MedMij:V2020.02/BgLZ-AddendaInhoudelijkeGegevens: verschil tussen versies
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(5 tussenliggende versies door 2 gebruikers niet weergegeven) | |||
Regel 1: | Regel 1: | ||
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__NUMBEREDHEADINGS__ | __NUMBEREDHEADINGS__ | ||
{{DISPLAYTITLE:Beschikbaarstellen Basisgegevens Langdurige Zorg: addenda inhoudelijke gegevens kwalificatie}} | {{DISPLAYTITLE:Beschikbaarstellen Basisgegevens Langdurige Zorg: addenda inhoudelijke gegevens kwalificatie}} | ||
Regel 142: | Regel 140: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Wilsverklaring | |colspan="2"|Wilsverklaring | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-wilsverklaring-01|Wilsverklaring: bglz-1-1-wilsverklaring-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|<span id="bglz-1-1-wilsverklaring-01" title="Intern ID = bglz-1-1-wilsverklaring-01">Wilsverklaring bglz-1-1-wilsverklaring-01</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="6"| | |rowspan="6"| | ||
Regel 159: | Regel 157: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Contactpersoon | |colspan="2"|Contactpersoon | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-contactpersoon-01|Contactpersoon: bglz-1-1-contactpersoon-01]] |
|} | |} | ||
=== Contactpersonen=== | === Contactpersonen=== | ||
Regel 170: | Regel 168: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|<span id="bglz-1-1-contactpersoon-01" title="Intern ID = bglz-1-1-contactpersoon-01">Contactpersoon bglz-1-1-contactpersoon-01</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="22"| | |rowspan="22"| | ||
Regel 236: | Regel 234: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|<span id="bglz-1-1-probleem-01" title="Intern ID = bglz-1-1-probleem-01">Probleem bglz-1-1-probleem-01</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="6"| | |rowspan="6"| | ||
Regel 255: | Regel 253: | ||
|style="background-color: white;"|Niet bekend met neurologische klachten | |style="background-color: white;"|Niet bekend met neurologische klachten | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|<span id="bglz-1-1-probleem-02" title="Intern ID = bglz-1-1-probleem-02">Probleem bglz-1-1-probleem-02</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
Regel 271: | Regel 269: | ||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|<span id="bglz-1-1-probleem-03" title="Intern ID = bglz-1-1-probleem-03">Probleem bglz-1-1-probleem-03</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
Regel 287: | Regel 285: | ||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|<span id="bglz-1-1-probleem-04" title="Intern ID = bglz-1-1-probleem-04">Probleem bglz-1-1-probleem-04</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
Regel 303: | Regel 301: | ||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|<span id="bglz-1-1-probleem-05" title="Intern ID = bglz-1-1-probleem-05">Probleem bglz-1-1-probleem-05</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
Regel 319: | Regel 317: | ||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|<span id="bglz-1-1-probleem-06" title="Intern ID = bglz-1-1-probleem-06">Probleem bglz-1-1-probleem-06</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
Regel 335: | Regel 333: | ||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|<span id="bglz-1-1-probleem-07" title="Intern ID = bglz-1-1-probleem-07">Probleem bglz-1-1-probleem-07</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
Regel 351: | Regel 349: | ||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|<span id="bglz-1-1-probleem-08" title="Intern ID = bglz-1-1-probleem-08">Probleem bglz-1-1-probleem-08</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
Regel 456: | Regel 454: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test datum tijd | |colspan="2"|Test datum tijd | ||
− | |style="background-color: white;"|T om 15 | + | |style="background-color: white;"|T om 15:00 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test uitslag | |colspan="2"|Test uitslag | ||
Regel 478: | Regel 476: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test datum tijd | |colspan="2"|Test datum tijd | ||
− | |style="background-color: white;"|T om 15 | + | |style="background-color: white;"|T om 15:00 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test uitslag | |colspan="2"|Test uitslag | ||
Regel 504: | Regel 502: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test datum tijd | |colspan="2"|Test datum tijd | ||
− | |style="background-color: white;"|T om 15 | + | |style="background-color: white;"|T om 15:00 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test uitslag | |colspan="2"|Test uitslag | ||
Regel 530: | Regel 528: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test datum tijd | |colspan="2"|Test datum tijd | ||
− | |style="background-color: white;"|T om 15 | + | |style="background-color: white;"|T om 15:00 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test uitslag | |colspan="2"|Test uitslag | ||
Regel 568: | Regel 566: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Probleem | |colspan="2"|Probleem | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-probleem-01|Probleem: bglz-1-1-probleem-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verrichting type | |colspan="3"|Verrichting type | ||
Regel 578: | Regel 576: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgaanbieder | |colspan="2"|Zorgaanbieder | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgaanbieder-01|Zorgaanbieder: bglz-1-1-zorgaanbieder-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Uitvoerder | |colspan="4"|Uitvoerder | ||
Regel 585: | Regel 583: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgverlener-02|Zorgverlener: bglz-1-1-zorgverlener-02]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Aanvrager | |colspan="4"|Aanvrager | ||
Regel 592: | Regel 590: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgverlener-02|Zorgverlener: bglz-1-1-zorgverlener-02]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verrichting | |colspan="5"|Verrichting | ||
Regel 609: | Regel 607: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Probleem | |colspan="2"|Probleem | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-probleem-01|Probleem: bglz-1-1-probleem-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verrichting type | |colspan="3"|Verrichting type | ||
Regel 619: | Regel 617: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgaanbieder | |colspan="2"|Zorgaanbieder | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgaanbieder-01|Zorgaanbieder: bglz-1-1-zorgaanbieder-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Uitvoerder | |colspan="4"|Uitvoerder | ||
Regel 626: | Regel 624: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgverlener-02|Zorgverlener: bglz-1-1-zorgverlener-02]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Aanvrager | |colspan="4"|Aanvrager | ||
Regel 633: | Regel 631: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgverlener-02|Zorgverlener: bglz-1-1-zorgverlener-02]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verrichting | |colspan="5"|Verrichting | ||
Regel 647: | Regel 645: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Probleem | |colspan="2"|Probleem | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-probleem-05|Probleem: bglz-1-1-probleem-05]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verrichting type | |colspan="3"|Verrichting type | ||
Regel 657: | Regel 655: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgaanbieder | |colspan="2"|Zorgaanbieder | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgaanbieder-01|Zorgaanbieder: bglz-1-1-zorgaanbieder-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Uitvoerder | |colspan="4"|Uitvoerder | ||
Regel 664: | Regel 662: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgverlener-04|Zorgverlener: bglz-1-1-zorgverlener-04]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Aanvrager | |colspan="4"|Aanvrager | ||
Regel 671: | Regel 669: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgverlener-02|Zorgverlener: bglz-1-1-zorgverlener-02]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verrichting | |colspan="5"|Verrichting | ||
Regel 685: | Regel 683: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Probleem | |colspan="2"|Probleem | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-probleem-06|Probleem: bglz-1-1-probleem-06]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verrichting type | |colspan="3"|Verrichting type | ||
Regel 695: | Regel 693: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgaanbieder | |colspan="2"|Zorgaanbieder | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgaanbieder-01|Zorgaanbieder: bglz-1-1-zorgaanbieder-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Uitvoerder | |colspan="4"|Uitvoerder | ||
Regel 702: | Regel 700: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgverlener-05|Zorgverlener: bglz-1-1-zorgverlener-05]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Aanvrager | |colspan="4"|Aanvrager | ||
Regel 709: | Regel 707: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgverlener-02|Zorgverlener: bglz-1-1-zorgverlener-02]] |
|} | |} | ||
=== Verpleegkundig zorgplan=== | === Verpleegkundig zorgplan=== | ||
Regel 724: | Regel 722: | ||
|rowspan="83"| | |rowspan="83"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|<span id="bglz-1-1-verpleegkundigeinterventie-01" title="Intern ID = bglz-1-1-verpleegkundigeinterventie-01">Verpleegkundige interventie bglz-1-1-verpleegkundigeinterventie-01</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="16"| | |rowspan="16"| | ||
Regel 736: | Regel 734: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Probleem | |colspan="3"|Probleem | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-probleem-03|Probleem: bglz-1-1-probleem-03]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Behandeldoel | |colspan="5"|Behandeldoel | ||
Regel 761: | Regel 759: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgverlener-03|Zorgverlener: bglz-1-1-zorgverlener-03]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|<span id="bglz-1-1-verpleegkundigeinterventie-02" title="Intern ID = bglz-1-1-verpleegkundigeinterventie-02">Verpleegkundige interventie bglz-1-1-verpleegkundigeinterventie-02</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="16"| | |rowspan="16"| | ||
Regel 775: | Regel 773: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Probleem | |colspan="3"|Probleem | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-probleem-04|Probleem: bglz-1-1-probleem-04]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Behandeldoel | |colspan="5"|Behandeldoel | ||
Regel 800: | Regel 798: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgverlener-03|Zorgverlener: bglz-1-1-zorgverlener-03]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|<span id="bglz-1-1-verpleegkundigeinterventie-03" title="Intern ID = bglz-1-1-verpleegkundigeinterventie-03">Verpleegkundige interventie bglz-1-1-verpleegkundigeinterventie-03</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="15"| | |rowspan="15"| | ||
Regel 814: | Regel 812: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Probleem | |colspan="3"|Probleem | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-probleem-05|Probleem: bglz-1-1-probleem-05]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Behandeldoel | |colspan="5"|Behandeldoel | ||
Regel 836: | Regel 834: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgverlener-03|Zorgverlener: bglz-1-1-zorgverlener-03]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|<span id="bglz-1-1-verpleegkundigeinterventie-04" title="Intern ID = bglz-1-1-verpleegkundigeinterventie-04">Verpleegkundige interventie bglz-1-1-verpleegkundigeinterventie-04</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="15"| | |rowspan="15"| | ||
Regel 850: | Regel 848: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Probleem | |colspan="3"|Probleem | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-probleem-07|Probleem: bglz-1-1-probleem-07]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Behandeldoel | |colspan="5"|Behandeldoel | ||
Regel 872: | Regel 870: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgverlener-03|Zorgverlener: bglz-1-1-zorgverlener-03]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|<span id="bglz-1-1-verpleegkundigeinterventie-05" title="Intern ID = bglz-1-1-verpleegkundigeinterventie-05">Verpleegkundige interventie bglz-1-1-verpleegkundigeinterventie-05</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="15"| | |rowspan="15"| | ||
Regel 886: | Regel 884: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Probleem | |colspan="3"|Probleem | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-probleem-08|Probleem: bglz-1-1-probleem-08]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Behandeldoel | |colspan="5"|Behandeldoel | ||
Regel 908: | Regel 906: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgverlener-03|Zorgverlener: bglz-1-1-zorgverlener-03]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Uitkomsten | |colspan="7"|Uitkomsten | ||
Regel 926: | Regel 924: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verpleegkundige interventie | |colspan="3"|Verpleegkundige interventie | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-verpleegkundigeinterventie-01|Verpleegkundige interventie: bglz-1-1-verpleegkundigeinterventie-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Uitkomst van zorg | |colspan="6"|Uitkomst van zorg | ||
Regel 940: | Regel 938: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verpleegkundige interventie | |colspan="3"|Verpleegkundige interventie | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-verpleegkundigeinterventie-02|Verpleegkundige interventie: bglz-1-1-verpleegkundigeinterventie-02]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Uitkomst van zorg | |colspan="6"|Uitkomst van zorg | ||
Regel 954: | Regel 952: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verpleegkundige interventie | |colspan="3"|Verpleegkundige interventie | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-verpleegkundigeinterventie-03|Verpleegkundige interventie: bglz-1-1-verpleegkundigeinterventie-03]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Uitkomst van zorg | |colspan="6"|Uitkomst van zorg | ||
