vpk:V4.0 Testgegevens eOverdracht Aanmeldbericht addendum: verschil tussen versies
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{{DISPLAYTITLE:e-overdracht: addendum inhoudelijke gegevens aanmeldbericht '''[dit laatste nog toe laten voegen]'''}} | |||
=Addenda voor inhoudelijke gegevens= | |||
<section begin=eovd-saa-tst-1.1-alle_zibs /> | |||
==Aanmeldbericht== | |||
=== Administratieve gegevens=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Administratieve gegevens | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="6" width="30%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Datum overplaatsing | |||
|style="background-color: white;"|T + 1 dag | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Persoonsgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="47"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Patient | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="18"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Erik | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|E | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|XXX_Altenborg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Straat | |||
|style="background-color: white;"|Knolweg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Huisnummer | |||
|style="background-color: white;"|1000 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Postcode | |||
|style="background-color: white;"|9999XA | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Woonplaats | |||
|style="background-color: white;"|Stitswerd | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Adres soort | |||
|style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Identificatienummer | |||
|style="background-color: white;"|999911612 (in identificerend systeem: BSN) | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geboortedatum | |||
|style="background-color: white;"|14 aug 1964 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslacht | |||
|style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Betaler | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verzekeraar | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Verzekering | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Eind datum tijd | |||
|style="background-color: white;"|T + 1 jaar | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Verzekeringssoort | |||
|style="background-color: white;"|Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactpersoon | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="18"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Johanna | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|J | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Roepnaam | |||
|style="background-color: white;"|Hanna | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Bakker | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"|+31645678912 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email adres | |||
|style="background-color: white;"|jbakker@123net.nl | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Relatie | |||
|style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Sturende organisatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="16"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="14"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgaanbieder identificatienummer | |||
|style="background-color: white;"|06590457 (in identificerend systeem: AGB-Z) | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Organisatie naam | |||
|style="background-color: white;"|AB-zkh | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Organisatie locatie | |||
|style="background-color: white;"|Noord | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Afdeling specialisme | |||
|style="background-color: white;"|Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"|+31182435770 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email adres | |||
|style="background-color: white;"|neurologie@ABZ.nl | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Organisatie type | |||
|style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Ontvangende organisatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Afdeling specialisme | |||
|style="background-color: white;"|Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Organisatie type | |||
|style="background-color: white;"|Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||
|} | |||
=== Algemene patienten context=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Algemene patienten context | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="4" width="30%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Juridische situatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|<span id="tst-1.1-juridischesituatie-01" title="Intern ID = tst-1.1-juridischesituatie-01">Juridische situatie tst-1.1-juridischesituatie-01</span> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Vertegenwoordiging | |||
|style="background-color: white;"|Onder curatele stelling (code = '9' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.3') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Datum aanvang | |||
|style="background-color: white;"|T - 1 jaar | |||
|} | |||
=== Medische context=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Medische context | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="4" width="30%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Medische diagnose | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="18"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Toelichting | |||
|style="background-color: white;"|niet bekend met neurologische klachten | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|neoplasma van colon (code = '126838000') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|oksel (code = '238600001' in codeSystem 'SNOMED Clinical Terms') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|inverse psoriasis (code = '238600001') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Voorgeschiedenis | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|diabetes mellitus (code = '73211009') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Let op | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Alert | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Alert naam | |||
|style="background-color: white;"|Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Alert | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Alert naam | |||
