider within the (other) institution.
Requesting additional diagnostic testing such as lab or X-ray examination.
Requesting interventions (including interventions and treatments outsourced to other specializations or disciplines).
Requesting opinion/adivce from a fellow healthcare provider regarding diagnosis or treatment.
Requesting additional medical/administrative information from an internal or external source.
Contextual search for information including personalization and notification.
Reviewing all relevant information in the patient’s file(s). Studying and assessing information from and about the patient. Analyzing conclusion, diagnosis, history, research results, evaluation of previous treatment, etc.
Recording date, time, place, for a healthcare provider(s) and patient appointment for (in-person or virtual) contact/interaction.
Ensuring materials, instruments and equipment are free of microorganisms to prevent infections.
Choosing a supplier who may deliver the goods or services, at what price and purchase conditions, arranging tenders and selection, recording in contracts.
The researcher or research group submits a research application to the review committee (e.g., Research Committee/Medical Ethics Committee).
Research assistance includes literature review, laboratory preparation, subject recruitment, analysis of findings, preparation of manuscripts and other work products, etc.
Managing the organization and formation, personnel assessment, career development and competence management.
Recruitment supports the activities aimed at approaching candidates. Selection involves selecting the right candidate and subsequent appointment.
Support in the event of an employee's departure as a result of retirement, voluntary or forced dismissal, death.
Research projects require such administrative support as budgeting, planning, staffing, communications, resource acquisition, submission of work products, etc.
Implementation and support in research and therapy (clinical physics).
Taking the patient’s medical history.
Collecting information about past history and complaints by means of targeted questions; this may also have been provided prior to the consultation by means of, for example, questionnaires or self-management information or checking medical history.
Taking a history appropriate for a particular therapy.
Providing services that may include personal care, food assistance, observation, reporting.
Making research results (publications, research data) available and suitable for application in products, processes, and services such as interaction with society and private organizations.
Accountability of the hospital to its environment
Performing additional research such as clinical chemical research, X-ray research, microbiological research, pathological research, etc. In fact, there is a domain research with specializations into the type of research. Specializations can be added within the DRH for specific applications.
Giving treatment advice
<languages xml:space="preserve"><nl-NL>Het uitvoeren en verslagleggen van klinisch chemisch laboratorium (KCL) onderzoek.</nl-NL><en-US>The most commonly analyzed fluids are: blood, urine, fluid that surrounds the spinal cord and brain (cerebraospinal fluid), fluid within a joint (synovial fluid). Less often, sweat, saliva and fluid from the digestive tract are analyzed. Sometimes the fluids analyzed are present only if a disorder is present, as when fluid collects in the abdomen, causing ascites, or in the space between the two-layered membrane covering the lungs and lining the chest wall (pleura), casing pleural effusion. </en-US></languages>
<languages xml:space="preserve"><nl-NL>Het uitvoeren en verslagleggen van genetisch onderzoek.</nl-NL><en-US>Usually, cells from skin, blood, or bone marrow are analyzed. Cells are examined to check for abnormalities of chromosomes, genes (including DNA), or both. Genetic testing may be done in the following:
· Fetuses: To determine whether they have a genetic disorder
· Children and young adults: To determine whether they have a disorder or are at risk of developing a disorder
· Adults: Sometimes to help determine the likelihood that their relatives, such as children or grandchildren, will develop certain disorders.</en-US></languages>
<languages xml:space="preserve"><nl-NL>Het uitvoeren en verslagleggen van biopsie.</nl-NL><en-US>Tissue samples are removed and examined, usually with a microscope. The examination often focuses on finding abnormal cells that may provide evidence of inflammation or of a disorder, such as cancer. Tissues that are commonly examined include skin, breast, lung, liver, kidney, and bone..</en-US></languages>
collection of data for invoicing (DBC registration and invoicing). The handling of the invoice itself is part of the financial administration.
Actual movement of people and resources
information, fundraising and complaints handling
Determining the nature and cause of the patient's complaints or need for care.
The (re)development and evaluation of courses, minors and units of study
<languages xml:space="preserve"><nl-NL>Het uitvoeren en verslagleggen van endoscopisch onderzoek.</nl-NL><en-US>"A viewing tube (endoscope) is used to directly observe the inside of body organs or spaces (cavities). Most often, a flexible endoscope is used, but in some cases, a rigid one is more useful. The tip of the endoscope is usually equipped with a light and a camera, so the examiner watches the images on a television monitor rather than looking directly through the endoscope. Tools are often passed through a channel in the endoscope. One type of tool is used to cut and remove tissue samples.
Endoscopy usually consists of passing the viewing tube through an existing body opening, such as the following:
· Nose: To examine the voice box (laryngoscopy) or the lungs (bronchoscopy)
· Mouth: To examine the esophagus (esophagoscopy), stomach (gastroscopy), and small intestine (upper gastrointestinal endoscopy)
· Anus: To examine the large intestine, rectum, and anus (coloscopy)
· Urethra: To examine the bladder (cystoscopy)
· Vagina: To examine the uterus (hysteroscopy)
However, sometimes an opening in the body must be created. A small cut (incision) is made through the skin and the layers of tissue beneath the skin, so that the endoscope can be passed into a body cavity. Such incisions are used to view the inside of the following:
· Joints (arthroscopy)
· Abdominal cavity (laparoscopy)
· Area of the chest between the lungs (mediastinoscopy)
· Lungs and pleura (thoracoscopy)"</en-US></languages>
Taking care of all incoming and outgoing financial flows
Onderhouden en identificeren van zorgrelaties, inclusief patiënten, zorgverleners en zorgverzekeraars
hospitality with regard to the reception and stay of patients, employees, visitors and guests
<languages xml:space="preserve"><nl-NL>Het management van personeelszaken binnen het ziekenhuis.</nl-NL><en-US>Human resources management within the hospital.</en-US></languages>
Develop, maintain and support Information Technology
<languages xml:space="preserve"><nl-NL>Het uitvoeren en verslagleggen van beeldvormend onderzoek zoals radiologie en nucleair.</nl-NL><en-US>These tests provide a picture of the inside of the body—in its entirety or only of certain parts. Ordinary x-rays are the most common imaging tests. Others include ultrasonography, radioisotope (nuclear) scanning, computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and angiography.</en-US></languages>
Developing existing and new services
managing of knowledge
Ensuring that the organization operates within the boundaries of legislation and regulations.
Optimal coordination between the supply and demand of services, including researching social developments that (will) determine the demand, with the aim of assigning as much value as possible to the existing services and responding as well as possible to wishes and opportunities for new or customized services.
<languages xml:space="preserve"><nl-NL>Het uitvoeren en verslagleggen van functieonderzoeken. </nl-NL><en-US>Often, body functions are measured by recording and analyzing the activity of various organs. For example, electrical activity of the heart is measured with electrocardiography (ECG), and electrical activity of the brain is measured with electroencephalography (EEG). The lungs� ability to hold air, to move air in and out, and to exchange oxygen and carbon dioxide is measured with pulmonary function tests.</en-US></languages>
Maintaining and supporting medical technology.
Drug treatment of the patient
<languages xml:space="preserve"><nl-NL>Het uitvoeren en verslagleggen van microbiologisch en immunologisch labonderzoek.</nl-NL><en-US>Conducting and reporting microbiological and immunological lab research</en-US></languages>
Treatment of the patient through nursing interventions
Behandeling van de patiënt doormiddel van verzorgende taken.
<languages xml:space="preserve"><nl-NL>Behandeling niet afgedekt door de overig soorten van behandeling.</nl-NL><en-US>Type of treatment not covered in the other five treatment business function categories.</en-US></languages>
Participation of the patient in his/her own care process
Create, measure and direct on performance indicators; about care, research and educational services to be provided, as well as research in order to arrive at the right range of services
<languages xml:space="preserve"><nl-NL>Het geheel van activiteiten om te bepalen wat er in een bepaalde periode moet gebeuren (planning), de rapportage daarover en de benodigde bijsturing en uiteindelijke verantwoording over de behaalde resultaat (control).</nl-NL><en-US>The whole of activities to determine what needs to be done in a certain period (planning), the reporting on this and the necessary adjustments and ultimate accountability for the result achieved (control).</en-US></languages>
Operating the hospital's buildings and inventory.
Acquiring resources and monitoring agreements about this with the supplier, including the management of stocks.
Guaranteeing the quality of care, research and education and patient safety.
Referrals and transfer to and from other healthcare providers, including the necessary information exchange
Ensuring an accepted research proposal
Het daadwerkelijk uitvoeren van het onderzoek
Ensuring that the preconditions for the research are safeguarded.
Draw up and distributing publications related to the research.
Administrative and substantive support for investigations.
Managing and optimizing business support, facility safety, quality, health and safety and environmental aspects within the hospital.
Making research results (publications, research data) public available and suitable for application in products, processes and services such as interaction with society and private organizations.
Determining the mission, vision, strategy and policy, including the policy direction and management
Surgical procedures as part of the patient's treatment
<languages xml:space="preserve"><nl-NL>Het testen van de resultaten van het onderwijs.</nl-NL><en-US>Evaluating the impact of teaching</en-US></languages>
<languages xml:space="preserve"><nl-NL>Het voorbereiden en uitvoeren van alle direct aan het onderwijs gerelateerde activiteiten.</nl-NL><en-US>Preparing and executing all activities directly related to education.</en-US></languages>
<languages xml:space="preserve"><nl-NL>Administratief, inhoudelijk, ondersteuning van onderwijs</nl-NL><en-US>Administrative, substantive, educational support</en-US></languages>
Form of treatment that deals with the treatment or cure of diseases or the relief of symptoms
Treatment of the patient
Determining and setting out a treatment plan
There are 2 types of activities, which are ordered and unordered. A certain activity, operation, series of actions with which a certain result can be achieved.
Request for planning and execution of a transfer (admission/discharge/transfer) of a patient.
The supply of a medication product to a specific patient (or the administerer or a representative) with the intent that it be used according to a supplied instruction (usually as an implementation of the dispensing request in a medication prescription).
The healthcare provider's advice to the patient as a result of the consultation and the diagnostic process (other than treatment).
Recording of the advice given.
An overview with dates and times in which the scheduled appointments of one specific resource (person or agent) are recorded. A group calendar is an aggregation of multiple calendars.
Recording of the interview between care provider and patient a personal representative or healthcare proxy, in which the care provider asks specific questions about the care demand.
Recording of the anesthesia performed during an operation.
Accountability for the plan for the coming (financial) year
Accountability of an organization for the course of business in the past (financial) year.
Recording data regarding a patient's appointment with a healthcare provider.
Request to schedule a contact between a patient and a healthcare provider.
Commodity and quantity present in a given place, expressed in units or in money
Overview of all assets; on the left (assets or debit side) and the debt plus equity on the right side (liabilities or credit side) at any given time
Building
Record nursing assistance activities
Record observations of the patient by the caregiver.
A group of caregivers, often from different disciplines, assigned to the patient.
The patient’s care needs aso determined by a healthcare provider.
Care plan includes the diet.
Documentary evidence of a final judgment on the completion of a PhD, study programme, minor or unit of study by an institution. (source HORA)
A collection of participants carrying out jointly scheduled educational activities.
Request for opinion or advice from a colleague/health care professional regarding diagnosis or treatment.
An integrated whole of knowledge, skills, insight and attitude, which is necessary to realize professional products in a professional context that meet the applicable quality requirements. Competences are composed in character, refer to underlying skill, knowledge and attitude domains and are applied and developed in a context.
A subjective perception of health that is experienced as negative.
All reports concerning complaints about care or services provided.
Recording of the unintended and undesired outcomes, during or following the actions of a healthcare provider, that are detrimental to the health of the patient to such an extent that an adjustment of the medical treatment or treatment is necessary, or that irreparable damage has occurred.
Official paper with agreements to which those involved must adhere.
Disorder, illness, or complaint in which a certain therapy, for example medication, may not be used.
Document with which healthcare providers inform each other about the status of the patient, their medical history and treatment(s), e.g. upon discharge, admission, or other transfer situations.
Description of the chronological course of the patient's disease process and of the progress of treatment, written down/summarized by the physician.
Recording of the current medication use by a patient.
Description of a work, construction plan
Established relationship between education and care process, e.g. supervision of care professional for doctor in training
Account for costs incurred or services rendered
Data for external parties such as healthcare ministries, public health (physical and mental) agencies, public and private insurers, etc.
Description of the delivery conditions
The plan in which the employee records his personal development
Recording the name of the disease or condition that a person is believed to be suffering from, as stated by the physician.
Any result from a diagnostic tests
Request to terminate the provision of care. This results in an exchange information object or a transfer information object.
All information regarding education and training that is necessary to be able to comply with the linked competencies.