Regel 968: | Regel 966: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verpleegkundige interventie | |colspan="3"|Verpleegkundige interventie | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-verpleegkundigeinterventie-04|Verpleegkundige interventie: bglz-1-1-verpleegkundigeinterventie-04]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Uitkomst van zorg | |colspan="6"|Uitkomst van zorg | ||
Regel 982: | Regel 980: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verpleegkundige interventie | |colspan="3"|Verpleegkundige interventie | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-verpleegkundigeinterventie-05|Verpleegkundige interventie: bglz-1-1-verpleegkundigeinterventie-05]] |
|} | |} | ||
=== Zorgsetting=== | === Zorgsetting=== | ||
Regel 997: | Regel 995: | ||
|rowspan="12"| | |rowspan="12"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|<span id="bglz-1-1-zorgverlener-01" title="Intern ID = bglz-1-1-zorgverlener-01">Zorgverlener bglz-1-1-zorgverlener-01</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="10"| | |rowspan="10"| | ||
Regel 1.028: | Regel 1.026: | ||
|rowspan="15"| | |rowspan="15"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|<span id="bglz-1-1-zorgverlener-02" title="Intern ID = bglz-1-1-zorgverlener-02">Zorgverlener bglz-1-1-zorgverlener-02</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="13"| | |rowspan="13"| | ||
Regel 1.057: | Regel 1.055: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Zorgaanbieder | |colspan="3"|Zorgaanbieder | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgaanbieder-01|Zorgaanbieder: bglz-1-1-zorgaanbieder-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorgverleners rol | |colspan="4"|Zorgverleners rol | ||
Regel 1.066: | Regel 1.064: | ||
|rowspan="40"| | |rowspan="40"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|<span id="bglz-1-1-zorgverlener-03" title="Intern ID = bglz-1-1-zorgverlener-03">Zorgverlener bglz-1-1-zorgverlener-03</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="12"| | |rowspan="12"| | ||
Regel 1.095: | Regel 1.093: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Zorgaanbieder | |colspan="3"|Zorgaanbieder | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgaanbieder-01|Zorgaanbieder: bglz-1-1-zorgaanbieder-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|<span id="bglz-1-1-zorgverlener-04" title="Intern ID = bglz-1-1-zorgverlener-04">Zorgverlener bglz-1-1-zorgverlener-04</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="12"| | |rowspan="12"| | ||
Regel 1.126: | Regel 1.124: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Zorgaanbieder | |colspan="3"|Zorgaanbieder | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgaanbieder-01|Zorgaanbieder: bglz-1-1-zorgaanbieder-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|<span id="bglz-1-1-zorgverlener-05" title="Intern ID = bglz-1-1-zorgverlener-05">Zorgverlener bglz-1-1-zorgverlener-05</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="12"| | |rowspan="12"| | ||
Regel 1.157: | Regel 1.155: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Zorgaanbieder | |colspan="3"|Zorgaanbieder | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-1-zorgaanbieder-01|Zorgaanbieder: bglz-1-1-zorgaanbieder-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="7"| | + | |colspan="7"|<span id="bglz-1-1-zorgaanbieder-01" title="Intern ID = bglz-1-1-zorgaanbieder-01">Zorgaanbieder bglz-1-1-zorgaanbieder-01</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="24"| | |rowspan="24"| | ||
Regel 1.425: | Regel 1.423: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|<span id="bglz-1-3-probleem-01" title="Intern ID = bglz-1-3-probleem-01">Probleem bglz-1-3-probleem-01</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="7"| | |rowspan="7"| | ||
Regel 1.468: | Regel 1.466: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test datum tijd | |colspan="2"|Test datum tijd | ||
− | |style="background-color: white;"|T om 15 | + | |style="background-color: white;"|T om 15:00 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test uitslag | |colspan="2"|Test uitslag | ||
Regel 1.494: | Regel 1.492: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test datum tijd | |colspan="2"|Test datum tijd | ||
− | |style="background-color: white;"|T + 1 maand om 16 | + | |style="background-color: white;"|T + 1 maand om 16:00 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test uitslag | |colspan="2"|Test uitslag | ||
Regel 1.521: | Regel 1.519: | ||
|rowspan="26"| | |rowspan="26"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="7"| | + | |colspan="7"|<span id="bglz-1-3-verpleegkundigeinterventie-01" title="Intern ID = bglz-1-3-verpleegkundigeinterventie-01">Verpleegkundige interventie bglz-1-3-verpleegkundigeinterventie-01</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="24"| | |rowspan="24"| | ||
Regel 1.533: | Regel 1.531: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Probleem | |colspan="4"|Probleem | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-3-probleem-01|Probleem: bglz-1-3-probleem-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Frequentie | |colspan="5"|Frequentie | ||
Regel 1.596: | Regel 1.594: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Verpleegkundige interventie | |colspan="4"|Verpleegkundige interventie | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1-3-verpleegkundigeinterventie-01|Verpleegkundige interventie: bglz-1-3-verpleegkundigeinterventie-01]] |
|}<section end=BgLZ-3.0-LZB-1.3-v1 /> | |}<section end=BgLZ-3.0-LZB-1.3-v1 /> | ||
− | + | ==Scenario BgLZ-3.0-LZB-1.5-v2== | |
− | + | <section begin=BgLZ-3.0-LZB-1.5-v2 /> | |
− | |||
− | |||
− | ==Scenario BgLZ-3.0-LZB-1.5- | ||
− | <section begin=BgLZ-3.0-LZB-1.5- | ||
=== Demografie en identificatie=== | === Demografie en identificatie=== | ||
Regel 1.738: | Regel 1.732: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Wilsverklaring | |colspan="2"|Wilsverklaring | ||
− | |style="background-color: white;"|Zie wilsverklaring met id: '[[#bglz-1.5-wilsverklaring-01|bglz-1.5-wilsverklaring-01]] | + | |style="background-color: white;"|Zie [[#bglz-1.5-wilsverklaring-01|Wilsverklaring: bglz-1.5-wilsverklaring-01]] |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|<span id="bglz-1.5-wilsverklaring-01" title="Intern ID = bglz-1.5-wilsverklaring-01">Wilsverklaring bglz-1.5-wilsverklaring-01</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Wilsverklaring type | ||
+ | |style="background-color: white;"|Niet reanimeren verklaring (code = 'NR' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.14.1') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Wilsverklaring datum | ||
+ | |style="background-color: white;"|T | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Vertegenwoordiger | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Contactpersoon | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-contactpersoon-01|Contactpersoon: bglz-1.5-contactpersoon-01]] | ||
+ | |} | ||
+ | === Contactpersonen=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactpersonen | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="5" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|<span id="bglz-1.5-contactpersoon-01" title="Intern ID = bglz-1.5-contactpersoon-01">Contactpersoon bglz-1.5-contactpersoon-01</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="22"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Naamgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Voornamen | ||
+ | |style="background-color: white;"|Robert | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Initialen | ||
+ | |style="background-color: white;"|R. | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Naamgebruik | ||
+ | |style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslachtsnaam | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Achternaam | ||
+ | |style="background-color: white;"|Prins | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Contactgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Telefoonnummers | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Telefoonnummer | ||
+ | |style="background-color: white;"|06-34567891 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Telecom type | ||
+ | |style="background-color: white;"|Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Nummer soort | ||
+ | |style="background-color: white;"|Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Email adressen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Email adres | ||
+ | |style="background-color: white;"|bprins@123net.nl | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Email soort | ||
+ | |style="background-color: white;"|Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Rol | ||
+ | |style="background-color: white;"|Eerste relatie/contactpersoon (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Relatie | ||
+ | |style="background-color: white;"|Zoon (code = 'SONC' in codeSystem 'HL7 RoleCode') | ||
+ | |} | ||
+ | === Klachten en diagnoses=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Klachten en diagnoses | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|<span id="bglz-1.5-probleem-01" title="Intern ID = bglz-1.5-probleem-01">Probleem bglz-1.5-probleem-01</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem type | ||
+ | |style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem naam | ||
+ | |style="background-color: white;"|ischemisch cerebrovasculair accident (code = '422504002' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem begin datum | ||
+ | |style="background-color: white;"|T | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem status | ||
+ | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Toelichting | ||
+ | |style="background-color: white;"|Niet bekend met neurologische klachten | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|<span id="bglz-1.5-probleem-02" title="Intern ID = bglz-1.5-probleem-02">Probleem bglz-1.5-probleem-02</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem type | ||
+ | |style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem naam | ||
+ | |style="background-color: white;"|diabetes mellitus (code = '73211009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem begin datum | ||
+ | |style="background-color: white;"|T - 14 jaar | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem status | ||
+ | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|<span id="bglz-1.5-probleem-06" title="Intern ID = bglz-1.5-probleem-06">Probleem bglz-1.5-probleem-06</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem type | ||
+ | |style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem naam | ||
+ | |style="background-color: white;"|afasie (code = '87486003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem begin datum | ||
+ | |style="background-color: white;"|T | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem status | ||
+ | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
+ | |} | ||
+ | === Allergieen=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Allergieen | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Allergie intolerantie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Veroorzakende stof | ||
+ | |style="background-color: white;"|pinda (code = '762952008' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Allergie status | ||
+ | |style="background-color: white;"|Actief (code = 'active' in codeSystem 'HL7 ActStatus') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Mate van kritiek zijn | ||
+ | |style="background-color: white;"|Fataal (code = '399166001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Toelichting | ||
+ | |style="background-color: white;"|Na het eten van pinda's als student ontstond er een klinisch beeld van anafylaxie waarop de HA epipen heeft moeten toedienen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Reactie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Symptoom | ||
+ | |style="background-color: white;"|Anafylaxie (code = '39579001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Reactie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Symptoom | ||
+ | |style="background-color: white;"|Angio-oedeem (code = '41291007' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Reactie beschrijving | ||
+ | |style="background-color: white;"|Angio-oedeem van de tong, lippen en peri-orbitale regio met acute benauwdheid na het eten van pinda's. | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Allergie intolerantie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Veroorzakende stof | ||
+ | |style="background-color: white;"|nikkelsulfaat (code = '255848005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Allergie status | ||
+ | |style="background-color: white;"|Actief (code = 'active' in codeSystem 'HL7 ActStatus') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Mate van kritiek zijn | ||
+ | |style="background-color: white;"|Matig (code = '6736007' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Toelichting | ||
+ | |style="background-color: white;"|Opgemerkt bij het dragen van nikkel bevattende sieraden. | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Reactie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Symptoom | ||
+ | |style="background-color: white;"|Contactdermatitis (code = '40275004' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Reactie beschrijving | ||
+ | |style="background-color: white;"|Last van jeuk, roodheid en irritatie op de contactplek van nikkel bevattende sieraden. | ||
+ | |} | ||
+ | === Uitslagen=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Uitslagen | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Laboratorium uitslag | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="17"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Laboratorium test | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Test code | ||
+ | |style="background-color: white;"|Hemoglobine (code = '718-7' in codeSystem 'LOINC') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Test datum tijd | ||