|style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Vrijheidsbeperking | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Vrijheidsbeperkende interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Wilsbekwaam | |||
|style="background-color: white;"|Ja | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Juridische situatie | |||
|style="background-color: white;"|Zie [[#tst-1.1-juridischesituatie-01|Juridische situatie: tst-1.1-juridischesituatie-01]] | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Soort interventie | |||
|style="background-color: white;"|geforceerd toedienen van voeding bij patiënt (code = '37041007' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Reden van toepassen | |||
|style="background-color: white;"|bevorderen van fysieke gezondheid (code = '121581000146106' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Instemming | |||
|style="background-color: white;"|Instemming patiënt (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.6.1') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Begin | |||
|style="background-color: white;"|T - 50 dagen | |||
|} | |||
=== Verpleegkundige context zorgplan=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Verpleegkundige context zorgplan | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="6" width="30%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Actuele patientproblemen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="64"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Patientprobleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="15"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|<span id="tst-1.1-patientprobleem-01" title="Intern ID = tst-1.1-patientprobleem-01">Probleem tst-1.1-patientprobleem-01</span> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem naam | |||
|style="background-color: white;"|probleem met zichzelf wassen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Toelichting | |||
|style="background-color: white;"|meneer kan niet buigen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verpleegkundige interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="8"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Interventie | |||
|style="background-color: white;"|ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED Clinical Terms') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="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 [[#tst-1.1-patientprobleem-01|Probleem: tst-1.1-patientprobleem-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;"|Ja | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Patientprobleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="11"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|<span id="tst-1.1-patientprobleem-02" title="Intern ID = tst-1.1-patientprobleem-02">Probleem tst-1.1-patientprobleem-02</span> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem naam | |||
|style="background-color: white;"|probleem met zichzelf kleden (code = '284972002' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verpleegkundige interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Interventie | |||
|style="background-color: white;"|ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Indicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem | |||
|style="background-color: white;"|Zie [[#tst-1.1-patientprobleem-02|Probleem: tst-1.1-patientprobleem-02]] | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Patientprobleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="22"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|<span id="tst-1.1-patientprobleem-03" title="Intern ID = tst-1.1-patientprobleem-03">Probleem tst-1.1-patientprobleem-03</span> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem naam | |||
|style="background-color: white;"|decubitus (code = '399912005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verpleegkundige interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Interventie | |||
|style="background-color: white;"|aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED Clinical Terms') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Indicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem | |||
|style="background-color: white;"|Zie [[#tst-1.1-patientprobleem-03|Probleem: tst-1.1-patientprobleem-03]] | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verpleegkundige interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="10"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Interventie | |||
|style="background-color: white;"|wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED Clinical Terms') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="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 [[#tst-1.1-patientprobleem-03|Probleem: tst-1.1-patientprobleem-03]] | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Actie start datum tijd | |||
|style="background-color: white;"|T - 10 dagen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Actie eind datum tijd | |||
|style="background-color: white;"|T - 1 dag | |||
|-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;"|Ja | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Patientprobleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="11"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|<span id="tst-1.1-patientprobleem-04" title="Intern ID = tst-1.1-patientprobleem-04">Probleem tst-1.1-patientprobleem-04</span> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem naam | |||
|style="background-color: white;"|loopt risico op delier (code = '430794006' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verpleegkundige interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Interventie | |||
|style="background-color: white;"|bevorderen van vochtinname (code = '113148007' in codeSystem 'SNOMED Clinical Terms') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Indicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem | |||
|style="background-color: white;"|Zie [[#tst-1.1-patientprobleem-04|Probleem: tst-1.1-patientprobleem-04]] | |||
|} | |||
=== Verpleegkundige context specificatie gezondheidstoestand=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Verpleegkundige context specificatie gezondheidstoestand | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="7" width="30%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Voedingvocht | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="32"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Sonde systeem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Sonde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Product type | |||
