BgZ CDA Implementation Guide

This version is not final yet. Do not use.

1 Introduction

TODO

2 Actors involved

Persons		Systems
Name	Description	Name	Description
Referring medical specialist	Medical specialist who sends a BgZ along with a referral	EHR	Electronic health record
Receiving medical specialist	Medical specialist receives a BgZ along with a referral	EHR	Electronic health record

5 CDA templates

Section	Titel	Title	CDA Template
0	BgZ		Template CDA Basisgegevensset Zorg 2017 (BgZ)
1. Demografie en identificatie		Demographics and identification
	Patient	Patient
2. Financiële informatie		Financial information
	Betaler	Payer
3. Behandelrestricties
	BehandelAanwijzing	TreatmentDirective	http://nictiz.nl/fhir/StructureDefinition/zib-TreatmentDirective
	Wilsverklaring	AdvanceDirective	http://nictiz.nl/fhir/StructureDefinition/zib-AdvanceDirective
4. Contactpersonen
	Contactpersoon	ContactPerson	http://fhir.nl/fhir/StructureDefinition/nl-core-patient
5. Functionele status
	Funct. OfMentaleStatus	FunctionalOrMentalStatus	http://nictiz.nl/fhir/StructureDefinition/zib-FunctionalOrMentalStatus
6. Klachten en diagnoses
	Probleem	Problem	http://nictiz.nl/fhir/StructureDefinition/zib-Problem
7. Sociale anamnese
	Woonsituatie	LivingSituation	http://nictiz.nl/fhir/StructureDefinition/zib-LivingSituation
	DrugsGebruik	DrugUse	http://nictiz.nl/fhir/StructureDefinition/zib-DrugUse
	AlcoholGebruik	AlcoholUse	http://nictiz.nl/fhir/StructureDefinition/zib-AlcoholUse
	TabakGebruik	TobaccoUse	http://nictiz.nl/fhir/StructureDefinition/zib-TobaccoUse
	Voedingsadvies	NutritionAdvice	http://nictiz.nl/fhir/StructureDefinition/zib-NutritionAdvice
8. Waarschuwingen
	Alert	Alert	http://nictiz.nl/fhir/StructureDefinition/zib-Alert
9. Allergieën
	AllergieIntolerantie	AllergyIntolerance	http://nictiz.nl/fhir/StructureDefinition/zib-AllergyIntolerance
10. Medicatie
	MedicatieGebruik2	MedicationUse2	http://nictiz.nl/fhir/StructureDefinition/zib-MedicationUse
	Medicatieafspraak	MedicationAgreement	http://nictiz.nl/fhir/StructureDefinition/zib-MedicationAgreement
	Toedieningsafspraak	AdministrationAgreement	http://nictiz.nl/fhir/StructureDefinition/zib-AdministrationAgreement
11. Medische hulpmiddelen
	MedischHulpmiddel	MedicalDevice	http://nictiz.nl/fhir/StructureDefinition/zib-MedicalDeviceProduct
12. Vaccinaties
	Vaccinatie	Vaccination	http://nictiz.nl/fhir/StructureDefinition/zib-Vaccination
13. Vitale functies
	Bloeddruk	BloodPressure	http://nictiz.nl/fhir/StructureDefinition/zib-BloodPressure
	LichaamsGewicht	BodyWeight	http://nictiz.nl/fhir/StructureDefinition/zib-BodyWeight
	LichaamsLengte	BodyHeight	http://nictiz.nl/fhir/StructureDefinition/zib-BodyHeight
14. Uitslagen
	LaboratoriumUitslag	LaboratoryTestResult	http://nictiz.nl/fhir/StructureDefinition/zib-LaboratoryTestResult-Observation
			http://nictiz.nl/fhir/StructureDefinition/zib-LaboratoryTestResult-Specimen
15. Verrichtingen
	Verrichting	Procedure	http://nictiz.nl/fhir/StructureDefinition/zib-Procedure
16. Contacten
	Contact	Encounter	http://nictiz.nl/fhir/StructureDefinition/zib-Encounter
17. Zorgplan
	OverdrachtGeplandeZorgActiviteit	PlannedCareActivityForTransfer	http://nictiz.nl/fhir/StructureDefinition/zib-ProcedureRequest
			http://nictiz.nl/fhir/StructureDefinition/zib-VaccinationRecommendation
			http://nictiz.nl/fhir/StructureDefinition/zib-MedicalDeviceRequest
			http://nictiz.nl/fhir/StructureDefinition/eAfspraak-Appointment
18. Zorgverleners
	Zorgverlener	HealthProfessional	http://fhir.nl/fhir/StructureDefinition/nl-core-practitioner
	Zorgaanbieder	HealthcareProvider	http://fhir.nl/fhir/StructureDefinition/nl-core-organization