|
|
(7 tussenliggende versies door een andere gebruiker niet weergegeven) |
Regel 1: |
Regel 1: |
− | {{#customtitle:Casuïstieken|Casuïstieken}} | + | {{DISPLAYTITLE:Casuïstieken|Casuïstieken}} |
| | | |
| ==Inleiding== | | ==Inleiding== |
Regel 7: |
Regel 7: |
| De volgende bouwstenen zijn van toepassing: | | De volgende bouwstenen zijn van toepassing: |
| *[[File:Bouwsteen.png]] Overdracht Concern | | *[[File:Bouwsteen.png]] Overdracht Concern |
− | *[[File:Bouwsteen.png]] Contact Moment | + | *[[File:Bouwsteen.png]] Contactmoment |
− | *[[File:Bouwsteen.png]] Contact Verslag | + | *[[File:Bouwsteen.png]] Contactverslag |
| *[[File:Bouwsteen.png]] Labbepaling | | *[[File:Bouwsteen.png]] Labbepaling |
| *[[File:Bouwsteen.png]] Algemene Bepalingen | | *[[File:Bouwsteen.png]] Algemene Bepalingen |
− | *[[File:Bouwsteen.png]] Medicatievoorschrift | + | *[[File:Bouwsteen.png]] Medicatieafspraak |
| *[[File:Bouwsteen.png]] Alert | | *[[File:Bouwsteen.png]] Alert |
| *[[File:Bouwsteen.png]] Allergie/Intolerantie | | *[[File:Bouwsteen.png]] Allergie/Intolerantie |
Regel 28: |
Regel 28: |
| *[[File:Bouwsteen.png]] Overdracht Concern | | *[[File:Bouwsteen.png]] Overdracht Concern |
| *[[File:Bouwsteen.png]] Algemene bepalingen | | *[[File:Bouwsteen.png]] Algemene bepalingen |
− | *[[File:Bouwsteen.png]] Medicatievoorschrift | + | *[[File:Bouwsteen.png]] Medicatieafspraak |
| *[[File:Bouwsteen.png]] Contactverslag | | *[[File:Bouwsteen.png]] Contactverslag |
| | | |
Regel 156: |
Regel 156: |
| *[[File:Bouwsteen.png]] Overdracht concern | | *[[File:Bouwsteen.png]] Overdracht concern |
| *[[File:Bouwsteen.png]] Algemene bepaling | | *[[File:Bouwsteen.png]] Algemene bepaling |
− | *[[File:Bouwsteen.png]] Medicatievoorschrift | + | *[[File:Bouwsteen.png]] Medicatieafspraak |
| *[[File:Bouwsteen.png]] Contactverslag | | *[[File:Bouwsteen.png]] Contactverslag |
| *[[File:Bouwsteen.png]] Alert | | *[[File:Bouwsteen.png]] Alert |
Regel 186: |
Regel 186: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
| |
− | {{Beginbouwsteenvoorbeeld|Overdracht concern}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Overdracht concern-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.212"/>
| |
− | <id extension="79df97d1-9fc5-48c5-bea2-593d06f6fc5a" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>
| |
− | <text>Hoesten</text>
| |
− | <statusCode code="active"/>
| |
− | <effectiveTime>
| |
− | <low value="20150601"/>
| |
− | </effectiveTime>
| |
− | <entryRelationship typeCode="SUBJ">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="de84b7fc-5a56-49d8-b9bc-35ad339727c3" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150601"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="R05" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Hoesten"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
| | | |
− | {{Beginbouwsteenvoorbeeld|Contactmoment}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <!--Contactmoment-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.201"/>
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="b8d68cb2-9701-4b76-9d61-bd8da0b33900"/>
| |
− | <code code="03" codeSystem="2.16.840.1.113883.2.4.4.30.14" displayName="consult" codeSystemVersion="v3"/>
| |
− | <effectiveTime>
| |
− | <low value="20150601"/>
| |
− | </effectiveTime>
| |
− | <performer typeCode="PRF">
| |
− | <assignedEntity>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <assignedPerson>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </assignedPerson>
| |
− | <representedOrganization>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <name>Gezondheidscentrum Amby</name>
| |
− | </representedOrganization>
| |
− | </assignedEntity>
| |
− | </performer>
| |
− | </encounter>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− |
| |
− | {{Beginbouwsteenvoorbeeld|Contactverslag}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Contactverslag-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.20.77.10.206"/>
| |
− | <id extension="8bc7589a-ae7a-48b1-9b7f-307bee144beb" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="34900-1" codeSystem="2.16.840.1.113883.6.1" displayName="General medicine Progress note" codeSystemName="LOINC"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150601"/>
| |
− | <participant typeCode="RESP">
| |
− | <participantRole>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <playingEntity>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </playingEntity>
| |
− | <scopingEntity>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <desc>Gezondheidscentrum Amby</desc>
| |
− | </scopingEntity>
| |
− | </participantRole>
| |
− | </participant>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="b8d68cb2-9701-4b76-9d61-bd8da0b33900"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <id extension="79df97d1-9fc5-48c5-bea2-593d06f6fc5a" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" codeSystemName="HL7ActClass" displayName="Concern"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--S-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.208"/>
| |
− | <code code="61150-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Subjective Narrative"/>
| |
− | <text>al 2-3 weken hinderlijke prikkelhoest, slaapt er slecht van. Iets tegen te doen? Codeine? Niet duidelijk benauwd, kan nog goed inspannen. Mogelijk iets verkouden geweest. Rookt niet.</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--O-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.209"/>
| |
− | <code code="61149-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Objective Narrative"/>
| |
− | <text>niet ziek, T36,7 P60 ra Pulm: normale geruizen, geen piepen. Expirium normaal.</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--E-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.210"/>
| |
− | <code code="51848-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Evaluation note"/>
| |
− | <text>Hoesten</text>
| |
− | <statusCode code="completed"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="f867f165-e880-4168-b117-5c4941261623" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150601"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="R05" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Hoesten"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--P-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.211"/>
| |
− | <code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of treatment (narrative)"/>
| |
− | <text>expectatief, uitleg, herstel wsl komende weken. Codeïne in principe niet geïndiceerd. Info thuisarts mee. Bij toename/blijvend retour</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| | | |
| Twee weken later op spreekuur (16 juni). | | Twee weken later op spreekuur (16 juni). |
Regel 356: |
Regel 210: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
| |
− | {{Beginbouwsteenvoorbeeld|Overdracht concern}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Overdracht concern-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.212"/>
| |
− | <id extension="79df97d1-9fc5-48c5-bea2-593d06f6fc5a" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>
| |
− | <text>Hyperreactiviteit luchtwegen</text>
| |
− | <statusCode code="active"/>
| |
− | <effectiveTime>
| |
− | <low value="20150616"/>
| |
− | </effectiveTime>
| |
− | <entryRelationship typeCode="SUBJ">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="d4a2b322-9fce-4d1e-b911-5ee58159e83c" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150616"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="R96.01" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Hyperreactiviteit luchtwegen"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
| | | |
− | {{Beginbouwsteenvoorbeeld|Contactmoment}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <!--Contactmoment-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.201"/>
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="7e4e143e-2f7b-472a-b6f9-9ef6365ac695"/>
| |
− | <code code="03" codeSystem="2.16.840.1.113883.2.4.4.30.14" displayName="consult" codeSystemVersion="v3"/>
| |
− | <effectiveTime>
| |
− | <low value="20150616"/>
| |
− | </effectiveTime>
| |
− | <performer typeCode="PRF">
| |
− | <assignedEntity>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <assignedPerson>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </assignedPerson>
| |
− | <representedOrganization>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <name>Gezondheidscentrum Amby</name>
| |
− | </representedOrganization>
| |
− | </assignedEntity>
| |
− | </performer>
| |
− | </encounter>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− |
| |
− | {{Beginbouwsteenvoorbeeld|Contactverslag}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Contactverslag-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.20.77.10.206"/>
| |
− | <id extension="1c0f553b-4f10-417f-aeed-aaa0e1c59fb7" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="34900-1" codeSystem="2.16.840.1.113883.6.1" displayName="General medicine Progress note" codeSystemName="LOINC"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150616"/>
| |
− | <participant typeCode="RESP">
| |
− | <participantRole>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <playingEntity>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </playingEntity>
| |
− | <scopingEntity>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <desc>Gezondheidscentrum Amby</desc>
| |
− | </scopingEntity>
| |
− | </participantRole>
| |
− | </participant>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="7e4e143e-2f7b-472a-b6f9-9ef6365ac695"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <id extension="79df97d1-9fc5-48c5-bea2-593d06f6fc5a" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" codeSystemName="HL7ActClass" displayName="Concern"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--S-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.208"/>
| |
− | <code code="61150-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Subjective Narrative"/>
| |
