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(30 tussenliggende versies door 3 gebruikers niet weergegeven) |
Regel 1: |
Regel 1: |
− | {{#customtitle:Use Cases en Storyboards|Casuïtieken}} | + | {{DISPLAYTITLE:Casuïstieken|Casuïstieken}} |
− | {{underconstruction}}
| + | |
| + | ==Inleiding== |
| + | De use cases dienen als voorbeeld. Ze laten zien hoe de bouwstenen worden gebruikt. Ze zijn niet normstellend. |
| | | |
| ==Bouwstenen== | | ==Bouwstenen== |
− | De bouwstenen zijn zo opgezet dat uitwisseling van informatie mogelijk is zowel binnen de 1e lijn als in de ketenzorg. | + | De volgende bouwstenen zijn van toepassing: |
− | De opgestelde use cases dekken de informatieuitwisseling af zodat een toetsing op de bouwsteenmodellen mogelijk is.
| + | *[[File:Bouwsteen.png]] Overdracht Concern |
− | | + | *[[File:Bouwsteen.png]] Contactmoment |
− | De bouwstenen die van toepassing zijn binnen deze informatiestandaard:
| |
− | *[[File:Bouwsteen.png]] Overdracht concern | |
− | *[[File:Bouwsteen.png]] Algemene bepaling
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− | *[[File:Bouwsteen.png]] Medicatievoorschrift | |
| *[[File:Bouwsteen.png]] Contactverslag | | *[[File:Bouwsteen.png]] Contactverslag |
| + | *[[File:Bouwsteen.png]] Labbepaling |
| + | *[[File:Bouwsteen.png]] Algemene Bepalingen |
| + | *[[File:Bouwsteen.png]] Medicatieafspraak |
| *[[File:Bouwsteen.png]] Alert | | *[[File:Bouwsteen.png]] Alert |
| *[[File:Bouwsteen.png]] Allergie/Intolerantie | | *[[File:Bouwsteen.png]] Allergie/Intolerantie |
− | *[[File:Bouwsteen.png]] Labbepaling
| |
− |
| |
− | Per Use Case wordt toegelicht welke bouwstenen van toepassing zijn.
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− |
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− | {{NoteBox|Ten opzichte van COPD en Diabetes is er bij CVRM een andere werkwijze. Niet procedureel in OZIS. Wel inhoudelijk in het gebruik van ICPC.
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| | | |
− | Bij CVRM: In het HIS hebben Veel CVRM patiënten meer dan 1 ICPC code. Het KIS ontvangt dus ook meerdere ICPC codes in de context van CVMR. De informatie die in het KIS aangevuld wordt, wordt gekoppeld aan meerdere ICPC codes. (zoals A04, A06, K90 etc). Er worden dus meerdere gegevens vastgelegd. De samenhang is namelijk bepalend voor CVRM. Om informatie van het KIS naar het HIS te sturen worden deze codes gegroepeerd. Volgens OZIS procesbeschrijving moeten meerdere ICPC codes gemapt worden naar 1 OZIS code in het HIS (zie beschrijving NHG 2010, Khing). De POH kiest de code waarnaar toe gemapt wordt. De ‘gemapte’ code wordt verstuurd naar het HIS, Dit kan dus A04, K90 of A06 zijn. Er wordt dus een hiërarchie gecreëerd van ICPC codes. In het HIS wordt 1 ICPC code ontvangen, met daaronder de individuele codes. Het HIS moet de juiste logica hebben om de mapping goed te krijgen
| + | Per use case wordt toegelicht welke bouwstenen van toepassing zijn. De [[kezo:Huidige_Functionele_toelichting_bouwstenen|huidige functionele bouwstenen]] zijn hier beschreven. |
− | | |
− | Opmerking: In de nieuwe situatie van bouwstenen zal deze mapping niet van toepassing zijn. In de bouwsteen worden alle ICPC codes verstuurd zonder hiërarchie.
