vpk:V4.0 Testgegevens eOverdracht Aanmeldbericht addendum: verschil tussen versies
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(11 tussenliggende versies door 2 gebruikers niet weergegeven) | |||
Regel 1: | Regel 1: | ||
− | + | __NUMBEREDHEADINGS__ | |
+ | {{DISPLAYTITLE:e-overdracht: addendum inhoudelijke gegevens aanmeldbericht}} | ||
+ | |||
+ | =Addenda voor inhoudelijke gegevens= | ||
+ | <section begin=eovd-saa-tst-1.1-alle_zibs /> | ||
+ | ==Test Aanmelding 1.1== | ||
+ | |||
+ | === Administratieve gegevens=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Administratieve gegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="6" width="30%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Datum overplaatsing | ||
+ | |style="background-color: white;"|T + 1 dag | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Persoonsgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="65"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Patient | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="18"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Naamgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Voornamen | ||
+ | |style="background-color: white;"|Erik | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Initialen | ||
+ | |style="background-color: white;"|E | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslachtsnaam | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Achternaam | ||
+ | |style="background-color: white;"|XXX_Altenborg | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Adresgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Straat | ||
+ | |style="background-color: white;"|Knolweg | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Huisnummer | ||
+ | |style="background-color: white;"|1000 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Postcode | ||
+ | |style="background-color: white;"|9999XA | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Woonplaats | ||
+ | |style="background-color: white;"|Stitswerd | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Adres soort | ||
+ | |style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Identificatienummer | ||
+ | |style="background-color: white;"|999911612 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortedatum | ||
+ | |style="background-color: white;"|14 aug 1964 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslacht | ||
+ | |style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Betaler | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verzekeraar | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Verzekering | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eind datum tijd | ||
+ | |style="background-color: white;"|T + 1 jaar | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Verzekeringssoort | ||
+ | |style="background-color: white;"|Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verzekerde nummer | ||
+ | |style="background-color: white;"|12345678 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Contactpersoon | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="19"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Naamgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Voornamen | ||
+ | |style="background-color: white;"|Johanna | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Initialen | ||
+ | |style="background-color: white;"|J | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Roepnaam | ||
+ | |style="background-color: white;"|Hanna | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslachtsnaam | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Achternaam | ||
+ | |style="background-color: white;"|Bakker | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Contactgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Telefoonnummers | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Telefoonnummer | ||
+ | |style="background-color: white;"|+31645678912 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Email adressen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Email adres | ||
+ | |style="background-color: white;"|jbakker@123net.nl | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Rol | ||
+ | |style="background-color: white;"|Eerste relatie/contactpersoon (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Relatie | ||
+ | |style="background-color: white;"|Dochter (code = 'DAUC' in codeSystem 'HL7 RoleCode') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Contactpersoon | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="15"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Naamgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Voornamen | ||
+ | |style="background-color: white;"|Johannes | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Roepnaam | ||
+ | |style="background-color: white;"|Hans | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslachtsnaam | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voorvoegsels | ||
+ | |style="background-color: white;"|van | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Achternaam | ||
+ | |style="background-color: white;"|Dijk | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Contactgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Telefoonnummers | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Telefoonnummer | ||
+ | |style="background-color: white;"|+31612121212 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Relatie | ||
+ | |style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Achterneef | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Sturende organisatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="16"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Zorgaanbieder | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="14"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorgaanbieder identificatienummer | ||
+ | |style="background-color: white;"|06590457 (in identificerend systeem: AGB-Z) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Organisatie naam | ||
+ | |style="background-color: white;"|AB-zkh | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Organisatie locatie | ||
+ | |style="background-color: white;"|Noord | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Afdeling specialisme | ||
+ | |style="background-color: white;"|Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Contactgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Telefoonnummers | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Telefoonnummer | ||
+ | |style="background-color: white;"|+31182435770 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Email adressen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Email adres | ||