− | <text>hoesten blijft, lijkt toch meer aanvalsgewijs bij inspannen of prikkels (mn rooklucht). Heeft salbutamol van zoontje geprobeerd en dat gaf meer lucht.</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--O-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.209"/>
| |
− | <code code="61149-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Objective Narrative"/>
| |
− | <text>Pulm: bdz normaal geruis, minimaal exp piepen?</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--E-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.210"/>
| |
− | <code code="51848-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Evaluation note"/>
| |
− | <text>postvirale hyperreactiviteit, dd begin astma</text>
| |
− | <statusCode code="completed"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="a60ed5b3-e57e-45e1-8242-536e38ee57d5" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150616"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="R96.01" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Hyperreactiviteit luchtwegen"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--P-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.211"/>
| |
− | <code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of treatment (narrative)"/>
| |
− | <text>proef salbutamol, expectatief Uitleg tav hyperreactiviteit en mglk astma. Co 4 wkn</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− |
| |
− | {{Beginbouwsteenvoorbeeld|Medicatievoorschrift}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <substanceAdministration classCode="SBADM" moodCode="RQO">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.204"/>
| |
− | <id extension="ee44e9d1-ce96-4409-b85f-64a2d812de5f" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <text mediaType="text/plain">SALBUTAMOL AEROSOL 100UG/DO 200DO ADEMH 4 x per dag 1 inhalatie, 1 STUKS</text>
| |
− | <statusCode code="active"/>
| |
− | <effectiveTime xsi:type="PIVL_TS">
| |
− | <period value="0.25" unit="d"/>
| |
− | </effectiveTime>
| |
− | <doseQuantity>
| |
− | <center value="1" unit="1">
| |
− | <translation value="1" code="208" codeSystem="2.16.840.1.113883.2.4.4.1.900.2" displayName="Dosis"/>
| |
− | <translation value="1" code="36" codeSystem="2.16.840.1.113883.2.4.4.1.361" displayName="inhalatie"/>
| |
− | </center>
| |
− | </doseQuantity>
| |
− | <consumable>
| |
− | <manufacturedProduct classCode="MANU">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.20.77.10.116"/>
| |
− | <manufacturedMaterial classCode="MMAT" determinerCode="KIND">
| |
− | <code code="83704" codeSystem="2.16.840.1.113883.2.4.4.1" codeSystemName="G-Standaard GPK Generieke productcode" displayName="SALBUTAMOL AEROSOL 100UG/DO">
| |
− | <translation code="43281" codeSystem="2.16.840.1.113883.2.4.4.10" codeSystemName="G-Standaard PRK Voorschrijfcode"/>
| |
− | </code>
| |
− | </manufacturedMaterial>
| |
− | </manufacturedProduct>
| |
− | </consumable>
| |
− | <entryRelationship typeCode="SPRT">
| |
− | <act classCode="INFRM" moodCode="RQO">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.20.77.10.113"/>
| |
− | <code code="1023" codeSystem="2.16.840.1.113883.2.4.4.5" displayName="bij benauwdheid"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <id extension="79df97d1-9fc5-48c5-bea2-593d06f6fc5a" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" codeSystemName="HL7ActClass" displayName="Concern"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | </substanceAdministration>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| | | |
| Vier weken later (15 juli). | | Vier weken later (15 juli). |
Regel 562: |
Regel 228: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
| |
− | {{Beginbouwsteenvoorbeeld|Overdracht concern}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Overdracht concern-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.212"/>
| |
− | <id extension="79df97d1-9fc5-48c5-bea2-593d06f6fc5a" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>
| |
− | <text>Hyperreactiviteit luchtwegen</text>
| |
− | <statusCode code="active"/>
| |
− | <effectiveTime>
| |
− | <low value="20150715"/>
| |
− | </effectiveTime>
| |
− | <entryRelationship typeCode="SUBJ">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="e4355ee1-36f1-485d-8e21-d0673f1a0bbb" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150715"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="R96.01" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Hyperreactiviteit luchtwegen"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
| | | |
− | {{Beginbouwsteenvoorbeeld|Contactmoment}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <!--Contactmoment-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.201"/>
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="18e8207d-9a2d-494c-848e-67dbf23bc47e"/>
| |
− | <code code="03" codeSystem="2.16.840.1.113883.2.4.4.30.14" displayName="consult" codeSystemVersion="v3"/>
| |
− | <effectiveTime>
| |
− | <low value="20150715"/>
| |
− | </effectiveTime>
| |
− | <performer typeCode="PRF">
| |
− | <assignedEntity>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <assignedPerson>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </assignedPerson>
| |
− | <representedOrganization>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <name>Gezondheidscentrum Amby</name>
| |
− | </representedOrganization>
| |
− | </assignedEntity>
| |
− | </performer>
| |
− | </encounter>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− |
| |
− | {{Beginbouwsteenvoorbeeld|Contactverslag}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Contactverslag-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.20.77.10.206"/>
| |
− | <id extension="c9d75542-4e93-4351-b1cd-efa23a477b9c" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="34900-1" codeSystem="2.16.840.1.113883.6.1" displayName="General medicine Progress note" codeSystemName="LOINC"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150715"/>
| |
− | <participant typeCode="RESP">
| |
− | <participantRole>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <playingEntity>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </playingEntity>
| |
− | <scopingEntity>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <desc>Gezondheidscentrum Amby</desc>
| |
− | </scopingEntity>
| |
− | </participantRole>
| |
− | </participant>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="18e8207d-9a2d-494c-848e-67dbf23bc47e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <id extension="79df97d1-9fc5-48c5-bea2-593d06f6fc5a" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" codeSystemName="HL7ActClass" displayName="Concern"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--S-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.208"/>
| |
− | <code code="61150-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Subjective Narrative"/>
| |
− | <text>met salbutamol goed effect, gebruikt voor sporten en gaat duidelijk beter. Slapen ook eindelijk weer goed. Weinig zorgen over astma, als het maar te behandelen is. Zonder salbutamol echter snel weer gespannen gevoel op de borst.</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--E-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.210"/>
| |
− | <code code="51848-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Evaluation note"/>
| |
− | <text>dd astma</text>
| |
− | <statusCode code="completed"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="45cc63f9-73ff-4efb-b1cf-0e4998249cc7" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150715"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="R96.01" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Hyperreactiviteit luchtwegen"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--P-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.211"/>
| |
− | <code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of treatment (narrative)"/>
| |
− | <text>longfunctie, lab allergie, co 1 week</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| | | |
| Een week later (23 juli), ondertussen longfunctie met duidelijk reversibiliteit. | | Een week later (23 juli), ondertussen longfunctie met duidelijk reversibiliteit. |
Regel 746: |
Regel 275: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
| |
− | {{Beginbouwsteenvoorbeeld|Overdracht concern}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Overdracht concern-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.212"/>
| |
− | <id extension="79df97d1-9fc5-48c5-bea2-593d06f6fc5a" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>
| |
− | <text>Astma</text>
| |
− | <statusCode code="active"/>
| |
− | <effectiveTime>
| |
− | <low value="20150723"/>
| |
− | </effectiveTime>
| |
− | <entryRelationship typeCode="SUBJ">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="786137ff-36be-4e5f-88fa-05b5f0f05a0f" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150723"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="R96" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Astma"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
| | | |
− | {{Beginbouwsteenvoorbeeld|Contactmoment}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <!--Contactmoment-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.201"/>
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="15128496-36e0-40e5-872e-46b3e6fada19"/>
| |
− | <code code="03" codeSystem="2.16.840.1.113883.2.4.4.30.14" displayName="consult" codeSystemVersion="v3"/>
| |
− | <effectiveTime>
| |
− | <low value="20150723"/>
| |
− | </effectiveTime>
| |
− | <performer typeCode="PRF">
| |
− | <assignedEntity>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <assignedPerson>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </assignedPerson>
| |
− | <representedOrganization>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <name>Gezondheidscentrum Amby</name>
| |
− | </representedOrganization>
| |
− | </assignedEntity>
| |
− | </performer>
| |
− | </encounter>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− |
| |
− | {{Beginbouwsteenvoorbeeld|Contactverslag}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Contactverslag-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.20.77.10.206"/>
| |