An agreement that regulates the rights and obligations in education-related matters between the educational institution and a participant. (source HORA)
An individual who participates in educational activities. (source HORA)
Curriculum and study programming for regular (including medicine, nursing, paramedical) and further education (medical and nursing specializations). A collection of units of study that belong to a study program in a specific educational period. (source HORA)
Material that is used in transferring or testing knowledge and competences. (source HORA)
The extent to which the education offered meets predetermined criteria.
A consistent set of principles and models that guide the design and realization of the (processes, organizational structure,) information provision, software development and technical infrastructure of an organization.
Documentation of the conversation with the patient at the end of care, in which information is provided about aftercare, and in which the opinion and experiences of the patient about the care provided can be discussed.
A participant-specific interpretation of an examination program, consisting of a set of educational units. (source HORA)
Information that is exchanged between healthcare providers / institutions. Specific instances are ”referral information� and “transfer information.�
External (medical) information, supplied by the patient.
Results of performed testing of processes/products/services within the institution. Not only the finding itself is recorded, the status and follow-up are also included. Examples include quality measurements and checks of medical equipment.
All physical (touchable) parts of a computer and its peripherals. Monitors, routers, hubs, printers and scanners belong to the category of hardware, among others.
Healthcare insurance provider, contracting party for healthcare provider/care provider.
Person who provides care professionally under a particular qualification and/or approval to do so from a competent authority.
Publications, professional literature, knowledge about healthcare.
Administrative unit for a form of medical action or research that serves as the basis on which the declaration/invoicing of care takes place.
Organization that provides care under a specific qualification and/or approval for this from a competent authority.
Patient history, possibly (partly) obtained through referral information
Guidelines for achieving hospital goals.
Description of current and desired accommodation requirements for temporary or permanent shelter
IT services such as: helpdesk, user support. IT services include presentation aggregation (portals), search engine, business intelligence (BI), web content management, knowledge creation and social media, email and calendar, telephone and video, speech recognition.
Internal or external messages/announcements that can be communicated by means of press releases, email, intranet, website, organizational magazines, staff newspaper, etc.
Signed statement by a patient that they agree with what is specified in the statement, for example, with regard to nature, approach, and risk of scientific research, diagnosis or treatment that the patient is undergoing.
Strategic plan containing the direction and all associated activities aimed at innovation in an organization.
A learning activity in which a participant carries out an internship/graduation assignment. (HORA)
A possible assignment for an internship or graduation.
An organization that offers internships/graduations to participants. (bon HORA)
Household effects
Overview of delivered products and services with associated prices, with the request to the addressee for payment.
Descriptions of tasks, responsibilities and required competences of professionals in a specific work situation and/or field
An agreement between employer and employee, whereby the employee undertakes to perform work for a number of hours per week in the employer's service. This can also be a volunteer or learning/work agreement.
Documents with medical information to support the primary process
A participant activity in which a participant acquires competences. (source HORA)
A collection of participants carrying out common learning activities. (source HORA)
Educational materials that participants use to learn. (source HORA)
Legal advice on medical-ethical issues and the handling of claims and complaints
Place or room where patient care (eg consultation, treatment and diagnostics) takes place.
Description of the nature of the malfunction and its handling
Research into the relationship between supply and demand in a particular market and the factors that influence it. Also uses SWOT analysis.
A consumable within the healthcare institution that is used to support the process (e.g. durable medical equipment, medicine, beds, etc).
Means of transport with maintenance status, type, identification number, shed/parking details, lease contract
The activity of determining a quantitative/objective value.
The result of determining a quantitative measure (for example, from a device, like a scale or monitor.)
The result of determining a qualitative measure using a clinical assessment tool (for example, a questionnaire, index, scale, or other scoring tool).
Physical machine units used in healthcare, for example, ultrasounds, lasers, audio and visual devices, PET cameras and X-ray machines.
Description of the actual administration of a medication to a patient.
Proposal by a healthcare provider in the role of prescriber for the use of medication by a patient.
Description of the provision of a medicine.
Recording of the intake or administration of prescribed or over-the-counter medication, as reported by the patient, an informal caregiver, or a health care provider.
Information about the data. Definition of data (entities). All information needed for data management.
A collection of units of study that are offered as a whole. (source HORA)
The mission of an organization is a relatively static and concise description of the primary function(s), the mission or the raison d'être of the organization, which evolves little if at all over the years.
Recording the name of the illness or condition that a person is believed to be suffering from, stated by the nurse.
Assessment of the nursing care provided, in which the opinion and experiences of the patient can also be discussed.
Record nursing activities
Intervention is a conditional activity that does not require an order. For example, the nursing plan may state: If the patient has a headache, give aspirin.
Background and history of a patient, obtained through systematic questioning by a nurse
Recording the plan with regard to the nursing care to be provided to the patient with the aim of alleviating or eliminating illness and health complaints.
Provide (additional) control to the processes within an organization, including financial planning, monitoring and adjusting the time and commitment of people.
An order is synonymous with a request for something (an activity).
Elaboration of the way in which tasks are divided within an organization and the way in which coordination between subtasks is subsequently established.
Other information objects for P&O include vacancy, applicant, volunteer and competence.
A complete overview of all ongoing investigations within the healthcare institution.
An individual who participates in educational activities. (source HORA)
An exclusive property right for the invention of a technical product or process
Administrative information about the patient. This is a person who receives care (eg medical, paramedical or nursing) from a care provider.
Information about a disease/treatment provided to the patient by a healthcare professional.
All data recorded about the patient.
A quantifiable, measurable indication that shows whether an organization or organizational unit has succeeded in achieving a particular objective.
Person who has a role in the care process, this can also be the patient.
Administrative data relating to staff
Findings from the observations of examined bodily functions.
(Multi-year) plan for budget and organizational activities based on the objective.
Applicable policy, legislation and regulations and protocols with which new research must comply and which are therefore preconditions for new research.
Recording the findings of the preoperative screening.
Description of the way in which information about persons or groups is communicated to others and how personal freedom is safeguarded.
Administrative code containing information about actions performed by a healthcare provider in the context of diagnosis or treatment.
Agreements between budgeted healthcare institutions and healthcare insurers about production, which are taken into account in the (cost) budget to be agreed for a particular year.
Defining the goal and possibly, sub-goals, as well as procedures, to achieve intended production.
An overview of all products and services with associated descriptions that an organization offers.
A set of related projects with a common goal.
The progress report is a periodic report from a contractor to the client. The report describes the status and progress of a specific appointment/assignment.
A project is a (set of related) activity(ies) with a defined goal, limited in time and resources.
Overviews of the steps that need to be taken to carry out a project.
Medication prescription from a doctor to a pharmacist to provide the patient with a specific medication.
Overview of all publications produced by the healthcare institution.
This includes regulations, protocols, manuals, guidelines and policies
This includes all information related to quality accountability such as audits, among other things
Indication of price and delivery conditions for an order or project from potential suppliers, requested by the purchaser.
Reference data refers to data (often supplied by standardization organizations) which, apart from an incidental mutation, is static (unchangeable). Examples of reference data are: nations, place, postcodes, operations
The information that a healthcare provider uses to refer a patient to another healthcare provider.
Order to transfer a patient.
Request to (sometimes temporarily) take over or take back the care of a patient.
Record of a specific additional diagnostic test
Request for planning and execution of a clinical movement (admission/discharge/transfer) care trajectory.
The data collected during the research.
The (biomedical) material collected during the scientific research (e.g. blood, tissue, etc.).
Basic data of the person or subject of research such as animal, patient, blood. Persons are recorded in a pseudonymized or anonymized manner.
Description of the design of the research, the research question, objective, etc.
Description of the protocol that will be followed during the study.
Publications and information from scientific research.
Record of the complete additional findings
The results from registrations and analysis of the project are processed into a final report (publication, dissertation or presentation).
Request to conduct research
Information for the substantive and administrative support of research.
People and other non-material assets that are used within a healthcare institution to support the healthcare process
Recording the result of an activity.
Information about the outcome of a request for peer consultation.
Findings of the research conducted by the healthcare provider himself.
Assessment of the probability and possible consequences of the occurrence of various types of hazards in and around the facility, including hazards that may be caused by the interaction between individual activities and existing installations.
A roadmap is a strategic plan for the further development of a specific area (product, technology, etc.) and is directly linked to the strategic objectives of the organization. The roadmap provides a commonly agreed description of the direction and associated objectives needed to achieve the business objectives in the coming years.
An overview with dates and times in which the availability (occupied and open slots) of one resource is recorded.
Overview of reserved, reservable and returned services
The activity of determining a qualitative/perceived value.
Information yet to be validated by the treating physician obtained from the patient as a result of their own care process (self measurement, diary reports, images, etc.). This can be obtained for example, from completed questionnaires or a personal health file.
Offered service or product such as parking, catering, shops, (meeting) space, telecom facilities, mobility equipment, waste, sterilization, repro, post, etc.
The operating and application programs, procedures, and associated documentation related to the operation of a computer system.
Human body, or material derived from the human body on which research can be carried out for the purpose of diagnosis, treatment or scientific research.
Recording of data based on statutory obligations for safety, quality, labor, and enviornment (VKAM in Dutch) such as hazardous substances registration, radiation hygiene, and environmental registration.
The multi-year approach elaborated by the management in order to realize the vision and mission. Planned and targeted deployment of people and resources to realize policy decisions in order to realize the vision and mission of the organization and the goals derived from it.
The natural or legal person who supplies goods
Description of the intended or performed surgical intervention.
Recording of the course of an surgery performed, including materials used.
Teaching materials and educational information.
Technical facilities incl. specifications (descriptions, instruction, manuals, etc.) such as heating, air conditioning, water pipes, etc.
A participant activity that examines the knowledge, insight and skills of a participant and that should lead to a test result. (source HORA)
Educational materials used for testing. Typically consists of a set of questions and rules about how answers to the questions are judged. (source HORA)
The result of performing a test activity (for example: grade, attendance, completion of internship). (source HORA)
Recording the name of the disease or condition from which a person is believed to be suffering.
Background and history of a patient, obtained through systematic questioning by a paramedical care provider.
Request for treatment, carried out by a specific paramedical discipline, eg physiotherapy, speech therapy.
Establishing the plan with regard to the paramedical care to be provided to the patient, with the aim of alleviating or removing health complaints or defects.
Recording of the therapy performed by the paramedical care provider.
The collection of educational activities scheduled in time, linked to the necessary resources and employees. (source HORA)
A coherent whole of education units, aimed at achieving competences or objectives in the field of knowledge, insight, attitudes and skills that the person completing the study program must possess. (source HORA)
Selection of data from the file intended for the transfer of the patient.
Patient transfer policy, including reason, treatment goal and destination.
Treatment of the patient, other than medical, surgical, paramedical, nursing or caring.
The treatment options that are identified during the consultation and the diagnostic process.
Recording the plan with regard to the care to be provided to the patient with the aim of alleviating or removing health complaints or ailments.
Documentation of the treatment of the patient, other than medical, surgical, paramedical, nursing or caring.
The composite result of a unit of study based on underlying test results. (source HORA)
Advising in safety, quality, labor, and enviornment (VKAM in Dutch) field such as purchase and implementation of new equipment, prevention, etc.
Established policy or plans in the areas of safety, quality, labor, and enviornment (??VKAM in Dutch)
An inspiring vision of the future for the organization that distances itself from daily practice.
An artifact created as part of an activity. Examples are a thesis, report, paper, dissertation or photos of physical products that have been made.
The collection of all ledger accounts with the changes that occur during a certain period.
Functionality to support the determination and management of policy, development of products & services, planning & control cycle and supporting management information
Functionality for developing and managing the enterprise architecture (organization, processes, information, application, technology)
Functionality for managing projects and programs.
Functionality to support the creation, processing and management of quality documents (including protocols)
Functionality for managing production agreements, KPIs including management of regulatory accountability as well as performance and social responsibility
Functionality to support market analysis and contract management
Functionality that makes it possible for patients to have digital access to medical records that healthcare providers keep about them.
Functionality for informing, coaching and communicating with the patient about his care with the aim of helping the patient to achieve the treatment goals and to give (joint) responsibility for treatment choices and treatment (patient empowerment)
Functionality for support and integrations with a personal health environment
Functionality for offering an online environment for patients (e.g. discussion forum for patients)
Functionality to promote health and to prevent complaints and problems. (e.g., reviewing patient information to provide alerts, notifications, and reminders about health, preventive care, and wellness, helps determine ongoing and relevant provider-to-patient communications to promote health)
Functionality for completing questionnaires online, for example anamnestic questionnaires or health questionnaires
Functionality to measure and determine the effects of treatments and patient satisfaction.
Functionality to consult a healthcare professional remotely (not in each other's physical presence) in the context of a health question.
Functionality to monitor own health status.
Functionality with which the patient is remotely followed and guided by the healthcare provider using monitoring equipment present at the patient’s location.
Functionality for making appointments online
Functionality for sending, receiving and processing file information by, for example, referrer, transferring or consulting physician.