| |
− | }}
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| | | |
| ==Uitwerking Use Cases== | | ==Uitwerking Use Cases== |
− | De volgende casus zijn beschreven naar scenario's die binnen huisartsenpraktijk voorkomen. Dit is de bron van de informatie, die m.b.v. de bouwstenen gecommuniceerd gaat worden. In tabellen is weergegeven wat de verslaglegging is na het consult. | + | De volgende use cases zijn beschreven naar praktijkvoorbeelden die binnen huisartsenpraktijken voorkomen. |
| | | |
| ===Use Case 1: COPD Patiënt === | | ===Use Case 1: COPD Patiënt === |
| Kenmerken: | | Kenmerken: |
| * Weinig complex, enkele episode | | * Weinig complex, enkele episode |
− | * Niet echt een ketenzorg scenario met gegevensuitwisseling tussen ketenpartners maar meer bedoelt om kennis te maken met de bouwstenen
| |
| Aandachtspunten: | | Aandachtspunten: |
− | *Episode die in de loop van de tijd van titel verandert | + | *De episode verandert in de loop van de tijd van titel |
| Bouwstenen: | | Bouwstenen: |
− | *[[File:Bouwsteen.png]] Overdracht concern | + | *[[File:Bouwsteen.png]] Overdracht Concern |
− | *[[File:Bouwsteen.png]] Algemene bepaling | + | *[[File:Bouwsteen.png]] Algemene bepalingen |
− | *[[File:Bouwsteen.png]] Medicatievoorschrift | + | *[[File:Bouwsteen.png]] Medicatieafspraak |
| *[[File:Bouwsteen.png]] Contactverslag | | *[[File:Bouwsteen.png]] Contactverslag |
| | | |
| | | |
| {{BeginPurpleBox|Casus 1}} | | {{BeginPurpleBox|Casus 1}} |
− | De heer Sigurd Tabarook, 62 jaar, bezoekt zijn huisarts op 3 augustus 2015 nu hij merkt dat hij na twee trappen lopen wel erg kortademig is. Hij weet al langer zijn conditiegebrek aan het roken en stelde dus doktersbezoek uit. Hij komt nu naar de dokter om zijn longen te laten onderzoek, ook aangezien zijn vader emfyseem had en op latere leeftijd aan de zuurstof moest. Hij is bang dat hem hetzelfde overkomt. | + | De heer Sigurd Tabarook, 62 jaar, bezoekt zijn huisarts op 3 augustus 2015 nu hij merkt dat hij na twee trappen lopen wel erg kortademig is. Hij verwijt al langere tijd zijn conditiegebrek aan het roken en stelde daarom het bezoek aan de dokter uit. Hij komt nu naar de dokter om zijn longen te laten onderzoeken, ook omdat zijn vader longemfyseem had en moest op latere leeftijd aan de zuurstof. Hij is bang dat hem hetzelfde overkomt. |
| {| class="wikitable" width=70% | | {| class="wikitable" width=70% |
| ! width=100px | Episode (nieuw) | | ! width=100px | Episode (nieuw) |
Regel 59: |
Regel 51: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
| |
− | {{Beginbouwsteenvoorbeeld|Overdracht concern}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
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− | <!--Overdracht concern-->
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| |
− | <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>
| |
− | <text>Dyspnoe/benauwdheid toegeschreven aan luchtwegen [ex. K02]</text>
| |
− | <statusCode code="active"/>
| |
− | <effectiveTime>
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| |
− | <statusCode code="completed"/>
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− | <low value="20150803"/>
| |
− | </effectiveTime>
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− | <value xsi:type="CD" code="R02" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Dyspnoe/benauwdheid toegeschreven aan luchtwegen [ex. K02]"/>
| |
− | </observation>
| |
− | </entryRelationship>
| |
− | </act>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− |
| |
− | {{Beginbouwsteenvoorbeeld|Contactmoment}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <encounter classCode="ENC" moodCode="EVN">
| |
− | <!--Contactmoment-->
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| |
− | <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>
| |
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| |
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| |
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| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− |
| |
− | {{Beginbouwsteenvoorbeeld|Contactverslag}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--Contactverslag-->
| |
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− | <participant typeCode="RESP">
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− | <given>Koos</given>
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− | <family qualifier="BR">Jansma</family>
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− | <desc>Gezondheidscentrum Amby</desc>
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− | <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>langer dyspnoe, geen duidelijke oorzaak. Niet ziek geweest, geen koorts. Met name bij inspannen, maar ook wat bij warm weer. Emfyseem? Al langer hoesten met sputum (wit). Geen piepen. Iets afgevallen, geen bloed bij sputum. Geen pijn op de borst. VG: 1967 appendectomie, pneumonie 1989 Med: geen All: geen</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
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− | <entryRelationship typeCode="COMP">
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− | <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 acuut dyspnoische man, tonvormige thorax. Pulm: beiderzijds normaal ademgeruis, zachte geruizen. Percutoir weinig verschuivende longgrenzen. Geen piepen. Cor: normale harttonen, geen souffles</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
