A pattern profile for creating (mostly) HL7 Vital Signs compatible zib profiles.

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.

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.

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.

Personal grooming activity means taking care of skin, nails and hair (and beard or mustache, if applicable). This 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.

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.

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.

Address information includes data where a person resides (temporarily, permanently) or where a building is located.

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.

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.

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 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

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

An anatomical location specifies the location (e.g. foot) and laterality (e.g. left) of a body part.

The Apgar score represents the overall clinical status of a newborn child. This is evaluated one, five and ten minutes after birth based on 5 parameters: Appearance, Pulse, Grimace, Activity, Respiration. If the score measured at 5 minutes is < 8, the Apgar score is measured again at 10, 15, 20 minutes etc. until the score = 8. The zib explicitly defines the Apgar score at 1, 5 and 10 minutes after birth. This profile represents the Apgar score at 10 minutes after birth. Profiles have also been defined for the Apgar score at 1 minute and at 5 minutes after birth.

The Apgar score represents the overall clinical status of a newborn child. This is evaluated one, five and ten minutes after birth based on 5 parameters: Appearance, Pulse, Grimace, Activity, Respiration. If the score measured at 5 minutes is < 8, the Apgar score is measured again at 10, 15, 20 minutes etc. until the score = 8. The zib explicitly defines the Apgar score at 1, 5 and 10 minutes after birth. This profile represents the Apgar score at 1 minute after birth. Profiles have also been defined for the Apgar score at 5 minutes and at 10 minutes after birth.

The Apgar score represents the overall clinical status of a newborn child. This is evaluated one, five and ten minutes after birth based on 5 parameters: Appearance, Pulse, Grimace, Activity, Respiration. If the score measured at 5 minutes is < 8, the Apgar score is measured again at 10, 15, 20 minutes etc. until the score = 8. The zib explicitly defines the Apgar score at 1, 5 and 10 minutes after birth. This profile represents the Apgar score at 5 minutes after birth. Profiles have also been defined for the Apgar score at 1 minute and at 10 minutes after birth.

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.

The blood pressure is a parameter for determining the condition of the blood circulation and is expressed in systolic and diastolic pressure in mmHg.

A person’s body height.

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)

Body weight is the common name for (human) body mass.

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.

A care team is a group of health professionals and other people involved in caring for a patient for one or more problems.

The CPB (Checklist Pain Behaviour) is a pain assessment tool, that is used to assess pain in children with a limited expressive repertoire or with a profound cognitive impairment, by observing their behaviour. The CPB has ten observations that need to be addressed. The final score indicates whether the observed child suffers pain and ‘how much’. The score is often combined with a VAS score that is completed by the nurses on basis of clinical experience.

The Comfort Behaviour scale/ComfortNeo scale is an assessment tool, that is used to assess the pain behaviour of neonates (newborn). The Comfort Behaviour scale has 7 observation points that need to be addressed. For each observation a value is assigned from a 5-point scale, the final score indicates whether the observed child suffers pain and ‘how much’. The score is combined with an NRS score that is completed by the nurses on basis of clinical experience.

Contact information includes a person’s telephone numbers en e-mail addresses.

Contact information includes a person’s telephone numbers en e-mail addresses.

A contact is a person not being a healthcare professional 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.

The Delirium Observation Screening Scale is a tool to determine whether a patient has delirium. The DOSS includes 13 observations of behavior (verbal and non-verbal) which represent the symptoms of a delirium. These observations can be performed during regular contact with the patient.

Information on the development and growth of a child is important in determining the kind of care that should be provided to the child and the family. When the child is being transferred, continuity of care can be achieved. Information can provide insight in the process of development and whether the child has a developmental delay.

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.

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. Contacts 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 includes past and future contacts.

The period in which a health problem, such as a complaint or illness, receives attention from a care provider. During this period the designation of this health problem can change due to evolving insight and/or the progress of the illness. An episode of care serves as a context for all data related to the health problem.

The FLACC (Faces, Legs, Activity, Cry and Consolability) is a pain assessment tool, that is used to assess pain in children aged 0-7 years old by observing their behaviour. The FLACC has five subscales that need to be addressed. The final score indicates whether the observed child suffers pain and ‘how much’. The score is often combined with a NRS-score that is completed by the nurses on basis of clinical experience.