|style="background-color: white;"|PEJ sonde (code = '8911000146104' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Product omschrijving | |||
|style="background-color: white;"|PEJ sonde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Infuus | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="10"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Infuuskatheter | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Product type | |||
|style="background-color: white;"|Centraal veneuze katheter (code = '52124006' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Product omschrijving | |||
|style="background-color: white;"|centraal veneuze katheter | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Toelichting | |||
|style="background-color: white;"|voor voeding | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Infuus | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Infuuskatheter | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Product type | |||
|style="background-color: white;"|Perifeer intraveneus infuus (code = '82449006' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Product omschrijving | |||
|style="background-color: white;"|voor medicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Uitscheiding | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="8"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Stoma | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Stoma type | |||
|style="background-color: white;"|eindstandige ileostoma (code = '311412005' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Toelichting | |||
|style="background-color: white;"|na subtotale darmresectie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Stoma | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Stoma type | |||
|style="background-color: white;"|urostoma (code = '281601009' in codeSystem 'SNOMED CT') | |||
|}<section end=eovd-saa-tst-1.1-alle_zibs /> | |||
<section begin=eovd-saa-tst-1.1b-alle_zibs /> | |||
==Aanmeldbericht - overlap BgZ== | |||
=== Administratieve gegevens=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Administratieve gegevens | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="6" width="30%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Datum overplaatsing | |||
|style="background-color: white;"|T + 1 dag | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Persoonsgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="47"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Patient | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="18"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Erik | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|E | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|XXX_Altenborg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Straat | |||
|style="background-color: white;"|Knolweg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Huisnummer | |||
|style="background-color: white;"|1000 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Postcode | |||
|style="background-color: white;"|9999XA | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Woonplaats | |||
|style="background-color: white;"|Stitswerd | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Adres soort | |||
|style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Identificatienummer | |||
|style="background-color: white;"|999911612 (in identificerend systeem: BSN) | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geboortedatum | |||
|style="background-color: white;"|14 aug 1964 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslacht | |||
|style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Betaler | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verzekeraar | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Verzekering | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Eind datum tijd | |||
|style="background-color: white;"|T + 1 jaar | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Verzekeringssoort | |||
|style="background-color: white;"|Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactpersoon | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="18"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Johanna | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|J | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Roepnaam | |||
|style="background-color: white;"|Hanna | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Bakker | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"|+31645678912 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email adres | |||
|style="background-color: white;"|jbakker@123net.nl | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Relatie | |||
|style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Sturende organisatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="16"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="14"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgaanbieder identificatienummer | |||
|style="background-color: white;"|06590457 (in identificerend systeem: AGB-Z) | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Organisatie naam | |||
|style="background-color: white;"|AB-zkh | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Organisatie locatie | |||
|style="background-color: white;"|Noord | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Afdeling specialisme | |||
|style="background-color: white;"|Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"|+31182435770 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email adres | |||
|style="background-color: white;"|neurologie@ABZ.nl | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Organisatie type | |||
|style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Ontvangende organisatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Afdeling specialisme | |||
|style="background-color: white;"|Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Organisatie type | |||
|style="background-color: white;"|Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||
|} | |||
=== Medische context=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Medische context | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="4" width="30%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Medische diagnose | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="18"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Toelichting | |||