+ | |style="background-color: white;"|T om 15:00 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Test uitslag | ||
+ | |style="background-color: white;"|11.0 g/dl | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Referentie bovengrens | ||
+ | |style="background-color: white;"|16.0 g/dl | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Referentie ondergrens | ||
+ | |style="background-color: white;"|12.0 g/dl | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Interpretatie vlaggen | ||
+ | |style="background-color: white;"|Onder referentiewaarde (code = '281300000' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Laboratorium test | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Test code | ||
+ | |style="background-color: white;"|Hematocriet (code = '20570-8' in codeSystem 'LOINC') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Test datum tijd | ||
+ | |style="background-color: white;"|T om 15:00 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Test uitslag | ||
+ | |style="background-color: white;"|47 % | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Referentie bovengrens | ||
+ | |style="background-color: white;"|51 % | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Referentie ondergrens | ||
+ | |style="background-color: white;"|39 % | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Onderzoek | ||
+ | |style="background-color: white;"|hemoglobine & hematocriet panel (code = '24360-0' in codeSystem 'LOINC') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Laboratorium uitslag | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Laboratorium test | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Test code | ||
+ | |style="background-color: white;"|glucose 2 uur na maaltijd massa/volume serum of plasma (code = '1521-4' in codeSystem 'LOINC') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Test datum tijd | ||
+ | |style="background-color: white;"|T om 15:00 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Test uitslag | ||
+ | |style="background-color: white;"|5.9 mg/dl | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Referentie bovengrens | ||
+ | |style="background-color: white;"|7.8 mg/dl | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Referentie ondergrens | ||
+ | |style="background-color: white;"|3.5 mg/dl | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Interpretatie vlaggen | ||
+ | |style="background-color: white;"|Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Laboratorium uitslag | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Laboratorium test | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Test code | ||
+ | |style="background-color: white;"|cholesterol:mol/volume:moment:serum of plasma:kwantitatief: (code = '14647-2' in codeSystem 'LOINC') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Test datum tijd | ||
+ | |style="background-color: white;"|T om 15:00 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Test uitslag | ||
+ | |style="background-color: white;"|5.5 mmol/l | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Referentie bovengrens | ||
+ | |style="background-color: white;"|1.8 mmol/l | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Interpretatie vlaggen | ||
+ | |style="background-color: white;"|Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Toelichting | ||
+ | |style="background-color: white;"|Volgens richtlijn herseninfarct: streven naar <1,8mmol/L | ||
+ | |} | ||
+ | === Verrichtingen=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Verrichtingen | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="16"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting start datum | ||
+ | |style="background-color: white;"|T | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting eind datum | ||
+ | |style="background-color: white;"|T | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Indicatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-probleem-01|Probleem: bglz-1.5-probleem-01]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|computertomografie van hersenen (code = '34227000' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Locatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgaanbieder | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-zorgaanbieder-01|Zorgaanbieder: bglz-1.5-zorgaanbieder-01]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Uitvoerder | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgverlener | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-zorgverlener-02|Zorgverlener: bglz-1.5-zorgverlener-02]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Aanvrager | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgverlener | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-zorgverlener-02|Zorgverlener: bglz-1.5-zorgverlener-02]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="16"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting start datum | ||
+ | |style="background-color: white;"|T | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting eind datum | ||
+ | |style="background-color: white;"|T | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Indicatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-probleem-01|Probleem: bglz-1.5-probleem-01]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|percutane trombolyse van intracraniële arterie (code = '230935003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Locatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgaanbieder | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-zorgaanbieder-01|Zorgaanbieder: bglz-1.5-zorgaanbieder-01]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Uitvoerder | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgverlener | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-zorgverlener-02|Zorgverlener: bglz-1.5-zorgverlener-02]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Aanvrager | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgverlener | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-zorgverlener-02|Zorgverlener: bglz-1.5-zorgverlener-02]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting start datum | ||
+ | |style="background-color: white;"|T | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|fysiotherapie (code = '91251008' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Locatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgaanbieder | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-zorgaanbieder-01|Zorgaanbieder: bglz-1.5-zorgaanbieder-01]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Uitvoerder | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgverlener | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-zorgverlener-04|Zorgverlener: bglz-1.5-zorgverlener-04]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Aanvrager | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgverlener | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-zorgverlener-02|Zorgverlener: bglz-1.5-zorgverlener-02]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="15"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting start datum | ||
+ | |style="background-color: white;"|T | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Indicatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-probleem-06|Probleem: bglz-1.5-probleem-06]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|logopedische behandeling (code = '5154007' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Locatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgaanbieder | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-zorgaanbieder-01|Zorgaanbieder: bglz-1.5-zorgaanbieder-01]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Uitvoerder | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgverlener | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-zorgverlener-05|Zorgverlener: bglz-1.5-zorgverlener-05]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Aanvrager | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgverlener | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-zorgverlener-02|Zorgverlener: bglz-1.5-zorgverlener-02]] | ||
+ | |} | ||
+ | === Verpleegkundig zorgplan=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Verpleegkundig zorgplan | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Verpleegkundig zorgplan ongestructureerd | ||
+ | |style="background-color: white;"|<div>Verpleegkundig zorgplan in opgemaakte tekst. Onderstaande is een voorbeeld. Het hoeft niet letterlijk te worden overgenomen.</div><div> </div><div><table class="fr-tinymce-table" style="border: 1px solid black; min-width: 50%; cell-padding: 1em; cell-spacing: 1em;"><tr><th colspan="1" rowspan="1" style="width: 30%; text-align: left;">probleem</th><th colspan="1" rowspan="1" style="width: 20%; text-align: left;">behandeldoel</th><th colspan="1" rowspan="1" style="width: 50%; text-align: left;">interventie</th></tr><tr><td colspan="1" rowspan="1" valign="top">probleem met zichzelf wassen en afdrogen</td><td colspan="1" rowspan="1" valign="top">wassen onafhankelijk</td><td colspan="1" rowspan="1" valign="top">ondersteunen bij wassen en/of persoonlijke hygiëne <br/>1 x per dag</td></tr><tr><td colspan="1" rowspan="1" valign="top">probleem met zichzelf kleden</td><td colspan="1" rowspan="1" valign="top">kleden onafhankelijk</td><td colspan="1" rowspan="1" valign="top">ondersteunen bij aankleden <br/>2 x per dag</td></tr><tr><td colspan="1" rowspan="1" valign="top">probleem met lopen</td><td colspan="1" rowspan="1" valign="top">lopen met hulp</td><td colspan="1" rowspan="1" valign="top">patiënt mobiliseren</td></tr><tr><td colspan="1" rowspan="1" valign="top">risico op decubitus</td><td colspan="1" rowspan="1" valign="top">huid blijft intact</td><td colspan="1" rowspan="1" valign="top">wisselen van positie van patiënt</td></tr><tr><td colspan="1" rowspan="1" valign="top">overbelaste mantelzorg</td><td colspan="1" rowspan="1" valign="top">zorgtaken voor echtgenoot worden gecontinueerd</td><td colspan="1" rowspan="1" valign="top">ondersteuning voor verzorger</td></tr></table></div><div><table class="fr-tinymce-table"><tr><td colspan="1" rowspan="1"><table class="fr-tinymce-table" style="width: 604.84375px;"><tr><td colspan="2" rowspan="1"><table class="fr-tinymce-table" style="width: 598.84375px;"><tr><td colspan="1" rowspan="1"> </td></tr></table></td></tr></table></td></tr></table></div> | ||
+ | |} | ||
+ | === Zorgsetting=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Zorgsetting | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="6" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Huisarts | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|<span id="bglz-1.5-zorgverlener-01" title="Intern ID = bglz-1.5-zorgverlener-01">Zorgverlener bglz-1.5-zorgverlener-01</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Naamgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Voornamen | ||
+ | |style="background-color: white;"|Laura | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Initialen | ||
+ | |style="background-color: white;"|L. | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslachtsnaam | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Achternaam | ||
+ | |style="background-color: white;"|Lanen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Specialisme | ||
+ | |style="background-color: white;"|Huisarts (code = '01.015' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorgverleners rol | ||
+ | |style="background-color: white;"|Verwijzer (code = 'REF' in codeSystem 'HL7 ParticipationType') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Hoofdbehandelaar | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="15"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|<span id="bglz-1.5-zorgverlener-02" title="Intern ID = bglz-1.5-zorgverlener-02">Zorgverlener bglz-1.5-zorgverlener-02</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="13"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Naamgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Voornamen | ||
+ | |style="background-color: white;"|Niels | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Initialen | ||
+ | |style="background-color: white;"|N. | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslachtsnaam | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Achternaam | ||
+ | |style="background-color: white;"|Helmond | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Specialisme | ||
+ | |style="background-color: white;"|Neuroloog (code = '01.026' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zorgaanbieder | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Zorgaanbieder | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-zorgaanbieder-01|Zorgaanbieder: bglz-1.5-zorgaanbieder-01]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorgverleners rol | ||
+ | |style="background-color: white;"|Hoofdbehandelaar (code = 'RESP' in codeSystem 'HL7 ParticipationType') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Overige behandelaars | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="40"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|<span id="bglz-1.5-zorgverlener-03" title="Intern ID = bglz-1.5-zorgverlener-03">Zorgverlener bglz-1.5-zorgverlener-03</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Naamgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Voornamen | ||
+ | |style="background-color: white;"|Petra Johanna | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Initialen | ||
+ | |style="background-color: white;"|P.J. | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslachtsnaam | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Achternaam | ||
+ | |style="background-color: white;"|Vreeswijk | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Specialisme | ||
+ | |style="background-color: white;"|Verpleegkundige (code = '30.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zorgaanbieder | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Zorgaanbieder | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-zorgaanbieder-01|Zorgaanbieder: bglz-1.5-zorgaanbieder-01]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|<span id="bglz-1.5-zorgverlener-04" title="Intern ID = bglz-1.5-zorgverlener-04">Zorgverlener bglz-1.5-zorgverlener-04</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Naamgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Voornamen | ||