− | <id extension="77421fc2-9c1e-413d-aa29-5658dce9d430" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="34900-1" codeSystem="2.16.840.1.113883.6.1" displayName="General medicine Progress note" codeSystemName="LOINC"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150723"/>
| |
− | <participant typeCode="RESP">
| |
− | <participantRole>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <playingEntity>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </playingEntity>
| |
− | <scopingEntity>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <desc>Gezondheidscentrum Amby</desc>
| |
− | </scopingEntity>
| |
− | </participantRole>
| |
− | </participant>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="15128496-36e0-40e5-872e-46b3e6fada19"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <id extension="79df97d1-9fc5-48c5-bea2-593d06f6fc5a" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" codeSystemName="HL7ActClass" displayName="Concern"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--S-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.208"/>
| |
− | <code code="61150-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Subjective Narrative"/>
| |
− | <text>is weer zwanger! Helemaal blij, maar hoe moet dat met medicatie? Lijkt ook meer medicatie nodig te hebben. Het werkt wel, maar het wordt helaas niet minder.</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--O-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.209"/>
| |
− | <code code="61149-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Objective Narrative"/>
| |
− | <text>longfunctie: duidelijke reversibiliteit met salbutamol</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--E-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.210"/>
| |
− | <code code="51848-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Evaluation note"/>
| |
− | <text>dd astma en zwanger</text>
| |
− | <statusCode code="completed"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="3c7333ce-dc77-4c0c-a626-0f9a31083550" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150723"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="R96" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Astma"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--P-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.211"/>
| |
− | <code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of treatment (narrative)"/>
| |
− | <text>uitleg dat medicatie vaak wel met zwangerschap samen kan, zelfs juist complicaties kan voorkomen (slechte controle astma is slechter voor ongeboren kind). Co via POH, wel overleg indien andere medicatie gestart zou moeten worden. PM consult longarts indien geen goede co. Pte informeert verloskundige over astma.</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− |
| |
− | {{Beginbouwsteenvoorbeeld|Labbepaling/Algemene bepaling}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="3a243dd6-d51f-4aa1-bfb6-10a0a96ac3bc" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1681" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="FEV1 pré-BD"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20151023"/>
| |
− | <value xsi:type="PQ" value="2.84" unit="L"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="15128496-36e0-40e5-872e-46b3e6fada19"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="39292740-62f0-4009-99c4-ca279b004f71" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1677" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="FEV1 post-BD"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20151023"/>
| |
− | <value xsi:type="PQ" value="4.05" unit="L"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="15128496-36e0-40e5-872e-46b3e6fada19"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="5a9db5ad-f273-4307-837f-d7f301653df9" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1686" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="FEV1 reversibiliteit"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20151023"/>
| |
− | <value xsi:type="PQ" value="43" unit="%"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="15128496-36e0-40e5-872e-46b3e6fada19"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="7a9db5ad-f273-4307-837f-d7f301653df0" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="852" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="Multi-rast (Phadiatop)"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20151023"/>
| |
− | <value xsi:type="CV" code="237" codeSystem="2.16.840.1.113883.2.4.4.30.1045" displayName="2+"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="15128496-36e0-40e5-872e-46b3e6fada19"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="d338c1f9-0d4b-4d27-b3ef-0dae287e43aa" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="906" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="as. Dermatophagoidus pteronyssinus d1"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20151023"/>
| |
− | <value xsi:type="CV" code="237" codeSystem="2.16.840.1.113883.2.4.4.30.1045" displayName="2+"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="15128496-36e0-40e5-872e-46b3e6fada19"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="d5775ae5-7934-46bf-96ed-9e9d4cc83cb5" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1000" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="as. kat e1"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20151023"/>
| |
− | <value xsi:type="CV" code="237" codeSystem="2.16.840.1.113883.2.4.4.30.1045" displayName="2+"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="15128496-36e0-40e5-872e-46b3e6fada19"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="49172c68-3eeb-4627-8665-562596112c06" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1001" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="as. honde-epitheel e2"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20151023"/>
| |
− | <value xsi:type="CV" code="235" codeSystem="2.16.840.1.113883.2.4.4.30.1045" displayName="1+"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="15128496-36e0-40e5-872e-46b3e6fada19"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="e0a762e7-7116-40d7-9bfa-600b7986bfc6" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1237" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="as. mengsel graspollen gx1"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20151023"/>
| |
− | <value xsi:type="CV" code="238" codeSystem="2.16.840.1.113883.2.4.4.30.1045" displayName="3+"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="15128496-36e0-40e5-872e-46b3e6fada19"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| | | |
| {| class="wikitable" width=70% | | {| class="wikitable" width=70% |
Regel 1.022: |
Regel 288: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
| |
− | {{Beginbouwsteenvoorbeeld|Overdracht concern}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Overdracht concern-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.212"/>
| |
− | <id extension="da0ac0d3-f233-43f7-94a0-d243efd1a866" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>
| |
− | <text>Zwangerschap</text>
| |
− | <statusCode code="active"/>
| |
− | <effectiveTime>
| |
− | <low value="20150723"/>
| |
− | </effectiveTime>
| |
− | <entryRelationship typeCode="SUBJ">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="c3778cf3-ab56-409d-9228-1385c26016d3" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150723"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="W78" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Zwangerschap"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
| | | |
− | {{Beginbouwsteenvoorbeeld|Contactverslag}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Contactverslag-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.20.77.10.206"/>
| |
− | <id extension="292284ef-51aa-4c52-a5a4-92e7e7858aa4" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="34900-1" codeSystem="2.16.840.1.113883.6.1" displayName="General medicine Progress note" codeSystemName="LOINC"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150723"/>
| |
− | <participant typeCode="RESP">
| |
− | <participantRole>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <playingEntity>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </playingEntity>
| |
− | <scopingEntity>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <desc>Gezondheidscentrum Amby</desc>
| |
− | </scopingEntity>
| |
− | </participantRole>
| |
− | </participant>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="15128496-36e0-40e5-872e-46b3e6fada19"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <id extension="da0ac0d3-f233-43f7-94a0-d243efd1a866" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" codeSystemName="HL7ActClass" displayName="Concern"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--S-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.208"/>
| |
− | <code code="61150-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Subjective Narrative"/>
| |
− | <text>Zwanger, zie consult astma</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--E-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.210"/>
| |
− | <code code="51848-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Evaluation note"/>
| |
− | <text>Zwanger</text>
| |
− | <statusCode code="completed"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="986be128-bb32-4050-8bbc-743fea193537" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150723"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="W78" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Zwangerschap"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| | | |
| Bij het vastleggen van de ICPC voor zwangerschap krijgt de huisarts de melding of deze dan ook zwangerschap als contra-indicatie voor medicatie wil vastleggen. De huisarts bevestigt dit. | | Bij het vastleggen van de ICPC voor zwangerschap krijgt de huisarts de melding of deze dan ook zwangerschap als contra-indicatie voor medicatie wil vastleggen. De huisarts bevestigt dit. |
Regel 1.132: |
Regel 300: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
| + | |