|style="background-color: white;"|niet bekend met neurologische klachten | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|neoplasma van colon (code = '126838000') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|oksel (code = '238600001' in codeSystem 'SNOMED Clinical Terms') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|inverse psoriasis (code = '238600001') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Voorgeschiedenis | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|diabetes mellitus (code = '73211009') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Let op | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Alert | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Alert naam | |||
|style="background-color: white;"|Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Alert | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Alert naam | |||
|style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie | |||
|}<section end=eovd-saa-tst-1.1b-alle_zibs /> | |||
<section begin=eovd-saa-tst-q.qb-alle_zibs_kind_0-1_jaar /> | |||
==Aanmeldbericht Kinderen 0-1 jaar - overlap BgZ (concept)== | |||
=== Administratieve gegevens=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Administratieve gegevens | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="6" width="30%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Datum overplaatsing | |||
|style="background-color: white;"|T + 2 dagen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Persoonsgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="47"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Patient | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="18"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Erik | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|E | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|XXX_Altenborg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Straat | |||
|style="background-color: white;"|Knolweg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Huisnummer | |||
|style="background-color: white;"|1000 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Postcode | |||
|style="background-color: white;"|9999XA | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Woonplaats | |||
|style="background-color: white;"|Stitswerd | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Adres soort | |||
|style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Identificatienummer | |||
|style="background-color: white;"|999911612 (in identificerend systeem: BSN) | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geboortedatum | |||
|style="background-color: white;"|14 aug 1964 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslacht | |||
|style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Betaler | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verzekeraar | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Verzekering | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Eind datum tijd | |||
|style="background-color: white;"|T + 1 jaar | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Verzekeringssoort | |||
|style="background-color: white;"|Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactpersoon | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="18"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Johanna | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|J | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Roepnaam | |||
|style="background-color: white;"|Hanna | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Bakker | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"|+31645678912 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email adres | |||
|style="background-color: white;"|jbakker@123net.nl | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Relatie | |||
|style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Sturende organisatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="16"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="14"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgaanbieder identificatienummer | |||
|style="background-color: white;"|06590457 (in identificerend systeem: AGB-Z) | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Organisatie naam | |||
|style="background-color: white;"|AB-zkh | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Organisatie locatie | |||
|style="background-color: white;"|Noord | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Afdeling specialisme | |||
|style="background-color: white;"|Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"|+31182435770 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email adres | |||
|style="background-color: white;"|neurologie@ABZ.nl | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Organisatie type | |||
|style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Ontvangende organisatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Afdeling specialisme | |||
|style="background-color: white;"|Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Organisatie type | |||
|style="background-color: white;"|Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||
|} | |||
=== Algemene patienten context=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Algemene patienten context | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="4" width="30%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Juridische situatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|<span id="JuridischeSituatie-01" title="Intern ID = JuridischeSituatie-01">Juridische situatie JuridischeSituatie-01</span> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Vertegenwoordiging | |||
|style="background-color: white;"|Onder curatele stelling (code = '9' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.3') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Datum aanvang | |||
|style="background-color: white;"|T - 1 jaar | |||
|} | |||
=== Medische context=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Medische context | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="4" width="30%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Medische diagnose | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="18"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Toelichting | |||
|style="background-color: white;"|niet bekend met neurologische klachten | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|neoplasma van colon (code = '126838000') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|oksel (code = '238600001' in codeSystem 'SNOMED Clinical Terms') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|inverse psoriasis (code = '238600001') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Voorgeschiedenis | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|diabetes mellitus (code = '73211009') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Let op | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Alert | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Alert naam | |||