Information exchange functionality with third parties for the collection of additional data
Functionality for coordinating care with other healthcare providers and documenting it
Functionality for consulting the file through different views such as patient history, course, summary, problems, diagnoses and allergies.
Functionality for updating the file based on data from consultation, treatment and input from other sources
Functionality of drug treatment support
Functionality for supporting the operative process
Functionality for patient monitoring (e.g. medical alarm, monitoring, wandering detection, fall detection, etc.)
Healthcare decision support functionality
Functionality to support the care process as requests for care services
Functionality to manage demographics, contacts and any other (non-medical) information needed to support the consultation and treatment
Functionality for the execution of the closed order loop of diagnostic tests (request, planning, delivery, acceptance)
Functionality for the analysis and reporting of results and notification to healthcare providers and/or patient
Functionality for monitoring and signaling (possible) errors (wrong patient, wrong dose, wrong time, wrong next step)
Functionality for supporting processes in laboratories (kcl, microbiology, pathology, clinical genetics, pharmacy lab, etc)
Functionality to support Imaging research for e.g. Radiology, Nuclear, Cardology including image management (such as VNA)
Functionality for supporting measurement of body functions (examples ECG, Lung function, Audiology)
Functionality for managing all data of healthcare relations (healthcare providers, healthcare providers, health insurers, etc.)
Functionality for creating and managing appointments, admissions, transfers, discharges and referrals
Functionality for planning resources (persons, caregivers) and resources
Functionality for supporting the movement of people and resources (e.g. transport logistics, route support, track & tracing, registration registration, queue management, call; Functionality and; Functionality for sterilization of resources)
Functionality for recording the transaction and invoicing the care product
Functionality for administrative support for submitting a research application, drawing up a research protocol, drawing up a research proposal and the medical ethics examination
Functionality for the administrative preparation of the research such as applications for permits and funding
Functionality for the administrative execution of the research such as requesting patient selection, obtaining consent,
Functionality for collecting, editing, analyzing and publishing research data
Functionality for storing publications of research results
Functionality for creation and management of the education portfolio
Functionality creation and management of educational content
Functionality for providing education through digital means
Functionality for giving and grading tests
Functionality for managing all information from and about the student
Functionality for scheduling and planning the curriculum
Functionality that supports the management, construction and operation of buildings and the associated facilities and goods flows.
Functionality that supports purchasing of products and services as well as managing suppliers and contracts.
Managing/controlling the incoming and outgoing flow of goods (by means of planning tools) including the supply chain
Functionality that supports the creation and sharing of joint knowledge.
Functionality to support data management, including reference & master data management, metadata management, data analytics
Functionality that supports the provision of information through various channels
Functionality that supports the hotel function, including parking, catering, cash register
Functionality that supports the handling of complaints
Functionality that supports the administration and management of employees.
Functionality that supports recording the time spent by individuals.
Functionality that supports the financial administration and processing of financial flows.
Functionality that supports the payment of salaries to employees.
Functionality that supports management, maintenance and use of various medical equipment
Functionality that supports the performance of safety, quality and environmental tasks and obligations
Functionality to support relationship management in a broad sense.
Functions for facilitating requests for help and solutions.
Functionality for managing hardware (PC, monitor, mobile device, printers, scanners, bedside, TV, etc.) and software at the workplace or bedside site. (LCM, CMDB, deployment, virtual desktop, etc.)
Functionality for printing and scanning.
Functionality for standard office support (word processing, spreadsheet, e-mail and calendar, etc.)
Functionality for (integrated) communication between people via different channels (speech, instant messaging, video, etc.)
Functionality for managing documents and images
Functionality for collecting, managing and publishing (non-patient-related) information in any form or medium (e.g. documents, images, web content)
Functionality for offering radio and TV, internet, e-books, netflix, etc.)
Functionality for identifying and authenticating individuals in systems
Functionality for managing rights and access
Functionality for auditing and monitoring in the context of lawful use and access
Certificate issuance and management functionality
Functionality for managing vulnerabilities and penetrations
Functionality for the provision of server infrastructure (CPU power)
Functionality for managing the data center, e.g. physical access, cooling.
Data storage functionality
Data archiving functionality
Backup and restore functionality
Functionality for managing databases
Functionality for distributing and automating services/applications.
Functionality for monitoring and analyzing the data center
Functionality for managing servers
Functionality for managing the network such as e.g. hardware acceptance on network/ DC-lAN, Campus-LAN, NXN-WAN
Tracking and tracking features for items or property, now or in the past. For example, RFID applications.
Functionality for managing DNS and IP addresses
Remote access functionality such as dial-up facilities
Server and network load management functionality
Functionality for data exchange support (ESB, Message broker, etc.)
! Attention: this information model is undergoing major revision. A new version will be available after summer.
Being able to get dressed independently is part of self-care. Limitations in this ability indicate a reduced ability to cope for oneself.
This activity and activities such as those including eating, drinking, and bathing are also known as activities of daily living (ADL). These are the activities people go through in daily life. The extent to which a person is able to do all these activities by themselves is a measure for their total ability to do things independently.
! Attention: this information model is undergoing major revision. A new version will be available after summer.
Being able to independently prepare and drink beverages is part of self-care. Limitations in this ability indicate a reduced ability to cope for oneself.
This activity and activities such as those including eating, getting dressed and bathing are also known as activities of daily living (ADL). These are the activities people go through in daily life. The extent to which a person is able to do all these activities by themselves is a measure for their total ability to do things independently.
! Attention: this information model is undergoing major revision. A new version will be available after summer.
Being able to independently prepare and consume food is part of self-care. Limitations in this ability indicate a reduced ability to cope for oneself.
This activity and activities such as those including drinking, getting dressed and bathing are also known as activities of daily living (ADL). These are the activities people go through in daily life. The extent to which a person is able to do all these activities by themselves is a measure for their total ability to do things independently.
<languages xml:space="preserve"><nl-NL>! Let op: deze bouwsteen ondergaat momenteel een substantiele revisie. Een nieuwe versie zal na de zomer beschikbaar zijn.
Zelfstandig het haar en indien van toepassing de baard of snor kunnen verzorgen is een onderdeel van zelfzorg. Beperkingen in dit vermogen duiden op een verminderde zelfredzaamheid op dit gebied. Het wassen van het haar valt hier niet onder; dit valt onder vermogen om zich te wassen.
Deze activiteit wordt samen met activiteiten zoals onder andere eten, zich kleden en zich wassen, ook aangeduid als algemene dagelijkse levensverrichtingen (ADL). Dit zijn de handelingen die mensen dagelijks in het gewone leven verrichten. De mate waarin een persoon al deze activiteiten zelfstandig kan verrichten zijn een maat voor de totale zelfredzaamheid.
{</nl-NL><en-US>! Attention: this information model is undergoing major revision. A new version will be available after summer.
A patient being able to independently do their hair (and beard or mustache, if applicable) is a part of self-care. Limitations in this ability indicate a reduced ability to cope for oneself. Washing hair does not fall into this category; it falls under the ability to wash oneself.
This activity and activities such as those including eating, getting dressed and bathing are also known as activities of daily living (ADL). These are the activities people go through in daily life. The extent to which a person is able to do all these activities by themselves is a measure for their total ability to do things independently.</en-US></language>
<languages xml:space="preserve"><nl-NL>! Let op: deze bouwsteen ondergaat momenteel een substantiele revisie. Een nieuwe versie zal na de zomer beschikbaar zijn.
Zelfstandig de mond kunnen verzorgen is een onderdeel van zelfzorg. Het gaat hierbij om tweemaal daags poetsen van de tanden en kiezen met fluoride tandpasta en/of het reinigen van het (gedeeltelijk) kunstgebit en het reinigen van een kaak zonder tanden of kiezen (edentate kaak) en het verzorgen van het mondslijmvlies.
Beperkingen in dit vermogen duiden op een verminderde zelfredzaamheid op dit gebied.
Deze activiteit wordt samen met activiteiten zoals onder andere eten, zich kleden en zich wassen, ook aangeduid als algemene dagelijkse levensverrichtingen (ADL). Dit zijn de handelingen die mensen dagelijks in het gewone leven verrichten. De mate waarin een persoon al deze activiteiten zelfstandig kan verrichten zijn een maat voor de totale zelfredzaamheid. (Bron: Instructiekaart Mondverzorging, 2011)
{</nl-NL><en-US>! Attention: this information model is undergoing major revision. A new version will be available after summer.
The ability to keep up one's own dental hygiene is part of self-care. This includes brushing teeth twice a day with fluoride toothpaste and/or cleaning (partial) dentures, cleaning jaws without teeth (edentulous jaws) and taking care of the mucous membrane of the mouth.
Limitations in this ability indicate a reduced ability to cope for oneself.
This activity and activities such as those including eating, getting dressed and bathing are also known as activities of daily living (ADL). These are the activities people go through in daily life. The extent to which a person is able to do all these activities by themselves is a measure for their total ability to do things independently. (Source: Instruction card for oral hygiene, 2011)</en-US></language>
! Attention: this information model is undergoing major revision. A new version will be available after summer.
Being able to urinate, defecate and keep up hygiene during a menstrual cycle independently is part of self-care. Limitations in this ability indicate a reduced ability to cope for oneself.
This activity and activities such as those including eating, getting dressed and bathing are also known as activities of daily living (ADL). These are the activities people go through in daily life. The extent to which a person is able to do all these activities by themselves is a measure for their total ability to do things independently.
! Attention: this information model is undergoing major revision. A new version will be available after summer.
Being able to bathe independently is part of self-care. Limitations in this ability indicate a reduced ability to cope for oneself.
This activity and activities such as those including eating, drinking, and dressing are also known as activities of daily living (ADL). These are the activities people go through in daily life. The extent to which a person is able to do all these activities by themselves is a measure for their total ability to do things independently.
<languages xml:space="preserve"><nl-NL>Een wilsverklaring is een mondelinge of schriftelijke omschrijving van de wens van de patiënt ten aanzien van toekomstig medisch handelen of het levenseinde. Een wilsverklaring is vooral voor situaties waarin de patiënt niet meer over deze beslissingen kan praten met de zorgverlener.
{</nl-NL><en-US>A living will is a verbal or written description of the patient's wishes with regard to future medical action or end of their life. A living will is mainly used for situations in which the patient is no longer able to speak about these decisions with their healthcare provider.</en-US></language>
In the context of this information model, alcohol is the collective term for alcoholic beverages consumed as a leisure product. This information model describes the information asked of the patient about their alcohol use.
<languages xml:space="preserve"><nl-NL>Een alert beschrijft een klinisch of administratief feit dat onder de aandacht van de gebruikers van de klinische systemen wordt gebracht , om er bij het vormen van diagnostisch en therapeutisch beleid of bij de omgang met de patiënt rekening mee te houden, meestal wegens een veiligheidsrisico.
Aandoeningen, die de overgevoeligheid van het lichaam voor een stof beschrijven, zich uitend in een specifieke fysiologische reactie na blootstelling, worden allergieën genoemd. Deze worden in een aparte bouwsteen beschreven.
Waarschuwingen voor niet allergische aandoeningen kunnen betreffen:
-een aandoening (conditie of diagnose die beschouwd kan worden als contra-indicatie voor het gebruik van groepen van geneesmiddelen of het ondergaan van een bepaalde therapie), zoals zwangerschap of een verlengd QT-syndroom
-Verminderde functie van een orgaansysteem (hartfalen, verminder lever- of nierfunctie, verminderde afweer)
-Kans op verspreiding van bepaalde micro-organismen (multiresistente bacterie, tuberkelbacterie, HIV, HBV, Ebola virus)
-Andere risico's
{</nl-NL><en-US>An alert describes a clinical or administrative fact brought to the attention of the users of the clinical systems to be taken into account when shaping diagnostic and therapeutic policy or in dealing with the patient, usually because of a safety risk.
Disorders that describe the body's sensitivity to a substance which results in a specific physiological reaction after being exposed to that substance are referred to as allergies. These are described in a separate information model.
Warnings for non-allergic disorders can concern:
- A disorder (condition or diagnosis which can be considered as a contraindication for the use of groups of medication or undergoing a certain type of therapy), such as pregnancy or long QT syndrome
- Impaired functioning of an organ system (heart failure, impaired liver or kidney function, weakened immune system)
- Risk of spreading certain microorganisms (multi-resistant bacteria, tubercle bacilli, HIV, HBV, Ebola virus)
- Other risks</en-US></language>
<languages xml:space="preserve"><nl-NL>Een allergie of intolerantie beschrijft de geneigdheid tot overgevoeligheid van een patiënt voor een stof, zodat na blootstelling een ongewenste fysiologische reactie verwacht wordt, terwijl bij de meeste mensen bij die hoeveelheid geen reactie zou optreden. De waargenomen fysiologische veranderingen zijn meestal het resultaat van een immunologische reactie.