+ | |style="background-color: white;"|neurologie@ABZ.nl | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Organisatie type | ||
+ | |style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Ontvangende organisatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Zorgaanbieder | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Afdeling specialisme | ||
+ | |style="background-color: white;"|Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Organisatie type | ||
+ | |style="background-color: white;"|Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060') | ||
+ | |} | ||
+ | === Algemene patienten context=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Algemene patienten context | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="30%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Juridische situatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|<span id="t-1-1-juridischesituatie-01" title="Intern ID = t-1-1-juridischesituatie-01">Juridische situatie t-1-1-juridischesituatie-01</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Vertegenwoordiging | ||
+ | |style="background-color: white;"|Onder curatele stelling (code = '9' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.3') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum aanvang | ||
+ | |style="background-color: white;"|T - 1 jaar | ||
+ | |} | ||
+ | === Medische context=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Medische context | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="30%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Medische diagnose | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="14"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem naam | ||
+ | |style="background-color: white;"|ischemisch cerebrovasculair incident (code = '422504002' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem status | ||
+ | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Toelichting | ||
+ | |style="background-color: white;"|niet bekend met neurologische klachten | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem naam | ||
+ | |style="background-color: white;"|neoplasma van colon (code = '126838000') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem status | ||
+ | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem naam | ||
+ | |style="background-color: white;"|inverse psoriasis (code = '238600001') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem status | ||
+ | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Voorgeschiedenis | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem naam | ||
+ | |style="background-color: white;"|diabetes mellitus (code = '73211009') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem status | ||
+ | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Let op | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Alert | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Alert naam | ||
+ | |style="background-color: white;"|Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Alert | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Alert naam | ||
+ | |style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Vrijheidsbeperking | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Vrijheidsbeperkende interventie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Wilsbekwaam | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Juridische situatie | ||
+ | |style="background-color: white;"|Zie [[#t-1-1-juridischesituatie-01|Juridische situatie: t-1-1-juridischesituatie-01]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Soort interventie | ||
+ | |style="background-color: white;"|geforceerd toedienen van voeding bij patiënt (code = '37041007' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Reden van toepassen | ||
+ | |style="background-color: white;"|bevorderen van fysieke gezondheid (code = '121581000146106' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Instemming | ||
+ | |style="background-color: white;"|Instemming patiënt (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.6.1') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Begin | ||
+ | |style="background-color: white;"|T - 50 dagen | ||
+ | |} | ||
+ | === Verpleegkundige context zorgplan=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="11" | Verpleegkundige context zorgplan | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="10" width="30%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="11"|Actuele patientproblemen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="95"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="10"|Patientprobleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="16"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="9"|<span id="t-1-1-patientprobleem-01" title="Intern ID = t-1-1-patientprobleem-01">Probleem t-1-1-patientprobleem-01</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Probleem naam | ||
+ | |style="background-color: white;"|probleem met zichzelf wassen en afdrogen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Probleem status | ||
+ | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Toelichting | ||
+ | |style="background-color: white;"|meneer kan niet buigen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="9"|Verpleegkundige interventie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Interventie | ||
+ | |style="background-color: white;"|ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED Clinical Terms') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Indicatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Probleem | ||
+ | |style="background-color: white;"|Zie [[#t-1-1-patientprobleem-01|Probleem: t-1-1-patientprobleem-01]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Actie start datum tijd | ||
+ | |style="background-color: white;"|T - 90 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Uitvoerder | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Zorgverlener | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="10"|Patientprobleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="11"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="9"|<span id="t-1.1-patientprobleem-02" title="Intern ID = t-1.1-patientprobleem-02">Probleem t-1.1-patientprobleem-02</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Probleem naam | ||
+ | |style="background-color: white;"|probleem met zichzelf kleden (code = '284972002' in codeSystem 'Referentieset Nationale kernset patientproblemen') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Probleem status | ||
+ | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="9"|Verpleegkundige interventie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Interventie | ||