A healthy diet means that we do not consume too much or too little (energy intake balanced with energy use) and that the composition of food (mainly important nutrients) follows the recommendations from the Health Council. For an infant, this means that the child receives breastfeeding or formula milk or a combination thereof.

The total water intake and water excretion within a certain time period: a disbalance can lead to for example dehydration or overfilling.

Freedom restricting interventions are interventions that are used against the will of the person concerned and that consciously restrict the person’s freedom to protect the person or his environment. This definition includes many forms of freedom restriction, such as (not exhaustive)

• Forced administration of fluid and nutrition
• Forced administration of medication
• Performing medical checks or other medical procedures
• Restricting freedom of movement
• Admitting to an accommodation and secluding when admitted to an accommodation.
• Exercising supervision
• Searching of clothing or body
• Restriction of visitors and the use of communication means In the hospital, it is usually about restricting the freedom of movement, for example by using bed rails, moving a chair near to the table or using an arm splint for infusion. In combination with freedom-restricting interventions, soothing medication can be administered. In the case of small children, it is often a question of fixing hands, for example, to prevent a stomach tube from being pulled out. For nurses to use it in hospitals, Dutch Nurses Association (V&VN) published a guideline [ref. 3]. In mental health care, care for the disabled and psychogeriatric care, it always concerns care that is used against the will of the patient. The legal framework for using these interventions is (per 1-1-2020) governed by two laws, namely:
• The Wet verplichte ggz (Wvggz: Mandatory Care In Mental Health Act) for people with psychiatric disorders
• The Wet zorg en dwang (Wzd: Care and Compulsion Act) for people with intellectual disabilities and people with a psychogeriatric disorder, such as dementia. The Wvggz refers to the term compulsory care, while the Wzd uses the term involuntary care. A national registration system, the Argus registration, is used to register the interventions in the context of the Wvggz.

The functional or mental status provides insight into the patient’s functional and mental limitations.

The head circumference is the size of the head as measured around the head.

A health professional is a person who is authorized to perform actions in the field of individual healthcare.

A health professional is a person who is authorized to perform actions in the field of individual healthcare.

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.

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.

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.

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.

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 rate 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.

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).

A laboratory result describes the result of a laboratory analysis. These are specimen-oriented tests as performed in laboratories such as Clinical Chemistry, Serology, Microbiology, etc. In addition to the results of tests with a singular result, this concept can also contain the results of more complex tests with multiple results or a ‘panel’.

Obtained specimen material or a microbial isolate that is used in a laboratory analysis.

Source of obtained specimen material or a microbial isolate that is used in a laboratory analysis.

A legal situation can concern a legal status and/or representation. The legal status indicates the basis on which the patient is staying in a healthcare organization. This can be either voluntary or involuntary, however the legal status is always determined by a judge.

A legal situation can concern a legal status and/or representation. Representation is important in situations where a person is legally not competent to give permission and/or factually (partly) incapable of doing so. A representative supports and takes decisions in the interest of the representee when they cannot do so themselves (temporarily or permanently).

Patient’s life stance and/or religion.

The living situation is the physical environment in which the patient normally lives, sleeps, keeps their clothing, etc.

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.)

Medical devices 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.

Medical devices 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.

A contraindication (CI) for medication safety is a condition or characteristic of a patient where healthcare professionals are not allowed to subscribe certain medicines, or only under certain conditions.

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.

A person’s official name information, including given names, last name and possibly the partner’s last name.

The name normally used to address the person.

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. Following the NEN-EN-ISO 18104 norm, it is possible to structure nursing interventions (or actions) in a hierarchy, where one intervention can be part of another intervention. In a home care situation some actions can also be performed by the patient or a caregiver after a relevant instruction.

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.

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.

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: NRS (Numeric Rating Scale) in which the patient gives the pain a number on a scale of 1 (no pain) to 10 (unbearable pain). 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.

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.

A person who receives medical, psychological, paramedical or nursing care. In some care settings, the term client or participant is used instead of the term patient. Nationality is used as an indication of the country of citizenship. Marital status is a person’s formal position as defined by the Dutch civil code. There is a distinction between marriage and civil union. Linguistic proficiency is the ability to express oneself in a certain language and understand statements made in that language. This includes both oral and written communication.

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.

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.

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.