De stoffen kunnen als volgt worden ingedeeld:
-Geneesmiddel
-Geneesmiddelgroep
-Ingrediënt/toevoeging
-Voeding
-Omgevingsfactor
-Dier
-Planten
-Chemicaliën
-Inhalatieallergenen
{</nl-NL><en-US>An allergy or intolerance describes a patient's tendency towards hypersensitivity to a certain substance, so that an unwanted physiological reaction is expected after exposure to the substance, while most people would not exhibit such a reaction to that amount. The observed physiological changes are usually the result of an immunological reaction.
The substances can be categorized as follows:
- Medicine
- Medicine category
- Ingredient/addition
- Nutrition
- Environmental factor
- Animal
- Plants
- Chemicals
- Inhaled allergenic</en-US></language>
<languages xml:space="preserve"><nl-NL>De Barthel-index is een gevalideerd meetinstrument voor het vastleggen en volgen van activiteiten van het dagelijks leven (ADL) van patiënten en indirect de mate van afhankelijk zijn van hulp.
De lijst bestaat uit 10 onderdelen: darm, blaas, uiterlijke verzorging, toiletgebruik, eten, transfers (bed-stoel en omgekeerd), mobiliteit, aan- en uitkleden, trappen lopen en baden/douchen waaraan een score wordt toegekend.
De totaalscore is de som van de scores van de 10 onderdelen.
{</nl-NL><en-US>The Barthel ADL index is a validated scale used to measure and track patients' activities of daily living (ADL) and indirectly, the extent to which they are dependent on help.
The list comprises 10 variables: bowels, bladder, grooming, toilet use, feeding, transfers (from chair to bed and vice versa), mobility, dressing, climbing stairs and bathing, which are all given a score.
The total score is the sum of the scores of the 10 variables.</en-US></language>
! Attention: this information model is undergoing major revision. A new version will be available after summer.
The primary function of the bladder is temporary storage of urine. A second important function of the bladder is secretion of the stored urine at the moment there is cause to do so. These functions can be disrupted due to various causes.
The blood pressure is a parameter for determining the condition of the blood circulation and is expressed in systolic and diastolic pressure in mmHg.
<languages xml:space="preserve"><nl-NL>De lichaamslengte van een persoon.
{</nl-NL><en-US>A person's body height.</en-US></language>
<languages xml:space="preserve"><nl-NL>Het meten en vastleggen van de lichaamstemperatuur van een persoon als surrogaat voor de centrale lichaamstemperatuur (de hoogste temperatuur midden in de romp) van een persoon
{</nl-NL><en-US>Measuring and documenting the body temperature of a person as a surrogate for a person's central body temperature (the highest temperature at the centre of the torso)</en-US></language>
Body weight is the common name for (human) body mass.
! Attention: this information model is undergoing major revision. A new version will be available after summer.
An important function of the rectum in particular is the temporary storage and excretion of feces, at the moment there is cause to do so. Disrupting the bowel functions can lead to fecal incontinence and constipation.
<languages xml:space="preserve"><nl-NL>Een brandwond is een verwonding door invloed van hitte op de huid gedurende een bepaalde tijd en boven een bepaalde kritische temperatuur. Boven deze kritische temperatuur (+/- 40 graden Celsius) treedt beschadiging van de huid op. Er zijn verschillende soorten brandwonden en deze worden ingedeeld naar de diepte van de brandwond.
De diepte van de brandwond hangt af van:
- de temperatuur van de inwerkende hitte;
- de tijd dat de hitte inwerkt op de huid;
- de oorzaak van de verbranding (bijvoorbeeld hete vloeistof, vuur).
{</nl-NL><en-US>A burn wound is a wound caused by skin being exposed to heat for a certain time above a certain critical temperature. Heat above this critical temperature (+/- 40 degrees Celsius) will cause damage to the skin. There are different types of burn wounds, which are categorized according to the depth of the burn wound.
The depth of the burn wound depends on:
- the temperature of the impacting heat;
- the duration of the impact of heat on the skin;
- the source of the burn (e.g. fire, fluid).</en-US></language>
<languages xml:space="preserve"><nl-NL>! Let op: deze bouwsteen ondergaat momenteel een substantiele revisie. Een nieuwe versie zal na de zomer beschikbaar zijn.
Communicatievaardigheden zijn de vaardigheden van patiënt m.b.t. het delen van informatie (zowel verbaal als non-verbaal), waarbij een onderscheid wordt gemaakt tussen het begrijpen van de gecommuniceerde informatie en het zich kunnen uiten, zowel verbaal als non-verbaal.
Beperkingen in communicatievaardigheden kunnen verschillende oorzaken hebben. Het kan een gevolg zijn van hersenletsel, zoals afasie, of een stoornis in de mentale functies. Dit kan een grote impact hebben op de mate waarin iemand informatie begrijpt of de manier waarop iemand zich kan uiten. Ook patiënten die slechthorend zijn kunnen moeite hebben met communicatie.
Mate van taalbeheersing is geen onderdeel van communicatievaardigheden.
{</nl-NL><en-US>! Attention: this information model is undergoing major revision. A new version will be available after summer.
Communication skills are a patient's skills in terms of sharing information (both verbally and non-verbally), with a distinction between understanding the communicated information and the ability to express oneself, both verbally and non-verbally.
Limitations in communication skills can have various causes. They can result from brain damage, such as aphasia, or mental function disorders. This can have a major impact on the extent to which a person is able to understand information or the way in which a person can express themselves. Hearing impaired patients can also have difficulty in communication.
Linguistic competence is not a part of communication skills.</en-US></language>
<languages xml:space="preserve"><nl-NL>Bij het vastleggen van relevante gezondheidsproblemen van de patiënt zijn twee aspecten van belang: enerzijds de waarneming van het probleem (de klacht, het symptoom, de diagnose enz.) zelf en anderzijds de beoordeling of het actief beleid vergt. Deze beoordeling door de zorgverlener ligt vast in het 'Concern', het punt van aandacht. Het is mogelijk om Problemen, die onderling samenhangen, onder te brengen onder één Concern.
Het onderscheid tussen vastgestelde problemen en de aandacht die deze vergen, maakt het mogelijk aan te geven waarop medisch of verpleegkundig beleid van toepassing dan wel noodzakelijk is. Als voorbeeld kan een goed ingestelde diabetes worden genoemd; deze vereist geen actief beleid van de zorgverlener.
Een probleem beschrijft een toestand met betrekking tot de gezondheid en/of het welzijn van een individu. Deze toestand kan zijn benoemd door de betroffene (de patiënt) zelf (een klacht), of door zijn of haar zorgverlener (onder andere een diagnose). De toestand kan aanleiding zijn voor diagnostisch of therapeutisch beleid.
Een probleem omvat allerlei soorten medische of verpleegkundige gegevens, die een gezondheidsprobleem representeren. Een probleem kan verschillende typen gezondheidsproblemen representeren:
- Een klacht (Complaint, finding by patient): een subjectieve, als negatief ervaren waarneming van de gezondheid. Voorbeelden: buikpijn, geheugenverlies
- Een symptoom (Symptom): een waarneming door of over de patiënt die de betrekking zou kunnen hebben op een bepaalde ziekte. Voorbeelden : koorts, bloed bij de ontlasting, witte vlekken op het gehemelte;
- Een bevinding (Finding): een waarneming van de zorgverlener m.b.t. de gezondheid van de patiënt. Voorbeelden: vergrote lever, pathologische voetzoolreflex, afwijkende Minimal Mental State, afwezig gebitselement.
- Een conditie (Condition): een beschrijving van een (afwijkende) toestand van het lichaam, die niet noodzakelijkerwijs als ziekte wordt gezien. Voorbeelden: zwangerschap, circulatiestoornis, vergiftiging.
- Een diagnose (Diagnosis): medische interpretatie van klachten en bevindingen. Voorbeelden: Diabetes Mellitus type II, pneumonie, Hemolytisch Uremisch Syndroom.
- Een functionele beperking (Functional Limitation): een vermindering van functionele mogelijkheden. Voorbeelden: verminderde mobiliteit, hulp nodig bij aankleden.
- Een complicatie (Complication): Iedere diagnose die door de zorgverlener gezien wordt als een onvoorzien en ongewenst gevolg van medisch handelen. Voorbeelden: wondinfectie na chirurgie, gehoorverlies door antibioticagebruik.
- Een aandachtspunt (Problem): iedere omstandigheid die relevant is bij de medische behandeling, maar niet in één van de genoemde categorieën past. Voorbeelden: patiënt verblijft in Nederland zonder rechtmatige status en is niet verzekerd, patiënt kan geen glucosecontrole uitvoeren.
In de eerste lijn vervult het concept Episode de rol van Concern.
{</nl-NL><en-US>Determining relevant health issues of the patient involves two important aspects: observing the problem itself on the one hand (complaints, symptoms, diagnosis, etc.) and evaluation of whether or not an active policy is required on the other. This evaluation by the healthcare provider is documented in the 'Concern', the point of attention. Multiple, linked Problems can be subsumed under a single Concern.
The difference between recorded problems and the attention they require enables an indication of which issues medical or nursing policy applies to, or in which issues policy is necessary. An example is well-managed diabetes; this requires no active policy of the healthcare provider.
A problem describes a situation with regard to an individual's health and/or welfare. This situation can be described by the person involved (the patient) themselves (in the form of a complaint), or by their healthcare provider (in the form of a diagnosis, for example). The situation can form cause for </en-US></language>
<languages xml:space="preserve"><nl-NL>Een contactpersoon is een persoon anders dan zorgverleners, die betrokken zijn bij de zorg voor de patiënt, zoals familieleden, mantelzorgers, geestelijke verzorgers, voogden en wettelijkelijk vertegenwoordigers.
Naast identificerende gegevens als naam kunnen ook adres- en contactgegevens worden toegevoegd. Daarnaast kan relatie tot de patiënt en rol die de persoon heeft, meegegeven worden.
{</nl-NL><en-US>A contact is a different person than a healthcare provider who is involved in the patient's care, such as family members, caregivers, mental caretakers, guardians and legal representatives.
In addition to identification information such as the name, address and contact information can also be entered. The relationship to the patient and the role this person has can be entered as well.</en-US></language>
Drugs (or: narcotics, amphetamines, intoxicants, highs, hallucinogenics, illegal substances or dope) is a collective term for drugs and chemical substances with a more or less ?drugging' (anesthetic, boosting and/or hallucinogenic) effect and which can lead to addiction. Drug [Online] Available at: nl.Wikipedia.org/wiki/drug [Accessed: 11 February 2015].
This information model describes the information asked of the patient about their drug use.
Education indicates the highest level of education achieved.
<languages xml:space="preserve"><nl-NL>Een contact is een interactie, onafhankelijk van de situatie, tussen een patiënt en een zorgverlener, waarbij de zorgverlener de primaire verantwoordelijkheid heeft de conditie van de patiënt te diagnosticeren, te evalueren, te behandelen en de patiënt te informeren. Dit kunnen bezoeken, afspraken of niet face-to-face interacties zijn.
oben kunnen huisarts- of praktijkbezoeken, thuisbezoeken, opnames (in bijvoorbeeld ziekenhuizen, verpleeg/verzorgingstehuizen, psychiatrische inrichtingen of revalidatieklinieken) of andere relevante contacten betreffen. Het betreft alleen historische contacten. De toekomstige contacten kunnen vastgelegd worden in de bouwsteen GeplandeZorgActiviteit.
{</nl-NL><en-US>A contact is any interaction, regardless of the situation, between a patient and the healthcare provider, in which the healthcare provider has primary responsibility for diagnosing, evaluating and treating the patient's condition and informing the patient. These can be visits, appointments or non face-to-face interactions.
obs can be visits to the general practitioner or other practices, home visits, admissions (in hospitals, nursing homes or care homes, psychiatric institutions or convalescent homes) or other relevant contacts. This only includes past contacts. Future contacts can be documented in the PlannedCareActivity information model.</en-US></language>
Falling is the most common cause of damage resulting from accidents among seniors. Once a patient has fallen, they run a higher risk of falling again. The right approach can effectively reduce the risk of falling among seniors.
The family history describes any health problems of biological relatives that may be relevant. The family history contains information on the medical disorders of the family member and the biological relationship between the patient and the described family member.
Traditionally, a family is defined as a group of people of one or more adults who carry responsibility for caring for and raising one or more children.
Currently, the term is used more broadly for all forms of cohabitation which form a recognizable social unit, of people who are or who are not related and who have long-lasting, affective bonds and provide each other with support and care.
<languages xml:space="preserve"><nl-NL>Een sonde is een speciale katheter die gebruikt wordt om:
- vloeibare voeding toe te dienen aan mensen die niet op een normale manier kunnen eten of drinken,
- medicatie toe te dienen,
- maagsap af te laten lopen (hevelen) of af te zuigen.
Sondes kunnen op verschillende wijzen ingebracht worden. Een sonde kan, via de neus, worden ingebracht in de maag of darm (duodenum, jejunum).