+ | |style="background-color: white;"|ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Indicatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Probleem | ||
+ | |style="background-color: white;"|Zie [[#t-1.1-patientprobleem-02|Probleem: t-1.1-patientprobleem-02]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="10"|Patientprobleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="32"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="9"|<span id="t-1-1-patientprobleem-03" title="Intern ID = t-1-1-patientprobleem-03">Probleem t-1-1-patientprobleem-03</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Probleem naam | ||
+ | |style="background-color: white;"|decubitus (code = '399912005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Probleem status | ||
+ | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="9"|Verpleegkundige interventie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="15"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Interventie | ||
+ | |style="background-color: white;"|aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED Clinical Terms') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Indicatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Probleem | ||
+ | |style="background-color: white;"|Zie [[#t-1-1-patientprobleem-03|Probleem: t-1-1-patientprobleem-03]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Medisch hulpmiddel | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Product | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Product type | ||
+ | |style="background-color: white;"|schuimverband (code = '448416005' in codeSystem 'SNOMED Clinical Terms') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Medisch hulpmiddel | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Product | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Product type | ||
+ | |style="background-color: white;"|huidvervangende wondbedekkers (code = '465239008' in codeSystem 'SNOMED Clinical Terms') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="9"|Verpleegkundige interventie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Interventie | ||
+ | |style="background-color: white;"|wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED Clinical Terms') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Indicatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Probleem | ||
+ | |style="background-color: white;"|Zie [[#t-1-1-patientprobleem-03|Probleem: t-1-1-patientprobleem-03]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Actie start datum tijd | ||
+ | |style="background-color: white;"|T - 10 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Actie eind datum tijd | ||
+ | |style="background-color: white;"|T - 1 dag | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Uitvoerder | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Zorgverlener | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="10"|Patientprobleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="31"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="9"|<span id="t-1-1-patientprobleem-04" title="Intern ID = t-1-1-patientprobleem-04">Probleem t-1-1-patientprobleem-04</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Probleem naam | ||
+ | |style="background-color: white;"|loopt risico op delier (code = '430794006' in codeSystem 'Referentieset Nationale kernset patientproblemen') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Probleem status | ||
+ | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Toelichting | ||
+ | |style="background-color: white;"|vastgesteld met DOS score | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="9"|Verpleegkundige interventie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="24"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Interventie | ||
+ | |style="background-color: white;"|bevorderen van vochtinname (code = '113148007' in codeSystem 'SNOMED Clinical Terms') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Indicatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Probleem | ||
+ | |style="background-color: white;"|Zie [[#t-1-1-patientprobleem-04|Probleem: t-1-1-patientprobleem-04]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Uitvoerder | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="18"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Verzorger | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="16"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Contactpersoon | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="14"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Naamgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Voornamen | ||
+ | |style="background-color: white;"|Gerda | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Naamgebruik | ||
+ | |style="background-color: white;"|Geslachtsnaam partner (code = 'NL2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslachtsnaam partner | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Achternaam partner | ||
+ | |style="background-color: white;"|XXX_Altenborg | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Contactgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Telefoonnummers | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Telefoonnummer | ||
+ | |style="background-color: white;"|+31662626262 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Relatie | ||
+ | |style="background-color: white;"|Echtgenoot (code = 'HUSB' in codeSystem 'HL7 RoleCode') | ||
+ | |} | ||
+ | === Verpleegkundige context specificatie gezondheidstoestand=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Verpleegkundige context specificatie gezondheidstoestand | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="7" width="30%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Voedingvocht | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="44"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Sonde systeem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Sonde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Medisch hulpmiddel | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Product | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Product type | ||
+ | |style="background-color: white;"|Neus-maagsonde (code = '17102003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Product omschrijving | ||
+ | |style="background-color: white;"|neus- maagsonde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Toelichting | ||
+ | |style="background-color: white;"|wegens misselijkheid door chemotherapie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Sonde systeem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Sonde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Medisch hulpmiddel | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Product | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Product type | ||