− | {{Beginbouwsteenvoorbeeld|Alert/Co-morbiditeit}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <entryRelationship typeCode="COMP">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <!--Alert/Conditie-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.214"/>
| |
− | <id extension="2c3085e9-a384-4eb5-afe1-4c2b5dd76eb9" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="75323-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Condition"/>
| |
− | <statusCode code="completed"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <id extension="da0ac0d3-f233-43f7-94a0-d243efd1a866" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| | | |
| {{EndPurpleBox}} | | {{EndPurpleBox}} |
Regel 1.221: |
Regel 369: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
| + | |
− | {{Beginbouwsteenvoorbeeld|Labbepaling/Algemene bepaling}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="06f100d2-05e7-46f2-9726-892f17c288c9" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="560" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="lengte patiënt"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20151024"/>
| |
− | <value xsi:type="PQ" value="195" unit="cm"/>
| |
− | </observation>
| |
− | </entry> /> <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="eff4c972-dbdf-4ea2-86ed-acae0248d746" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="357" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="gewicht patiënt"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20151024"/>
| |
− | <value xsi:type="PQ" value="105" unit="kg"/>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="bbd0998c-12b6-44a1-9cf1-fb1331798469" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1272" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="Quetelet-index (BMI) patiënt"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20151024"/>
| |
− | <value xsi:type="PQ" value="35" unit="kg/m2"/>
| |
− | </observation>
| |
− | </entry>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| | | |
| {{EndPurpleBox}} | | {{EndPurpleBox}} |
Regel 1.266: |
Regel 383: |
| Bouwstenen: | | Bouwstenen: |
| *[[File:Bouwsteen.png]] Overdracht concern | | *[[File:Bouwsteen.png]] Overdracht concern |
− | *[[File:Bouwsteen.png]] Medicatievoorschrift | + | *[[File:Bouwsteen.png]] Medicatieafspraak |
| *[[File:Bouwsteen.png]] Contactverslag | | *[[File:Bouwsteen.png]] Contactverslag |
| *[[File:Bouwsteen.png]] Allergie/Intolerantie | | *[[File:Bouwsteen.png]] Allergie/Intolerantie |
Regel 1.314: |
Regel 431: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
| |
− | {{Beginbouwsteenvoorbeeld|Overdracht concern}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Overdracht concern-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.212"/>
| |
− | <id extension="a53b23a8-4eef-47bf-b7d9-3ceddb4c1580" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>
| |
− | <text>CVRM: Cerebrovasculair accident (CVA)</text>
| |
− | <statusCode code="active"/>
| |
− | <effectiveTime>
| |
− | <low value="20150603"/>
| |
− | </effectiveTime>
| |
− | <entryRelationship typeCode="SUBJ">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="3a3c8bf8-365f-4ed4-97ac-860154b44175" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150603"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="K90" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="CVRM: Cerebrovasculair accident (CVA)"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− |
| |
− | {{Beginbouwsteenvoorbeeld|Contactmoment}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <!--Contactmoment-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.201"/>
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="258faa22-af6b-4c12-8ac9-505ee9f94394"/>
| |
− | <code code="03" codeSystem="2.16.840.1.113883.2.4.4.30.14" displayName="consult" codeSystemVersion="v3"/>
| |
− | <effectiveTime>
| |
− | <low value="20150603"/>
| |
− | </effectiveTime>
| |
− | <performer typeCode="PRF">
| |
− | <assignedEntity>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <assignedPerson>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </assignedPerson>
| |
− | <representedOrganization>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <name>Gezondheidscentrum Amby</name>
| |
− | </representedOrganization>
| |
− | </assignedEntity>
| |
− | </performer>
| |
− | </encounter>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
| | | |
− | {{Beginbouwsteenvoorbeeld|Contactverslag}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Contactverslag-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.20.77.10.206"/>
| |
− | <id extension="d08dcbf9-fb0e-4813-bdbd-0112ff983ccc" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="34900-1" codeSystem="2.16.840.1.113883.6.1" displayName="General medicine Progress note" codeSystemName="LOINC"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150603"/>
| |
− | <participant typeCode="RESP">
| |
− | <participantRole>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <playingEntity>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </playingEntity>
| |
− | <scopingEntity>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <desc>Gezondheidscentrum Amby</desc>
| |
− | </scopingEntity>
| |
− | </participantRole>
| |
− | </participant>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="258faa22-af6b-4c12-8ac9-505ee9f94394"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <id extension="a53b23a8-4eef-47bf-b7d9-3ceddb4c1580" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" codeSystemName="HL7ActClass" displayName="Concern"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--S-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.208"/>
| |
− | <code code="61150-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Subjective Narrative"/>
| |
− | <text>gaat zo-zo, probeert erop uit te trekken, maar zit toch vaak thuis. Concentratie is ook minder, snel moe in drukke groepen. Leeft wel op als ze een dagje met haar zoon of een vriendin een rondje in de stad maakt. Med: ascal, enalapril, simvastatine, vit d, calcichew, hydrochlorothiazide</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--O-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.209"/>
| |
− | <code code="61149-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Objective Narrative"/>
| |
− | <text>RR 160/80 P80 ra</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--E-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.210"/>
| |
− | <code code="51848-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Evaluation note"/>
| |
− | <text>Hypertensie en lusteloosheid</text>
| |
− | <statusCode code="completed"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="3d60c11f-8f6b-4aa0-99df-4c43b65d3201" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150603"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="K90" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="CVRM: Cerebrovasculair accident (CVA)"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--P-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.211"/>
| |
− | <code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of treatment (narrative)"/>
| |
− | <text>Voor hypertensie co 1 maand, nu geen medicatie aanpassen. naar POH GGZ, contact kerk?</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| | | |
| {{EndPurpleBox}} | | {{EndPurpleBox}} |
Regel 1.539: |
Regel 510: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
| |
− | {{Beginbouwsteenvoorbeeld|Overdracht concern}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Overdracht concern-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.212"/>
| |
− | <id extension="55d24110-326d-402d-81d9-e9c522b8ddf6" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>
| |
− | <text>Flauwvallen/syncope</text>
| |
− | <statusCode code="active"/>
| |
− | <effectiveTime>
| |
− | <low value="20150610"/>
| |
− | </effectiveTime>
| |
− | <entryRelationship typeCode="SUBJ">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="c3ddd16b-2cae-4b39-896e-f36ea1aa9bd9" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150610"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="A06" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Flauwvallen/syncope"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
| | | |
− | {{Beginbouwsteenvoorbeeld|Contactmoment}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <!--Contactmoment-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.201"/>
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="1b0b4011-9715-4289-8e36-642df26165f9"/>
| |
− | <code code="03" codeSystem="2.16.840.1.113883.2.4.4.30.14" displayName="consult" codeSystemVersion="v3"/>
| |
− | <effectiveTime>
| |
− | <low value="20150610"/>
| |
− | </effectiveTime>
| |
− | <performer typeCode="PRF">
| |
− | <assignedEntity>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <assignedPerson>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </assignedPerson>
| |
− | <representedOrganization>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <name>Gezondheidscentrum Amby</name>
| |
− | </representedOrganization>
| |
− | </assignedEntity>
| |
− | </performer>
| |
− | </encounter>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− |
| |
− | {{Beginbouwsteenvoorbeeld|Contactverslag}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Contactverslag-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.20.77.10.206"/>
| |
− | <id extension="f9d448c7-cc91-4f0b-a71d-3f0a5f31d876" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="34900-1" codeSystem="2.16.840.1.113883.6.1" displayName="General medicine Progress note" codeSystemName="LOINC"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150610"/>
| |
− | <participant typeCode="RESP">
| |
− | <participantRole>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <playingEntity>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </playingEntity>
| |
− | <scopingEntity>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <desc>Gezondheidscentrum Amby</desc>
| |
− | </scopingEntity>
| |
− | </participantRole>
| |