|style="background-color: white;"|Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Alert | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Alert naam | |||
|style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Vrijheidsbeperking | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Vrijheidsbeperkende interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Wilsbekwaam | |||
|style="background-color: white;"|Ja | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Juridische situatie | |||
|style="background-color: white;"|Zie [[#JuridischeSituatie-01|Juridische situatie: JuridischeSituatie-01]] | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Soort interventie | |||
|style="background-color: white;"|geforceerd toedienen van voeding bij patiënt (code = '37041007' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Reden van toepassen | |||
|style="background-color: white;"|bevorderen van fysieke gezondheid (code = '121581000146106' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Instemming | |||
|style="background-color: white;"|Instemming patiënt (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.6.1') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Begin | |||
|style="background-color: white;"|T - 50 dagen | |||
|} | |||
=== Verpleegkundige context zorgplan=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Verpleegkundige context zorgplan | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="6" width="30%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Actuele patientproblemen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="64"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Patientprobleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="15"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|<span id="patientprobleem-01" title="Intern ID = patientprobleem-01">Probleem patientprobleem-01</span> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem naam | |||
|style="background-color: white;"|probleem met zichzelf wassen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Toelichting | |||
|style="background-color: white;"|meneer kan niet buigen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verpleegkundige interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="8"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Interventie | |||
|style="background-color: white;"|ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED Clinical Terms') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="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 [[#patientprobleem-01|Probleem: patientprobleem-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;"|Ja | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Patientprobleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="11"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|<span id="patientprobleem-02" title="Intern ID = patientprobleem-02">Probleem patientprobleem-02</span> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem naam | |||
|style="background-color: white;"|probleem met zichzelf kleden (code = '284972002' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verpleegkundige interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Interventie | |||
|style="background-color: white;"|ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Indicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem | |||
|style="background-color: white;"|Zie [[#patientprobleem-02|Probleem: patientprobleem-02]] | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Patientprobleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="22"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|<span id="eovd-saa-tst-patientprobleem-03" title="Intern ID = eovd-saa-tst-patientprobleem-03">Probleem eovd-saa-tst-patientprobleem-03</span> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem naam | |||
|style="background-color: white;"|decubitus (code = '399912005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verpleegkundige interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Interventie | |||
|style="background-color: white;"|aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED Clinical Terms') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Indicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem | |||
|style="background-color: white;"|Zie [[#eovd-saa-tst-patientprobleem-03|Probleem: eovd-saa-tst-patientprobleem-03]] | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verpleegkundige interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="10"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Interventie | |||
|style="background-color: white;"|wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED Clinical Terms') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="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 [[#eovd-saa-tst-patientprobleem-03|Probleem: eovd-saa-tst-patientprobleem-03]] | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Actie start datum tijd | |||
|style="background-color: white;"|T - 10 dagen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Actie eind datum tijd | |||
|style="background-color: white;"|T - 1 dag | |||
|-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;"|Ja | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Patientprobleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="11"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|<span id="eovd-saa-tst-patientprobleem-04" title="Intern ID = eovd-saa-tst-patientprobleem-04">Probleem eovd-saa-tst-patientprobleem-04</span> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem naam | |||
|style="background-color: white;"|loopt risico op delier (code = '430794006' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verpleegkundige interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Interventie | |||
|style="background-color: white;"|bevorderen van vochtinname (code = '113148007' in codeSystem 'SNOMED Clinical Terms') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Indicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem | |||
|style="background-color: white;"|Zie [[#eovd-saa-tst-patientprobleem-04|Probleem: eovd-saa-tst-patientprobleem-04]] | |||
|} | |||