+ | |style="background-color: white;"|PEJ sonde (code = '8911000146104' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Product omschrijving | ||
+ | |style="background-color: white;"|PEJ sonde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Infuus | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Infuuskatheter | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Medisch hulpmiddel | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Product | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Product type | ||
+ | |style="background-color: white;"|Centraal veneuze katheter (code = '52124006' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Product omschrijving | ||
+ | |style="background-color: white;"|centraal veneuze katheter | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Toelichting | ||
+ | |style="background-color: white;"|voor voeding | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Infuus | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Infuuskatheter | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Medisch hulpmiddel | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Product | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Product type | ||
+ | |style="background-color: white;"|Perifeer intraveneus infuus (code = '82449006' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Product omschrijving | ||
+ | |style="background-color: white;"|Perifeer intraveneus infuus | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Toelichting | ||
+ | |style="background-color: white;"|voor medicatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Uitscheiding | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Stoma | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Stoma type | ||
+ | |style="background-color: white;"|eindstandige ileostoma (code = '311412005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Toelichting | ||
+ | |style="background-color: white;"|na subtotale darmresectie wegens coloncarcinoom | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Stoma | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Stoma type | ||
+ | |style="background-color: white;"|urostoma (code = '281601009' in codeSystem 'SNOMED CT') | ||
+ | |}<section end=eovd-saa-tst-1.1-alle_zibs /> | ||
+ | <section begin=eovd-saa-tst-1.2-zwangerschap /> | ||
+ | ==Test Aanmelding 1.2== | ||
+ | |||
+ | === Administratieve gegevens=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Administratieve gegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="6" width="30%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Datum overplaatsing | ||
+ | |style="background-color: white;"|T + 1 dag | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Persoonsgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="29"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Patient | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="18"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Naamgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Initialen | ||
+ | |style="background-color: white;"|M | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslachtsnaam | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voorvoegsels | ||
+ | |style="background-color: white;"|van de | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Achternaam | ||
+ | |style="background-color: white;"|XXX_Quigleys | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Adresgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Straat | ||
+ | |style="background-color: white;"|Knolweg | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Huisnummer | ||
+ | |style="background-color: white;"|1000 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Postcode | ||
+ | |style="background-color: white;"|9999ZA | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Woonplaats | ||
+ | |style="background-color: white;"|Stitswerd | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Adres soort | ||
+ | |style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Identificatienummer | ||
+ | |style="background-color: white;"|999900912 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortedatum | ||
+ | |style="background-color: white;"|5 nov 1963 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslacht | ||
+ | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Betaler | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verzekeraar | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Verzekering | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eind datum tijd | ||
+ | |style="background-color: white;"|T + 250 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Verzekeringssoort | ||
+ | |style="background-color: white;"|Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verzekerde nummer | ||
+ | |style="background-color: white;"|12345678 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Sturende organisatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Zorgaanbieder | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorgaanbieder identificatienummer | ||
+ | |style="background-color: white;"|75616161 (in identificerend systeem: AGB-Z) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Organisatie naam | ||
+ | |style="background-color: white;"|HomeCare | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Organisatie type | ||
+ | |style="background-color: white;"|Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Ontvangende organisatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Zorgaanbieder | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Afdeling specialisme | ||
+ | |style="background-color: white;"|Medisch specialisten, obstetrie en gynaecologie (code = '0307' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Organisatie type | ||
+ | |style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | ||
+ | |} | ||
+ | === Medische context=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Medische context | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="30%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Medische diagnose | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem naam | ||
+ | |style="background-color: white;"|zwangerschapsgeïnduceerde hypertensie (code = '48194001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem status | ||
+ | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
+ | |} | ||