− | </participant>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="1b0b4011-9715-4289-8e36-642df26165f9"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <id extension="55d24110-326d-402d-81d9-e9c522b8ddf6" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" codeSystemName="HL7ActClass" displayName="Concern"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--S-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.208"/>
| |
− | <code code="61150-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Subjective Narrative"/>
| |
− | <text>visite: pte rustig in stoel, kan zich niet herinneren wat er gebeurd is, niet gevallen. Was niet ziek. Zat vanochtend rustig omroep Max te kijken.</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--O-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.209"/>
| |
− | <code code="61149-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Objective Narrative"/>
| |
− | <text>in stoel, alert, wel vermoeide indruk. RR 140/70 P70ra Gluc 6.8 Cor: s1s2s- Pulm: bdz normale geruizen. Neurol: iets verminderde kracht re arm en re been, status quo.</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--E-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.210"/>
| |
− | <code code="51848-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Evaluation note"/>
| |
− | <text>onwelwording eci, dd PAF, recidief CVA, epilepsie</text>
| |
− | <statusCode code="completed"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="671d4019-281b-4003-afb5-2bf6a5f6df55" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150610"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="A06" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Flauwvallen/syncope"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--P-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.211"/>
| |
− | <code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of treatment (narrative)"/>
| |
− | <text>overleg neuroloog, ivm mglk recidief CVA wel insturen, therapeutische opties wsl wel beperkt.</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| | | |
| {| class="wikitable" width=70% | | {| class="wikitable" width=70% |
Regel 1.741: |
Regel 566: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
| + | |
− | {{Beginbouwsteenvoorbeeld|Allergie/Intolerantie}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Allergie/Intolerantie-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.215"/>
| |
− | <id extension="5116eaee-5c4f-438f-bc70-2f1c8171b396" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>
| |
− | <statusCode code="active"/>
| |
− | <effectiveTime>
| |
− | <low value="20150304"/>
| |
− | </effectiveTime>
| |
− | <entryRelationship typeCode="SUBJ">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.216"/>
| |
− | <id extension="66935281-de15-4033-9be4-a4127812dd95" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150304"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="419199007" codeSystem="2.16.840.1.113883.6.96" displayName="Allergy to substance"/>
| |
− | <participant typeCode="CSM">
| |
− | <participantRole classCode="MANU">
| |
− | <playingEntity classCode="MMAT">
| |
− | <code nullFlavor="OTH">
| |
− | <originalText>Amoxicilline, opmerking: via neuroloog</originalText>
| |
− | </code>
| |
− | </playingEntity>
| |
− | </participantRole>
| |
− | </participant>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| | | |
| Na de consulten ziet de registratie in de samengestelde episode er als volgt uit: | | Na de consulten ziet de registratie in de samengestelde episode er als volgt uit: |
Regel 1.879: |
Regel 668: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
| |
− | {{Beginbouwsteenvoorbeeld|Overdracht concern}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Overdracht concern-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.212"/>
| |
− | <id extension="140b8365-b566-4e1b-8590-deb152b15e73" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>
| |
− | <text>Diabetes mellitus type 2</text>
| |
− | <statusCode code="active"/>
| |
− | <effectiveTime>
| |
− | <low value="20150203"/>
| |
− | </effectiveTime>
| |
− | <entryRelationship typeCode="SUBJ">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="b1c8f0b5-8298-4ae8-b7fe-b8e7c1f44cb0" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150203"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="T90.02" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Diabetes mellitus type 2"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
| | | |
− | {{Beginbouwsteenvoorbeeld|Contactmoment}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <!--Contactmoment-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.201"/>
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | <code code="03" codeSystem="2.16.840.1.113883.2.4.4.30.14" displayName="consult" codeSystemVersion="v3"/>
| |
− | <effectiveTime>
| |
− | <low value="20150203"/>
| |
− | </effectiveTime>
| |
− | <performer typeCode="PRF">
| |
− | <assignedEntity>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <assignedPerson>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </assignedPerson>
| |
− | <representedOrganization>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <name>Gezondheidscentrum Amby</name>
| |
− | </representedOrganization>
| |
− | </assignedEntity>
| |
− | </performer>
| |
− | </encounter>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− |
| |
− | {{Beginbouwsteenvoorbeeld|Contactverslag}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Contactverslag-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.20.77.10.206"/>
| |
− | <id extension="bce2b8a3-e721-4eba-ab2f-2c4ba9c7ec41" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="34900-1" codeSystem="2.16.840.1.113883.6.1" displayName="General medicine Progress note" codeSystemName="LOINC"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150203"/>
| |
− | <participant typeCode="RESP">
| |
− | <participantRole>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <playingEntity>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </playingEntity>
| |
− | <scopingEntity>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <desc>Gezondheidscentrum Amby</desc>
| |
− | </scopingEntity>
| |
− | </participantRole>
| |
− | </participant>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <id extension="140b8365-b566-4e1b-8590-deb152b15e73" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" codeSystemName="HL7ActClass" displayName="Concern"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--S-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.208"/>
| |
− | <code code="61150-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Subjective Narrative"/>
| |
− | <text>weinig klachten, geen last van bijwerkingen. Bewegen steeds moeizamer door rugklachten en sinds kort ook vervelend wondje op de enkel. Doet pijn bij lopen, dus beweegt eigenlijk niet meer. Wil wel graag dat waardes goed zijn. Nog niet klaar om het roken te staken, mag wel vragen naar staken.</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--O-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.209"/>
| |
− | <code code="61149-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Objective Narrative"/>
| |
− | <text>RR 145/75 P80 ra gluc 7.6 niet nuchter Ext: enkel rechts mediaal een kleine ulcus, gelig beslag. Voeten: gevoel beiderzijds duidelijk minder.</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--E-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.210"/>
| |
− | <code code="51848-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Evaluation note"/>
| |
− | <text>diabetes mellitus, type 2, slechte controle Cave diabetisch ulcus</text>
| |
− | <statusCode code="completed"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="d3b0ba2d-0d7f-4d64-9e92-efe52ca90fe2" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150203"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="T90.02" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Diabetes mellitus type 2"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--P-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.211"/>
| |
− | <code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of treatment (narrative)"/>
| |
− | <text>metformine naar 3d 1000 mg. Start siliconen wondverband op ulcus, co via wondverpleegkundige. Over drie maanden jaarcontrole op spreekuur huisarts, vooraf metingen POH.</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| *POH voert controle in KIS in | | *POH voert controle in KIS in |
| *POH logt in in het KIS. De POH haalt de meest recente gegevens op uit het HIS. | | *POH logt in in het KIS. De POH haalt de meest recente gegevens op uit het HIS. |
Regel 2.138: |
Regel 781: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
| + | |