The prescribed substance is usually medication. However, medical aids and bandages can also be prescribed and supplied via the pharmacy. Food and blood products do not strictly belong in the medication category, but can be prescribed and supplied by a pharmacy as well. A type of medication can be indicated with a single code. That code can be chosen from several possible coding systems (concretely: GPK, PRK, HPK or article numbers). Correct use of these codes in the software systems will sufficiently record the composition of the product used, making a complete product specification unnecessary. In addition to a primary code, alternative codes from other coding systems can also be entered (so that the GPK can be sent along in the event that the patient was registered based on PRK, for example). Entering multiple ingredients will enable you to display a compound product. If one of the composite parts is liquid, the dosage will be given in milliliters; otherwise it will be given in ‘units’. In that case, the composition of the medication can be specified implicitly (with the use of a medication code) or explicitly, for example by listing the (active) ingredient(s) of the medication. Magistral prescriptions can be entered as well. This can be done by means of the option listed above to enter coded ingredients and/or by entering the composition and preparation method as free text. This is a partial information model.

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.

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.

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.

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.

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.

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.

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 diagnostic or therapeutic policy. A problem includes all kinds of medical or nursing information that represents a health problem. A problem can represent various types of health problems: A complaint, finding by patient: a subjective, negatively experienced observation of the patient’s health. Examples: stomach ache, amnesia A symptom: an observation by or about the patient which may indicate a certain disease. Examples: fever, blood in stool, white spots on the roof of the mouth; A diagnosis: medical interpretation of complaints and findings. Examples: Diabetes Mellitus type II, pneumonia, hemolytic-uremic syndrome. A functional limitation: a reduction of functional options. Examples: reduced mobility, help required for dressing. A complication: Every diagnosis seen by the healthcare provider as an unforeseen and undesired result of medical action. Examples: post-operative wound infections, loss of hearing through the use of antibiotics.

Therapeutic or diagnostic procedure undergone by the patient (the complementary profile zib-Procedure-request can be used for therapeutic or diagnostic procedures that the patient will undergo). A procedure can be a simple blood pressure measurement, but also a complex heart surgery. In some care settings, the term treatment is used instead of the term procedure.

Therapeutic or diagnostic procedure the patient will undergo (the complementary profile zib-Procedure-event can be used for therapeutic or diagnostic procedures that the patient has undergone). A procedure can be a simple blood pressure measurement, but also a complex heart surgery. In some care settings, the term treatment is used instead of the term procedure.

The pulse rate is the number of palpations per minute measured at an artery.

The refraction measurement is a measurement with which the refractive error of the eye is determined. During the refraction measurement, the necessary correction is established: the spherical power (in diopters), the cylindrical power (in diopters), the axis direction (in degrees) for any cylindrical correction, the prism (in prism diopters) and any additional power of the reading area (in diopters), the so-called reading addition.

A SOAP report is a textual report of a (partial) consult with relation to a single problem according to the SOAP structure. SOAP (acronym for subjective, objective, assessment, plan) is a method used by health professionals to structurally record information that comes up during contact between the patient and a health professionals in the patient’s record. The following standardized format is used for reporting:

• Subjective: the patient’s complaint and request for help and the amnesic data
• Objective: the findings from the physical and supplementary examination.
• Assessment: the working hypothesis and the thinking process, for example a differential diagnosis of the healthcare professional.
• Plan: the diagnostic plan or treatment plan and what has been discussed or agreed with the patient. The SOAP report is mainly used in general practice care. Note: the zib doesn’t state explicitly if zib SOAPReport pertains a consult or a partial consult, but it has become clear that the zib, and thus this profile, should be interpreted as a partial consult with relation to a single problem (see <https://bits.nictiz.nl/browse/ZIB-1474>). The text above has been adjusted according to this insight.

A SOAP report is a textual report of a (partial) consult with relation to a single problem according to the SOAP structure. SOAP (acronym for subjective, objective, assessment, plan) is a method used by health professionals to structurally record information that comes up during contact between the patient and a health professionals in the patient’s record. The following standardized format is used for reporting:

• Subjective: the patient’s complaint and request for help and the amnesic data
• Objective: the findings from the physical and supplementary examination.
• Assessment: the working hypothesis and the thinking process, for example a differential diagnosis of the healthcare professional.
• Plan: the diagnostic plan or treatment plan and what has been discussed or agreed with the patient. The SOAP report is mainly used in general practice care. Note: the zib doesn’t state explicitly if zib SOAPReport pertains a consult or a partial consult, but it has become clear that the zib, and thus this profile, should be interpreted as a partial consult with relation to a single problem (see <https://bits.nictiz.nl/browse/ZIB-1474>). The text above has been adjusted according to this insight.