+ | === Verpleegkundige context zorgplan=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Verpleegkundige context zorgplan | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="6" width="30%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Actuele patientproblemen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="14"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Patientprobleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|<span id="t-1-2-probleem-01" title="Intern ID = t-1-2-probleem-01">Probleem t-1-2-probleem-01</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem naam | ||
+ | |style="background-color: white;"|pijn (bevinding) (code = '22253000' in codeSystem 'Referentieset Nationale kernset patientproblemen') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem status | ||
+ | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Toelichting | ||
+ | |style="background-color: white;"|bij lopen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verpleegkundige interventie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Interventie | ||
+ | |style="background-color: white;"|afleiden (code = '414039005' in codeSystem 'SNOMED Clinical Terms') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Indicatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem | ||
+ | |style="background-color: white;"|Zie [[#t-1-2-probleem-01|Probleem: t-1-2-probleem-01]] | ||
+ | |}<section end=eovd-saa-tst-1.2-zwangerschap /> | ||
+ | <section begin=eovd-saa-tst-1.3-minimaal /> | ||
+ | ==Test Aanmelding 1.3== | ||
+ | |||
+ | === Administratieve gegevens=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Administratieve gegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="6" width="30%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Datum overplaatsing | ||
+ | |style="background-color: white;"|T + 1 dag | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Persoonsgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="19"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Patient | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="17"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Naamgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Initialen | ||
+ | |style="background-color: white;"|J | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslachtsnaam | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Achternaam | ||
+ | |style="background-color: white;"|XXX_Verhulst | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Adresgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Straat | ||
+ | |style="background-color: white;"|Knolweg | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Huisnummer | ||
+ | |style="background-color: white;"|1001 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Postcode | ||
+ | |style="background-color: white;"|9999XX | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Woonplaats | ||
+ | |style="background-color: white;"|Stitswerd | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Adres soort | ||
+ | |style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Identificatienummer | ||
+ | |style="background-color: white;"|999900092 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortedatum | ||
+ | |style="background-color: white;"|18 sep 1963 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslacht | ||
+ | |style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Sturende organisatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="16"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Zorgaanbieder | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="14"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorgaanbieder identificatienummer | ||
+ | |style="background-color: white;"|06590457 (in identificerend systeem: AGB-Z) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Organisatie naam | ||
+ | |style="background-color: white;"|AB-zkh | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Organisatie locatie | ||
+ | |style="background-color: white;"|Noord | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Afdeling specialisme | ||
+ | |style="background-color: white;"|Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Contactgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Telefoonnummers | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Telefoonnummer | ||
+ | |style="background-color: white;"|+31182435770 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Email adressen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Email adres | ||
+ | |style="background-color: white;"|neurologie@ABZ.nl | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Organisatie type | ||
+ | |style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | ||
+ | |} | ||
+ | === Medische context=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Medische context | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="30%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Medische diagnose | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem naam | ||
+ | |style="background-color: white;"|ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem status | ||
+ | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
+ | |} | ||
+ | === Verpleegkundige context zorgplan=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Verpleegkundige context zorgplan | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="5" width="30%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Actuele patientproblemen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Patientprobleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|<span id="t-1.3-patientprobleem-01" title="Intern ID = t-1.3-patientprobleem-01">Probleem t-1.3-patientprobleem-01</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem naam | ||
+ | |style="background-color: white;"|probleem met zichzelf wassen en afdrogen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem status | ||
+ | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Verpleegkundige interventie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Interventie | ||
+ | |style="background-color: white;"|ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED Clinical Terms') | ||
+ | |}<section end=eovd-saa-tst-1.3-minimaal /> | ||
+ | <section begin=eovd-saa-tst-1.4-minimaal /> | ||
+ | ==Test Aanmelding 1.4== | ||
+ | |||
+ | === Administratieve gegevens=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Administratieve gegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="6" width="30%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Datum overplaatsing | ||
+ | |style="background-color: white;"|T + 1 dag | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Persoonsgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="20"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Patient | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="18"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Naamgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Initialen | ||