− | {{Beginbouwsteenvoorbeeld|Labbepaling/Algemene bepaling}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="b7bb2a48-90e3-4e5c-b56d-0a39c83c183f" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="357" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="gewicht patiënt"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="PQ" value="67.5" unit="kg"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="d095f881-02bf-4b58-a794-899729842344" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1272" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="Quetelet-index (BMI) patiënt"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="PQ" value="29.0" unit="kg/m2"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="1a6ec2a7-b63a-4998-b8ac-825b47e50413" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1744" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="systolische bloeddruk"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="PQ" value="120" unit="mm[Hg]"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="0899eed0-3514-4638-a9cc-ef5a14e3e7a9" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1740" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="diastolische bloeddruk"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="PQ" value="80" unit="mm[Hg]"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="80f431c1-405a-46b9-8191-3958d6d7810c" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="2816" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="HbA1c (glycohemoglobine) IFCC"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="PQ" value="125" unit="mmol/mol"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="f31eb4a8-35ac-43f3-9219-f2440b05cf47" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="192" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="cholesterol totaal"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="PQ" value="4.0" unit="mmol/L"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="3afbaada-55ee-4685-a136-95c92d850fcc" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="446" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="HDL-cholesterol"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="PQ" value="1.5" unit="mmol/L"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="9ec1d43d-0301-4fcb-87ab-f42bd79a8991" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="542" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="LDL-cholesterol"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="PQ" value="1.8" unit="mmol/L"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="381d0df6-f9e1-4ee3-ba0c-d071ded9a7e4" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="181" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="cholesterol/HDL-cholesterol ratio"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="PQ" value="15.1" unit="{1}"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="6e6ea14c-043c-486b-a296-6304634b5be5" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1377" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="triglyceriden"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="PQ" value="0.9" unit="mmol/L"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="8f173d76-d2c4-4246-85f7-4836dcf1d3d9" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="523" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="kreatinine"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="PQ" value="80" unit="umol/L"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="3e7b81ab-b1dc-4812-b01e-2988c24a783d" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="38" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="albumine (micro-) urine portie"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="PQ" value="12" unit="mg/24.h"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="30009ffd-3599-4faf-a818-0aec9635017f" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1919" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="eGFR volgens MDRD formule"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="PQ" value="85" unit="ml/min/1,73 m2"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="5ea5e258-b129-4024-ab17-e57a1ea20898" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1697" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="inspectie linkervoet (diabetes)"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="CV" code="13" codeSystem="2.16.840.1.113883.2.4.4.30.1045" displayName="afwijkend"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="e8bbd8b7-ff81-4c0b-baac-e5f9546a6b7c" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1698" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="inspectie rechtervoet (diabetes)"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="CV" code="13" codeSystem="2.16.840.1.113883.2.4.4.30.1045" displayName="afwijkend"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="ab01f836-cc73-46d4-aecb-7ea7b821ea54" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1641" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="doorbloeding linkervoet"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="CV" code="8" codeSystem="2.16.840.1.113883.2.4.4.30.1045" displayName="onduidelijk"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="273824b7-9f98-4c50-b6a6-8271b4e7e258" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1642" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="doorbloeding rechtervoet"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="CV" code="12" codeSystem="2.16.840.1.113883.2.4.4.30.1045" displayName="normaal"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="fcdace18-cae3-4318-b732-6ec869f28c3e" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1710" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="monofilamentenonderzoek linkervoet"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="CV" code="12" codeSystem="2.16.840.1.113883.2.4.4.30.1045" displayName="normaal"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="6f2909dd-cb9a-456a-a70b-30f883dfec80" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1711" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="monofilamentenonderzoek rechtervoet"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="CV" code="13" codeSystem="2.16.840.1.113883.2.4.4.30.1045" displayName="afwijkend"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="9c8577fc-96cd-480e-a9b1-b957e343fd0b" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="2196" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="risico voetulcera (SIMM's)"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="PQ" value="2" unit="{1}"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="95ca8bec-f5d7-4c76-921c-9ac809a4acfa" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1739" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="roken"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="CV" code="1" codeSystem="2.16.840.1.113883.2.4.4.30.1045" displayName="ja"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="c9456696-1975-4c64-a47f-9fb8dab1fe2e" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1814" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="advies stoppen met roken gegeven"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="CV" code="1" codeSystem="2.16.840.1.113883.2.4.4.30.1045" displayName="ja"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="72dd15f6-d51b-4c26-aec6-2366ab781e49" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1591" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="alcoholgebruik"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="CV" code="2" codeSystem="2.16.840.1.113883.2.4.4.30.1045" displayName="nee"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="bf71c31b-dede-43b1-a145-2b60d389e22f" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="2718" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="bijzonderheden voedingspatroon"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150831"/>
| |
− | <value xsi:type="CV" code="6" codeSystem="2.16.840.1.113883.2.4.4.30.1045" displayName="aanwezig"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="ab1af8cb-3b3e-4d25-931e-ad1fb7889f1e"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| | | |
| De wondverpleegkundige bekijkt de wond en verbindt de voet. | | De wondverpleegkundige bekijkt de wond en verbindt de voet. |
Regel 2.504: |
Regel 806: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
| |
− | {{Beginbouwsteenvoorbeeld|Overdracht concern}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Overdracht concern-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.212"/>
| |
− | <id extension="140b8365-b566-4e1b-8590-deb152b15e73" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>
| |
− | <text>Diabetes mellitus type 2</text>
| |
− | <statusCode code="active"/>
| |
− | <effectiveTime>
| |
− | <low value="20150216"/>
| |
− | </effectiveTime>
| |
− | <entryRelationship typeCode="SUBJ">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="301c4798-6e41-459a-8e4c-242268d983d7" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150216"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="T90.02" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Diabetes mellitus type 2"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
| | | |
− | {{Beginbouwsteenvoorbeeld|Contactmoment}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <!--Contactmoment-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.201"/>
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="12d29aa5-50c1-4e35-80f9-72c12dd6e647"/>
| |
− | <code code="03" codeSystem="2.16.840.1.113883.2.4.4.30.14" displayName="consult" codeSystemVersion="v3"/>
| |
− | <effectiveTime>
| |
− | <low value="20150216"/>
| |
− | </effectiveTime>
| |
− | <performer typeCode="PRF">
| |
− | <assignedEntity>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <assignedPerson>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </assignedPerson>
| |
− | <representedOrganization>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <name>Gezondheidscentrum Amby</name>
| |
− | </representedOrganization>
| |
− | </assignedEntity>
| |
− | </performer>
| |
− | </encounter>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− |
| |
− | {{Beginbouwsteenvoorbeeld|Contactverslag}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Contactverslag-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.20.77.10.206"/>
| |
− | <id extension="f82a5fa8-cdbd-4592-9139-1c3932fbf776" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="34900-1" codeSystem="2.16.840.1.113883.6.1" displayName="General medicine Progress note" codeSystemName="LOINC"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150216"/>
| |
− | <participant typeCode="RESP">
| |
− | <participantRole>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <playingEntity>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </playingEntity>
| |
− | <scopingEntity>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <desc>Gezondheidscentrum Amby</desc>
| |
− | </scopingEntity>
| |
− | </participantRole>
| |
− | </participant>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="12d29aa5-50c1-4e35-80f9-72c12dd6e647"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <id extension="140b8365-b566-4e1b-8590-deb152b15e73" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" codeSystemName="HL7ActClass" displayName="Concern"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--S-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.208"/>