A skin condition is a disturbance of the organ skin caused by a source to be specified later on.

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.

The StrongKids score is a (validated) measuring tool for determining the extent of a child’s malnutrition. StrongKids is developed to recognize and treat malnutrition in children aged > 1 month to 18 years in a hospital setting. The tool comprises four questions, each of which is assigned a score. The total score determines the extent of malnutrition. (STRONGkids= Screening Tool Risk On Nutritional Status and Growth)

Textual results describe the findings and interpretation of diagnostic or therapeutic procedures carried out on patients or on specimens from the patient.

Visual examination results that are the starting point and reason for the textual report as represented by the zib TextResult. These results include visual material - e.g. radiological images, scopy images, medical photos and videos - as well as graphic recordings - e.g. ECGs, EEGs etc.

A time interval indicates the time between two moments in time. Interval can be defined by a start time and end time, start time and duration or duration and end time.

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.

A treatment directive contains a joint decision between a health professional (for example a general practitioner) and a patient or his representative(s) about the desirability of performing a certain treatment, such as resuscitation, before this treatment becomes (acute) necessary. When the need arises and the treatment cannot be discussed with the patient or representative (s), that decision is an important indication for the treating health professional (for example an ER doctor). The term treatment limit is a synonym of the term treatment directive.

Immunization can be defined as “Generating natural immunity against pathogens by means of vaccination (active immunization) or by administering immunoglobulins (passive immunization)”. Only the (administered and planned) 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.

Immunization can be defined as “Generating natural immunity against pathogens by means of vaccination (active immunization) or by administering immunoglobulins (passive immunization)”. Only the (administered and planned) 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.

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.

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.

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.

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.

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.

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.

Personal grooming activity means taking care of skin, nails and hair (and beard or mustache, if applicable). This 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.

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.

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.

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.

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.

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 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

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

The Apgar score represents the overall clinical status of a newborn child. This is evaluated one, five and ten minutes after birth based on 5 parameters: Appearance, Pulse, Grimace, Activity, Respiration. If the score measured at 5 minutes is < 8, the Apgar score is measured again at 10, 15, 20 minutes etc. until the score = 8. The zib explicitly defines the Apgar score at 1, 5 and 10 minutes after birth. This profile represents the Apgar score at 10 minutes after birth. Profiles have also been defined for the Apgar score at 1 minute and at 5 minutes after birth.

The Apgar score represents the overall clinical status of a newborn child. This is evaluated one, five and ten minutes after birth based on 5 parameters: Appearance, Pulse, Grimace, Activity, Respiration. If the score measured at 5 minutes is < 8, the Apgar score is measured again at 10, 15, 20 minutes etc. until the score = 8. The zib explicitly defines the Apgar score at 1, 5 and 10 minutes after birth. This profile represents the Apgar score at 1 minute after birth. Profiles have also been defined for the Apgar score at 5 minutes and at 10 minutes after birth.

The Apgar score represents the overall clinical status of a newborn child. This is evaluated one, five and ten minutes after birth based on 5 parameters: Appearance, Pulse, Grimace, Activity, Respiration. If the score measured at 5 minutes is < 8, the Apgar score is measured again at 10, 15, 20 minutes etc. until the score = 8. The zib explicitly defines the Apgar score at 1, 5 and 10 minutes after birth. This profile represents the Apgar score at 5 minutes after birth. Profiles have also been defined for the Apgar score at 1 minute and at 10 minutes after birth.

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.

The blood pressure is a parameter for determining the condition of the blood circulation and is expressed in systolic and diastolic pressure in mmHg.

A person’s body height.

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)

Body weight is the common name for (human) body mass.

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.

A care team is a group of health professionals and other people involved in caring for a patient for one or more problems.

The CPB (Checklist Pain Behaviour) is a pain assessment tool, that is used to assess pain in children with a limited expressive repertoire or with a profound cognitive impairment, by observing their behaviour. The CPB has ten observations that need to be addressed. The final score indicates whether the observed child suffers pain and ‘how much’. The score is often combined with a VAS score that is completed by the nurses on basis of clinical experience.