− | </entryRelationship>
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− | <entryRelationship typeCode="COMP">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <!--E-->
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− | <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>dyspnoe, wsl beginnende COPD</text>
| |
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| |
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| |
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− | <id extension="0cc14c38-33f5-4b3e-847a-db6fa06d804f" root="2.16.528.1.1007.3.3.765332.1.12"/>
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| |
− | <statusCode code="completed"/>
| |
− | <effectiveTime>
| |
− | <low value="20150803"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="R02" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Dyspnoe/benauwdheid toegeschreven aan luchtwegen [ex. K02]"/>
| |
− | </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>eerst longfunctie, dringend advies staken roken, uitleg tav rol roken op COPD/longfunctie, co na longfunctie</text>
| |
− | <statusCode code="completed"/>
| |
− | </act>
| |
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| |
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| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| | | |
− | Patiënt komt diezelfde week (6 augustus) nog bij de POH voor de longfunctie. Deze neemt bij de patiënt ook de CCQ af. | + | Patiënt komt in die zelfde week (6 augustus) nog bij de POH voor de longfunctie en neemt bij de patiënt ook de CCQ af. |
| | | |
| {| class="wikitable" width=70% | | {| class="wikitable" width=70% |
Regel 235: |
Regel 80: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
| |
− | {{Beginbouwsteenvoorbeeld|Labepaling/Algemene Bepaling}}
| |
− | <syntaxhighlight lang="xml" enclose="div">
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| |
− | <code code="1704" codeSystem="2.16.840.1.113883.2.4.4.30.45" displayName="conclusie longfunctieonderzoek"/>
| |
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| |
− | <effectiveTime value="20150806"/>
| |
− | <value xsi:type="ST">Conclusie longfunctieonderzoek: N.B.De flow-volume curve wordt als pdf toegevoegd aan het dossier; bij herhaling irreversibele luchtwegobstructie</value>
| |
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− | <value xsi:type="PQ" value="1" unit="{score}"/>
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− | <statusCode code="completed"/>
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− | <effectiveTime value="20150806"/>
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− | <value xsi:type="PQ" value="1.25" unit="{score}"/>
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− | <entryRelationship typeCode="REFR">
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| |
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− | <value xsi:type="PQ" value="27.0" unit="kg/m2"/>
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− | </entryRelationship>
| |
− | </observation>
| |
− | </entry>
| |
− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| | | |
− | De week erna (11 augustus) komt patiënt met zijn echtgenote op het spreekuur om de uitslagen te bespreken
| + | Een week later (11 augustus) komt patiënt met zijn echtgenote op het spreekuur om de uitslagen te bespreken |
| | | |
| {| class="wikitable" width=70% | | {| class="wikitable" width=70% |
Regel 341: |
Regel 96: |
| | stoppen met roken volhouden! Uitleg over COPD, info thuisarts mee. Proef salbutamol 100ug/dosis 1-4d1I, evalueer effect op hoesten/dyspnoe. Co twee weken HA. Aanmelden voor ketenzorg. Start controles POH tav voorlichting, behandeling en controles. | | | stoppen met roken volhouden! Uitleg over COPD, info thuisarts mee. Proef salbutamol 100ug/dosis 1-4d1I, evalueer effect op hoesten/dyspnoe. Co twee weken HA. Aanmelden voor ketenzorg. Start controles POH tav voorlichting, behandeling en controles. |
| |- | | |- |
− | | Voorschrift | + | | Medicatieafspraak |
| | SALBUTAMOL AEROSOL 100UG/DO 200DO ADEMH 4 x per dag 1 inhalatie, 1 STUKS | | | SALBUTAMOL AEROSOL 100UG/DO 200DO ADEMH 4 x per dag 1 inhalatie, 1 STUKS |
| |} | | |} |
| | | |
− | {{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="adbfb4cf-1736-41ff-9f55-140e008aa498" 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>Emfyseem/COPD</text>
| |
− | <statusCode code="active"/>
| |
− | <effectiveTime>
| |
− | <low value="20150811"/>
| |
− | </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="c4543900-ee6f-44c6-ab71-315b29da078e" 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="20150811"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="R95" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Emfyseem/COPD"/>
| |
− | </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="c5853925-550f-49aa-9af7-48d3e266024b"/>
| |
− | <code code="03" codeSystem="2.16.840.1.113883.2.4.4.30.14" displayName="consult" codeSystemVersion="v3"/>
| |
− | <effectiveTime>
| |
− | <low value="20150811"/>
| |
− | </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="3b79e6be-3bcb-402d-9fe4-66b166c73891" 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="20150811"/>
| |