Percutane endoscopische gastrostomie (PEG) is een techniek om een sondeslang in de maag te leggen via de buikwand. Deze dunne slang wordt gebruikt om een patiënt te voeden die gedurende lange tijd geen voeding op de normale wijze tot zich kan nemen (PEG-sonde).
{</nl-NL><en-US>A feeding tube is a special catheter used to:
- administer liquid food to people who are incapable of oral intake of food or liquid,
- administer medication,
- drain (siphon) or pump out gastric juice.
There are different ways to place a feeding tube. A feeding tube can be inserted through the nose, in the stomach or in the intestines (duodenum, jejunum). Percutaneous endoscopic gastrostomy (PEG) is a technique in which a feeding tube is placed into the stomach through the abdominal wall. This thin tube (PEG tube) is used to feed a patient who is incapable of oral food intake for a prolonged period of time.</en-US></language>
<languages xml:space="preserve">
<nl-NL>Vrijheidsbeperkende maatregelen zijn maatregelen (fysiek of verbaal) die gebruikt worden om de betrokkene bewust in zijn/haar vrijheid te beperken.
In het ziekenhuis gaat het meestal om het gebruik van bedhekken, een onrustband (band om de taille), pols- of enkelbanden of een tentbed. Meestal wordt in combinatie met vrijheidsbeperkende interventies ook rustgevende medicatie toegediend.
Het toepassen van vrijheidsbeperkende maatregelen is aan strikte voorwaarden gebonden. Voor het toepassen ervan in ziekenhuizen door verpleegkundigen heeft de Verpleegkundigen & Verzorgenden Nederland (V&VN) een richtlijn gepubliceerd.
Het risicogedrag van de betrokkene, dat de aanleiding vormt voor de maatregelen, wordt niet in dit concept beschreven.</nl-NL>
<en-US>Medical restraints are (physical or verbal) measures used to restrict the freedom of the patient in question.
In hospitals, these often include the use of side rails, a cushion belt (around the waist), limb restraints or a Posey bed. Medical restraints are often used in combination with sedatives.
Medical restraints may only be implemented under strict conditions. The Vereniging Verpleegkundigen & Verzorgenden Nederland (V&VN) [Dutch Nurses and Carers Association] published a set of guidelines for nurses to implement these restraints in hospitals.
The patient's high-risk behavior providing cause for the restraints is not described in this concept.</en-US>
</languages>
<languages xml:space="preserve"><nl-NL>Vrijheidsbeperkende maatregelen zijn maatregelen (fysiek of verbaal) die gebruikt worden om de betrokkene bewust zijn/haar vrijheid te beperken. Onder deze definitie vallen vele vormen van vrijheidsbeperking, zoals (niet uitputtend)
- dwangbehandeling
- beperking in bewegingsvrijheid (bv. onrustband)
- huisregels
Het toepassen van vrijheidsbeperkende maatregelen is aan strikte voorwaarden gebonden. De Wet Bijzondere Opnemingen in Psychiatrische Ziekenhuizen (Wet BOPZ) beschermt de rechten van cliënten die niet vrijwillig zijn opgenomen in de geestelijke gezondheidszorg, de gehandicaptenzorg en in de psychogeriatrie. De wet is uitsluitend van toepassing in BOPZ-aangemerkte instellingen en geldt ook voor sommige (gesloten) afdelingen in het verzorgingshuis.
Voor de registratie van de maatregelen wordt binnen de GGZ instellingen gebruik gemaakt van een landelijk registratiesysteem, de Argusregistratie.
Het riscicogedrag van de betrokkene, dat de aanleiding vormt voor de maatregelen, wordt niet in dit concept beschreven.
{</nl-NL><en-US>Medical restraints are (physical or verbal) measures used to restrict the freedom of the patient in question. Many forms of medical restraints fall under this definition, including but not limited to:
- involuntary treatment
- physical restraints (such as a cushion belt)
- house rules
Medical restraints may only be implemented under strict conditions. The 'Wet BOPZ' [Dutch Psychiatric Hospitals (Compulsory Admissions) Act] protects the rights of clients who are involuntarily admitted into mental healthcare, services for the disabled and in geriatric psychiatry. The act only applies in 'BOPZ'-marked facilities and also applies to some (closed) wards in retirement homes.
Mental healthcare facilities use a national registration system to register the restraints called Argus registration.</en-US></language>
<languages xml:space="preserve"><nl-NL>De functionele of mentale status geeft inzicht in de functionele en mentale beperkingen van de patiënt.
{</nl-NL><en-US>The functional or mental status provides insight into the patient's functional and mental limitations.</en-US></language>
<languages xml:space="preserve"><nl-NL>Een algemene meting legt de uitkomst vast van een meting of bepaling die bij een patiënt is uitgevoerd. De bouwsteen wordt gebruikt om de uitslagen van metingen vast te leggen waarvoor geen specifieke bouwstenen zijn geformuleerd. De bouwsteen is niet bedoeld voor laboratorium bepalingen die uitgevoerd worden op materiaal dat bij de patiënt is afgenomen.
{</nl-NL><en-US>A general measurement determines the result of a measurement or determination made for a patient. The information model is used to record the measurement results for which no specific information models have yet been formulated. The information model is not intended for laboratory determinations to be carried out on the material taken from the patient.</en-US></language>
<languages xml:space="preserve"><nl-NL>! Let op: deze bouwsteen ondergaat momenteel een substantiele revisie. Een nieuwe versie zal na de zomer beschikbaar zijn.
Belangrijke onderdelen van de algemene mentale functies van de hersenen zijn intellectuele functies, oriëntatie en bewustzijn.
Als er sprake is van stoornis in intellectuele functies t.g.v. verstandelijke beperking wordt dit niet beschreven in deze bouwsteen maar als medische diagnose vastgelegd.
Stoornissen in oriëntatie en bewustzijn in combinatie met stoornissen in aandacht, geheugen en waarneming worden gezien als belangrijke symptomen voor de mogelijke aanwezigheid van een delier. Laatstgenoemde stoornissen worden vastgelegd in de bouwsteen SpecifiekeMentaleFuncties.
{</nl-NL><en-US>! Attention: this information model is undergoing major revision. A new version will be available after summer.
Important parts of the brain's general mental functions are intellectual functions, orientation and consciousness.
If there is a disorder in the intellectual functions as a result of a mental disability, it is not described in this information model but is recorded as a medical diagnosis.
Disorders in orientation and consciousness combined with disorders in attention, memory and observation are seen as important symptoms for the potential presence of a delirium. The latter disorders are recorded in the SpecificMentalFunctions information model.</en-US></language>
<languages xml:space="preserve"><nl-NL>Vijftienpuntschaal waarmee het bewustzijnsniveau van een persoon, van volkomen helder tot diep bewusteloos, kan worden weergegeven in een cijfer, de zogenaamde EMV-score.
De Glasgow comascore ofwel EMV (Eye-Motor-Verbal) score is een maat voor de mate van het bewustzijn, gebaseerd op oog-, verbale en bewegingsreacties op specifieke voorgeschreven hoorbare en voelbare prikkels.
{</nl-NL><en-US>Fifteen-point scale for expressing a person's level of consciousness, from fully awake to deep unconsciousness, in a number: the so-called EMV score.
The Glasgow Coma Scale score or EMV (Eye-Motor-Verbal) score is a scale to measure the extent of consciousness, based on eye, verbal and motor responses to specific prescribed sound and pain stimuli.</en-US></language>
A healthcare provider is a person authorized to act in individual healthcare.
<languages xml:space="preserve"><nl-NL>Een zorgaanbieder is een organisatie die medische-, paramedische- en/of verpleegkundige zorg aanbiedt, en ook daadwerkelijk verleent, aan cliënten/patiënten. Voorbeelden zijn: ziekenhuis, verpleeghuis, huisartsenpraktijk.
{</nl-NL><en-US>A healthcare provider is an organization that offers and provides medical, paramedic and/or nursing care to patients/clients. Examples include: hospitals, nursing homes, doctor's offices.</en-US></language>
! Attention: this information model is undergoing major revision. A new version will be available after summer.
Hearing is the ability to observe sound, with the purpose of communicating with others, localizing the source of the sound and recognizing certain sounds. This pertains to observing the sound waves, and not processing the sounds in the brain.
A hearing disorder can lead to things including communication problems.
The heart frequency is the number of heartbeats per minute.
There are often multiple people or parties involved in the care for a patient with a disorder or disability, particularly in the event of home care. Their efforts enable the patient to function more or less independently. This includes not only caregivers, but also professional help such as that offered by home care organizations, nurses, aids and helpers.
Current doctors and staff from the facility to which a patient is admitted do not fall under this concept.
Help with medication describes the extent to which the patient is independently capable of using medication and is a part of self-care. This only concerns the aspect of independence and not the specifications of the medication.
<languages xml:space="preserve"><nl-NL>Een langdurige of levenbedreigende ziekte is in vrijwel alle gevallen een traumatisch ervaring voor de patiënt en zijn omgeving. Iedere patiënt gaat op zijn eigen manier hiermee om. De manier waarop iemand met problemen en stress omgaat, wordt ook wel coping genoemd. Ziektebeleving gaat in op zowel de inschatting door de patiënt van zijn situatie als op de wijze waarop de patiënt en zijn omgeving met deze situatie omgaan (copingstrategieën).
{</nl-NL><en-US>In nearly all cases, a lengthy or life-threatening illness is a traumatic experience for the patient and their environment. Every patient deals with this in their own way. The way in which a person deals with problems and stress is also referred to as coping. Illness perception entails both the way the patient sees their situation and the way in which the patient and their environment deal with the situation (coping strategies). </en-US></language>
<languages xml:space="preserve"><nl-NL>Een infuus is een apparaat waarmee vloeistof langzaam in een bloedvat wordt gespoten. Het infuus bestaat uit een aantal delen.
Tot het infuus behoort:
- de canule (perifeer) of de katheter (centraal) die perifeer of centraal wordt ingebracht bij de patiënt;
- het toedieningssysteem dat aangesloten is op de canule/katheter waardoor de vloeistof loopt die wordt toegediend;
- de infuuszak waar de vloeistof zich in bevindt.
Op één canule/katheter kunnen meerdere toedieningssystemen zijn aangesloten. Daarnaast kan een centraal veneuze katheter meerdere lumina bevatten.
Naast veneuze katheters zijn er ook arteriële en epidurale katheters.
{</nl-NL><en-US>A drip is a machine that slowly injects fluid into a blood vessel. The drip has a number of components.
The drip contains:
- the (peripheral) cannula or the (central) catheter put into the patient peripherally or centrally;
- the administering system connected to the cannula/catheter allowing the administered fluid to run;
- the drip bag containing the fluid.
Multiple administering systems may be connected to one cannula/catheter. Furthermore, a central venous catheter may have multiple lumens.
Arterial and epidural catheters also exist in addition to venous catheters.</en-US></language>
<languages xml:space="preserve"><nl-NL>Een laboratoriumuitslag beschrijft het resultaat van een laboratoriumbepaling.
Behalve de uitkomsten van testen met een enkelvoudig resultaat kunnen ook de uitkomsten van meer complexe testen met meervoudige resultaten of 'panel' vastgelegd worden.
{</nl-NL><en-US>A laboratory result describes the result of a laboratory analysis.
In addition to the results of tests with a singular result, the results of more complex tests with multiple results or a 'panel' can also be recorded.</en-US></language>
Linguistic competence is the ability to express oneself in a certain language and understand statements made in that language. This includes both oral and written communication.
<languages xml:space="preserve"><nl-NL>De levens- en/of geloofsovertuiging van de patiënt.
{</nl-NL><en-US>Patient's life stance and/or religion.</en-US></language>
The living situation is the physical environment in which the patient normally lives, sleeps, keeps their clothing, etc.
<languages xml:space="preserve"><nl-NL>De Malnutrition Universal Screening Tool (MUST) is een (gevalideerd) diagnostisch screeningsinstrument voor het bepalen van de mate van ondervoeding van de patiënt.
Voor dit screeningsinstrument wordt bij elke patiënt de Body Mass Index (BMI) en het percentage gewichtsverlies berekend en wordt de patiënt een ziektefactor toegekend. De MUST ondersteunt het vroegtijdig herkennen en behandelen van ondervoeding. (Bron: Richtlijn Behandeling en screening ondervoeding.)
{</nl-NL><en-US>The Malnutrition Universal Screening Tool (MUST) is a (validated) diagnostic screening tool for determining the extent of a patient's malnutrition.
For this screening tool, every patient's Body Mass Index (BMI) and weight loss percentage is calculated, after which the patient is assigned a disease factor. The MUST helps to recognize and treat malnutrition at an early stage. (Source: Guidelines for Screening and Treating Malnutrition.)</en-US></language>
<languages xml:space="preserve"><nl-NL>Ondervoeding is een voedingstoestand, waarbij een disbalans van energie, eiwit en andere voedingsstoffen leidt tot meetbare nadelige effecten op lichaamssamenstelling en functioneren. Dit komt met name door een klinisch relevante afname van de spiermassa.