The Comfort Behaviour scale /Comfortneo scale is an assessment tool, that is used to assess the pain behaviour of neonates (new born). The Comfort Behaviour scale has 7 observation points that that need to be addressed. For each on observation is value is assigned from a 5-point scale, the final score indicates whether the observed child suffers pain and ‘how much’. The score is combined with an NRS score that is completed by the nurses on basis of clinical experience.

A contact is a person not being a healthcare professional 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.

The Delirium Observation Screening Scale is a tool to determine whether a patient has delirium. The DOSS includes 13 observations of behavior (verbal and non-verbal) which represent the symptoms of a delirium. These observations can be performed during regular contact with the patient.

Information on the development and growth of a child is important in determining the kind of care that should be provided to the child and the family. When the child is being transferred, continuity of care can be achieved. Information can provide insight in the process of development and whether the child has a developmental delay.

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.

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. Contacts 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 includes past and future contacts.

The period in which a health problem, such as a complaint or illness, receives attention from a care provider. During this period the designation of this health problem can change due to evolving insight and/or the progress of the illness. An episode of care serves as a context for all data related to the health problem.

The FLACC (Faces, Legs, Activity, Cry and Consolability) is a pain assessment tool, that is used to assess pain in children aged 0-7 years old by observing their behaviour. The FLACC has five subscales that need to be addressed. The final score indicates whether the observed child suffers pain and ‘how much’. The score is often combined with a NRS-score that is completed by the nurses on basis of clinical experience.

A healthy diet means that we do not consume too much or too little (energy intake balanced with energy use) and that the composition of food (mainly important nutrients) follows the recommendations from the Health Council. For an infant, this means that the child receives breastfeeding or formula milk or a combination thereof.

The total water intake and water excretion within a certain time period: a disbalance can lead to for example dehydration or overfilling.

Freedom restricting interventions are interventions that are used against the will of the person concerned and that consciously restrict the person’s freedom to protect the person or his environment. This definition includes many forms of freedom restriction, such as (not exhaustive)

• Forced administration of fluid and nutrition
• Forced administration of medication
• Performing medical checks or other medical procedures
• Restricting freedom of movement
• Admitting to an accommodation and secluding when admitted to an accommodation.
• Exercising supervision
• Searching of clothing or body
• Restriction of visitors and the use of communication means In the hospital, it is usually about restricting the freedom of movement, for example by using bed rails, moving a chair near to the table or using an arm splint for infusion. In combination with freedom-restricting interventions, soothing medication can be administered. In the case of small children, it is often a question of fixing hands, for example, to prevent a stomach tube from being pulled out. For nurses to use it in hospitals, Dutch Nurses Association (V&VN) published a guideline [ref. 3]. In mental health care, care for the disabled and psychogeriatric care, it always concerns care that is used against the will of the patient. The legal framework for using these interventions is (per 1-1-2020) governed by two laws, namely:
• The Wet verplichte ggz (Wvggz: Mandatory Care In Mental Health Act) for people with psychiatric disorders
• The Wet zorg en dwang (Wzd: Care and Compulsion Act) for people with intellectual disabilities and people with a psychogeriatric disorder, such as dementia. The Wvggz refers to the term compulsory care, while the Wzd uses the term involuntary care. A national registration system, the Argus registration, is used to register the interventions in the context of the Wvggz.

The functional or mental status provides insight into the patient’s functional and mental limitations.

The head circumference is the size of the head as measured around the head.

A health professional is a person who is authorized to perform actions in the field of individual healthcare.

A health professional is a person who is authorized to perform actions in the field of individual healthcare.

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.

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.

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.

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.

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 rate 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.

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).

A laboratory result describes the result of a laboratory analysis. These are specimen-oriented tests as performed in laboratories such as Clinical Chemistry, Serology, Microbiology, etc. In addition to the results of tests with a singular result, this concept can also contain the results of more complex tests with multiple results or a ‘panel’.

Obtained specimen material or a microbial isolate that is used in a laboratory analysis.

Source of obtained specimen material or a microbial isolate that is used in a laboratory analysis.

A legal situation can concern a legal status and/or representation. The legal status indicates the basis on which the patient is staying in a healthcare organization. This can be either voluntary or involuntary, however the legal status is always determined by a judge.