+ | |style="background-color: white;"|N | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslachtsnaam | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voorvoegsels | ||
+ | |style="background-color: white;"|van | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Achternaam | ||
+ | |style="background-color: white;"|XXX_Grieken | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Adresgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Straat | ||
+ | |style="background-color: white;"|Knolweg | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Huisnummer | ||
+ | |style="background-color: white;"|1002 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Postcode | ||
+ | |style="background-color: white;"|9999XX | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Woonplaats | ||
+ | |style="background-color: white;"|Stitswerd | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Adres soort | ||
+ | |style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Identificatienummer | ||
+ | |style="background-color: white;"|999900109 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortedatum | ||
+ | |style="background-color: white;"|18 sep 1963 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslacht | ||
+ | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Sturende organisatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="16"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Zorgaanbieder | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="14"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorgaanbieder identificatienummer | ||
+ | |style="background-color: white;"|06590457 (in identificerend systeem: AGB-Z) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Organisatie naam | ||
+ | |style="background-color: white;"|AB-zkh | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Organisatie locatie | ||
+ | |style="background-color: white;"|Noord | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Afdeling specialisme | ||
+ | |style="background-color: white;"|Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Contactgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Telefoonnummers | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Telefoonnummer | ||
+ | |style="background-color: white;"|+31182435770 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Email adressen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Email adres | ||
+ | |style="background-color: white;"|neurologie@ABZ.nl | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Organisatie type | ||
+ | |style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | ||
+ | |} | ||
+ | === Medische context=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Medische context | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="30%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Medische diagnose | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem naam | ||
+ | |style="background-color: white;"|ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem status | ||
+ | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
+ | |} | ||
+ | === Verpleegkundige context zorgplan=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Verpleegkundige context zorgplan | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="7" width="30%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Actuele patientproblemen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="15"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Patientprobleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="13"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Probleem naam | ||
+ | |style="background-color: white;"|probleem met zichzelf kleden (code = '284972002' in codeSystem 'Referentieset Nationale kernset patientproblemen') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Probleem status | ||
+ | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Verpleegkundige interventie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Interventie | ||
+ | |style="background-color: white;"|ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Medisch hulpmiddel | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Product | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Product type | ||
+ | |style="background-color: white;"|(code = '' in codeSystem 'SNOMED Clinical Terms') | ||
+ | |}<section end=eovd-saa-tst-1.4-minimaal /> |
Huidige versie van 23 nov 2022 om 10:01
1 Addenda voor inhoudelijke gegevens
1.1 Test Aanmelding 1.1
1.1.1 Administratieve gegevens
Administratieve gegevens | ||||||
Gegevenselement | Waarde | |||||
Datum overplaatsing | T + 1 dag | |||||
Persoonsgegevens | ||||||
Patient | ||||||
Naamgegevens | ||||||
Voornamen | Erik | |||||
Initialen | E | |||||
Geslachtsnaam | ||||||
Achternaam | XXX_Altenborg | |||||
Adresgegevens | ||||||
Straat | Knolweg | |||||
Huisnummer | 1000 | |||||
Postcode | 9999XA | |||||
Woonplaats | Stitswerd | |||||
Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||||
Identificatienummer | 999911612 (in identificerend systeem: BSN) | |||||
Geboortedatum | 14 aug 1964 | |||||
Geslacht | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |||||
Betaler | ||||||
Verzekeraar | ||||||
Verzekering | ||||||
Eind datum tijd | T + 1 jaar | |||||
Verzekeringssoort | Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') | |||||
Verzekerde nummer | 12345678 | |||||
Contactpersoon | ||||||
Naamgegevens | ||||||
Voornamen | Johanna | |||||
Initialen | J | |||||
Roepnaam | Hanna | |||||
Geslachtsnaam | ||||||
Achternaam | Bakker | |||||
Contactgegevens | ||||||
Telefoonnummers | ||||||
Telefoonnummer | +31645678912 | |||||
Email adressen | ||||||
Email adres | jbakker@123net.nl | |||||
Rol | Eerste relatie/contactpersoon (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472') | |||||
Relatie | Dochter (code = 'DAUC' in codeSystem 'HL7 RoleCode') | |||||
Contactpersoon | ||||||
Naamgegevens | ||||||
Voornamen | Johannes | |||||
Roepnaam | Hans | |||||
Geslachtsnaam | ||||||
Voorvoegsels | van | |||||
Achternaam | Dijk | |||||
Contactgegevens | ||||||
Telefoonnummers | ||||||
Telefoonnummer | +31612121212 | |||||
Relatie | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Achterneef | |||||
Sturende organisatie | ||||||
Zorgaanbieder | ||||||
Zorgaanbieder identificatienummer | 06590457 (in identificerend systeem: AGB-Z) | |||||
Organisatie naam | AB-zkh | |||||
Organisatie locatie | Noord | |||||
Afdeling specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
Contactgegevens | ||||||
Telefoonnummers | ||||||
Telefoonnummer | +31182435770 | |||||