− | <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="c5853925-550f-49aa-9af7-48d3e266024b"/>
| |
− | </encounter>
| |
− | </entryRelationship>
| |
− | <entryRelationship typeCode="REFR">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <id extension="adbfb4cf-1736-41ff-9f55-140e008aa498" 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>nagedacht over het roken, patiënt is gelijk gestopt. Zijn vrouw zal ook stoppen met roken. Hoe nu verder?</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>COPD, licht</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="b75eb286-135c-4e67-8834-cb69a65d6885" 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="20150811"/>
| |
− | </effectiveTime>
| |
− | <value xsi:type="CD" code="R95" codeSystem="2.16.840.1.113883.2.4.4.31.1" displayName="Emfyseem/COPD"/>
| |
− | </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>stoppen met roken volhouden! Uitleg over COPD, info thuisarts mee. Proef salbutamol 100ug/dosis 1-4d1I, evalueer effect op hoesten/dyspnoe. Co twee weken HA. Aanmelden voor ketenzorg. Start controles POH tav voorlichting, behandeling en controles.</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="b244e9d1-ce96-4409-b85f-64a2d812de5d" 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="REFR">
| |
− | <act classCode="ACT" moodCode="EVN">
| |
− | <id extension="adbfb4cf-1736-41ff-9f55-140e008aa498" 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}}
| |
| | | |
− | De patiënt wordt aangemeld in het KIS met behulp van het aanmeldbericht. Patiënt wordt ingevoerd in KIS met BSN nummer. POH voert intake uit en legt de gegevens vast in het KIS. Dit wordt gedaan volgens het protocol dat in het KIS wordt aangeboden. | + | De patiënt wordt aangemeld in het KIS met behulp van het aanmeldbericht. Patiënt wordt ingevoerd in KIS met BSN nummer. POH voert intake uit en legt de gegevens vast in het KIS. |
| | | |
| De informatie staat in Prodigmo van het NHG en daarvan afgeleide bepalingenclusters. | | De informatie staat in Prodigmo van het NHG en daarvan afgeleide bepalingenclusters. |
Regel 575: |
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 581: |
Regel 162: |
| | | |
| {{BeginPurpleBox|Casus 2}} | | {{BeginPurpleBox|Casus 2}} |
− | Mevrouw Klaartje uit de Lucht, 35 jaar, komt op het spreekuur op 1 juni 2015. De huisarts heeft haar een paar keer gezien toen ze voor haar zoontje Tijmen op het spreekuur verscheen, toen hij een periode van eczeem en vervolgens astma doormaakte. Zelf komt ze eigenlijk nooit, is ze gezond en gebruikte in het hooikoortsseizoen loratidine en livocab neusspray zo nodig. Vandaag komt ze in verband met langdurig hoesten. | + | Mevrouw Klaartje (35j) uit de Lucht komt op het spreekuur op 1 juni 2015. De huisarts heeft haar een paar keer gezien toen ze voor haar zoontje Tijmen op het spreekuur verscheen. Zelf komt ze eigenlijk nooit, is ze gezond en gebruikte in het hooikoortsseizoen loratidine en livocab neusspray zo nodig. Vandaag komt ze in verband met langdurig hoesten. |
| | | |
| {| class="wikitable" width=70% | | {| class="wikitable" width=70% |
Regel 605: |
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 771: |
Regel 206: |
| | proef salbutamol, expectatief Uitleg tav hyperreactiviteit en mglk astma. Co 4 wkn | | | proef salbutamol, expectatief Uitleg tav hyperreactiviteit en mglk astma. Co 4 wkn |
| |- | | |- |
− | | Voorschrift | + | | Medicatieafspraak |
| | SALBUTAMOL AEROSOL 100UG/DO 200DO ADEMH 1-4 x per dag 1 inhalatie zo nodig bij benauwdheid, 1 STUKS | | | SALBUTAMOL AEROSOL 100UG/DO 200DO ADEMH 1-4 x per dag 1 inhalatie zo nodig bij benauwdheid, 1 STUKS |
| |} | | |} |
| | | |
− | {{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 981: |
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 1.165: |
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 1.441: |
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 1.551: |
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 1.640: |
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 1.685: |
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 1.733: |
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 1.958: |
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 2.160: |
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 2.298: |
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 2.557: |
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>
| |
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| |
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− | </syntaxhighlight>
| |
− | {{Eindbouwsteenvoorbeeld}}
| |
− | {{Eindresultbouwstenenvoorbeelden}}
| |
| | | |
| De wondverpleegkundige bekijkt de wond en verbindt de voet. | | De wondverpleegkundige bekijkt de wond en verbindt de voet. |
Regel 2.923: |
Regel 806: |
| |} | | |} |
| | | |
− | {{Beginresultbouwstenenvoorbeelden}}
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− | {{Beginbouwsteenvoorbeeld|Overdracht concern}}
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− | <!--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 3.090: |
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 3.256: |
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 3.418: |
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 3.594: |
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. |