HCIM Problem

Problem as defined by the Dutch Health and Care Information models (Dutch: Zorginformatiebouwsteen or ZIB) version 4.1, release 2017. 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.