+ | |style="background-color: white;"|Thomas | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Initialen | ||
+ | |style="background-color: white;"|T. | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslachtsnaam | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Achternaam | ||
+ | |style="background-color: white;"|Janssen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Specialisme | ||
+ | |style="background-color: white;"|Fysiotherapeut (code = '04.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zorgaanbieder | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Zorgaanbieder | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-zorgaanbieder-01|Zorgaanbieder: bglz-1.5-zorgaanbieder-01]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|<span id="bglz-1.5-zorgverlener-05" title="Intern ID = bglz-1.5-zorgverlener-05">Zorgverlener bglz-1.5-zorgverlener-05</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Naamgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Voornamen | ||
+ | |style="background-color: white;"|Hilda | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Initialen | ||
+ | |style="background-color: white;"|H. | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslachtsnaam | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Achternaam | ||
+ | |style="background-color: white;"|Bruinsma | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Specialisme | ||
+ | |style="background-color: white;"|Logopedist (code = '91.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zorgaanbieder | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Zorgaanbieder | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-zorgaanbieder-01|Zorgaanbieder: bglz-1.5-zorgaanbieder-01]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|<span id="bglz-1.5-zorgaanbieder-01" title="Intern ID = bglz-1.5-zorgaanbieder-01">Zorgaanbieder bglz-1.5-zorgaanbieder-01</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="24"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Organisatie naam | ||
+ | |style="background-color: white;"|AA-zkh | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Organisatie locatie | ||
+ | |style="background-color: white;"|Noord | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Afdeling specialisme | ||
+ | |style="background-color: white;"|Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT (Vektis Zorgverlenersspecificatie (subberoepsgroep))') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Contactgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Telefoonnummers | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Telefoonnummer | ||
+ | |style="background-color: white;"|+31182435768 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Telecom type | ||
+ | |style="background-color: white;"|Vast telefoonnummer (code = 'LL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.22.1') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Nummer soort | ||
+ | |style="background-color: white;"|Zakelijk telefoonnummer (code = 'WP' in codeSystem 'HL7 AddressUse') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Email adressen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Email adres | ||
+ | |style="background-color: white;"|neurologie@AAZ.nl | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Email soort | ||
+ | |style="background-color: white;"|Zakelijk e-mailadres (code = 'WP' in codeSystem 'HL7 AddressUse') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Adresgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Straat | ||
+ | |style="background-color: white;"|De Weststraat | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Huisnummer | ||
+ | |style="background-color: white;"|3 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Postcode | ||
+ | |style="background-color: white;"|9999PK | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Woonplaats | ||
+ | |style="background-color: white;"|Stitswerd | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Land | ||
+ | |style="background-color: white;"|Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Adres soort | ||
+ | |style="background-color: white;"|Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Organisatie type | ||
+ | |style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | ||
+ | |}<section end=BgLZ-3.0-LZB-1.5-v2 /> | ||
+ | ==Scenario BgLZ-3.0-LZR-1.5-v1== | ||
+ | <section begin=BgLZ-3.0-LZR-1.5-v1 /> | ||
+ | === Demografie en identificatie=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Demografie en identificatie | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="5" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Patient | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="32"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Naamgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Voornamen | ||
+ | |style="background-color: white;"|Fiona | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Initialen | ||
+ | |style="background-color: white;"|F. | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Naamgebruik | ||
+ | |style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslachtsnaam | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Achternaam | ||
+ | |style="background-color: white;"|XXX_Mutter | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Adresgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Straat | ||
+ | |style="background-color: white;"|Knolweg | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Huisnummer | ||
+ | |style="background-color: white;"|1001 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Postcode | ||
+ | |style="background-color: white;"|9999XX | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Woonplaats | ||
+ | |style="background-color: white;"|Stitswerd | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Land | ||
+ | |style="background-color: white;"|Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Adres soort | ||
+ | |style="background-color: white;"|Postadres (code = 'PST' in codeSystem 'HL7 AddressUse') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Contactgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Telefoonnummers | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Telefoonnummer | ||
+ | |style="background-color: white;"|+31634567891 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Telecom type | ||
+ | |style="background-color: white;"|Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Nummer soort | ||
+ | |style="background-color: white;"|Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Email adressen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Email adres | ||
+ | |style="background-color: white;"|fmutter@hotmail.com | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Email soort | ||
+ | |style="background-color: white;"|Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Identificatienummer | ||
+ | |style="background-color: white;"|999911673 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortedatum | ||
+ | |style="background-color: white;"|8 feb 1964 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslacht | ||
+ | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Meerling indicator | ||
+ | |style="background-color: white;"|Nee | ||
+ | |} | ||
+ | === Behandelrestricties=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Behandelrestricties | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Behandel aanwijzing | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Verificatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Geverifieerd | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Geverifieerd bij | ||
+ | |style="background-color: white;"|Patiënt (code = '116154003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Verificatie datum | ||
+ | |style="background-color: white;"|T - 0 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Behandeling | ||
+ | |style="background-color: white;"|Cardiopulmonaire resuscitatie (code = '89666000' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Behandeling toegestaan | ||
+ | |style="background-color: white;"|Behandeling niet toegestaan en/of wenselijk (code = 'NEE' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Begin datum | ||
+ | |style="background-color: white;"|T | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Wilsverklaring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Wilsverklaring | ||
+ | |style="background-color: white;"|Zie [[#bglz-1.5-wilsverklaring-01|Wilsverklaring: bglz-1.5-wilsverklaring-01]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|<span id="bglz-1.5-wilsverklaring-01" title="Intern ID = bglz-1.5-wilsverklaring-01">Wilsverklaring bglz-1.5-wilsverklaring-01</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="6"| | |rowspan="6"| | ||
Regel 1.755: | Regel 2.619: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Contactpersoon | |colspan="2"|Contactpersoon | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-contactpersoon-01|Contactpersoon: bglz-1.5-contactpersoon-01]] |
|} | |} | ||
=== Contactpersonen=== | === Contactpersonen=== | ||
Regel 1.766: | Regel 2.630: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|<span id="bglz-1.5-contactpersoon-01" title="Intern ID = bglz-1.5-contactpersoon-01">Contactpersoon bglz-1.5-contactpersoon-01</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="22"| | |rowspan="22"| | ||
Regel 1.832: | Regel 2.696: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|<span id="bglz-1.5-probleem-01" title="Intern ID = bglz-1.5-probleem-01">Probleem bglz-1.5-probleem-01</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="6"| | |rowspan="6"| | ||
Regel 1.851: | Regel 2.715: | ||
|style="background-color: white;"|Niet bekend met neurologische klachten | |style="background-color: white;"|Niet bekend met neurologische klachten | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|<span id="bglz-1.5-probleem-02" title="Intern ID = bglz-1.5-probleem-02">Probleem bglz-1.5-probleem-02</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
Regel 1.867: | Regel 2.731: | ||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|<span id="bglz-1.5-probleem-03" title="Intern ID = bglz-1.5-probleem-03">Probleem bglz-1.5-probleem-03</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
Regel 1.883: | Regel 2.747: | ||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|<span id="bglz-1.5-probleem-04" title="Intern ID = bglz-1.5-probleem-04">Probleem bglz-1.5-probleem-04</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
Regel 1.899: | Regel 2.763: | ||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|<span id="bglz-1.5-probleem-05" title="Intern ID = bglz-1.5-probleem-05">Probleem bglz-1.5-probleem-05</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
Regel 1.915: | Regel 2.779: | ||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|<span id="bglz-1.5-probleem-06" title="Intern ID = bglz-1.5-probleem-06">Probleem bglz-1.5-probleem-06</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
Regel 1.931: | Regel 2.795: | ||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|<span id="bglz-1.5-probleem-07" title="Intern ID = bglz-1.5-probleem-07">Probleem bglz-1.5-probleem-07</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
Regel 1.947: | Regel 2.811: | ||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|<span id="bglz-1.5-probleem-08" title="Intern ID = bglz-1.5-probleem-08">Probleem bglz-1.5-probleem-08</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
Regel 2.052: | Regel 2.916: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test datum tijd | |colspan="2"|Test datum tijd | ||
− | |style="background-color: white;"|T om 15 | + | |style="background-color: white;"|T - 0 dagen om 15:00 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test uitslag | |colspan="2"|Test uitslag | ||
Regel 2.074: | Regel 2.938: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test datum tijd | |colspan="2"|Test datum tijd | ||
− | |style="background-color: white;"|T om 15 | + | |style="background-color: white;"|T - 0 dagen om 15:00 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test uitslag | |colspan="2"|Test uitslag | ||
Regel 2.100: | Regel 2.964: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test datum tijd | |colspan="2"|Test datum tijd | ||
− | |style="background-color: white;"|T om 15 | + | |style="background-color: white;"|T - 0 dagen om 15:00 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test uitslag | |colspan="2"|Test uitslag | ||
Regel 2.126: | Regel 2.990: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test datum tijd | |colspan="2"|Test datum tijd | ||
− | |style="background-color: white;"|T om 15 | + | |style="background-color: white;"|T - 0 dagen om 15:00 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test uitslag | |colspan="2"|Test uitslag | ||
Regel 2.164: | Regel 3.028: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Probleem | |colspan="2"|Probleem | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-probleem-01|Probleem: bglz-1.5-probleem-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verrichting type | |colspan="3"|Verrichting type | ||
Regel 2.174: | Regel 3.038: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgaanbieder | |colspan="2"|Zorgaanbieder | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-zorgaanbieder-01|Zorgaanbieder: bglz-1.5-zorgaanbieder-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Uitvoerder | |colspan="4"|Uitvoerder | ||
Regel 2.181: | Regel 3.045: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-zorgverlener-02|Zorgverlener: bglz-1.5-zorgverlener-02]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Aanvrager | |colspan="4"|Aanvrager | ||
Regel 2.188: | Regel 3.052: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-zorgverlener-02|Zorgverlener: bglz-1.5-zorgverlener-02]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verrichting | |colspan="5"|Verrichting | ||
Regel 2.205: | Regel 3.069: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Probleem | |colspan="2"|Probleem | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-probleem-01|Probleem: bglz-1.5-probleem-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verrichting type | |colspan="3"|Verrichting type | ||