A legal situation can concern a legal status and/or representation. Representation is important in situations where a person is legally not competent to give permission and/or factually (partly) incapable of doing so. A representative supports and takes decisions in the interest of the representee when they cannot do so themselves (temporarily or permanently).

Patient’s life stance and/or religion.

The living situation is the physical environment in which the patient normally lives, sleeps, keeps their clothing, etc.

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.)

Medical devices 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.

Medical devices 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.

A contra-indication (CI) for medication safety is a condition or characteristic of a patient where healthcare professionals are not allowed to subscribe certain medicines, or only under certain conditions.

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.

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. Following the NEN-EN-ISO 18104 norm, it is possible to structure nursing interventions (or actions) in a hierarchy, where one intervention can be part of another intervention. In a home care situation some actions can also be performed by the patient or a caregiver after a relevant instruction.

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.

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.

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: NRS (Numeric Rating Scale) in which the patient gives the pain a number on a scale of 1 (no pain) to 10 (unbearable pain). 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.

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.

A person who receives medical, psychological, paramedical or nursing care. In some care settings, the term client or participant is used instead of the term patient. Nationality is used as an indication of the country of citizenship. Marital status is a person’s formal position as defined by the Dutch civil code. There is a distinction between marriage and civil union. Linguistic proficiency is the ability to express oneself in a certain language and understand statements made in that language. This includes both oral and written communication.

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.

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.

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.

The prescribed substance is usually medication. However, medical aids and bandages can also be prescribed and supplied via the pharmacy. Food and blood products do not strictly belong in the medication category, but can be prescribed and supplied by a pharmacy as well. A type of medication can be indicated with a single code. That code can be chosen from several possible coding systems (concretely: GPK, PRK, HPK or article numbers). Correct use of these codes in the software systems will sufficiently record the composition of the product used, making a complete product specification unnecessary. In addition to a primary code, alternative codes from other coding systems can also be entered (so that the GPK can be sent along in the event that the patient was registered based on PRK, for example). Entering multiple ingredients will enable you to display a compound product. If one of the composite parts is liquid, the dosage will be given in milliliters; otherwise it will be given in ‘units’. In that case, the composition of the medication can be specified implicitly (with the use of a medication code) or explicitly, for example by listing the (active) ingredient(s) of the medication. Magistral prescriptions can be entered as well. This can be done by means of the option listed above to enter coded ingredients and/or by entering the composition and preparation method as free text. This is a partial information model.

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.

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.

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.

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.

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.

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.

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 diagnostic or therapeutic policy. A problem includes all kinds of medical or nursing information that represents a health problem. A problem can represent various types of health problems: A complaint, finding by patient: a subjective, negatively experienced observation of the patient’s health. Examples: stomach ache, amnesia A symptom: an observation by or about the patient which may indicate a certain disease. Examples: fever, blood in stool, white spots on the roof of the mouth; A diagnosis: medical interpretation of complaints and findings. Examples: Diabetes Mellitus type II, pneumonia, hemolytic-uremic syndrome. A functional limitation: a reduction of functional options. Examples: reduced mobility, help required for dressing. A complication: Every diagnosis seen by the healthcare provider as an unforeseen and undesired result of medical action. Examples: post-operative wound infections, loss of hearing through the use of antibiotics.

​Therapeutic or diagnostic procedure undergone by the patient (the complementary profile nl-core-Procedure-request can be used for therapeutic or diagnostics procedures that the patient will undergo). A procedure can be a simple blood pressure measurement, but also a complex heart surgery. In some care settings, the term treatment is used instead of the term procedure.

Therapeutic or diagnostic procedure the patient will undergo (the complementary profile nl-core-Procedure-request can be used for therapeutic or diagnostics procedures that the has undergone). A procedure can be a simple blood pressure measurement, but also a complex heart surgery. In some care settings, the term treatment is used instead of the term procedure.

The pulse rate is the number of palpations per minute measured at an artery.

The refraction measurement is a measurement with which the refractive error of the eye is determined. During the refraction measurement, the necessary correction is established: the spherical power (in diopters), the cylindrical power (in diopters), the axis direction (in degrees) for any cylindrical correction, the prism (in prism diopters) and any additional power of the reading area (in diopters), the so-called reading addition.