=== Verpleegkundige context specificatie gezondheidstoestand=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Verpleegkundige context specificatie gezondheidstoestand | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="7" width="30%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Voedingvocht | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="32"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Sonde systeem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Sonde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Product type | |||
|style="background-color: white;"|PEJ sonde (code = '8911000146104' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Product omschrijving | |||
|style="background-color: white;"|PEJ sonde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Infuus | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="10"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Infuuskatheter | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Product type | |||
|style="background-color: white;"|Centraal veneuze katheter (code = '52124006' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Product omschrijving | |||
|style="background-color: white;"|centraal veneuze katheter | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Toelichting | |||
|style="background-color: white;"|voor voeding | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Infuus | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Infuuskatheter | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Product type | |||
|style="background-color: white;"|Perifeer intraveneus infuus (code = '82449006' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Product omschrijving | |||
|style="background-color: white;"|voor medicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Uitscheiding | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="8"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Stoma | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Stoma type | |||
|style="background-color: white;"|eindstandige ileostoma (code = '311412005' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Toelichting | |||
|style="background-color: white;"|na subtotale darmresectie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Stoma | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Stoma type | |||
|style="background-color: white;"|urostoma (code = '281601009' in codeSystem 'SNOMED CT') | |||
|}<section end=eovd-saa-tst-q.qb-alle_zibs_kind_0-1_jaar /> | |||
Versie van 22 dec 2021 09:04
__NUMBEREDHEADINGS__
Addenda voor inhoudelijke gegevens
Aanmeldbericht
Administratieve gegevens
| Administratieve gegevens | ||||||
| Gegevenselement | Waarde | |||||
| Datum overplaatsing | T + 1 dag | |||||
| Persoonsgegevens | ||||||
| Patient | ||||||
| Naamgegevens | ||||||
| Voornamen | Erik | |||||
| Initialen | E | |||||
| Geslachtsnaam | ||||||
| Achternaam | XXX_Altenborg | |||||
| Adresgegevens | ||||||
| Straat | Knolweg | |||||
| Huisnummer | 1000 | |||||
| Postcode | 9999XA | |||||
| Woonplaats | Stitswerd | |||||
| Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||||
| Identificatienummer | 999911612 (in identificerend systeem: BSN) | |||||
| Geboortedatum | 14 aug 1964 | |||||
| Geslacht | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |||||
| Betaler | ||||||
| Verzekeraar | ||||||
| Verzekering | ||||||
| Eind datum tijd | T + 1 jaar | |||||
| Verzekeringssoort | Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') | |||||
| Contactpersoon | ||||||
| Naamgegevens | ||||||
| Voornamen | Johanna | |||||
| Initialen | J | |||||
| Roepnaam | Hanna | |||||
| Geslachtsnaam | ||||||
| Achternaam | Bakker | |||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31645678912 | |||||
| Email adressen | ||||||
| Email adres | jbakker@123net.nl | |||||
| Relatie | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef | |||||
| Sturende organisatie | ||||||
| Zorgaanbieder | ||||||
| Zorgaanbieder identificatienummer | 06590457 (in identificerend systeem: AGB-Z) | |||||
| Organisatie naam | AB-zkh | |||||
| Organisatie locatie | Noord | |||||
| Afdeling specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31182435770 | |||||
| Email adressen | ||||||
| Email adres | neurologie@ABZ.nl | |||||
| Organisatie type | Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||||
| Ontvangende organisatie | ||||||
| Zorgaanbieder | ||||||
| Afdeling specialisme | Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
| Organisatie type | Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||||
Algemene patienten context
| Algemene patienten context | ||||
| Gegevenselement | Waarde | |||
| Juridische situatie | ||||
| Juridische situatie tst-1.1-juridischesituatie-01 | ||||
| Vertegenwoordiging | Onder curatele stelling (code = '9' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.3') | |||
| Datum aanvang | T - 1 jaar | |||
Medische context
| Medische context | ||||
| Gegevenselement | Waarde | |||
| Medische diagnose | ||||
| Probleem | ||||
| Probleem naam | ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT') | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
| Toelichting | niet bekend met neurologische klachten | |||
| Probleem | ||||
| Probleem naam | neoplasma van colon (code = '126838000') | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
| Probleem | ||||
| Probleem naam | oksel (code = '238600001' in codeSystem 'SNOMED Clinical Terms') | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
| Probleem | ||||
| Probleem naam | inverse psoriasis (code = '238600001') | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
| Voorgeschiedenis | ||||
| Probleem | ||||
| Probleem naam | diabetes mellitus (code = '73211009') | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
| Let op | ||||
| Alert | ||||
| Alert naam | Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT') | |||
| Alert | ||||
| Alert naam | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie | |||
| Vrijheidsbeperking | ||||
| Vrijheidsbeperkende interventie | ||||
| Wilsbekwaam | Ja | |||
| Juridische situatie | Zie Juridische situatie: tst-1.1-juridischesituatie-01 | |||
| Soort interventie | geforceerd toedienen van voeding bij patiënt (code = '37041007' in codeSystem 'SNOMED CT') | |||
| Reden van toepassen | bevorderen van fysieke gezondheid (code = '121581000146106' in codeSystem 'SNOMED CT') | |||
| Instemming | Instemming patiënt (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.6.1') | |||
| Begin | T - 50 dagen | |||
Verpleegkundige context zorgplan
| Verpleegkundige context zorgplan | ||||||
| Gegevenselement | Waarde | |||||