Regel 2.215: | Regel 3.079: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgaanbieder | |colspan="2"|Zorgaanbieder | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-zorgaanbieder-01|Zorgaanbieder: bglz-1.5-zorgaanbieder-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Uitvoerder | |colspan="4"|Uitvoerder | ||
Regel 2.222: | Regel 3.086: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-zorgverlener-02|Zorgverlener: bglz-1.5-zorgverlener-02]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Aanvrager | |colspan="4"|Aanvrager | ||
Regel 2.229: | Regel 3.093: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-zorgverlener-02|Zorgverlener: bglz-1.5-zorgverlener-02]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verrichting | |colspan="5"|Verrichting | ||
Regel 2.243: | Regel 3.107: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Probleem | |colspan="2"|Probleem | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-probleem-05|Probleem: bglz-1.5-probleem-05]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verrichting type | |colspan="3"|Verrichting type | ||
Regel 2.253: | Regel 3.117: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgaanbieder | |colspan="2"|Zorgaanbieder | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-zorgaanbieder-01|Zorgaanbieder: bglz-1.5-zorgaanbieder-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Uitvoerder | |colspan="4"|Uitvoerder | ||
Regel 2.260: | Regel 3.124: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-zorgverlener-04|Zorgverlener: bglz-1.5-zorgverlener-04]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Aanvrager | |colspan="4"|Aanvrager | ||
Regel 2.267: | Regel 3.131: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-zorgverlener-02|Zorgverlener: bglz-1.5-zorgverlener-02]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verrichting | |colspan="5"|Verrichting | ||
Regel 2.281: | Regel 3.145: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Probleem | |colspan="2"|Probleem | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-probleem-06|Probleem: bglz-1.5-probleem-06]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verrichting type | |colspan="3"|Verrichting type | ||
Regel 2.291: | Regel 3.155: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgaanbieder | |colspan="2"|Zorgaanbieder | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-zorgaanbieder-01|Zorgaanbieder: bglz-1.5-zorgaanbieder-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Uitvoerder | |colspan="4"|Uitvoerder | ||
Regel 2.298: | Regel 3.162: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-zorgverlener-05|Zorgverlener: bglz-1.5-zorgverlener-05]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Aanvrager | |colspan="4"|Aanvrager | ||
Regel 2.305: | Regel 3.169: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-zorgverlener-02|Zorgverlener: bglz-1.5-zorgverlener-02]] |
|} | |} | ||
=== Verpleegkundig zorgplan=== | === Verpleegkundig zorgplan=== | ||
Regel 2.317: | Regel 3.181: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Verpleegkundig zorgplan ongestructureerd | |colspan="2"|Verpleegkundig zorgplan ongestructureerd | ||
− | |style="background-color: white;"|<div>Verpleegkundig zorgplan in opgemaakte tekst. Onderstaande is een voorbeeld. | + | |style="background-color: white;"|<div>Verpleegkundig zorgplan in opgemaakte tekst. Onderstaande is een voorbeeld. </div><div> </div><div><table><caption style="font-weight: bold;">Zorgplan. Subject: Fiona XXX_Mutter. Status: actief<span style="display: block;">Intentie: aanvraag</span></caption><tr><th colspan="1" rowspan="1" style="">Activiteit</th><td colspan="1" rowspan="1"><table style="width: 604.84375px;"><tr><th colspan="1" rowspan="1" style="width: 25%; text-align: left;">Resultaat</th><td colspan="1" rowspan="1">Wassen met hulp.</td></tr><tr><td colspan="2" rowspan="1"><table style="width: 598.84375px;"><caption style="font-weight: bold;">Details<span style="display: block;">Categorie: <span title="Nursing procedure (9632001 - SNOMED CT)">Nursing procedure</span>, Status: voltooid</span></caption><tr><th colspan="1" rowspan="1" style="width: 146.203125px;">Code</th><td colspan="1" rowspan="1"><span title="ondersteunen bij wassen en/of persoonlijke hygiëne (386420003 - SNOMED CT)">ondersteunen bij wassen en/of persoonlijke hygiëne</span></td></tr><tr><th colspan="1" rowspan="1" style="width: 146.203125px;">Schema</th><td colspan="1" rowspan="1">eenmalig per dag</td></tr><tr><th colspan="1" rowspan="1" style="width: 146.203125px;">Reden</th><td colspan="1" rowspan="1">probleem met zichzelf wassen en afdrogen </td></tr><tr><th colspan="1" rowspan="1" style="width: 146.203125px;">Doel</th><td colspan="1" rowspan="1">wassen onafhankelijk </td></tr><tr><th colspan="1" rowspan="1" style="width: 146.203125px;">Uitvoerende</th><td colspan="1" rowspan="1">Petra Johanna Vreeswijk </td></tr></table></td></tr></table></td></tr><tr><th colspan="1" rowspan="1" style="">Activiteit</th><td colspan="1" rowspan="1"><table style="width: 604.84375px;"><tr><th colspan="1" rowspan="1" style="width: 25%; text-align: left;">Resultaat</th><td colspan="1" rowspan="1">Kleden met hulp.</td></tr><tr><td colspan="2" rowspan="1"><table style="width: 598.84375px;"><caption style="font-weight: bold;">Details<span style="display: block;">Categorie: <span title="Nursing procedure (9632001 - SNOMED CT)">Nursing procedure</span>, Status: voltooid</span></caption><tr><th colspan="1" rowspan="1" style="width: 146.21875px;">Code</th><td colspan="1" rowspan="1"><span title="ondersteunen bij aankleden (313332003 - SNOMED CT)">ondersteunen bij aankleden</span></td></tr><tr><th colspan="1" rowspan="1" style="width: 146.21875px;">Schema</th><td colspan="1" rowspan="1">2 maal per dag</td></tr><tr><th colspan="1" rowspan="1" style="width: 146.21875px;">Reden</th><td colspan="1" rowspan="1">probleem met zichzelf kleden </td></tr><tr><th colspan="1" rowspan="1" style="width: 146.21875px;">Doel</th><td colspan="1" rowspan="1">kleden onafhankelijk </td></tr><tr><th colspan="1" rowspan="1" style="width: 146.21875px;">Uitvoerende</th><td colspan="1" rowspan="1">Petra Johanna Vreeswijk </td></tr></table></td></tr></table></td></tr><tr><th colspan="1" rowspan="1" style="">Activiteit</th><td colspan="1" rowspan="1"><table style="width: 604.84375px;"><tr><th colspan="1" rowspan="1" style="width: 25%; text-align: left;">Resultaat</th><td colspan="1" rowspan="1">Lopen geheel afhankelijk.</td></tr><tr><td colspan="2" rowspan="1"><table style="width: 598.84375px;"><caption style="font-weight: bold;">Details<span style="display: block;">Categorie: <span title="Nursing procedure (9632001 - SNOMED CT)">Nursing procedure</span>, Status: voltooid</span></caption><tr><th colspan="1" rowspan="1" style="width: 146.203125px;">Code</th><td colspan="1" rowspan="1"><span title="patiënt mobiliseren (62013009 - SNOMED CT)">patiënt mobiliseren</span></td></tr><tr><th colspan="1" rowspan="1" style="width: 146.203125px;">Reden</th><td colspan="1" rowspan="1">probleem met lopen </td></tr><tr><th colspan="1" rowspan="1" style="width: 146.203125px;">Doel</th><td colspan="1" rowspan="1">lopen met hulp </td></tr><tr><th colspan="1" rowspan="1" style="width: 146.203125px;">Uitvoerende</th><td colspan="1" rowspan="1">Petra Johanna Vreeswijk </td></tr></table></td></tr></table></td></tr><tr><th colspan="1" rowspan="1" style="">Activiteit</th><td colspan="1" rowspan="1"><table style="width: 604.84375px;"><tr><th colspan="1" rowspan="1" style="width: 25%; text-align: left;">Resultaat</th><td colspan="1" rowspan="1">Huid is intact zonder decubitus wonden.</td></tr><tr><td colspan="2" rowspan="1"><table style="width: 598.84375px;"><caption style="font-weight: bold;">Details<span style="display: block;">Categorie: <span title="Nursing procedure (9632001 - SNOMED CT)">Nursing procedure</span>, Status: voltooid</span></caption><tr><th colspan="1" rowspan="1" style="width: 146.203125px;">Code</th><td colspan="1" rowspan="1"><span title="wisselen van positie van patiënt (225286008 - SNOMED CT)">wisselen van positie van patiënt</span></td></tr><tr><th colspan="1" rowspan="1" style="width: 146.203125px;">Reden</th><td colspan="1" rowspan="1">risico op decubitus </td></tr><tr><th colspan="1" rowspan="1" style="width: 146.203125px;">Doel</th><td colspan="1" rowspan="1">huid blijft intact </td></tr><tr><th colspan="1" rowspan="1" style="width: 146.203125px;">Uitvoerende</th><td colspan="1" rowspan="1">Petra Johanna Vreeswijk </td></tr></table></td></tr></table></td></tr><tr><th colspan="1" rowspan="1" style="">Activiteit</th><td colspan="1" rowspan="1"><table style="width: 604.84375px;"><tr><th colspan="1" rowspan="1" style="width: 25%; text-align: left;">Resultaat</th><td colspan="1" rowspan="1">Thuiszorg is aangevraagd voor continuering van zorgtaken en huishoudelijke hulp.</td></tr><tr><td colspan="2" rowspan="1"><table style="width: 598.84375px;"><caption style="font-weight: bold;">Details<span style="display: block;">Categorie: <span title="Nursing procedure (9632001 - SNOMED CT)">Nursing procedure</span>, Status: voltooid</span></caption><tr><th colspan="1" rowspan="1" style="width: 146.21875px;">Code</th><td colspan="1" rowspan="1"><span title="ondersteuning voor verzorger (386229000 - SNOMED CT)">ondersteuning voor verzorger</span></td></tr><tr><th colspan="1" rowspan="1" style="width: 146.21875px;">Reden</th><td colspan="1" rowspan="1">overbelaste mantelzorg </td></tr><tr><th colspan="1" rowspan="1" style="width: 146.21875px;">Doel</th><td colspan="1" rowspan="1">zorgtaken voor echtgenoot worden gecontinueerd </td></tr><tr><th colspan="1" rowspan="1" style="width: 146.21875px;">Uitvoerende</th><td colspan="1" rowspan="1">Petra Johanna Vreeswijk </td></tr></table></td></tr></table></td></tr></table></div> |
|} | |} | ||
=== Zorgsetting=== | === Zorgsetting=== | ||
Regel 2.332: | Regel 3.196: | ||
|rowspan="12"| | |rowspan="12"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|<span id="bglz-1.5-zorgverlener-01" title="Intern ID = bglz-1.5-zorgverlener-01">Zorgverlener bglz-1.5-zorgverlener-01</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="10"| | |rowspan="10"| | ||
Regel 2.363: | Regel 3.227: | ||
|rowspan="15"| | |rowspan="15"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|<span id="bglz-1.5-zorgverlener-02" title="Intern ID = bglz-1.5-zorgverlener-02">Zorgverlener bglz-1.5-zorgverlener-02</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="13"| | |rowspan="13"| | ||
Regel 2.392: | Regel 3.256: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Zorgaanbieder | |colspan="3"|Zorgaanbieder | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-zorgaanbieder-01|Zorgaanbieder: bglz-1.5-zorgaanbieder-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorgverleners rol | |colspan="4"|Zorgverleners rol | ||
Regel 2.401: | Regel 3.265: | ||
|rowspan="40"| | |rowspan="40"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|<span id="bglz-1.5-zorgverlener-03" title="Intern ID = bglz-1.5-zorgverlener-03">Zorgverlener bglz-1.5-zorgverlener-03</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="12"| | |rowspan="12"| | ||
Regel 2.430: | Regel 3.294: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Zorgaanbieder | |colspan="3"|Zorgaanbieder | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-zorgaanbieder-01|Zorgaanbieder: bglz-1.5-zorgaanbieder-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|<span id="bglz-1.5-zorgverlener-04" title="Intern ID = bglz-1.5-zorgverlener-04">Zorgverlener bglz-1.5-zorgverlener-04</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="12"| | |rowspan="12"| | ||
Regel 2.461: | Regel 3.325: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Zorgaanbieder | |colspan="3"|Zorgaanbieder | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-zorgaanbieder-01|Zorgaanbieder: bglz-1.5-zorgaanbieder-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|<span id="bglz-1.5-zorgverlener-05" title="Intern ID = bglz-1.5-zorgverlener-05">Zorgverlener bglz-1.5-zorgverlener-05</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="12"| | |rowspan="12"| | ||
Regel 2.492: | Regel 3.356: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Zorgaanbieder | |colspan="3"|Zorgaanbieder | ||
− | |style="background-color: white;"|Zie | + | |style="background-color: white;"|Zie [[#bglz-1.5-zorgaanbieder-01|Zorgaanbieder: bglz-1.5-zorgaanbieder-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="7"| | + | |colspan="7"|<span id="bglz-1.5-zorgaanbieder-01" title="Intern ID = bglz-1.5-zorgaanbieder-01">Zorgaanbieder bglz-1.5-zorgaanbieder-01</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="24"| | |rowspan="24"| | ||
Regel 2.558: | Regel 3.422: | ||
|colspan="5"|Organisatie type | |colspan="5"|Organisatie type | ||
|style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | ||
− | |}<section end=BgLZ-3.0- | + | |}<section end=BgLZ-3.0-LZR-1.5-v1 /> |
[[Categorie:Kwalificatie]] | [[Categorie:Kwalificatie]] |
Huidige versie van 22 nov 2022 om 13:37
1 Addenda voor inhoudelijke gegevens
1.1 Scenario BgLZ-3.0-LZB-1.1-v1
1.1.1 Demografie en identificatie
Demografie en identificatie | |||||
Gegevenselement | Waarde | ||||
Patient | |||||
Naamgegevens | |||||
Voornamen | Fiona | ||||
Initialen | F. | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Mutter | ||||
Adresgegevens | |||||
Straat | Knolweg | ||||
Huisnummer | 1001 | ||||
Postcode | 9999XX | ||||
Woonplaats | Stitswerd | ||||
Land | Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | ||||
Adres soort | Postadres (code = 'PST' in codeSystem 'HL7 AddressUse') | ||||
Contactgegevens | |||||
Telefoonnummers | |||||
Telefoonnummer | +31634567891 | ||||
Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
Nummer soort | Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Email adressen | |||||
Email adres | fmutter@hotmail.com | ||||
Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Identificatienummer | 999911673 (in identificerend systeem: BSN) | ||||
Geboortedatum | 8 feb 1964 | ||||
Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