A SOAP report is a textual report of a (partial) consult with relation to a single problem according to the SOAP structure. SOAP (acronym for subjective, objective, assessment, plan) is a method used by health professionals to structurally record information that comes up during contact between the patient and a health professionals in the patient’s record. The following standardized format is used for reporting:

• Subjective: the patient’s complaint and request for help and the amnesic data
• Objective: the findings from the physical and supplementary examination.
• Assessment: the working hypothesis and the thinking process, for example a differential diagnosis of the healthcare professional.
• Plan: the diagnostic plan or treatment plan and what has been discussed or agreed with the patient. The SOAP report is mainly used in general practice care. Note: the zib doesn’t state explicitly if zib SOAPReport pertains a consult or a partial consult, but it has become clear that the zib, and thus this profile, should be interpreted as a partial consult with relation to a single problem (see <https://bits.nictiz.nl/browse/ZIB-1474>). The text above has been adjusted according to this insight.

A SOAP report is a textual report of a (partial) consult with relation to a single problem according to the SOAP structure. SOAP (acronym for subjective, objective, assessment, plan) is a method used by health professionals to structurally record information that comes up during contact between the patient and a health professionals in the patient’s record. The following standardized format is used for reporting:

• Subjective: the patient’s complaint and request for help and the amnesic data
• Objective: the findings from the physical and supplementary examination.
• Assessment: the working hypothesis and the thinking process, for example a differential diagnosis of the healthcare professional.
• Plan: the diagnostic plan or treatment plan and what has been discussed or agreed with the patient. The SOAP report is mainly used in general practice care. Note: the zib doesn’t state explicitly if zib SOAPReport pertains a consult or a partial consult, but it has become clear that the zib, and thus this profile, should be interpreted as a partial consult with relation to a single problem (see <https://bits.nictiz.nl/browse/ZIB-1474>). The text above has been adjusted according to this insight.

A skin condition is a disturbance of the organ skin caused by a source to be specified later on.

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.

The StrongKids score is a (validated) measuring tool for determining the extent of a child’s malnutrition. StrongKids is developed to recognize and treat malnutrition in children aged > 1 month to 18 years in a hospital setting. The tool comprises four questions, each of which is assigned a score. The total score determines the extent of malnutrition. (STRONGkids= Screening Tool Risk On Nutritional Status and Growth)

Textual results describe the findings and interpretation of diagnostic or therapeutic procedures carried out on patients or on specimens from the patient.

Textual results describe the findings and interpretation of diagnostic or therapeutic procedures carried out on patients or on specimens from the patient.

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.

A treatment directive contains a joint decision between a health professional (for example a general practitioner) and a patient or his representative(s) about the desirability of performing a certain treatment, such as resuscitation, before this treatment becomes (acute) necessary. When the need arises and the treatment cannot be discussed with the patient or representative (s), that decision is an important indication for the treating health professional (for example an ER doctor). The term treatment limit is a synonym of the term treatment directive.

Immunization can be defined as “Generating natural immunity against pathogens by means of vaccination (active immunization) or by administering immunoglobulins (passive immunization)”. Only the (administered and planned) 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.

Immunization can be defined as “Generating natural immunity against pathogens by means of vaccination (active immunization) or by administering immunoglobulins (passive immunization)”. Only the (administered and planned) 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.

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.

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.

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.

A Quantity datatype profile to add a Quantity translation in G-Standard units using the HL7 core iso21090-PQ-translation extension. The extension MAY be used to additionally add translations expressed in a different unit from a different unit code system (e.g. NHG table Gebruiksvoorschriften (Table 25)).

A SimpleQuantity datatype profile to add a SimpleQuantity translation in G-Standard units using the HL7 core iso21090-PQ-translation extension. The extension MAY be used to additionally add translations expressed in a different unit from a different unit code system (e.g. NHG table Gebruiksvoorschriften (Table 25)).

A Reference datatype profile for referring zib HealthProfessional from other zib profiles. This datatype profile is used in various resource profiles and is never instantiated directly.

A Reference datatype profile for referring zib HealthProfessional from other zib profiles. This datatype profile is used in various resource profiles and is never instantiated directly.

Address information includes data where a person resides (temporarily, permanently) or where a building is located.

An anatomical location specifies the location (e.g. foot) and laterality (e.g. left) of a body part.

Contact information includes a person’s telephone numbers en e-mail addresses.

Contact information includes a person’s telephone numbers en e-mail addresses.