Email adressen | ||||||
Email adres | neurologie@ABZ.nl | |||||
Organisatie type | Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||||
Ontvangende organisatie | ||||||
Zorgaanbieder | ||||||
Afdeling specialisme | Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
Organisatie type | Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060') |
1.1.2 Algemene patienten context
Algemene patienten context | ||||
Gegevenselement | Waarde | |||
Juridische situatie | ||||
Juridische situatie t-1-1-juridischesituatie-01 | ||||
Vertegenwoordiging | Onder curatele stelling (code = '9' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.3') | |||
Datum aanvang | T - 1 jaar |
1.1.3 Medische context
Medische context | ||||
Gegevenselement | Waarde | |||
Medische diagnose | ||||
Probleem | ||||
Probleem naam | ischemisch cerebrovasculair incident (code = '422504002' in codeSystem 'SNOMED CT') | |||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
Toelichting | niet bekend met neurologische klachten | |||
Probleem | ||||
Probleem naam | neoplasma van colon (code = '126838000') | |||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
Probleem | ||||
Probleem naam | inverse psoriasis (code = '238600001') | |||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
Voorgeschiedenis | ||||
Probleem | ||||
Probleem naam | diabetes mellitus (code = '73211009') | |||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
Let op | ||||
Alert | ||||
Alert naam | Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT') | |||
Alert | ||||
Alert naam | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie | |||
Vrijheidsbeperking | ||||
Vrijheidsbeperkende interventie | ||||
Wilsbekwaam | Ja | |||
Juridische situatie | Zie Juridische situatie: t-1-1-juridischesituatie-01 | |||
Soort interventie | geforceerd toedienen van voeding bij patiënt (code = '37041007' in codeSystem 'SNOMED CT') | |||
Reden van toepassen | bevorderen van fysieke gezondheid (code = '121581000146106' in codeSystem 'SNOMED CT') | |||
Instemming | Instemming patiënt (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.6.1') | |||
Begin | T - 50 dagen |
1.1.4 Verpleegkundige context zorgplan
Verpleegkundige context zorgplan | ||||||||||
Gegevenselement | Waarde | |||||||||
Actuele patientproblemen | ||||||||||
Patientprobleem | ||||||||||
Probleem t-1-1-patientprobleem-01 | ||||||||||
Probleem naam | probleem met zichzelf wassen en afdrogen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||||||||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||||||
Toelichting | meneer kan niet buigen | |||||||||
Verpleegkundige interventie | ||||||||||
Interventie | ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED Clinical Terms') | |||||||||
Indicatie | ||||||||||
Probleem | Zie Probleem: t-1-1-patientprobleem-01 | |||||||||
Actie start datum tijd | T - 90 dagen | |||||||||
Uitvoerder | ||||||||||
Zorgverlener | Ja | |||||||||
Patientprobleem | ||||||||||
Probleem t-1.1-patientprobleem-02 | ||||||||||
Probleem naam | probleem met zichzelf kleden (code = '284972002' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||||||||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||||||
Verpleegkundige interventie | ||||||||||
Interventie | ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms') | |||||||||
Indicatie | ||||||||||
Probleem | Zie Probleem: t-1.1-patientprobleem-02 | |||||||||
Patientprobleem | ||||||||||
Probleem t-1-1-patientprobleem-03 | ||||||||||
Probleem naam | decubitus (code = '399912005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||||||||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||||||
Verpleegkundige interventie | ||||||||||
Interventie | aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED Clinical Terms') | |||||||||
Indicatie | ||||||||||
Probleem | Zie Probleem: t-1-1-patientprobleem-03 | |||||||||
Medisch hulpmiddel | ||||||||||
Product | ||||||||||
Product type | schuimverband (code = '448416005' in codeSystem 'SNOMED Clinical Terms') | |||||||||
Medisch hulpmiddel | ||||||||||
Product | ||||||||||
Product type | huidvervangende wondbedekkers (code = '465239008' in codeSystem 'SNOMED Clinical Terms') | |||||||||
Verpleegkundige interventie | ||||||||||
Interventie | wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED Clinical Terms') | |||||||||
Indicatie | ||||||||||
Probleem | Zie Probleem: t-1-1-patientprobleem-03 | |||||||||
Actie start datum tijd | T - 10 dagen | |||||||||
Actie eind datum tijd | T - 1 dag | |||||||||
Uitvoerder | ||||||||||
Zorgverlener | Ja | |||||||||
Patientprobleem | ||||||||||
Probleem t-1-1-patientprobleem-04 | ||||||||||
Probleem naam | loopt risico op delier (code = '430794006' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||||||||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||||||
Toelichting | vastgesteld met DOS score | |||||||||
Verpleegkundige interventie | ||||||||||
Interventie | bevorderen van vochtinname (code = '113148007' in codeSystem 'SNOMED Clinical Terms') | |||||||||
Indicatie | ||||||||||
Probleem | Zie Probleem: t-1-1-patientprobleem-04 | |||||||||
Uitvoerder | ||||||||||
Verzorger | ||||||||||
Contactpersoon | ||||||||||
Naamgegevens | ||||||||||
Voornamen | Gerda | |||||||||
Naamgebruik | Geslachtsnaam partner (code = 'NL2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||||||||
Geslachtsnaam partner | ||||||||||
Achternaam partner | XXX_Altenborg | |||||||||
Contactgegevens | ||||||||||
Telefoonnummers | ||||||||||
Telefoonnummer | +31662626262 | |||||||||
Relatie | Echtgenoot (code = 'HUSB' in codeSystem 'HL7 RoleCode') |
1.1.5 Verpleegkundige context specificatie gezondheidstoestand
Verpleegkundige context specificatie gezondheidstoestand | |||||||
Gegevenselement | Waarde | ||||||
Voedingvocht | |||||||
Sonde systeem | |||||||
Sonde | |||||||
Medisch hulpmiddel | |||||||
Product | |||||||
Product type | Neus-maagsonde (code = '17102003' in codeSystem 'SNOMED CT') | ||||||
Product omschrijving | neus- maagsonde | ||||||
Toelichting | wegens misselijkheid door chemotherapie | ||||||
Sonde systeem | |||||||
Sonde | |||||||
Medisch hulpmiddel | |||||||
Product | |||||||
Product type | PEJ sonde (code = '8911000146104' in codeSystem 'SNOMED CT') | ||||||
Product omschrijving | PEJ sonde | ||||||
Infuus | |||||||
Infuuskatheter | |||||||
Medisch hulpmiddel | |||||||
Product | |||||||
Product type | Centraal veneuze katheter (code = '52124006' in codeSystem 'SNOMED CT') | ||||||
Product omschrijving | centraal veneuze katheter | ||||||
Toelichting | voor voeding | ||||||
Infuus | |||||||
Infuuskatheter | |||||||
Medisch hulpmiddel | |||||||
Product | |||||||