Meerling indicator | Nee |
1.1.2 Behandelrestricties
Behandelrestricties | ||||
Gegevenselement | Waarde | |||
Behandel aanwijzing | ||||
Verificatie | ||||
Geverifieerd | Ja | |||
Geverifieerd bij | Patiënt (code = '116154003' in codeSystem 'SNOMED CT') | |||
Verificatie datum | T | |||
Behandeling | Cardiopulmonaire resuscitatie (code = '89666000' in codeSystem 'SNOMED CT') | |||
Behandeling toegestaan | Behandeling niet toegestaan en/of wenselijk (code = 'NEE' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4') | |||
Begin datum | T | |||
Wilsverklaring | ||||
Wilsverklaring | Zie Wilsverklaring: bglz-1-1-wilsverklaring-01 | |||
Wilsverklaring bglz-1-1-wilsverklaring-01 | ||||
Wilsverklaring type | Niet reanimeren verklaring (code = 'NR' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.14.1') | |||
Wilsverklaring datum | T | |||
Vertegenwoordiger | ||||
Contactpersoon | Zie Contactpersoon: bglz-1-1-contactpersoon-01 |
1.1.3 Contactpersonen
Contactpersonen | |||||
Gegevenselement | Waarde | ||||
Contactpersoon bglz-1-1-contactpersoon-01 | |||||
Naamgegevens | |||||
Voornamen | Robert | ||||
Initialen | R. | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam | |||||
Achternaam | Prins | ||||
Contactgegevens | |||||
Telefoonnummers | |||||
Telefoonnummer | 06-34567891 | ||||
Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
Nummer soort | Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Email adressen | |||||
Email adres | bprins@123net.nl | ||||
Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Rol | Eerste relatie/contactpersoon (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472') | ||||
Relatie | Zoon (code = 'SONC' in codeSystem 'HL7 RoleCode') |
1.1.4 Klachten en diagnoses
Klachten en diagnoses | |||
Gegevenselement | Waarde | ||
Probleem bglz-1-1-probleem-01 | |||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | ischemisch cerebrovasculair accident (code = '422504002' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Toelichting | Niet bekend met neurologische klachten | ||
Probleem bglz-1-1-probleem-02 | |||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | diabetes mellitus (code = '73211009' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T - 14 jaar | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Probleem bglz-1-1-probleem-03 | |||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | probleem met zichzelf wassen en afdrogen (code = '288552005' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Probleem bglz-1-1-probleem-04 | |||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | probleem met zichzelf kleden (code = '284972002' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Probleem bglz-1-1-probleem-05 | |||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | probleem met lopen (code = '228158008' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Probleem bglz-1-1-probleem-06 | |||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | afasie (code = '87486003' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Probleem bglz-1-1-probleem-07 | |||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | risico op decubitus (code = '285304000' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Probleem bglz-1-1-probleem-08 | |||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | overbelaste mantelzorg (code = '705044006' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') |
1.1.5 Allergieen
Allergieen | ||||
Gegevenselement | Waarde | |||
Allergie intolerantie | ||||
Veroorzakende stof | pinda (code = '762952008' in codeSystem 'SNOMED CT') | |||
Allergie status | Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||
Mate van kritiek zijn | Fataal (code = '399166001' in codeSystem 'SNOMED CT') | |||
Toelichting | Na het eten van pinda's als student ontstond er een klinisch beeld van anafylaxie waarop de HA epipen heeft moeten toedienen | |||
Reactie | ||||
Symptoom | Anafylaxie (code = '39579001' in codeSystem 'SNOMED CT') | |||
Reactie | ||||
Symptoom | Angio-oedeem (code = '41291007' in codeSystem 'SNOMED CT') | |||
Reactie beschrijving | Angio-oedeem van de tong, lippen en peri-orbitale regio met acute benauwdheid na het eten van pinda's. | |||
Allergie intolerantie | ||||
Veroorzakende stof | nikkelsulfaat (code = '255848005' in codeSystem 'SNOMED CT') | |||
Allergie status | Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||
Mate van kritiek zijn | Matig (code = '6736007' in codeSystem 'SNOMED CT') | |||
Toelichting | Opgemerkt bij het dragen van nikkel bevattende sieraden. | |||
Reactie | ||||
Symptoom | Contactdermatitis (code = '40275004' in codeSystem 'SNOMED CT') | |||
Reactie beschrijving | Last van jeuk, roodheid en irritatie op de contactplek van nikkel bevattende sieraden. |
1.1.6 Uitslagen
Uitslagen | ||||
Gegevenselement | Waarde | |||
Laboratorium uitslag | ||||
Laboratorium test | ||||
Test code | Hemoglobine (code = '718-7' in codeSystem 'LOINC') | |||
Test datum tijd | T om 15:00 uur | |||
Test uitslag | 11.0 g/dl | |||
Referentie bovengrens | 16.0 g/dl | |||
Referentie ondergrens | 12.0 g/dl | |||
Interpretatie vlaggen | Onder referentiewaarde (code = '281300000' in codeSystem 'SNOMED CT') | |||
Laboratorium test | ||||
Test code | Hematocriet (code = '20570-8' in codeSystem 'LOINC') | |||
Test datum tijd | T om 15:00 uur | |||
Test uitslag | 47 % | |||
Referentie bovengrens | 51 % | |||
Referentie ondergrens | 39 % | |||
Onderzoek | hemoglobine & hematocriet panel (code = '24360-0' in codeSystem 'LOINC') | |||
Laboratorium uitslag | ||||
Laboratorium test | ||||
Test code | glucose 2 uur na maaltijd massa/volume serum of plasma (code = '1521-4' in codeSystem 'LOINC') | |||
Test datum tijd | T om 15:00 uur | |||
Test uitslag | 5.9 mg/dl | |||
Referentie bovengrens | 7.8 mg/dl | |||
Referentie ondergrens | 3.5 mg/dl | |||
Interpretatie vlaggen | Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
Laboratorium uitslag | ||||
Laboratorium test | ||||
Test code | cholesterol:mol/volume:moment:serum of plasma:kwantitatief: (code = '14647-2' in codeSystem 'LOINC') | |||
Test datum tijd | T om 15:00 uur | |||
Test uitslag | 5.5 mmol/l | |||
Referentie bovengrens | 1.8 mmol/l | |||
Interpretatie vlaggen | Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
Toelichting | Volgens richtlijn herseninfarct: streven naar <1,8mmol/L |
1.1.7 Verrichtingen
Verrichtingen | ||||
Gegevenselement | Waarde | |||
Verrichting | ||||
Verrichting start datum | T | |||
Verrichting eind datum | T | |||
Indicatie | ||||
Probleem | Zie Probleem: bglz-1-1-probleem-01 | |||
Verrichting type | computertomografie van hersenen (code = '34227000' in codeSystem 'SNOMED CT') | |||
Locatie | ||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1-1-zorgaanbieder-01 | |||
Uitvoerder | ||||
Zorgverlener | Zie Zorgverlener: bglz-1-1-zorgverlener-02 | |||
Aanvrager | ||||
Zorgverlener | Zie Zorgverlener: bglz-1-1-zorgverlener-02 | |||
Verrichting | ||||
Verrichting start datum | T | |||
Verrichting eind datum | T | |||
Indicatie | ||||
Probleem | Zie Probleem: bglz-1-1-probleem-01 | |||
Verrichting type | percutane trombolyse van intracraniële arterie (code = '230935003' in codeSystem 'SNOMED CT') | |||
Locatie | ||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1-1-zorgaanbieder-01 | |||
Uitvoerder | ||||
Zorgverlener | Zie Zorgverlener: bglz-1-1-zorgverlener-02 | |||
Aanvrager | ||||
Zorgverlener | Zie Zorgverlener: bglz-1-1-zorgverlener-02 | |||
Verrichting | ||||
Verrichting start datum | T | |||
Indicatie | ||||
Probleem | Zie Probleem: bglz-1-1-probleem-05 | |||
Verrichting type | fysiotherapie (code = '91251008' in codeSystem 'SNOMED CT') | |||
Locatie | ||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1-1-zorgaanbieder-01 | |||
Uitvoerder | ||||
Zorgverlener | Zie Zorgverlener: bglz-1-1-zorgverlener-04 | |||
Aanvrager | ||||
Zorgverlener | Zie Zorgverlener: bglz-1-1-zorgverlener-02 | |||
Verrichting | ||||
Verrichting start datum | T | |||
Indicatie | ||||
Probleem | Zie Probleem: bglz-1-1-probleem-06 | |||
Verrichting type | logopedische behandeling (code = '5154007' in codeSystem 'SNOMED CT') | |||
Locatie | ||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1-1-zorgaanbieder-01 | |||
Uitvoerder | ||||
Zorgverlener | Zie Zorgverlener: bglz-1-1-zorgverlener-05 | |||
Aanvrager | ||||
Zorgverlener | Zie Zorgverlener: bglz-1-1-zorgverlener-02 |
1.1.8 Verpleegkundig zorgplan
Verpleegkundig zorgplan | ||||||
Gegevenselement | Waarde | |||||
Doelen en interventies | ||||||
Verpleegkundige interventie bglz-1-1-verpleegkundigeinterventie-01 | ||||||
Interventie | ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED CT') | |||||
Indicatie | ||||||
Probleem | Zie Probleem: bglz-1-1-probleem-03 | |||||
Behandeldoel | ||||||
Behandeldoel | ||||||
Gewenst zorgresultaat | wassen onafhankelijk | |||||
Frequentie | 1 per dag | |||||
Uitvoerder | ||||||
Zorgverlener | ||||||
Zorgverlener | Zie Zorgverlener: bglz-1-1-zorgverlener-03 | |||||
Verpleegkundige interventie bglz-1-1-verpleegkundigeinterventie-02 | ||||||
Interventie | ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED CT') | |||||
Indicatie | ||||||
Probleem | Zie Probleem: bglz-1-1-probleem-04 | |||||
Behandeldoel | ||||||
Behandeldoel | ||||||
Gewenst zorgresultaat | kleden onafhankelijk | |||||
Frequentie | 2 per dag | |||||
Uitvoerder | ||||||
Zorgverlener | ||||||
Zorgverlener | Zie Zorgverlener: bglz-1-1-zorgverlener-03 | |||||
Verpleegkundige interventie bglz-1-1-verpleegkundigeinterventie-03 | ||||||
Interventie | patiënt mobiliseren (code = '62013009' in codeSystem 'SNOMED CT') | |||||
Indicatie | ||||||
Probleem | Zie Probleem: bglz-1-1-probleem-05 | |||||
Behandeldoel | ||||||
Behandeldoel | ||||||
Gewenst zorgresultaat | lopen met hulp | |||||
Uitvoerder | ||||||
Zorgverlener | ||||||
Zorgverlener | Zie Zorgverlener: bglz-1-1-zorgverlener-03 | |||||
Verpleegkundige interventie bglz-1-1-verpleegkundigeinterventie-04 | ||||||
Interventie | wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED CT') | |||||
Indicatie | ||||||
Probleem | Zie Probleem: bglz-1-1-probleem-07 | |||||
Behandeldoel | ||||||
Behandeldoel | ||||||
Gewenst zorgresultaat | huid blijft intact | |||||
Uitvoerder | ||||||
Zorgverlener | ||||||
Zorgverlener | Zie Zorgverlener: bglz-1-1-zorgverlener-03 | |||||
Verpleegkundige interventie bglz-1-1-verpleegkundigeinterventie-05 | ||||||
Interventie | ondersteuning voor verzorger (code = '386229000' in codeSystem 'SNOMED CT') | |||||
Indicatie | ||||||
Probleem | Zie Probleem: bglz-1-1-probleem-08 | |||||
Behandeldoel | ||||||
Behandeldoel | ||||||
Gewenst zorgresultaat | zorgtaken voor echtgenoot worden gecontinueerd | |||||
Uitvoerder | ||||||
Zorgverlener | ||||||
Zorgverlener | Zie Zorgverlener: bglz-1-1-zorgverlener-03 | |||||
Uitkomsten | ||||||
Uitkomst van zorg | ||||||
Zorgresultaat | Wassen met hulp. | |||||
Interventie | ||||||
Verpleegkundige interventie | Zie Verpleegkundige interventie: bglz-1-1-verpleegkundigeinterventie-01 | |||||
Uitkomst van zorg | ||||||
Zorgresultaat | Kleden met hulp. | |||||
Interventie | ||||||
Verpleegkundige interventie | Zie Verpleegkundige interventie: bglz-1-1-verpleegkundigeinterventie-02 | |||||
Uitkomst van zorg | ||||||
Zorgresultaat | Lopen geheel afhankelijk. | |||||
Interventie | ||||||
Verpleegkundige interventie | Zie Verpleegkundige interventie: bglz-1-1-verpleegkundigeinterventie-03 | |||||
Uitkomst van zorg | ||||||
Zorgresultaat | Huid is intact zonder decubitus wonden. | |||||
Interventie | ||||||
Verpleegkundige interventie | Zie Verpleegkundige interventie: bglz-1-1-verpleegkundigeinterventie-04 | |||||
Uitkomst van zorg | ||||||
Zorgresultaat | Thuiszorg is aangevraagd voor continuering van zorgtaken en huishoudelijke hulp. | |||||
Interventie | ||||||
Verpleegkundige interventie | Zie Verpleegkundige interventie: bglz-1-1-verpleegkundigeinterventie-05 |
1.1.9 Zorgsetting
Zorgsetting | ||||||
Gegevenselement | Waarde | |||||
Huisarts | ||||||
Zorgverlener bglz-1-1-zorgverlener-01 | ||||||
Naamgegevens | ||||||
Voornamen | Laura | |||||
Initialen | L. | |||||
Geslachtsnaam | ||||||
Achternaam | Lanen | |||||
Specialisme | Huisarts (code = '01.015' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
Zorgverleners rol | Verwijzer (code = 'REF' in codeSystem 'HL7 ParticipationType') | |||||
Hoofdbehandelaar | ||||||
Zorgverlener bglz-1-1-zorgverlener-02 | ||||||
Naamgegevens | ||||||
Voornamen | Niels | |||||
Initialen | N. | |||||
Geslachtsnaam | ||||||
Achternaam | Helmond | |||||
Specialisme | Neuroloog (code = '01.026' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
Zorgaanbieder | ||||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1-1-zorgaanbieder-01 | |||||
Zorgverleners rol | Hoofdbehandelaar (code = 'RESP' in codeSystem 'HL7 ParticipationType') | |||||
Overige behandelaars | ||||||
Zorgverlener bglz-1-1-zorgverlener-03 | ||||||
Naamgegevens | ||||||
Voornamen | Petra Johanna | |||||
Initialen | P.J. | |||||
Geslachtsnaam | ||||||
Achternaam | Vreeswijk | |||||
Specialisme | Verpleegkundige (code = '30.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
Zorgaanbieder | ||||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1-1-zorgaanbieder-01 | |||||
Zorgverlener bglz-1-1-zorgverlener-04 | ||||||
Naamgegevens | ||||||
Voornamen | Thomas | |||||
Initialen | T. | |||||
Geslachtsnaam | ||||||
Achternaam | Janssen | |||||
Specialisme | Fysiotherapeut (code = '04.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
Zorgaanbieder | ||||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1-1-zorgaanbieder-01 | |||||
Zorgverlener bglz-1-1-zorgverlener-05 | ||||||
Naamgegevens | ||||||
Voornamen | Hilda | |||||
Initialen | H. | |||||
Geslachtsnaam | ||||||
Achternaam | Bruinsma | |||||
Specialisme | Logopedist (code = '91.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
Zorgaanbieder | ||||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1-1-zorgaanbieder-01 | |||||
Zorgaanbieder bglz-1-1-zorgaanbieder-01 | ||||||
Organisatie naam | AA-zkh | |||||
Organisatie locatie | Noord | |||||
Afdeling specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT (Vektis Zorgverlenersspecificatie (subberoepsgroep))') | |||||
Contactgegevens | ||||||
Telefoonnummers | ||||||
Telefoonnummer | +31182435768 | |||||