Met name zieke mensen en kwetsbare ouderen lopen kans om ondervoed te raken. Een hulpmiddel bij het vaststellen van (risico op) ondervoeding zijn gevalideerde screeningsinstrumenten als de MUST en de SNAQ questionaire. (Bron: NHG, Landelijke Eerstelijns Samenwerkings Afspraak Ondervoeding)
{</nl-NL><en-US>Malnutrition is a nutritional condition in which the patient has an imbalance of energy, protein and other nutrients leading to measurable negative effects on the body's composition and functioning. This is largely caused by a clinically relevant reduction in muscle mass.
Ill and vulnerable elderly people are particularly prone to malnutrition. Aids in determining (the risk of) malnutrition are validated screening tools such as the MUST and SNAQ questionnaire. (Source: NHG, National Primary Care Collaboration Agreement on Malnutrition)</en-US></language>
<languages xml:space="preserve"><nl-NL>Burgerlijke staat is de formele positie van een mens in de zin en betekenis van het burgerlijk wetboek. Te onderscheiden vallen huwelijkse staat en partnerregistratie (geregistreerd partnerschap).
{</nl-NL><en-US>Marital status is a person's formal position as defined by the Dutch civil code. There is a distinction between marriage and civil union.</en-US></language>
<languages xml:space="preserve"><nl-NL>Medische hulpmiddelen kunnen worden omschreven als de inwendig geïmplanteerde en uitwendige apparatuur en/of hulpmiddelen die de patiënt gebruikt of heeft gebruikt om de gevolgen van functionele beperkingen van orgaansystemen te verminderen of om de behandeling van een ziekte mogelijk te maken.
{</nl-NL><en-US>Medical aids are any internally implanted and external devices and/or aids used by the patient (in the past) to reduce the effects of functional limitations in organ systems or to facilitate the treatment of a disease.</en-US></language>
Administration of medication describes the actual administration of the medication. This can be simply swallowing a tablet, applying ointment or paste, or an infusion that takes a considerable amount of time.
The administration can refer to a medication prescription, but can also refer to home medication.
<languages xml:space="preserve"><nl-NL>Medicatie verstrekking beschrijft de levering van een medicatieproduct aan een specifieke patiënt (of de toediener of een vertegenwoordiger), met de bedoeling dat het gebruikt wordt volgens een meegeleverde instructie (meestal als uitvoering van het verstrekkingsverzoek in een medicatievoorschrift).
Een verstrekking vindt plaats op het moment dat de patiënt (of de andere genoemden) het product fysiek ontvangt.
{</nl-NL><en-US>Medication supply describes the supply of a medicinal product to a specific patient (or the administerer or a representative), with the intention of it being used according to the included instructions (usually to honor the supply request in a medication prescription).
Medication supply takes place when the patient (or any of the others listed above) physically receives the product.</en-US></language>
<languages xml:space="preserve"><nl-NL>Een medicatievoorschrift is een afspraak of order voor het gebruik van medicatie, waarin beschreven worden: het voorgeschreven product, instructies voor het gebruik of toediening en (optioneel) een verzoek tot aflevering.
Van ieder voorgeschreven product wordt de dosisinformatie weergeven: de startdatum en tijd en eventuele stopdatum en tijd of totaal aantal giften, toedieningsschema (frequentie of interval, toedieningstijden, relatie met maaltijden e.d.), de keerdosis, toedieningssnelheid of -duur (voor infusen), en de toedieningsweg.
Ook wordt eventueel aangegeven of het 'zo nodig' medicatie betreft en onder welke voorwaarde het middel dan gebruikt dient te worden en hoe hoog dan de afgesproken maximale dosis in een periode is.
Zo mogelijk wordt de reden of indicatie van starten/stoppen/wijzigen van het gebruik vermeld.
Ook medicatie waarvan het gebruik tijdelijk onderbroken is, kan worden vermeld.
Wanneer het voorschrift ook de bestelling bevat om een middel aan patiënt of een toediener af te verstrekken, dan kan het voorschrift een recept genoemd worden.
{</nl-NL><en-US>A medication prescription is an agreement or order for the use of medication in which the following are described: the prescribed product, instructions for use or administration and (optionally) a request for delivery.
The dose information is given for every prescribed product: the start date and time, and if possible stop date and time or total number of administrations, administering schedule (frequency or interval, administering times, link with meals etc.), the number of doses, administering speed or time (for drips), and the route of administration.
An indication can also be included of whether the medication is only to be administered 'as needed' and under which conditions the product is to be used, and how high the agreed maximum dose is in a certain period.
If possible, the reason or indication of starting/stopping/changes in use is to be included.
Medication that has been discontinued temporarily can be included as well.
If the prescription also contains the order to pr</en-US></language>
<languages xml:space="preserve"><nl-NL>MedicatieGebruik beschrijft de inname of toediening van een medicament, veelal in relatie tot een voorschrift, maar ook op eigen initiatief. Het beschrijft het patroon van inname van medicatie, zoals gerapporteerd door de patiënt zelf, een mantelzorger of een zorgverlener. Het vastleggen van medicatie gebruik geeft naast het gebruik van voorgeschreven medicatie ook inzicht in het gebruik van thuismedicatie.
{</nl-NL><en-US>MedicationUse describes taking or administering the medication, often in relation to a prescription, but also on the person's own initiative. This describes the pattern of medication use, as reported by the patient themselves, a caregiver or healthcare provider. Documenting medication use provides insight into the use of prescribed medication as well as the use of medication at home.</en-US></language>
<languages xml:space="preserve"><nl-NL>! Let op: deze bouwsteen ondergaat momenteel een substantiele revisie. Een nieuwe versie zal na de zomer beschikbaar zijn.
De menstruatiecyclus is een periodieke verandering in het lichaam van de geslachtsrijpe vrouw tussen de puberteit en de menopauze. De cyclus heeft te maken met de eicelrijping en het klaarmaken van het lichaam voor mogelijke zwangerschap.
Door verschillende oorzaken kunnen er afwijkingen of verstoringen van de cyclus optreden.
Het concept gaat met name in op de stoornissen en beschrijft niet of de patiënt in staat is zelfstandig de verzorging bij menstruatie uit te voeren. Dit wordt beschreven in de bouwsteen VermogenTotToiletgang
{</nl-NL><en-US>! Attention: this information model is undergoing major revision. A new version will be available after summer.
The menstrual cycle is a periodical change in sexually mature women's bodies between puberty and menopause. The cycle has to do with egg cell maturation and getting the body ready for potential pregnancy.
Various causes can lead to deviations or disruptions in the cycle.
The concept mainly focuses on the disorders and does not describe whether the patient is capable of independently taking care of their menstrual hygiene. This is described in the ToiletUse information model.</en-US></language>
! Attention: this information model is undergoing major revision. A new version will be available after summer.
Mobility describes the abilities and any limitations in all aspects of mobility, such as changing position, walking and moving forward, in some cases with the help of an aid.
Nationality is used as an indication of the country of citizenship.
<languages xml:space="preserve"><nl-NL>Een verpleegkundige interventie is de verzorging en/of behandeling die een verpleegkundige uitvoert op basis van een deskundig oordeel en klinische kennis. Het is een onderdeel van het verpleegkundige proces; interventies worden bepaald naar aanleiding van geïndiceerde zorgproblemen (verpleegkundige diagnoses) en op grond van behandeldoelen. De interventies worden geconcretiseerd in verpleegkundige acties.
{</nl-NL><en-US>A nursing intervention is the care and/or treatment carried out by a nurse based on an expert opinion and clinical knowledge. It is part of the nursing process; interventions are determined as a result of indexed healthcare problems (nursing diagnoses) and based on treatment goals. The interventions are outlined in the nursing procedures.</en-US></language>
<languages xml:space="preserve"><nl-NL>Een voedingsadvies is een beschrijving van voeding voor de patiënt, die aan specifieke eisen moet voldoen in verband met de gezondheidstoestand van de patiënt. Allergieën en overgevoeligheden of kauw- en slikproblemen kunnen aanleiding zijn voor speciale voeding.
{</nl-NL><en-US>A nutritional advice is a description of nourishment for the patient, which must meet specific requirements in view of the health condition of the patient. Allergies and food intolerances or chewing and swallowing problems may be a reason for special nutrition.</en-US></language>
<languages xml:space="preserve"><nl-NL>De arteriële zuurstofsaturatie, kortweg saturatie, is een graadmeter voor de hoeveelheid zuurstof die aan het hemoglobine in de rode bloedcellen in de arteriën of slagaders gebonden is. De meting wordt meestal uitgevoerd als een transcutane meting met een saturatiemeter of pulsoximeter. De saturatie wordt uitgedrukt als een percentage en is bij gezonde personen meer dan 95%.
{</nl-NL><en-US>Arterial oxygen saturation, also referred to as saturation, is an indicator for the amount of oxygen bound to the hemoglobin in the red blood cells of the arteries. The measurement is usually carried out as a transcutaneous measurement with a blood oxygen monitor or pulse oximeter. The saturation level is expressed as a percentage and should be over 95% in healthy people.</en-US></language>
<languages xml:space="preserve"><nl-NL>Het concept Uitkomst van zorg (zorgresultaten) beschrijft de vastgestelde status van de patiënt met betrekking tot een bepaald probleem. Het geeft door vergelijking met het behandeldoel inzicht in de effectiviteit van verpleegkundige interventies/activiteiten die ingezet zijn met betrekking tot dit probleem. Het is een onderdeel van het verpleegkundig proces, samen met verpleegkundige diagnoses/problemen, behandeldoel en verpleegkundige interventies.
Er zijn verschillende classificatie systemen die zorgresulaten beschrijven met een meetwaarde, zoals NOC (Nursing Outcome Classification), Omaha System, ICF (International Classification of Functioning, Disability and Health). Zo mogelijk wordt gebruik gemaakt van één van deze indelingen.
{</nl-NL><en-US>The Healthcare Results (healthcare results) concept describes the determined status of the patient in terms of a certain problem. Comparing the healthcare result with the treatment goal provides insight into the effectivity of the nursing interventions/activities carried out for this problem. It is a part of the nursing process, together with nursing diagnoses/problems, the treatment goal and nursing interventions.
There are different classification systems that describe healthcare results with a measurement value, such as the NOC (Nursing Outcome Classification), Omaha System, and ICF (International Classification of Functioning, Disability and Health). One of these classifications is to be used if possible.</en-US></language>
Pain experience provides an indication of the pain experienced by the patient that is as comprehensive as possible. This includes not only the extent of the pain but also the context in which the pain is experienced. The extent of pain is recorded using the Numeric Rating Scale (NRS) or the Visual Analogue Score (VAS).
<languages xml:space="preserve"><nl-NL>De pijnscore is een algemene maat voor de pijnbeleving, geen beschrijving van specifieke, gelocaliseerde pijn.
Als goed reproduceerbare maat voor de beleving van pijn worden gebruikt:
1) NRS (Numeric Rating Scale) waarbij de patiënt een cijfer geeft aan de pijn op een schaal van 1 (geen pijn) en 10 (ondraaglijke pijn).
2) VAS (Visual Analogue Score) , waarbij de patiënt op een lat met een lijn aangeeft hoe de pijn ervaren wordt en op de achterkant van de lat staat een schaal van 0 (geen pijn) tot 10 (ondraaglijke pijn).
De uitslag van beide scores hebben dezelfde betekenis, maar de visueel analoge methode (VAS) wordt als betrouwbaarder aangemerkt dan de NRS pijnscore.
{</nl-NL><en-US>The pain score is a general measurement for pain experience, not a description of specific, localized pain.
The following are used as an easily reproducible measurement for pain experience:
1) NRS (Numeric Rating Scale) in which the patient gives the pain a number on a scale of 1 (no pain) to 10 (unbearable pain).
2) VAS (Visual Analogue Score), in which the patient points to a bar with a line to indicate the pain they feel. The back of the bar has a scale from 0 (no pain) to 10 (unbearable pain) on it.
The results of both scores have the same meaning, but the visual analogue method (VAS) is seen as more reliable than the NRS pain score.</en-US></language>
<languages xml:space="preserve"><nl-NL>Participatie in de maatschappij gaat in op deelname aan maatschappelijke activiteiten die patiënt in het dagelijks leven onderneemt, zoals het uitoefenen van een beroep en hobby activiteiten. Daarnaast beschrijft participatie in de maatschappij het sociale netwerk van de patiënt.
{</nl-NL><en-US>Participation in society pertains to the patient's initiative to participate in social activities in daily life, such as practicing a profession and hobbies. Participation in society also describes the patient's social network.</en-US></language>
A person who receives medical care.