| |
− | <code code="61150-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Subjective Narrative"/>
| |
− | <text>Verband van gister zit te strak, svp opnieuw verbinden</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--O-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.209"/>
| |
− | <code code="61149-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Objective Narrative"/>
| |
− | <text>Verband: circulair, distaal wel goed gevoel tenen, goede vascularisatie. Wond; status quo.</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--E-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.210"/>
| |
− | <code code="51848-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Evaluation note"/>
| |
− | <text>Verband te strak</text>
| |
− | <statusCode code="completed"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="e094a916-ce2d-4ec2-b2e0-86308e14e417" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150216"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="A87" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Complicatie(s) medische behandeling"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--P-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.211"/>
| |
− | <code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of treatment (narrative)"/>
| |
− | <text>Opnieuw verband, let op volgende keer niet te strak!!</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| | | |
| Dhr Zoet komt twee weken later op het spreekuur na terugverwezen te zijn door de POH. Vraag: medebeoordeling, verwijzing chirurg bij uitbreiding? | | Dhr Zoet komt twee weken later op het spreekuur na terugverwezen te zijn door de POH. Vraag: medebeoordeling, verwijzing chirurg bij uitbreiding? |
Regel 2.671: |
Regel 827: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
| |
− | {{Beginbouwsteenvoorbeeld|Overdracht concern}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Overdracht concern-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.212"/>
| |
− | <id extension="870921e3-a997-4d5d-9ecc-40e990b10a6e" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>
| |
− | <text>Ulcus cruris</text>
| |
− | <statusCode code="active"/>
| |
− | <effectiveTime>
| |
− | <low value="20150301"/>
| |
− | </effectiveTime>
| |
− | <entryRelationship typeCode="SUBJ">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="d401b0f4-b47b-4905-8779-712aa888e647" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150301"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="S97.01" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Ulcus cruris"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Beginbouwsteenvoorbeeld|Contactmoment}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <!--Contactmoment-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.201"/>
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="f36f9850-4441-4439-b30e-799ce91b0917"/>
| |
− | <code code="03" codeSystem="2.16.840.1.113883.2.4.4.30.14" displayName="consult" codeSystemVersion="v3"/>
| |
− | <effectiveTime>
| |
− | <low value="20150301"/>
| |
− | </effectiveTime>
| |
− | <performer typeCode="PRF">
| |
− | <assignedEntity>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <assignedPerson>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </assignedPerson>
| |
− | <representedOrganization>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <name>Gezondheidscentrum Amby</name>
| |
− | </representedOrganization>
| |
− | </assignedEntity>
| |
− | </performer>
| |
− | </encounter>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
| | | |
− | {{Beginbouwsteenvoorbeeld|Contactverslag}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Contactverslag-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.20.77.10.206"/>
| |
− | <id extension="42ab7119-6036-4e1a-ae81-fbaa7cefd22e" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="34900-1" codeSystem="2.16.840.1.113883.6.1" displayName="General medicine Progress note" codeSystemName="LOINC"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150301"/>
| |
− | <participant typeCode="RESP">
| |
− | <participantRole>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <playingEntity>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </playingEntity>
| |
− | <scopingEntity>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <desc>Gezondheidscentrum Amby</desc>
| |
− | </scopingEntity>
| |
− | </participantRole>
| |
− | </participant>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="f36f9850-4441-4439-b30e-799ce91b0917"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <id extension="870921e3-a997-4d5d-9ecc-40e990b10a6e" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" codeSystemName="HL7ActClass" displayName="Concern"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--S-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.208"/>
| |
− | <code code="61150-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Subjective Narrative"/>
| |
− | <text>Heeft steeds meer pijn aan wond, ook geregeld vocht. Ligt er soms ’s nachts wakker van. Gebruikt nu iedere dag paracetamol. Geen koorts.</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--O-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.209"/>
| |
− | <code code="61149-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Objective Narrative"/>
| |
− | <text>mediale zijde re enkel ulcus 5x4 cm, wondranden rood, centraal ook wat necrose. Rondom uitbreidende roodheid</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--E-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.210"/>
| |
− | <code code="51848-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Evaluation note"/>
| |
− | <text>ulcus cruris, diabetische voet</text>
| |
− | <statusCode code="completed"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="f987c1ba-8005-4254-8ad7-0ea00ca0dde1" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150301"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="S97.01" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Ulcus cruris"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--P-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.211"/>
| |
− | <code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of treatment (narrative)"/>
| |
− | <text>v/chirurgie</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| | | |
| Drie maanden later komt patiënt voor de jaarcontrole van de diabetes. Hij heeft een heel traject bij de chirurg gekregen, maar de wond is nog niet onder controle. Hij zet zijn hoop op een behandeling met hyperbare zuurstof, maar anders zal er waarschijnlijk een amputatie van de voet moeten komen. | | Drie maanden later komt patiënt voor de jaarcontrole van de diabetes. Hij heeft een heel traject bij de chirurg gekregen, maar de wond is nog niet onder controle. Hij zet zijn hoop op een behandeling met hyperbare zuurstof, maar anders zal er waarschijnlijk een amputatie van de voet moeten komen. |
Regel 2.837: |
Regel 848: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
| |
− | {{Beginbouwsteenvoorbeeld|Overdracht concern}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Overdracht concern-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.212"/>
| |
− | <id extension="140b8365-b566-4e1b-8590-deb152b15e73" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>
| |
− | <text>DM 2 risico amputatie bij diabetische voet</text>
| |
− | <statusCode code="active"/>
| |
− | <effectiveTime>
| |
− | <low value="20150529"/>
| |
− | </effectiveTime>
| |
− | <entryRelationship typeCode="SUBJ">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="86d6e85f-39ad-4c61-89d4-47df19a7eb7e" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150529"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="T90.02" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Diabetes mellitus type 2"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− |
| |
− | {{Beginbouwsteenvoorbeeld|Contactmoment}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <!--Contactmoment-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.201"/>
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="c7918ba3-c307-47a0-8802-2e342e65a03a"/>
| |
− | <code code="03" codeSystem="2.16.840.1.113883.2.4.4.30.14" displayName="consult" codeSystemVersion="v3"/>
| |
− | <effectiveTime>
| |
− | <low value="20150529"/>
| |
− | </effectiveTime>
| |
− | <performer typeCode="PRF">
| |
− | <assignedEntity>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <assignedPerson>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </assignedPerson>
| |
− | <representedOrganization>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <name>Gezondheidscentrum Amby</name>
| |
− | </representedOrganization>
| |
− | </assignedEntity>
| |
− | </performer>
| |
− | </encounter>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
| | | |
− | {{Beginbouwsteenvoorbeeld|Contactverslag}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Contactverslag-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.20.77.10.206"/>
| |
− | <id extension="a1488bd0-1f7d-4b48-a10a-b2d86ca30c1b" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="34900-1" codeSystem="2.16.840.1.113883.6.1" displayName="General medicine Progress note" codeSystemName="LOINC"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150529"/>
| |
− | <participant typeCode="RESP">
| |
− | <participantRole>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <playingEntity>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </playingEntity>
| |
− | <scopingEntity>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <desc>Gezondheidscentrum Amby</desc>
| |
− | </scopingEntity>
| |
− | </participantRole>
| |
− | </participant>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="c7918ba3-c307-47a0-8802-2e342e65a03a"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <id extension="140b8365-b566-4e1b-8590-deb152b15e73" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" codeSystemName="HL7ActClass" displayName="Concern"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--S-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.208"/>