Telecom type | Vast telefoonnummer (code = 'LL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.22.1') | |||||
Nummer soort | Zakelijk telefoonnummer (code = 'WP' in codeSystem 'HL7 AddressUse') | |||||
Email adressen | ||||||
Email adres | neurologie@AAZ.nl | |||||
Email soort | Zakelijk e-mailadres (code = 'WP' in codeSystem 'HL7 AddressUse') | |||||
Adresgegevens | ||||||
Straat | De Weststraat | |||||
Huisnummer | 3 | |||||
Postcode | 9999PK | |||||
Woonplaats | Stitswerd | |||||
Land | Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | |||||
Adres soort | Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | |||||
Organisatie type | Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') |
1.2 Scenario BgLZ-3.0-LZB-1.2-v1
1.2.1 Demografie en identificatie
Demografie en identificatie | |||||
Gegevenselement | Waarde | ||||
Patient | |||||
Naamgegevens | |||||
Voornamen | Gea | ||||
Initialen | G. | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Valk | ||||
Adresgegevens | |||||
Straat | Knolweg | ||||
Huisnummer | 1003 | ||||
Postcode | 9999ZA | ||||
Woonplaats | Stitswerd | ||||
Land | Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | ||||
Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | ||||
Contactgegevens | |||||
Telefoonnummers | |||||
Telefoonnummer | +31645678912 | ||||
Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
Nummer soort | Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Email adressen | |||||
Email adres | gvalk@hotmail.com | ||||
Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Identificatienummer | 999911697 (in identificerend systeem: BSN) | ||||
Geboortedatum | 8 feb 1964 | ||||
Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
Meerling indicator | Ja |
1.3 Scenario BgLZ-3.0-LZB-1.3-v1
1.3.1 Demografie en identificatie
Demografie en identificatie | |||||
Gegevenselement | Waarde | ||||
Patient | |||||
Naamgegevens | |||||
Voornamen | Fiona | ||||
Initialen | F. | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Mutter | ||||
Adresgegevens | |||||
Straat | Knolweg | ||||
Huisnummer | 1001 | ||||
Postcode | 9999XX | ||||
Woonplaats | Stitswerd | ||||
Land | Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | ||||
Adres soort | Postadres (code = 'PST' in codeSystem 'HL7 AddressUse') | ||||
Contactgegevens | |||||
Telefoonnummers | |||||
Telefoonnummer | +31634567891 | ||||
Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
Nummer soort | Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Email adressen | |||||
Email adres | fmutter@hotmail.com | ||||
Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Identificatienummer | 999911673 (in identificerend systeem: BSN) | ||||
Geboortedatum | 8 feb 1964 | ||||
Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
Meerling indicator | Nee |
1.3.2 Klachten en diagnoses
Klachten en diagnoses | |||
Gegevenselement | Waarde | ||
Probleem bglz-1-3-probleem-01 | |||
Probleem anatomische locatie | hiel (code = '76853006' in codeSystem 'SNOMED CT') | ||
Probleem lateraliteit | Links (code = '7771000' in codeSystem 'SNOMED CT') | ||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | decubitus (code = '399912005' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T + 1 maand | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') |
1.3.3 Uitslagen
Uitslagen | ||||
Gegevenselement | Waarde | |||
Laboratorium uitslag | ||||
Laboratorium test | ||||
Test code | cholesterol:mol/volume:moment:serum of plasma:kwantitatief: (code = '14647-2' in codeSystem 'LOINC') | |||
Test datum tijd | T om 15:00 uur | |||
Test uitslag | 5.5 mmol/l | |||
Referentie bovengrens | 1.8 mmol/l | |||
Interpretatie vlaggen | Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
Toelichting | Volgens richtlijn herseninfarct: streven naar <1,8mmol/L | |||
Laboratorium uitslag | ||||
Laboratorium test | ||||
Test code | cholesterol:mol/volume:moment:serum of plasma:kwantitatief: (code = '14647-2' in codeSystem 'LOINC') | |||
Test datum tijd | T + 1 maand om 16:00 uur | |||
Test uitslag | 1.7 mmol/l | |||
Referentie bovengrens | 1.8 mmol/l | |||
Interpretatie vlaggen | Onder referentiewaarde (code = '281300000' in codeSystem 'SNOMED CT') | |||
Toelichting | Volgens richtlijn herseninfarct: streven naar <1,8mmol/L |
1.3.4 Verpleegkundig zorgplan
Verpleegkundig zorgplan | |||||||
Gegevenselement | Waarde | ||||||
Doelen en interventies | |||||||
Verpleegkundige interventie bglz-1-3-verpleegkundigeinterventie-01 | |||||||
Interventie | aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED CT') | ||||||
Indicatie | |||||||
Probleem | Zie Probleem: bglz-1-3-probleem-01 | ||||||
Frequentie | 1 per dag | ||||||
Medisch hulpmiddel | |||||||
Medisch hulpmiddel | |||||||
Product | |||||||
Product type | schuimverband (code = '448416005' in codeSystem 'SNOMED CT') | ||||||
Anatomische locatie | hiel (code = '76853006' in codeSystem 'SNOMED CT') | ||||||
Lateraliteit | Links (code = '7771000' in codeSystem 'SNOMED CT') | ||||||
Medisch hulpmiddel | |||||||
Medisch hulpmiddel | |||||||
Product | |||||||
Product type | huidvervangende wondbedekkers (code = '465239008' in codeSystem 'SNOMED CT') | ||||||
Anatomische locatie | hiel (code = '76853006' in codeSystem 'SNOMED CT') | ||||||
Lateraliteit | Links (code = '7771000' in codeSystem 'SNOMED CT') | ||||||
Uitkomsten | |||||||
Uitkomst van zorg | |||||||
Zorgresultaat | Decubituswond is verbeterd van categorie 2 naar 1. | ||||||
Interventie | |||||||
Verpleegkundige interventie | Zie Verpleegkundige interventie: bglz-1-3-verpleegkundigeinterventie-01 |
1.4 Scenario BgLZ-3.0-LZB-1.5-v2
1.4.1 Demografie en identificatie
Demografie en identificatie | |||||
Gegevenselement | Waarde | ||||
Patient | |||||
Naamgegevens | |||||
Voornamen | Fiona | ||||
Initialen | F. | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Mutter | ||||
Adresgegevens | |||||
Straat | Knolweg | ||||
Huisnummer | 1001 | ||||
Postcode | 9999XX | ||||
Woonplaats | Stitswerd | ||||
Land | Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | ||||
Adres soort | Postadres (code = 'PST' in codeSystem 'HL7 AddressUse') | ||||
Contactgegevens | |||||
Telefoonnummers | |||||
Telefoonnummer | +31634567891 | ||||
Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
Nummer soort | Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Email adressen | |||||
Email adres | fmutter@hotmail.com | ||||
Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Identificatienummer | 999911673 (in identificerend systeem: BSN) | ||||
Geboortedatum | 8 feb 1964 | ||||
Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
Meerling indicator | Nee |
1.4.2 Behandelrestricties
Behandelrestricties | ||||
Gegevenselement | Waarde | |||
Behandel aanwijzing | ||||
Verificatie | ||||
Geverifieerd | Ja | |||
Geverifieerd bij | Patiënt (code = '116154003' in codeSystem 'SNOMED CT') | |||
Verificatie datum | T | |||
Behandeling | Cardiopulmonaire resuscitatie (code = '89666000' in codeSystem 'SNOMED CT') | |||
Behandeling toegestaan | Behandeling niet toegestaan en/of wenselijk (code = 'NEE' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4') | |||
Begin datum | T | |||
Wilsverklaring | ||||
Wilsverklaring | Zie Wilsverklaring: bglz-1.5-wilsverklaring-01 | |||
Wilsverklaring bglz-1.5-wilsverklaring-01 | ||||
Wilsverklaring type | Niet reanimeren verklaring (code = 'NR' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.14.1') | |||
Wilsverklaring datum | T | |||
Vertegenwoordiger | ||||
Contactpersoon | Zie Contactpersoon: bglz-1.5-contactpersoon-01 |
1.4.3 Contactpersonen
Contactpersonen | |||||
Gegevenselement | Waarde | ||||
Contactpersoon bglz-1.5-contactpersoon-01 | |||||
Naamgegevens | |||||
Voornamen | Robert | ||||
Initialen | R. | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam | |||||
Achternaam | Prins | ||||
Contactgegevens | |||||
Telefoonnummers | |||||
Telefoonnummer | 06-34567891 | ||||
Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
Nummer soort | Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Email adressen | |||||
Email adres | bprins@123net.nl | ||||
Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Rol | Eerste relatie/contactpersoon (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472') | ||||
Relatie | Zoon (code = 'SONC' in codeSystem 'HL7 RoleCode') |
1.4.4 Klachten en diagnoses
Klachten en diagnoses | |||
Gegevenselement | Waarde | ||
Probleem bglz-1.5-probleem-01 | |||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | ischemisch cerebrovasculair accident (code = '422504002' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Toelichting | Niet bekend met neurologische klachten | ||
Probleem bglz-1.5-probleem-02 | |||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | diabetes mellitus (code = '73211009' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T - 14 jaar | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Probleem bglz-1.5-probleem-06 | |||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | afasie (code = '87486003' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') |
1.4.5 Allergieen
Allergieen | ||||
Gegevenselement | Waarde | |||
Allergie intolerantie | ||||
Veroorzakende stof | pinda (code = '762952008' in codeSystem 'SNOMED CT') | |||
Allergie status | Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||
Mate van kritiek zijn | Fataal (code = '399166001' in codeSystem 'SNOMED CT') | |||
Toelichting | Na het eten van pinda's als student ontstond er een klinisch beeld van anafylaxie waarop de HA epipen heeft moeten toedienen | |||
Reactie | ||||
Symptoom | Anafylaxie (code = '39579001' in codeSystem 'SNOMED CT') | |||
Reactie | ||||
Symptoom | Angio-oedeem (code = '41291007' in codeSystem 'SNOMED CT') | |||
Reactie beschrijving | Angio-oedeem van de tong, lippen en peri-orbitale regio met acute benauwdheid na het eten van pinda's. | |||
Allergie intolerantie | ||||
Veroorzakende stof | nikkelsulfaat (code = '255848005' in codeSystem 'SNOMED CT') | |||
Allergie status | Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||
Mate van kritiek zijn | Matig (code = '6736007' in codeSystem 'SNOMED CT') | |||
Toelichting | Opgemerkt bij het dragen van nikkel bevattende sieraden. | |||
Reactie | ||||
Symptoom | Contactdermatitis (code = '40275004' in codeSystem 'SNOMED CT') | |||
Reactie beschrijving | Last van jeuk, roodheid en irritatie op de contactplek van nikkel bevattende sieraden. |
1.4.6 Uitslagen
Uitslagen | ||||
Gegevenselement | Waarde | |||
Laboratorium uitslag | ||||
Laboratorium test | ||||
Test code | Hemoglobine (code = '718-7' in codeSystem 'LOINC') | |||
Test datum tijd | T om 15:00 uur | |||
Test uitslag | 11.0 g/dl | |||
Referentie bovengrens | 16.0 g/dl | |||
Referentie ondergrens | 12.0 g/dl | |||
Interpretatie vlaggen | Onder referentiewaarde (code = '281300000' in codeSystem 'SNOMED CT') | |||
Laboratorium test | ||||
Test code | Hematocriet (code = '20570-8' in codeSystem 'LOINC') | |||
Test datum tijd | T om 15:00 uur | |||
Test uitslag | 47 % | |||
Referentie bovengrens | 51 % | |||
Referentie ondergrens | 39 % | |||
Onderzoek | hemoglobine & hematocriet panel (code = '24360-0' in codeSystem 'LOINC') | |||
Laboratorium uitslag | ||||
Laboratorium test | ||||
Test code | glucose 2 uur na maaltijd massa/volume serum of plasma (code = '1521-4' in codeSystem 'LOINC') | |||
Test datum tijd | T om 15:00 uur | |||
Test uitslag | 5.9 mg/dl | |||
Referentie bovengrens | 7.8 mg/dl | |||
Referentie ondergrens | 3.5 mg/dl | |||
Interpretatie vlaggen | Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
Laboratorium uitslag | ||||
Laboratorium test | ||||
Test code | cholesterol:mol/volume:moment:serum of plasma:kwantitatief: (code = '14647-2' in codeSystem 'LOINC') | |||
Test datum tijd | T om 15:00 uur | |||
Test uitslag | 5.5 mmol/l | |||
Referentie bovengrens | 1.8 mmol/l | |||
Interpretatie vlaggen | Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
Toelichting | Volgens richtlijn herseninfarct: streven naar <1,8mmol/L |
1.4.7 Verrichtingen
Verrichtingen | ||||
Gegevenselement | Waarde | |||
Verrichting | ||||
Verrichting start datum | T | |||
Verrichting eind datum | T | |||
Indicatie | ||||
Probleem | Zie Probleem: bglz-1.5-probleem-01 | |||
Verrichting type | computertomografie van hersenen (code = '34227000' in codeSystem 'SNOMED CT') | |||
Locatie | ||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1.5-zorgaanbieder-01 | |||
Uitvoerder | ||||
Zorgverlener | Zie Zorgverlener: bglz-1.5-zorgverlener-02 | |||
Aanvrager | ||||
Zorgverlener | Zie Zorgverlener: bglz-1.5-zorgverlener-02 | |||
Verrichting | ||||
Verrichting start datum | T | |||
Verrichting eind datum | T | |||
Indicatie | ||||
Probleem | Zie Probleem: bglz-1.5-probleem-01 | |||
Verrichting type | percutane trombolyse van intracraniële arterie (code = '230935003' in codeSystem 'SNOMED CT') | |||
Locatie | ||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1.5-zorgaanbieder-01 | |||
Uitvoerder | ||||
Zorgverlener | Zie Zorgverlener: bglz-1.5-zorgverlener-02 | |||
Aanvrager | ||||
Zorgverlener | Zie Zorgverlener: bglz-1.5-zorgverlener-02 | |||
Verrichting | ||||
Verrichting start datum | T | |||
Verrichting type | fysiotherapie (code = '91251008' in codeSystem 'SNOMED CT') | |||
Locatie | ||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1.5-zorgaanbieder-01 | |||
Uitvoerder | ||||
Zorgverlener | Zie Zorgverlener: bglz-1.5-zorgverlener-04 | |||
Aanvrager | ||||
Zorgverlener | Zie Zorgverlener: bglz-1.5-zorgverlener-02 | |||
Verrichting | ||||
Verrichting start datum | T | |||
Indicatie | ||||
Probleem | Zie Probleem: bglz-1.5-probleem-06 | |||
Verrichting type | logopedische behandeling (code = '5154007' in codeSystem 'SNOMED CT') | |||
Locatie | ||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1.5-zorgaanbieder-01 | |||
Uitvoerder | ||||
Zorgverlener | Zie Zorgverlener: bglz-1.5-zorgverlener-05 | |||
Aanvrager | ||||
Zorgverlener | Zie Zorgverlener: bglz-1.5-zorgverlener-02 |
1.4.8 Verpleegkundig zorgplan
Verpleegkundig zorgplan | ||||||||||||||||||||||||
Gegevenselement | Waarde | |||||||||||||||||||||||
Verpleegkundig zorgplan ongestructureerd | Verpleegkundig zorgplan in opgemaakte tekst. Onderstaande is een voorbeeld. Het hoeft niet letterlijk te worden overgenomen.