<languages xml:space="preserve"><nl-NL>Betalers zijn organisaties of individuen die betalen voor de aan de patiënt geleverde zorg. Deze organisaties of individuen kunnen zijn: instellingen of personen die financieel garant staan of verantwoordelijk zijn voor de patiënt (zoals ouders van minderjarigen), organisaties met directe financiële verantwoordelijkheid, combinaties van deze of de patiënt zelf.
{</nl-NL><en-US>Payers are organizations or individuals that pay for the healthcare supplied to the patient. These organizations or individuals can be: facilities or people who financially guarantee or who are responsible for the patient (such as parents or guardians of minors), organizations with direct financial responsibility, combinations of these or the patient themselves.</en-US></language>
<languages xml:space="preserve"><nl-NL>Alle geplande afspraken, verwijzingen, behandelingen en diagnostische procedures, uitstaande orders en orders waarvan de uitslag nog niet bekend is, relevant voor de zorg van de patiënt, kunnen worden vermeld. Ook kunnen hier Clinical reminders worden geplaatst. Dit zijn uitgestelde orders, die nog niet actief zijn. (Bijvoorbeeld: let op! patiënt moet nog een booster vaccinatie hebben over x weken; let op! controleer de volgende keer de wangslijmvliezen). Het concept GeplandeZorgActiviteit is een regel uit het behandelplan.
Hiermee kan elke ontvanger, raadpleger of zorginstelling inzicht krijgen in de geplande zorg voor deze patiënt.
{</nl-NL><en-US>All planned appointments, referrals, treatments and diagnostic procedures, open orders and orders of which the results are not yet known that are relevant to the patient's care may be included. Clinical reminders can also be included here. These are postponed orders that are not yet active. (For example: please note! patient still needs a booster vaccination in x weeks; or please note! check the oral mucosa next time). The PlannedCareActivity concept is a line from the treatment plan.
This gives every recipient, user or healthcare facility insight into the planned care for this patient.</en-US></language>
<languages xml:space="preserve"><nl-NL>Zwangerschap of graviditeit is de toestand waarin een vrouw een bevruchte eicel, en vervolgens embryo en foetus, in zich draagt. Een zwangerschapsduur tussen 37 en 42 weken wordt als normaal beschouwd. De periode van 37 tot 42 weken wordt de "à terme periode" genoemd. De term graviditeit wordt ook gebruikt voor het aantal malen dat een vrouw zwanger is geweest. Samen met de pariteit, het aantal keren dat een vrouw bevallen is, geeft dit inzicht in de obstetrische voorgeschiedenis van de patiënt.
{</nl-NL><en-US>Pregnancy or gravidity is the condition in which a woman carries a fertilized egg, which grows into an embryo and then a fetus. A pregnancy of between 37 and 42 weeks is considered normal. "Term pregnancy" is 37 to 42 weeks. The term gravidity is also used for the number of times a woman has been pregnant. This and parity - the number of times a woman has given birth - provides insight into the patient's obstetric history.</en-US></language>
A decubitus wound is localized damage to the skin and/or underlying tissue, often over a bony prominence, as a result of pressure or pressure combined with friction.
A decubitus wound involves a major disease burden and reduces the quality of life for a patient. Adequate risk evaluation, prevention and treatment of decubitus wounds can lead to a fewer incidences and prevalence of decubitus wounds.
The concept Procedure indicates a therapeutic procedure undergone by the patient. If relevant, diagnostic procedures can be listed as well.
A procedure can be a simple blood pressure measurement, but also a complex heart surgery.
<languages xml:space="preserve"><nl-NL>De polsfrequentie is het aantal palpaties per minuut gemeten aan een slagader.
{</nl-NL><en-US>The pulse rate is the number of palpations per minute measured at an artery.</en-US></language>
During breathing or respiration, air flows to and from the lungs, where gas exchange occurs, absorbing oxygen from the air into the blood and exhaling carbon dioxide into the air. Observations of spontaneous breathing, usually registered as part of the observation of vital functions.
<languages xml:space="preserve"><nl-NL>De Short Nutritional Assessment Questionnaire (SNAQ) is een (gevalideerd) meetinstrument voor het bepalen van de mate van ondervoeding van de patiënt. Het instrument bestaat uit drie vragen waaraan een score wordt toegekend. De totaalsom van deze score bepaalt de mate van ondervoeding. De SNAQ ondersteunt het vroegtijdig herkennen en behandelen van ondervoeding.
Er zijn drie varianten van het meetinstrument voor verschillende zorgsettingen ontwikkeld, te weten ziekenhuis, verzorgings- en verpleeghuizen en zelfstandig wonende ouderen. Dit concept beschrijft het instrument dat bedoeld is voor de ziekenhuissetting.
{</nl-NL><en-US>The Short Nutritional Assessment Questionnaire (SNAQ) is a (validated) measuring tool for determining the extent of a patient's malnutrition. The tool comprises three questions, each of which is assigned a score. The total score determines the extent of malnutrition. The SNAQ helps to recognize and treat malnutrition at an early stage.
Three varieties of the measuring tool were developed for different care settings: hospitals, nursing and retirement homes and independently living seniors. This concept describes the tool intended for the hospital setting.</en-US></language>
! Attention: this information model is undergoing major revision. A new version will be available after summer.
Sensory observation, also known as perception, is the process of obtaining, registering, interpreting, selecting and ordering sensory information.
The observation occurs when offering external stimuli to stimulus-specific receptors: the senses. Examples of stimuli include smells, heat and pressure.
The concept is limited to the function of the senses and any disorders of this function and does not include the interpretation of the observation in the brain.
Other information models are available for the hearing function and visual function.
A skin condition is a disturbance of the organ skin caused by a source to be specified later on.
! Attention: this information model is undergoing major revision. A new version will be available after summer.
Sleep is the period of inactivity and absence of waking consciousness in which the body relaxes and has lowered physiological and psychological activity.
Varying causes can lead to sleeping problems and disorders in the various aspects of sleep, such as falling asleep, sleeping soundly and maintaining a day-time/night-time sleeping pattern.
Sleeping mainly involves problems and disorders.
<languages xml:space="preserve">
<nl-NL>! Let op: deze bouwsteen ondergaat momenteel een substantiele revisie. Een nieuwe versie zal na de zomer beschikbaar zijn.
Belangrijke onderdelen van de specifieke mentale functies van de hersenen zijn aandacht, stemming, denken en geheugen.
Stoornissen in aandacht, geheugen en waarneming samen met oriëntatie en bewustzijn uit bouwsteen algemene mentale functies gezien als belangrijke symptomen voor het ontstaan van een delier.
Het concept specifieke mentale functies omvat niet het gedrag dat het gevolg is van een stoornis in de mentale functie.</nl-NL>
<en-US>! Attention: this information model is undergoing major revision. A new version will be available after summer.
Important parts of the brain's specific mental functions are attention, mood, thought and memory.
Disorders in attention, memory and observation combined with orientation and consciousness from the GeneralMentalFunctions information model are seen as important symptoms for a delirium.
The concept specific mental functions does not contain behavior resulting from a mental disorder.
</en-US></languages>
A stoma is an unnatural, surgically created opening connecting a body cavity with the outside world. A stoma is created e.g. as an exit opening for feces or urine in the event that they cannot leave the body naturally. In the case of a tracheostomy, the stoma is intended to facilitate breathing if that is no longer possible via the oral, nasal and throat cavity.
Tobacco is a product that comes from the leaves of the tobacco plant, which is smoked as a drug. Smokable forms of tobacco include rolling tobacco, cigarettes, cigars and pipe tobacco. This information model describes the information asked of the patient about their use of tobacco.
Textual results describe the findings and interpretation of diagnostic or therapeutic procedures carried out on patients or on specimens from the patient.
A treatment instruction includes an agreed constraint in the treatment based on the oral or written living will of the patient.
<languages xml:space="preserve"><nl-NL>Het behandeldoel omschrijft het gewenste resultaat van de behandeling/interventies met betrekking tot het benoemde probleem van de patiënt. Naast de streefwaarde wordt bij het te bereiken doel ook een streefdatum aangegeven. Vergelijking van het behandeldoel met de uitkomsten van zorg geeft inzicht in de effectiviteit van de behandeling/interventies.
Voor het verpleegkundig proces wordt het probleem uitgedrukt als verpleegkundige diagnose. Het behandeldoel is samen met verpleegkundige diagnoses, verpleegkundige interventies en uitkomsten van zorg, onderdeel van het verpleegkundig proces.
{</nl-NL><en-US>The treatment goal describes the desired result of the treatment/interventions in terms of the patient's diagnosed problem. The goal and target date are entered in addition to the target value. Comparing the healthcare results to the treatment goal provides insight into the effectivity of the treatment/interventions.
In the nursing process, the problem is expressed as a nursing diagnosis. The treatment goal, nursing diagnoses, nursing interventions and healthcare results are part of the nursing process.</en-US></language>
<languages xml:space="preserve"><nl-NL>Immunisatie kan worden gedefinieerd als 'Het opwekken van natuurlijke immuniteit tegen ziekteverwekkers door middel van vaccinatie (actieve immunisatie) of door toediening van immunoglobulinen (passieve immunisatie)'.
In deze bouwsteen worden alleen de vaccinaties opgenomen. De toediening van immunoglobulines maakt deel uit van het medicatieoverzicht. Vaccinaties hebben levenslang relevantie.
De meeste vaccinaties worden in Nederland uitgevoerd in het kader van het Rijksvaccinatieprogramma (RVP). RVP informatie is vooral van belang bij kinderen.
Vaccinaties zijn ook relevant bij volwassen patiënten zoals transplantatiepatiënten, dialysepatiënten en patiënten met een status na miltextirpatie. Daarnaast zijn er specifieke indicaties voor de vaccinatie van risicogroepen, zoals reizigers, professionals die met bloed in aanraking komen of patiënten met verwondingen, een verminderde afweer of verhoogd risico.
{</nl-NL><en-US>Immunization can be defined as 'Generating natural immunity against pathogens by means of vaccination (active immunization) or by administering immunoglobulins (passive immunization)'.
Only vaccinations are included in this information model. Administering immunoglobulins is part of the medication overview. Vaccinations have lifelong relevance.
Most vaccinations are carried out in the Netherlands as part of the RVP (Rijksvaccinatieprogramma, National Immunisation Program). RVP information is especially important for children.
Vaccinations are also relevant for adult patients such as transplant patients, dialysis patients and patients with a post-splenectomy status. In addition, there are specific indications for the vaccination of risk groups, such as travelers, professionals who come into contact with blood or patients with wounds, weakened immune systems or heightened risk.</en-US></language>
<languages xml:space="preserve"><nl-NL>! Let op: deze bouwsteen ondergaat momenteel een substantiele revisie. Een nieuwe versie zal na de zomer beschikbaar zijn.
Zien is het vermogen om belichte objecten waar te nemen, met als doel zich te oriërenteren op voorwerpen en personen in een belichte omgeving. Het gaat daarbij om de waarneming van de lichtprikkels en niet om de verwerking er van in de hersenen.
Een stoornis van de gezichtsfunctie kan leiden tot onder andere orientatieproblemen.
{</nl-NL><en-US>! Attention: this information model is undergoing major revision. A new version will be available after summer.
Sight is the ability to observe lit objects, with the goal of orienting yourself on objects and people in a lit environment. This pertains to observing the light stimuli, and not processing them in the brain.
A sight disorder can lead to things including orientation problems.</en-US></language>
<languages xml:space="preserve"><nl-NL>Een wond is een onderbreking van de continuïteit van de huid, veelal veroorzaakt door externe invloeden.
Een veelgebruikte model om de wondkenmerken vast te leggen is het TIME ('Tissue', 'Infection', 'Moisture', 'Edge') model, waarbij de wond systematisch wordt beschreven. Bij wondweefsel (T uit het TIME model) wordt gebruik gemaakt van de indeling van het WCS model (Woundcare Consultant Society, WCS Kenniscentrum Wondzorg). Het WCS model is niet geschikt voor de beschrijving oncologische ulcera. Hiervoor bestaat een andere classificatie.
Oncologische ulcera zijn huiddefecten die zijn ontstaan door het tumorproces. Zij onderscheiden zich van oncologische wonden die ontstaan ten gevolge van de behandeling van kanker, bijvoorbeeld radiotherapie, chemotherapie of chirurgie.
Het concept beschrijft geen decubituswonden en brandwonden. Hiervoor kunnen de betreffende bouwstenen gebruikt worden.
{</nl-NL><en-US>A wound is an interruption of the continuity of the skin, often caused by external influences.
A commonly used model for documenting the wound properties is the TIME ('Tissue', 'Infection', 'Moisture', 'Edge') model, which can be used to systematically describe the wound. For wound tissue (T in the TIME model), the structure of the WCS model (Woundcare Consultant Society, WCS Kenniscentrum Wondzorg) is used. The WCS model is not suited for describing oncological ulcers. There is a separate classification for that.