| Actuele patientproblemen | ||||||
| Patientprobleem | ||||||
| Probleem tst-1.1-patientprobleem-01 | ||||||
| Probleem naam | probleem met zichzelf wassen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
| Toelichting | meneer kan niet buigen | |||||
| Verpleegkundige interventie | ||||||
| Interventie | ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED Clinical Terms') | |||||
| Indicatie | ||||||
| Probleem | Zie Probleem: tst-1.1-patientprobleem-01 | |||||
| Uitvoerder | ||||||
| Zorgverlener | Ja | |||||
| Patientprobleem | ||||||
| Probleem tst-1.1-patientprobleem-02 | ||||||
| Probleem naam | probleem met zichzelf kleden (code = '284972002' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
| Verpleegkundige interventie | ||||||
| Interventie | ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms') | |||||
| Indicatie | ||||||
| Probleem | Zie Probleem: tst-1.1-patientprobleem-02 | |||||
| Patientprobleem | ||||||
| Probleem tst-1.1-patientprobleem-03 | ||||||
| Probleem naam | decubitus (code = '399912005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
| Verpleegkundige interventie | ||||||
| Interventie | aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED Clinical Terms') | |||||
| Indicatie | ||||||
| Probleem | Zie Probleem: tst-1.1-patientprobleem-03 | |||||
| Verpleegkundige interventie | ||||||
| Interventie | wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED Clinical Terms') | |||||
| Indicatie | ||||||
| Probleem | Zie Probleem: tst-1.1-patientprobleem-03 | |||||
| Actie start datum tijd | T - 10 dagen | |||||
| Actie eind datum tijd | T - 1 dag | |||||
| Uitvoerder | ||||||
| Zorgverlener | Ja | |||||
| Patientprobleem | ||||||
| Probleem tst-1.1-patientprobleem-04 | ||||||
| Probleem naam | loopt risico op delier (code = '430794006' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
| Verpleegkundige interventie | ||||||
| Interventie | bevorderen van vochtinname (code = '113148007' in codeSystem 'SNOMED Clinical Terms') | |||||
| Indicatie | ||||||
| Probleem | Zie Probleem: tst-1.1-patientprobleem-04 | |||||
Verpleegkundige context specificatie gezondheidstoestand
| Verpleegkundige context specificatie gezondheidstoestand | |||||||
| Gegevenselement | Waarde | ||||||
| Voedingvocht | |||||||
| Sonde systeem | |||||||
| Sonde | |||||||
| Medisch hulpmiddel | |||||||
| Product | |||||||
| Product type | PEJ sonde (code = '8911000146104' in codeSystem 'SNOMED CT') | ||||||
| Product omschrijving | PEJ sonde | ||||||
| Infuus | |||||||
| Infuuskatheter | |||||||
| Medisch hulpmiddel | |||||||
| Product | |||||||
| Product type | Centraal veneuze katheter (code = '52124006' in codeSystem 'SNOMED CT') | ||||||
| Product omschrijving | centraal veneuze katheter | ||||||
| Toelichting | voor voeding | ||||||
| Infuus | |||||||
| Infuuskatheter | |||||||
| Medisch hulpmiddel | |||||||
| Product | |||||||
| Product type | Perifeer intraveneus infuus (code = '82449006' in codeSystem 'SNOMED CT') | ||||||
| Product omschrijving | voor medicatie | ||||||
| Uitscheiding | |||||||
| Stoma | |||||||
| Stoma type | eindstandige ileostoma (code = '311412005' in codeSystem 'SNOMED CT') | ||||||
| Toelichting | na subtotale darmresectie | ||||||
| Stoma | |||||||
| Stoma type | urostoma (code = '281601009' in codeSystem 'SNOMED CT') | ||||||
Aanmeldbericht - overlap BgZ
Administratieve gegevens
| Administratieve gegevens | ||||||
| Gegevenselement | Waarde | |||||
| Datum overplaatsing | T + 1 dag | |||||
| Persoonsgegevens | ||||||
| Patient | ||||||
| Naamgegevens | ||||||
| Voornamen | Erik | |||||
| Initialen | E | |||||
| Geslachtsnaam | ||||||
| Achternaam | XXX_Altenborg | |||||
| Adresgegevens | ||||||
| Straat | Knolweg | |||||
| Huisnummer | 1000 | |||||
| Postcode | 9999XA | |||||
| Woonplaats | Stitswerd | |||||
| Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||||
| Identificatienummer | 999911612 (in identificerend systeem: BSN) | |||||
| Geboortedatum | 14 aug 1964 | |||||
| Geslacht | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |||||
| Betaler | ||||||
| Verzekeraar | ||||||
| Verzekering | ||||||
| Eind datum tijd | T + 1 jaar | |||||
| Verzekeringssoort | Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') | |||||
| Contactpersoon | ||||||
| Naamgegevens | ||||||
| Voornamen | Johanna | |||||
| Initialen | J | |||||
| Roepnaam | Hanna | |||||
| Geslachtsnaam | ||||||
| Achternaam | Bakker | |||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31645678912 | |||||
| Email adressen | ||||||
| Email adres | jbakker@123net.nl | |||||
| Relatie | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef | |||||
| Sturende organisatie | ||||||
| Zorgaanbieder | ||||||
| Zorgaanbieder identificatienummer | 06590457 (in identificerend systeem: AGB-Z) | |||||
| Organisatie naam | AB-zkh | |||||
| Organisatie locatie | Noord | |||||
| Afdeling specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31182435770 | |||||
| Email adressen | ||||||
| Email adres | neurologie@ABZ.nl | |||||
| Organisatie type | Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||||
| Ontvangende organisatie | ||||||
| Zorgaanbieder | ||||||
| Afdeling specialisme | Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
| Organisatie type | Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||||
Medische context
| Medische context | ||||
| Gegevenselement | Waarde | |||
| Medische diagnose | ||||
| Probleem | ||||
| Probleem naam | ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT') | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
| Toelichting | niet bekend met neurologische klachten | |||
| Probleem | ||||
| Probleem naam | neoplasma van colon (code = '126838000') | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
| Probleem | ||||
| Probleem naam | oksel (code = '238600001' in codeSystem 'SNOMED Clinical Terms') | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
| Probleem | ||||
| Probleem naam | inverse psoriasis (code = '238600001') | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
| Voorgeschiedenis | ||||
| Probleem | ||||
| Probleem naam | diabetes mellitus (code = '73211009') | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
| Let op | ||||
| Alert | ||||
| Alert naam | Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT') | |||
| Alert | ||||
| Alert naam | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie | |||
Aanmeldbericht Kinderen 0-1 jaar - overlap BgZ (concept)
Administratieve gegevens
| Administratieve gegevens | ||||||
| Gegevenselement | Waarde | |||||