|
1.4.9 Zorgsetting
Zorgsetting | ||||||
Gegevenselement | Waarde | |||||
Huisarts | ||||||
Zorgverlener bglz-1.5-zorgverlener-01 | ||||||
Naamgegevens | ||||||
Voornamen | Laura | |||||
Initialen | L. | |||||
Geslachtsnaam | ||||||
Achternaam | Lanen | |||||
Specialisme | Huisarts (code = '01.015' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
Zorgverleners rol | Verwijzer (code = 'REF' in codeSystem 'HL7 ParticipationType') | |||||
Hoofdbehandelaar | ||||||
Zorgverlener bglz-1.5-zorgverlener-02 | ||||||
Naamgegevens | ||||||
Voornamen | Niels | |||||
Initialen | N. | |||||
Geslachtsnaam | ||||||
Achternaam | Helmond | |||||
Specialisme | Neuroloog (code = '01.026' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
Zorgaanbieder | ||||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1.5-zorgaanbieder-01 | |||||
Zorgverleners rol | Hoofdbehandelaar (code = 'RESP' in codeSystem 'HL7 ParticipationType') | |||||
Overige behandelaars | ||||||
Zorgverlener bglz-1.5-zorgverlener-03 | ||||||
Naamgegevens | ||||||
Voornamen | Petra Johanna | |||||
Initialen | P.J. | |||||
Geslachtsnaam | ||||||
Achternaam | Vreeswijk | |||||
Specialisme | Verpleegkundige (code = '30.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
Zorgaanbieder | ||||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1.5-zorgaanbieder-01 | |||||
Zorgverlener bglz-1.5-zorgverlener-04 | ||||||
Naamgegevens | ||||||
Voornamen | Thomas | |||||
Initialen | T. | |||||
Geslachtsnaam | ||||||
Achternaam | Janssen | |||||
Specialisme | Fysiotherapeut (code = '04.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
Zorgaanbieder | ||||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1.5-zorgaanbieder-01 | |||||
Zorgverlener bglz-1.5-zorgverlener-05 | ||||||
Naamgegevens | ||||||
Voornamen | Hilda | |||||
Initialen | H. | |||||
Geslachtsnaam | ||||||
Achternaam | Bruinsma | |||||
Specialisme | Logopedist (code = '91.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
Zorgaanbieder | ||||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1.5-zorgaanbieder-01 | |||||
Zorgaanbieder bglz-1.5-zorgaanbieder-01 | ||||||
Organisatie naam | AA-zkh | |||||
Organisatie locatie | Noord | |||||
Afdeling specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT (Vektis Zorgverlenersspecificatie (subberoepsgroep))') | |||||
Contactgegevens | ||||||
Telefoonnummers | ||||||
Telefoonnummer | +31182435768 | |||||
Telecom type | Vast telefoonnummer (code = 'LL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.22.1') | |||||
Nummer soort | Zakelijk telefoonnummer (code = 'WP' in codeSystem 'HL7 AddressUse') | |||||
Email adressen | ||||||
Email adres | neurologie@AAZ.nl | |||||
Email soort | Zakelijk e-mailadres (code = 'WP' in codeSystem 'HL7 AddressUse') | |||||
Adresgegevens | ||||||
Straat | De Weststraat | |||||
Huisnummer | 3 | |||||
Postcode | 9999PK | |||||
Woonplaats | Stitswerd | |||||
Land | Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | |||||
Adres soort | Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | |||||
Organisatie type | Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') |
1.5 Scenario BgLZ-3.0-LZR-1.5-v1
1.5.1 Demografie en identificatie
Demografie en identificatie | |||||
Gegevenselement | Waarde | ||||
Patient | |||||
Naamgegevens | |||||
Voornamen | Fiona | ||||
Initialen | F. | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Mutter | ||||
Adresgegevens | |||||
Straat | Knolweg | ||||
Huisnummer | 1001 | ||||
Postcode | 9999XX | ||||
Woonplaats | Stitswerd | ||||
Land | Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | ||||
Adres soort | Postadres (code = 'PST' in codeSystem 'HL7 AddressUse') | ||||
Contactgegevens | |||||
Telefoonnummers | |||||
Telefoonnummer | +31634567891 | ||||
Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
Nummer soort | Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Email adressen | |||||
Email adres | fmutter@hotmail.com | ||||
Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Identificatienummer | 999911673 (in identificerend systeem: BSN) | ||||
Geboortedatum | 8 feb 1964 | ||||
Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
Meerling indicator | Nee |
1.5.2 Behandelrestricties
Behandelrestricties | ||||
Gegevenselement | Waarde | |||
Behandel aanwijzing | ||||
Verificatie | ||||
Geverifieerd | Ja | |||
Geverifieerd bij | Patiënt (code = '116154003' in codeSystem 'SNOMED CT') | |||
Verificatie datum | T - 0 dagen | |||
Behandeling | Cardiopulmonaire resuscitatie (code = '89666000' in codeSystem 'SNOMED CT') | |||
Behandeling toegestaan | Behandeling niet toegestaan en/of wenselijk (code = 'NEE' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4') | |||
Begin datum | T | |||
Wilsverklaring | ||||
Wilsverklaring | Zie Wilsverklaring: bglz-1.5-wilsverklaring-01 | |||
Wilsverklaring bglz-1.5-wilsverklaring-01 | ||||
Wilsverklaring type | Niet reanimeren verklaring (code = 'NR' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.14.1') | |||
Wilsverklaring datum | T | |||
Vertegenwoordiger | ||||
Contactpersoon | Zie Contactpersoon: bglz-1.5-contactpersoon-01 |
1.5.3 Contactpersonen
Contactpersonen | |||||
Gegevenselement | Waarde | ||||
Contactpersoon bglz-1.5-contactpersoon-01 | |||||
Naamgegevens | |||||
Voornamen | Robert | ||||
Initialen | R. | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam | |||||
Achternaam | Prins | ||||
Contactgegevens | |||||
Telefoonnummers | |||||
Telefoonnummer | 06-34567891 | ||||
Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
Nummer soort | Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Email adressen | |||||
Email adres | bprins@123net.nl | ||||
Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Rol | Eerste relatie/contactpersoon (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472') | ||||
Relatie | Zoon (code = 'SONC' in codeSystem 'HL7 RoleCode') |
1.5.4 Klachten en diagnoses
Klachten en diagnoses | |||
Gegevenselement | Waarde | ||
Probleem bglz-1.5-probleem-01 | |||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | ischemisch cerebrovasculair accident (code = '422504002' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Toelichting | Niet bekend met neurologische klachten | ||
Probleem bglz-1.5-probleem-02 | |||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | diabetes mellitus (code = '73211009' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T - 14 jaar | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Probleem bglz-1.5-probleem-03 | |||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | probleem met zichzelf wassen en afdrogen (code = '288552005' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Probleem bglz-1.5-probleem-04 | |||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | probleem met zichzelf kleden (code = '284972002' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Probleem bglz-1.5-probleem-05 | |||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | probleem met lopen (code = '228158008' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Probleem bglz-1.5-probleem-06 | |||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | afasie (code = '87486003' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Probleem bglz-1.5-probleem-07 | |||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | risico op decubitus (code = '285304000' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Probleem bglz-1.5-probleem-08 | |||
Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
Probleem naam | overbelaste mantelzorg (code = '705044006' in codeSystem 'SNOMED CT') | ||
Probleem begin datum | T | ||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') |
1.5.5 Allergieen
Allergieen | ||||
Gegevenselement | Waarde | |||
Allergie intolerantie | ||||
Veroorzakende stof | pinda (code = '762952008' in codeSystem 'SNOMED CT') | |||
Allergie status | Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||
Mate van kritiek zijn | Fataal (code = '399166001' in codeSystem 'SNOMED CT') | |||
Toelichting | Na het eten van pinda's als student ontstond er een klinisch beeld van anafylaxie waarop de HA epipen heeft moeten toedienen | |||
Reactie | ||||
Symptoom | Anafylaxie (code = '39579001' in codeSystem 'SNOMED CT') | |||
Reactie | ||||
Symptoom | Angio-oedeem (code = '41291007' in codeSystem 'SNOMED CT') | |||
Reactie beschrijving | Angio-oedeem van de tong, lippen en peri-orbitale regio met acute benauwdheid na het eten van pinda's. | |||
Allergie intolerantie | ||||
Veroorzakende stof | nikkelsulfaat (code = '255848005' in codeSystem 'SNOMED CT') | |||
Allergie status | Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||
Mate van kritiek zijn | Matig (code = '6736007' in codeSystem 'SNOMED CT') | |||
Toelichting | Opgemerkt bij het dragen van nikkel bevattende sieraden. | |||
Reactie | ||||
Symptoom | Contactdermatitis (code = '40275004' in codeSystem 'SNOMED CT') | |||
Reactie beschrijving | Last van jeuk, roodheid en irritatie op de contactplek van nikkel bevattende sieraden. |
1.5.6 Uitslagen
Uitslagen | ||||
Gegevenselement | Waarde | |||
Laboratorium uitslag | ||||
Laboratorium test | ||||
Test code | Hemoglobine (code = '718-7' in codeSystem 'LOINC') | |||
Test datum tijd | T - 0 dagen om 15:00 uur | |||
Test uitslag | 11.0 g/dl | |||
Referentie bovengrens | 16.0 g/dl | |||
Referentie ondergrens | 12.0 g/dl | |||
Interpretatie vlaggen | Onder referentiewaarde (code = '281300000' in codeSystem 'SNOMED CT') | |||
Laboratorium test | ||||
Test code | Hematocriet (code = '20570-8' in codeSystem 'LOINC') | |||
Test datum tijd | T - 0 dagen om 15:00 uur | |||
Test uitslag | 47 % | |||
Referentie bovengrens | 51 % | |||
Referentie ondergrens | 39 % | |||
Onderzoek | hemoglobine & hematocriet panel (code = '24360-0' in codeSystem 'LOINC') | |||
Laboratorium uitslag | ||||
Laboratorium test | ||||
Test code | glucose 2 uur na maaltijd massa/volume serum of plasma (code = '1521-4' in codeSystem 'LOINC') | |||
Test datum tijd | T - 0 dagen om 15:00 uur | |||
Test uitslag | 5.9 mg/dl | |||
Referentie bovengrens | 7.8 mg/dl | |||
Referentie ondergrens | 3.5 mg/dl | |||
Interpretatie vlaggen | Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
Laboratorium uitslag | ||||
Laboratorium test | ||||
Test code | cholesterol:mol/volume:moment:serum of plasma:kwantitatief: (code = '14647-2' in codeSystem 'LOINC') | |||
Test datum tijd | T - 0 dagen om 15:00 uur | |||
Test uitslag | 5.5 mmol/l | |||
Referentie bovengrens | 1.8 mmol/l | |||
Interpretatie vlaggen | Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
Toelichting | Volgens richtlijn herseninfarct: streven naar <1,8mmol/L |
1.5.7 Verrichtingen
Verrichtingen | ||||
Gegevenselement | Waarde | |||
Verrichting | ||||
Verrichting start datum | T | |||
Verrichting eind datum | T | |||
Indicatie | ||||
Probleem | Zie Probleem: bglz-1.5-probleem-01 | |||
Verrichting type | computertomografie van hersenen (code = '34227000' in codeSystem 'SNOMED CT') | |||
Locatie | ||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1.5-zorgaanbieder-01 | |||
Uitvoerder | ||||
Zorgverlener | Zie Zorgverlener: bglz-1.5-zorgverlener-02 | |||
Aanvrager | ||||
Zorgverlener | Zie Zorgverlener: bglz-1.5-zorgverlener-02 | |||
Verrichting | ||||
Verrichting start datum | T | |||
Verrichting eind datum | T | |||
Indicatie | ||||
Probleem | Zie Probleem: bglz-1.5-probleem-01 | |||
Verrichting type | percutane trombolyse van intracraniële arterie (code = '230935003' in codeSystem 'SNOMED CT') | |||
Locatie | ||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1.5-zorgaanbieder-01 | |||
Uitvoerder | ||||
Zorgverlener | Zie Zorgverlener: bglz-1.5-zorgverlener-02 | |||
Aanvrager | ||||
Zorgverlener | Zie Zorgverlener: bglz-1.5-zorgverlener-02 | |||
Verrichting | ||||
Verrichting start datum | T | |||
Indicatie | ||||
Probleem | Zie Probleem: bglz-1.5-probleem-05 | |||
Verrichting type | fysiotherapie (code = '91251008' in codeSystem 'SNOMED CT') | |||
Locatie | ||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1.5-zorgaanbieder-01 | |||
Uitvoerder | ||||
Zorgverlener | Zie Zorgverlener: bglz-1.5-zorgverlener-04 | |||
Aanvrager | ||||
Zorgverlener | Zie Zorgverlener: bglz-1.5-zorgverlener-02 | |||
Verrichting | ||||
Verrichting start datum | T | |||
Indicatie | ||||
Probleem | Zie Probleem: bglz-1.5-probleem-06 | |||
Verrichting type | logopedische behandeling (code = '5154007' in codeSystem 'SNOMED CT') | |||
Locatie | ||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1.5-zorgaanbieder-01 | |||
Uitvoerder | ||||
Zorgverlener | Zie Zorgverlener: bglz-1.5-zorgverlener-05 | |||
Aanvrager | ||||
Zorgverlener | Zie Zorgverlener: bglz-1.5-zorgverlener-02 |
1.5.8 Verpleegkundig zorgplan
Verpleegkundig zorgplan | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Gegevenselement | Waarde | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Verpleegkundig zorgplan ongestructureerd | Verpleegkundig zorgplan in opgemaakte tekst. Onderstaande is een voorbeeld.
|
1.5.9 Zorgsetting
Zorgsetting | ||||||
Gegevenselement | Waarde | |||||
Huisarts | ||||||
Zorgverlener bglz-1.5-zorgverlener-01 | ||||||
Naamgegevens | ||||||
Voornamen | Laura | |||||
Initialen | L. | |||||
Geslachtsnaam | ||||||
Achternaam | Lanen | |||||
Specialisme | Huisarts (code = '01.015' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
Zorgverleners rol | Verwijzer (code = 'REF' in codeSystem 'HL7 ParticipationType') | |||||
Hoofdbehandelaar | ||||||
Zorgverlener bglz-1.5-zorgverlener-02 | ||||||
Naamgegevens | ||||||
Voornamen | Niels | |||||
Initialen | N. | |||||
Geslachtsnaam | ||||||
Achternaam | Helmond | |||||
Specialisme | Neuroloog (code = '01.026' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
Zorgaanbieder | ||||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1.5-zorgaanbieder-01 | |||||
Zorgverleners rol | Hoofdbehandelaar (code = 'RESP' in codeSystem 'HL7 ParticipationType') | |||||
Overige behandelaars | ||||||
Zorgverlener bglz-1.5-zorgverlener-03 | ||||||
Naamgegevens | ||||||
Voornamen | Petra Johanna | |||||
Initialen | P.J. | |||||
Geslachtsnaam | ||||||
Achternaam | Vreeswijk | |||||
Specialisme | Verpleegkundige (code = '30.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
Zorgaanbieder | ||||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1.5-zorgaanbieder-01 | |||||
Zorgverlener bglz-1.5-zorgverlener-04 | ||||||
Naamgegevens | ||||||
Voornamen | Thomas | |||||
Initialen | T. | |||||
Geslachtsnaam | ||||||
Achternaam | Janssen | |||||
Specialisme | Fysiotherapeut (code = '04.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
Zorgaanbieder | ||||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1.5-zorgaanbieder-01 | |||||
Zorgverlener bglz-1.5-zorgverlener-05 | ||||||
Naamgegevens | ||||||
Voornamen | Hilda | |||||
Initialen | H. | |||||
Geslachtsnaam | ||||||
Achternaam | Bruinsma | |||||
Specialisme | Logopedist (code = '91.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
Zorgaanbieder | ||||||
Zorgaanbieder | Zie Zorgaanbieder: bglz-1.5-zorgaanbieder-01 | |||||
Zorgaanbieder bglz-1.5-zorgaanbieder-01 | ||||||
Organisatie naam | AA-zkh | |||||
Organisatie locatie | Noord | |||||
Afdeling specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT (Vektis Zorgverlenersspecificatie (subberoepsgroep))') | |||||
Contactgegevens | ||||||
Telefoonnummers | ||||||
Telefoonnummer | +31182435768 | |||||
Telecom type | Vast telefoonnummer (code = 'LL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.22.1') | |||||
Nummer soort | Zakelijk telefoonnummer (code = 'WP' in codeSystem 'HL7 AddressUse') | |||||
Email adressen | ||||||
Email adres | neurologie@AAZ.nl | |||||
Email soort | Zakelijk e-mailadres (code = 'WP' in codeSystem 'HL7 AddressUse') | |||||
Adresgegevens | ||||||
Straat | De Weststraat | |||||
Huisnummer | 3 | |||||
Postcode | 9999PK | |||||
Woonplaats | Stitswerd | |||||
Land | Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | |||||
Adres soort | Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | |||||
Organisatie type | Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') |