Oncological ulcers are skin defects which result from the tumor process. They are different from wounds resulting from cancer treatment, such as radiotherapy, chemotherapy or surgery.
The concept does not describe decubitus wounds and burn wounds. For these, the relevant information models can be used.</en-US></language>
*Motivation
The starting point in healthcare is that the patient comes first. It must be noted, however, that today processes are typically devised and designed by the care provider. This can lead to obstacles for the patient with respect to access to care and understanding and influencing the care process.
*Rationale
The hospital derives its raison d’être from the needs of the patient. The services are therefore focused on satisfaction and best results for the patient and the reduction of costs for the hospital (value-based healthcare).
*Implications
The care process is organized from the perspective of the patient, so in terms of services for the patient, this means:
· —� Information about the key care processes should be available to the patient
—� Care provision is patient-friendly, service-oriented, and professional
Many logistical processes underlying the provision of care are not important to communicate to the patient � he or she must be confronted with this as little as possible and not be bothered by it; this means:
—� The logistical processes should be in the best interest of the patient while also being practical for the provider
—� Patients are helped quickly, not unnecessarily referred, and need only provide information once � the client file must therefore be complete and known to every actor (insofar as privacy rules are followed)
The patient decides, in consultation with his or her provider, the course of care, which means:
—� Healthcare providers proactively inform the patient
—� Patient privacy is guaranteed; healthcare providers must comply with the healthcare privacy rules and regulations of the country where care is provided
—� The patient can go to a clear, open, and friendly counter/contact point for questions and complaints
*Motivation
Healthcare is provided in a network of formal and informal care giving. Networks exist in hospitals, in hospital systems, and in larger ecosystems. In a network, caregivers are separated by few if any degrees of separation. Operational and information management are still too focused on efficiency within an organization.
*Rationale
Typically, patient care is delivered by formal and/or informal caregivers in a network. Several care providers are involved in the care of a patient and they do not always work in a hospital or in the same hospital. By organizing operational management and information management through cooperation, the collaborating partners work together quickly and efficiently for the benefit of the patient. Both the operational management around the patient and the required information exchange are designed for interoperability across the boundaries of care lines.
*Implications
· Healthcare is increasingly developing in networked care � cooperation with collaboration partners in the service of the patient
· Anticipating and acting on internal and external developments and social involvement is a motivation of the hospital
· Information exchange in healthcare is essential to guarantee the quality and continuity of healthcare � information provision must therefore be up-to-date and set up for maximum interchangeability
· Patient care, research, and education reinforce and build on each other in a learning healthcare system; patients, healthcare providers, researchers, teachers, and students work together, which also requires adequate information exchange
*Motivation
Most hospitals experience data collection as burdensome. This is caused by, among other things, inefficient data management. Frequently, data is requested and stored multiple times, in multiple systems, and multiple places, unnecessarily. This is because data is often not coded using a standardized format. This limits the possibilities for reuse (which makes repeated data collection and entry necessary) and can lead to interpretation errors.
*Rationale
Data and information are among the most valuable resources in an organization. Unambiguous and one-time registration of data helps ensure that everyone has access to the same facts, including where key data is located. As a result, scientific research becomes easier. Patients no longer need to tell the same story every time. Because information is more widely available and usable, within boundaries set by safety and security protocols, patients and personal caregivers can exercise more control over care, permissioned providers can access necessary data when and where needed, and the quality of care may increase.
*Implications
· Data management is organized according to FAIR principles; this means:
—� Findable: data is easy to find (again), identifiable, and traceable to the source; data is accessed quickly, flexibly where possible, cautiously, and checked where necessary
—� Accessible: data is shared and is accessible to authorized persons; authorization is granted in accordance with legislation and policy; storage and disclosure of data is done centrally where possible, locally where necessary
—� Interoperable: data has a common vocabulary and clear definitions � we opt for uniformity and (international) standards where possible, and local nuances where necessary
—� Reusable: data is recorded once at the source for multiple use � data from one domain can be reused in one or more other domains
· One integrated longitudinal view of the patient (patient access and management, integrity, unambiguous, reusable longitudinal file)
· The purpose for which data is used and reused is compatible with the purpose for which data is collected (purpose limitation); customers have access to the data that they keep about patients, who has access to it, and who has edited it or consulted it
· Data is requested from the source and as much as possible use is made of the patient’s master record
· When in doubt about the correctness of data in a system, every user (patient or healthcare provider) must be able to report this to the source holder of that system, after which the source holder will adjust the data if necessary
· Data is created, used, and stored in accordance with the specifications of the healthcare information building blocks
Around this basic principle, a program called “Registration at the Source� was started January 2014 in collaboration between Nictiz and the eight University Medical Centers in the Netherlands. For more information, see https://amigo.nictiz.nl/programma/registratie-aan-de-bron.
*Motivation
Change happens faster and comes from more sources (including government, technology, and users) than ever before. Information exchange is often an impediment that delays responses to changing circumstances and needs of professionals and customers.
*Rationale
The provision of information must support the continuous improvement and innovation of care.
*Implications
· The provision of information is flexible
· The provision of information is increasingly service-oriented, based on loosely-coupled components; systems are synchronized and integrated in real time via an integration platform
· When multiple applications are used, the context of patient data must be clear
· Information provision uses national guidelines, generic standards, and proven solutions
· Information provision is secure and complies with laws and regulations and the standards for information security
· Measures have been put in place to guarantee the continuity of the service throughout the network of care
· Promote the shared use of applications
· Reuse comes before buying, before making
· The provision of information is set up in a sustainable and responsible manner
*Motivation
To be able to manage their care process, patients/customers need insight into the quality of care provided. Only then can they base their choices on the right information. But the registration burden in healthcare is high and the supply of (extra) quality information increases this burden even more. Data to be recorded must have added value for the (care for) the patient or contribute to determining the (quality of) care provided.
*Rationale
By realizing the desired transparency with unambiguous, anonymous data from the primary source registration, (satisfaction) measurements, and information to be derived from this, the registration burden can be limited. This also applies to transparency towards the government, insurers, or other organizations involved in healthcare.
*Implications
· (Re)design of processes based on value for the patient (outcomes, outcome)
· Quality registrations and other deliveries entail as little extra work as possible; this means:
—� The quality records are based on information from the primary process
—� Different quality registrations request similar information in the same way
—� Record data in accordance with the healthcare information building blocks
· Data capturing details of the patient experience is also required for complete transparency; this means:
—� Structural satisfaction and outcome measurements of the patient as part of the process
—� Drawing up and adjusting questionnaires in consultation with the patient, so that attention is paid to what they find important
· The technical design of systems should ensure, to the extent possible, that administrative burden is kept to a minimum; this means:
—� Data is recorded unambiguously to enable multiple use (see also Basic Principle 3)
—� For optimum user-friendliness, interfaces are designed in close collaboration with end users; e.g., using principles from interaction design and user experience design
· Healthcare providers record information clearly and once; this means:
—� Do not record something that has already been recorded
—� Providers should be aware of the usefulness and necessity of this
—� Structural support for caregivers in the use of quality improvement systems
—� Use semantic standards and the healthcare information building blocks
* Reason/Dilemma
How do we organize care in such a way that teams can take joint responsibility for the best outcomes of care.
*Rational
Improving the outcome of care and the patient experience in delivering care.
*Implications
- The patient as a partner: strengthening the involvement of the patient (and family/network) in his treatment and care, and in improving it. If desired, the patient can take the lead in this;
- Interprofessional cooperation: providing care and improving it as the joint responsibility of all professionals involved in hospitals, chains and regional networks.
* Reason/Dilemma
The provision of information does not adapt quickly and flexibly to changes in the approach and participation of the patient. Information provision is too rigid. Adjustments are laborious and complex due to many internal dependencies. Similar functionality occurs in multiple applications. Reuse of functionality is not always possible.
*Rational
A more service-oriented information provision responds more quickly to changing circumstances and new requirements and wishes.
*Implications
- Applications make their functionality and data available through services based on open standards. Open standards provide the best basis for integration because they are widely supported in the market. Open standards also prevent supplier dependencies.
* Reason/Dilemma
Data is now often exchanged without agreement on the meaning of the data. Data is therefore misinterpreted.
*Rational
Unambiguous agreements about the data that are exchanged are necessary for a correct understanding and interpretation of the data. Without these agreements, information exchange can pose a risk to patient safety.
*Implications
- In ICT terms, this means specifying a dataset that specifies which data types are needed and how they are captured.
- For example, implementation of information standards https://www.nictiz.nl/standaardisatie/informatiestandaarden
* Reason/Dilemma
Traditionally, data has been tied to one specific application. The understanding of this data lay within the application. With more and more cooperation and information exchange, this is no longer valid.
*Rational
Data is a valuable asset. They must therefore be managed in such a way that the customers in an organization (or chain) have access to the right data of the right quality at the right time, in a safe manner. Data is the basis of information, knowledge and decisions, and is therefore of crucial importance for the correct and efficient functioning of healthcare.
*Implications
- Monitoring the quality of data;
- Using uniform definitions for data;
- Setting up data governance.
* Reason/Dilemma
For data exchange, it is important that the data that is shared is also interpreted correctly.
*Rational
A healthcare information building block (ZIB) is a model that helps to record data in an unambiguous manner at an information level, where clarity relates to the recorded data and not to the interpretation of that data in a certain context.
*Implications
* Reason/Dilemma
Designing transmural processes is often still custom work aimed at a specific solution and data exchange, which means that this solution is often not reusable.
*Rational
Agreements have been made on the 5 layers of interoperability in the national care standards and guidelines.
*Implications
* Reason/Dilemma
Interoperability still fails too often due to a one-sided approach. Attention is either too one-sidedly focused on infrastructure (technical) or information (datasets). Sometimes only policy agreements have been made, but the implementation fails.
*Rational
All aspects represented in the five layers of the interoperability model require attention for successful implementation.
*Implications
- In ICT terminology this means that concrete 'use cases' are defined with associated actors, transactions and transaction information;
- Agreements are made and recorded on all five layers of the NICTIZ interoperability model;
- See also Checklist voor informatieuitwisseling in de zorg.
* Reason/Dilemma
Data sharing is hampered by the lack of a common definition of the basic set of healthcare data.
*Rational
A collection of patient data that is minimally required to provide patients with continuity of care
*Implications
Implementation of the basic dataset care (https://www.registratieaandebron.nl/pdf/Basisgegevensset_Zorg_v1_0.pdf )
* Reason/Dilemma
Lack of information about his own illness, and insufficient insight into which care provider has had access to his data, leads to the patient having insufficient control over his own care process.
The choice of control over his own process is a patient's right, not an obligation. The patient can hand over control to an informal carer, case manager or the attending physician.
*Rational
- Increase customer satisfaction;
- Increase effectiveness of care;
- The patient can exert influence himself.
*Implications
* Reason/Dilemma
Processes are now focused on internal efficiency.
*Rational
Making processes service-oriented focuses on the result and the added value to be delivered for the customer/patient and puts the customer at the center of the process.
*Implications
- Outcome for the customer is our main driving force in the design;
- A process provides a service. The interest of the customer of the service is leading and preferable to the interest of the actors and departments that carry out the process.
* Reason/Dilemma
When processing information within processes, the reuse of this data is often insufficiently taken into account.
*Rational
For efficient processes and reduction of the registration burden, it is important that data is entered unambiguously, so that it can be used multiple times.
*Implications
- Use of the healthcare information building blocks
- Use of semantic standards and code systems
* Reason/Dilemma
Applications in the chain are often only designed for information exchange and less for collaboration in chain care
*Rational
Collaboration in the chain goes further than just transferring and exchanging information. Continuity of chain care requires a clear, integrated overview based on the organization of data relating to clinical pictures. In addition, it is useful within the chain if functionality is available to support the collaboration between the patient's healthcare providers (e.g. logbook, chat functionality, consent registration, audit trail, integration of self-monitoring and connection to PHE).
*Implications
- An integrated overview is available for the care providers in the chain, in which the data are arranged around the clinical picture and the patient (and not around the care provider)
* Reason/Dilemma
During development and innovation, functional requirements often receive the most attention. Non-functional requirements such as quality criteria are undervalued.
*Rational
Non-functional requirements determine the quality of the system. They are essential for user acceptance, because they determine, among other things, user-friendliness, performance, reusability, extensibility, scalability, reliability, maintainability, future-proofness, effectiveness and efficiency.
The purpose of non-functional requirements is:
- specifying the desired quality characteristics;
- define constraints and design criteria of the system (e.g. secure and transferable);
- early sizing of the system and facilitating cost estimation;
- assess the viability of the proposed system.
*Implications
* Reason/Dilemma
Processes are often designed in different ways and are not uniform. The patient does not recognize uniformity and always feels treated differently.
*Rational
Process modeling according to a generic process model stimulates reuse and recognisability, and saves costs in design and layout
*Implications
- Modeling conventions for process design
- Common library of processes
- Reuse process models
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