Product type | Perifeer intraveneus infuus (code = '82449006' in codeSystem 'SNOMED CT') | ||||||
Product omschrijving | Perifeer intraveneus infuus | ||||||
Toelichting | voor medicatie | ||||||
Uitscheiding | |||||||
Stoma | |||||||
Stoma type | eindstandige ileostoma (code = '311412005' in codeSystem 'SNOMED CT') | ||||||
Toelichting | na subtotale darmresectie wegens coloncarcinoom | ||||||
Stoma | |||||||
Stoma type | urostoma (code = '281601009' in codeSystem 'SNOMED CT') |
1.2 Test Aanmelding 1.2
1.2.1 Administratieve gegevens
Administratieve gegevens | ||||||
Gegevenselement | Waarde | |||||
Datum overplaatsing | T + 1 dag | |||||
Persoonsgegevens | ||||||
Patient | ||||||
Naamgegevens | ||||||
Initialen | M | |||||
Geslachtsnaam | ||||||
Voorvoegsels | van de | |||||
Achternaam | XXX_Quigleys | |||||
Adresgegevens | ||||||
Straat | Knolweg | |||||
Huisnummer | 1000 | |||||
Postcode | 9999ZA | |||||
Woonplaats | Stitswerd | |||||
Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||||
Identificatienummer | 999900912 (in identificerend systeem: BSN) | |||||
Geboortedatum | 5 nov 1963 | |||||
Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |||||
Betaler | ||||||
Verzekeraar | ||||||
Verzekering | ||||||
Eind datum tijd | T + 250 dagen | |||||
Verzekeringssoort | Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') | |||||
Verzekerde nummer | 12345678 | |||||
Sturende organisatie | ||||||
Zorgaanbieder | ||||||
Zorgaanbieder identificatienummer | 75616161 (in identificerend systeem: AGB-Z) | |||||
Organisatie naam | HomeCare | |||||
Organisatie type | Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||||
Ontvangende organisatie | ||||||
Zorgaanbieder | ||||||
Afdeling specialisme | Medisch specialisten, obstetrie en gynaecologie (code = '0307' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
Organisatie type | Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') |
1.2.2 Medische context
Medische context | ||||
Gegevenselement | Waarde | |||
Medische diagnose | ||||
Probleem | ||||
Probleem naam | zwangerschapsgeïnduceerde hypertensie (code = '48194001' in codeSystem 'SNOMED CT') | |||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') |
1.2.3 Verpleegkundige context zorgplan
Verpleegkundige context zorgplan | ||||||
Gegevenselement | Waarde | |||||
Actuele patientproblemen | ||||||
Patientprobleem | ||||||
Probleem t-1-2-probleem-01 | ||||||
Probleem naam | pijn (bevinding) (code = '22253000' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
Toelichting | bij lopen | |||||
Verpleegkundige interventie | ||||||
Interventie | afleiden (code = '414039005' in codeSystem 'SNOMED Clinical Terms') | |||||
Indicatie | ||||||
Probleem | Zie Probleem: t-1-2-probleem-01 |
1.3 Test Aanmelding 1.3
1.3.1 Administratieve gegevens
Administratieve gegevens | ||||||
Gegevenselement | Waarde | |||||
Datum overplaatsing | T + 1 dag | |||||
Persoonsgegevens | ||||||
Patient | ||||||
Naamgegevens | ||||||
Initialen | J | |||||
Geslachtsnaam | ||||||
Achternaam | XXX_Verhulst | |||||
Adresgegevens | ||||||
Straat | Knolweg | |||||
Huisnummer | 1001 | |||||
Postcode | 9999XX | |||||
Woonplaats | Stitswerd | |||||
Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||||
Identificatienummer | 999900092 (in identificerend systeem: BSN) | |||||
Geboortedatum | 18 sep 1963 | |||||
Geslacht | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |||||
Sturende organisatie | ||||||
Zorgaanbieder | ||||||
Zorgaanbieder identificatienummer | 06590457 (in identificerend systeem: AGB-Z) | |||||
Organisatie naam | AB-zkh | |||||
Organisatie locatie | Noord | |||||
Afdeling specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
Contactgegevens | ||||||
Telefoonnummers | ||||||
Telefoonnummer | +31182435770 | |||||
Email adressen | ||||||
Email adres | neurologie@ABZ.nl | |||||
Organisatie type | Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') |
1.3.2 Medische context
Medische context | ||||
Gegevenselement | Waarde | |||
Medische diagnose | ||||
Probleem | ||||
Probleem naam | ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT') | |||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') |
1.3.3 Verpleegkundige context zorgplan
Verpleegkundige context zorgplan | |||||
Gegevenselement | Waarde | ||||
Actuele patientproblemen | |||||
Patientprobleem | |||||
Probleem t-1.3-patientprobleem-01 | |||||
Probleem naam | probleem met zichzelf wassen en afdrogen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | ||||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||||
Verpleegkundige interventie | |||||
Interventie | ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED Clinical Terms') |
1.4 Test Aanmelding 1.4
1.4.1 Administratieve gegevens
Administratieve gegevens | ||||||
Gegevenselement | Waarde | |||||
Datum overplaatsing | T + 1 dag | |||||
Persoonsgegevens | ||||||
Patient | ||||||
Naamgegevens | ||||||
Initialen | N | |||||
Geslachtsnaam | ||||||
Voorvoegsels | van | |||||
Achternaam | XXX_Grieken | |||||
Adresgegevens | ||||||
Straat | Knolweg | |||||
Huisnummer | 1002 | |||||
Postcode | 9999XX | |||||
Woonplaats | Stitswerd | |||||
Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||||
Identificatienummer | 999900109 (in identificerend systeem: BSN) | |||||
Geboortedatum | 18 sep 1963 | |||||
Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |||||
Sturende organisatie | ||||||
Zorgaanbieder | ||||||
Zorgaanbieder identificatienummer | 06590457 (in identificerend systeem: AGB-Z) | |||||
Organisatie naam | AB-zkh | |||||
Organisatie locatie | Noord | |||||
Afdeling specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
Contactgegevens | ||||||
Telefoonnummers | ||||||
Telefoonnummer | +31182435770 | |||||
Email adressen | ||||||
Email adres | neurologie@ABZ.nl | |||||
Organisatie type | Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') |
1.4.2 Medische context
Medische context | ||||
Gegevenselement | Waarde | |||
Medische diagnose | ||||
Probleem | ||||
Probleem naam | ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT') | |||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') |
1.4.3 Verpleegkundige context zorgplan
Verpleegkundige context zorgplan | |||||||
Gegevenselement | Waarde | ||||||
Actuele patientproblemen | |||||||
Patientprobleem | |||||||
Probleem | |||||||
Probleem naam | probleem met zichzelf kleden (code = '284972002' in codeSystem 'Referentieset Nationale kernset patientproblemen') | ||||||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||||||
Verpleegkundige interventie | |||||||
Interventie | ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms') | ||||||
Medisch hulpmiddel | |||||||
Product | |||||||
Product type | (code = in codeSystem 'SNOMED Clinical Terms') |