| |
− | <code code="61150-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Subjective Narrative"/>
| |
− | <text>veel zorgen om mogelijke amputatie. Door de stress stelt hij het stoppen met roken uit, ziet wel belang. Heeft dagelijks veel pijn in voet, in rust. Bewegen lukt eigenlijk ook niet goed meer. Heeft medicatie trouw genomen, eet gezonder (vrouw wil alleen maar gezond eten vanaf nu)</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--O-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.209"/>
| |
− | <code code="61149-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Objective Narrative"/>
| |
− | <text>Loopt op krukken, rechter voet in verband. Nu gluc 5,4 HbA1c 56 mmol/l RR 125/75 P72 ra. (Voet niet beoordeeld; via chirurg)</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--E-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.210"/>
| |
− | <code code="51848-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Evaluation note"/>
| |
− | <text>Jaarcontrole diabetes; betere controle, wel risico amputatie bij diabetische voet</text>
| |
− | <statusCode code="completed"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="e9a584b7-a37e-4e72-a3f8-0d730811f874" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150529"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="T90.02" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Diabetes mellitus type 2"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--P-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.211"/>
| |
− | <code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of treatment (narrative)"/>
| |
− | <text>jaarcontrole afronden bij POH, co 3 maanden POH. Vooruitgang vasthouden.</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| | | |
| {| class="wikitable" width=70% | | {| class="wikitable" width=70% |
Regel 2.999: |
Regel 864: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
| |
− | {{Beginbouwsteenvoorbeeld|Overdracht concern}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Overdracht concern-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.212"/>
| |
− | <id extension="870921e3-a997-4d5d-9ecc-40e990b10a6e" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>
| |
− | <text>Ulcus cruris</text>
| |
− | <statusCode code="active"/>
| |
− | <effectiveTime>
| |
− | <low value="20150601"/>
| |
− | </effectiveTime>
| |
− | <entryRelationship typeCode="SUBJ">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="01d1a561-786a-4e36-a48a-02b1843d2e1b" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150601"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="S97.01" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Ulcus cruris"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− |
| |
− | {{Beginbouwsteenvoorbeeld|Contactmoment}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <!--Contactmoment-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.201"/>
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="9015b590-aa62-4d74-83ab-34bea18af397"/>
| |
− | <code code="03" codeSystem="2.16.840.1.113883.2.4.4.30.14" displayName="consult" codeSystemVersion="v3"/>
| |
− | <effectiveTime>
| |
− | <low value="20150601"/>
| |
− | </effectiveTime>
| |
− | <performer typeCode="PRF">
| |
− | <assignedEntity>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <assignedPerson>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </assignedPerson>
| |
− | <representedOrganization>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <name>Gezondheidscentrum Amby</name>
| |
− | </representedOrganization>
| |
− | </assignedEntity>
| |
− | </performer>
| |
− | </encounter>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
| | | |
− | {{Beginbouwsteenvoorbeeld|Contactverslag}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Contactverslag-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.20.77.10.206"/>
| |
− | <id extension="785595f6-6733-404f-92c9-3ad253542c23" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="34900-1" codeSystem="2.16.840.1.113883.6.1" displayName="General medicine Progress note" codeSystemName="LOINC"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20150601"/>
| |
− | <participant typeCode="RESP">
| |
− | <participantRole>
| |
− | <id root="2.16.528.1.1007.3.1" extension="000002222"/>
| |
− | <code code="01.015" codeSystem="2.16.840.1.113883.2.4.15.111"/>
| |
− | <playingEntity>
| |
− | <name>
| |
− | <given>Koos</given>
| |
− | <family qualifier="BR">Jansma</family>
| |
− | </name>
| |
− | </playingEntity>
| |
− | <scopingEntity>
| |
− | <id root="2.16.528.1.1007.3.3" extension="00001111"/>
| |
− | <desc>Gezondheidscentrum Amby</desc>
| |
− | </scopingEntity>
| |
− | </participantRole>
| |
− | </participant>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="9015b590-aa62-4d74-83ab-34bea18af397"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <id extension="870921e3-a997-4d5d-9ecc-40e990b10a6e" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" codeSystemName="HL7ActClass" displayName="Concern"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--S-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.208"/>
| |
− | <code code="61150-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Subjective Narrative"/>
| |
− | <text>Veel pijn voet, zie DM2.</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--E-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.210"/>
| |
− | <code code="51848-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Evaluation note"/>
| |
− | <text>pijnklachten bij diabetische voet mglk amputatie voet</text>
| |
− | <statusCode code="completed"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.213"/>
| |
− | <id extension="cc42c46f-e3ec-4cc9-8abd-b06596be8f90" root="2.16.528.1.1007.3.3.765332.1.12"/>
| |
− | <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150601"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="S97.01" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Ulcus cruris"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--P-->
| |
− | <templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.211"/>
| |
− | <code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of treatment (narrative)"/>
| |
− | <text>verwijzing fysiotherapie en ergotherapie alvast</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| | | |
| Vervolgens voert POH reguliere controle uit door de POH. | | Vervolgens voert POH reguliere controle uit door de POH. |
Regel 3.175: |
Regel 903: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
| + | |
− | {{Beginbouwsteenvoorbeeld|Labbepaling/Algemene bepaling}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="a0d5c9ea-4038-481d-896f-cd8e92b0cd58" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="357" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="gewicht patiënt"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20151227"/>
| |
− | <value xsi:type="PQ" value="74" unit="kg"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="9015b590-aa62-4d74-83ab-34bea18af397"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="731678b9-ffb9-49eb-888a-b8dda229819a" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1272" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="Quetelet-index (BMI) patiënt"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20151227"/>
| |
− | <value xsi:type="PQ" value="30" unit="kg/m2"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="9015b590-aa62-4d74-83ab-34bea18af397"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="0aa903c4-0b54-458e-b5f8-e273eff468ea" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1744" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="systolische bloeddruk"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20151227"/>
| |
− | <value xsi:type="PQ" value="125" unit="mm[Hg]"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="9015b590-aa62-4d74-83ab-34bea18af397"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="789caf89-a627-4b43-b98a-79029cca1d00" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="1740" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="diastolische bloeddruk"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20151227"/>
| |
− | <value xsi:type="PQ" value="75" unit="mm[Hg]"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="9015b590-aa62-4d74-83ab-34bea18af397"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="b00135ab-8455-446c-982e-3e51701e973a" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="2816" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="HbA1c (glycohemoglobine) IFCC"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20151227"/>
| |
− | <value xsi:type="PQ" value="56" unit="mmol/mol"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="9015b590-aa62-4d74-83ab-34bea18af397"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="5c017222-4c6e-40d6-afc7-f10488757b58" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="192" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="cholesterol totaal"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20151227"/>
| |
− | <value xsi:type="PQ" value="5.4" unit="mmol/L"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="9015b590-aa62-4d74-83ab-34bea18af397"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | <entry typeCode="DRIV">
| |
− | <observation classCode="OBS" moodCode="EVN">
| |
− | <id extension="5a271ebb-66e0-48d9-b731-c2cce4c5d3a5" root="2.16.840.1.113883.2.4.6.6.100001111"/>
| |
− | <code code="446" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="HDL-cholesterol"/>
| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime value="20151227"/>
| |
− | <value xsi:type="PQ" value="1.2" unit="mmol/L"/>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <id root="2.16.528.1.1007.3.3.765332.1.12" extension="9015b590-aa62-4d74-83ab-34bea18af397"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| | | |
| De volledige set van gegevens die gewijzigd kunnen worden staat staat in de Samenvattingskaart_kernset_DM. | | De volledige set van gegevens die gewijzigd kunnen worden staat staat in de Samenvattingskaart_kernset_DM. |