A person’s official name information, including given names, last name and possibly the partner’s last name.

The name normally used to address the person.

A time interval indicates the time between two moments in time. Interval can be defined by a start time and end time , start time and duration or duration and end time.

An extension that mimics the default FHIR Resource.category element that can be used if multiple categories need to be captured, while the cardinality of the core element is 0..1. Resource types where this is the case are for example MedicationAdministration, MedicationDispense, MedicationStatement and Procedure. Note that in the current FHIR R5 build of these resource types, the cardinality of .category has been changed to 0..*.

An extension to bind the zib AddressInformation ValueSet “AdresTypeCodelijst” to the FHIR Address datatype.

An extension to provide the problem or disorder to which the living will applies.

An extension to provide information about body site to the anatomic location, e.g. left.

Materials that should be used during a CarePlan activity.

Sometimes it is not possible to use the ValueSet from the functional description on the corresponding FHIR element. This is a common occurrence when the FHIR element has datatype code and has a required binding with an incompatible FHIR core ValueSet. It can also happen when the FHIR element has a string or other non-coded datatype. In this case, the FHIR element may be augmented with this extension to communicate the code from the functional description. This information should always be added to the normal use of the FHIR element to allow for maximum interoperability.

This extension provides a generic method to extend profiles with a comment element.

This extension provides an indication whether the resource is original (false) or a copy from a different source (true).

This extension can be used to register the reference number of the Edifact message from which (a part of) this healthcare information originates.

An extension to provide a name that characterizes the episode of care for the care provider.

An extension to provide the method how the feeding is given to the infant.

An extension to provide the assent given to the health professional(s) by the patient or legal representative to implement the involuntary care.

An extension to indicate whether the patient is deemed capable of overseeing the consequences of a certain procedure, situation or decision, and to provide a comment on the decisions which the patient is legally capable of making.

An extension to provide the morphological abnormalities of the anatomical location where the specimen material is taken, for example wound, ulcer.

An extension to provide additional ways or tools that the person uses to communicate, such as braille, sign language, etc.

An extension to provide the health professional involved in the indication for use of the medical device implant.

An extension to provide the healthcare provider at which use of the medical device was initiated or where the aid was implanted.

An extension to provide a textual explanation of why the medication contraindication has been closed.

An extension to mark a CareTeam.contributor in profile <http://nictiz.nl/fhir/StructureDefinition/zib-NursingIntervention> as the Requester of the Dutch zib (‘Zorginformatiebouwsteen’, i.e. Health and Care Information Model) NursingIntervention v3.2 (2020).

This extension provides a generic method to extend profiles with a reference to zib-NursingIntervention. Often it is not possible to reference a CarePlan resource, on which zib-NursingIntervention is mapped, in an element whose definition matches that of zib-NursingIntervention.

This extension adds the BankInformation concept of the Dutch zib (‘Zorginformatiebouwsteen’, i.e. Health and Care Information Model) Payer v3.1.1 (2020) to the .payor element of the Consent resource. The extension contains all data elements of the BankInformation concept.

An extension to provide a textual description of the type of medication (including relevant properties of the composition and preparation method if possible), which is only used if no coded indication from the G Standard is available (historical data regarding magistral preparation which has been entered as free text instead of entering the substance codes).

An extension to specify the problem name. The extension can be seen as an addition to the ProblemName concept mapped to the code element.

An extension to provide the method or technique that was used to perform the procedure, e.g. approach, lavage, pressuring, etc.

An extension to provide the SOAPLine code. The extension can be seen as an addition to the SOAPLineHeader and SOAPLineText concept mapped to the code and text element.

This extension provides a generic method to extend profiles with a reference to zib-Stoma. Often it is not possible to reference a Condition resource, on which zib-Stoma is mapped, in an element whose definition matches that of zib-Stoma.

An extension to provide the Duration concept of zib TimeInterval.

An extension to provide all concepts of zib TimeInterval, to be used in resources where none of these concepts are natively supported.

An extension to provide a (written) statement in which a person indicates wishes concerning future medical action, in the event that this person is at that point no longer (deemed) capable of taking decisions on the matter.

An extension to provide the reason why the agreement on a treatment directive no longer applies.

An extension to provide the specification of the treatment decision when the decision is ‘Other’.

An extension to refer to zib PharmaceuticalProduct from an Immunization resource.