| Datum overplaatsing | T + 2 dagen | |||||
| Persoonsgegevens | ||||||
| Patient | ||||||
| Naamgegevens | ||||||
| Voornamen | Erik | |||||
| Initialen | E | |||||
| Geslachtsnaam | ||||||
| Achternaam | XXX_Altenborg | |||||
| Adresgegevens | ||||||
| Straat | Knolweg | |||||
| Huisnummer | 1000 | |||||
| Postcode | 9999XA | |||||
| Woonplaats | Stitswerd | |||||
| Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||||
| Identificatienummer | 999911612 (in identificerend systeem: BSN) | |||||
| Geboortedatum | 14 aug 1964 | |||||
| Geslacht | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |||||
| Betaler | ||||||
| Verzekeraar | ||||||
| Verzekering | ||||||
| Eind datum tijd | T + 1 jaar | |||||
| Verzekeringssoort | Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') | |||||
| Contactpersoon | ||||||
| Naamgegevens | ||||||
| Voornamen | Johanna | |||||
| Initialen | J | |||||
| Roepnaam | Hanna | |||||
| Geslachtsnaam | ||||||
| Achternaam | Bakker | |||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31645678912 | |||||
| Email adressen | ||||||
| Email adres | jbakker@123net.nl | |||||
| Relatie | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef | |||||
| Sturende organisatie | ||||||
| Zorgaanbieder | ||||||
| Zorgaanbieder identificatienummer | 06590457 (in identificerend systeem: AGB-Z) | |||||
| Organisatie naam | AB-zkh | |||||
| Organisatie locatie | Noord | |||||
| Afdeling specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31182435770 | |||||
| Email adressen | ||||||
| Email adres | neurologie@ABZ.nl | |||||
| Organisatie type | Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||||
| Ontvangende organisatie | ||||||
| Zorgaanbieder | ||||||
| Afdeling specialisme | Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
| Organisatie type | Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||||
Algemene patienten context
| Algemene patienten context | ||||
| Gegevenselement | Waarde | |||
| Juridische situatie | ||||
| Juridische situatie JuridischeSituatie-01 | ||||
| Vertegenwoordiging | Onder curatele stelling (code = '9' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.3') | |||
| Datum aanvang | T - 1 jaar | |||
Medische context
| Medische context | ||||
| Gegevenselement | Waarde | |||
| Medische diagnose | ||||
| Probleem | ||||
| Probleem naam | ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT') | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
| Toelichting | niet bekend met neurologische klachten | |||
| Probleem | ||||
| Probleem naam | neoplasma van colon (code = '126838000') | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
| Probleem | ||||
| Probleem naam | oksel (code = '238600001' in codeSystem 'SNOMED Clinical Terms') | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
| Probleem | ||||
| Probleem naam | inverse psoriasis (code = '238600001') | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
| Voorgeschiedenis | ||||
| Probleem | ||||
| Probleem naam | diabetes mellitus (code = '73211009') | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
| Let op | ||||
| Alert | ||||
| Alert naam | Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT') | |||
| Alert | ||||
| Alert naam | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie | |||
| Vrijheidsbeperking | ||||
| Vrijheidsbeperkende interventie | ||||
| Wilsbekwaam | Ja | |||
| Juridische situatie | Zie Juridische situatie: JuridischeSituatie-01 | |||
| Soort interventie | geforceerd toedienen van voeding bij patiënt (code = '37041007' in codeSystem 'SNOMED CT') | |||
| Reden van toepassen | bevorderen van fysieke gezondheid (code = '121581000146106' in codeSystem 'SNOMED CT') | |||
| Instemming | Instemming patiënt (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.6.1') | |||
| Begin | T - 50 dagen | |||
Verpleegkundige context zorgplan
| Verpleegkundige context zorgplan | ||||||
| Gegevenselement | Waarde | |||||
| Actuele patientproblemen | ||||||
| Patientprobleem | ||||||
| Probleem patientprobleem-01 | ||||||
| Probleem naam | probleem met zichzelf wassen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
| Toelichting | meneer kan niet buigen | |||||
| Verpleegkundige interventie | ||||||
| Interventie | ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED Clinical Terms') | |||||
| Indicatie | ||||||
| Probleem | Zie Probleem: patientprobleem-01 | |||||
| Uitvoerder | ||||||
| Zorgverlener | Ja | |||||
| Patientprobleem | ||||||
| Probleem patientprobleem-02 | ||||||
| Probleem naam | probleem met zichzelf kleden (code = '284972002' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
| Verpleegkundige interventie | ||||||
| Interventie | ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms') | |||||
| Indicatie | ||||||
| Probleem | Zie Probleem: patientprobleem-02 | |||||
| Patientprobleem | ||||||
| Probleem eovd-saa-tst-patientprobleem-03 | ||||||
| Probleem naam | decubitus (code = '399912005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
| Verpleegkundige interventie | ||||||
| Interventie | aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED Clinical Terms') | |||||
| Indicatie | ||||||
| Probleem | Zie Probleem: eovd-saa-tst-patientprobleem-03 | |||||
| Verpleegkundige interventie | ||||||
| Interventie | wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED Clinical Terms') | |||||
| Indicatie | ||||||
| Probleem | Zie Probleem: eovd-saa-tst-patientprobleem-03 | |||||
| Actie start datum tijd | T - 10 dagen | |||||
| Actie eind datum tijd | T - 1 dag | |||||
| Uitvoerder | ||||||
| Zorgverlener | Ja | |||||
| Patientprobleem | ||||||
| Probleem eovd-saa-tst-patientprobleem-04 | ||||||
| Probleem naam | loopt risico op delier (code = '430794006' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
| Verpleegkundige interventie | ||||||
| Interventie | bevorderen van vochtinname (code = '113148007' in codeSystem 'SNOMED Clinical Terms') | |||||
| Indicatie | ||||||
| Probleem | Zie Probleem: eovd-saa-tst-patientprobleem-04 | |||||
Verpleegkundige context specificatie gezondheidstoestand
| Verpleegkundige context specificatie gezondheidstoestand | |||||||
| Gegevenselement | Waarde | ||||||
| Voedingvocht | |||||||
| Sonde systeem | |||||||
| Sonde | |||||||
| Medisch hulpmiddel | |||||||
| Product | |||||||
| Product type | PEJ sonde (code = '8911000146104' in codeSystem 'SNOMED CT') | ||||||
| Product omschrijving | PEJ sonde | ||||||
| Infuus | |||||||
| Infuuskatheter | |||||||
| Medisch hulpmiddel | |||||||
| Product | |||||||
| Product type | Centraal veneuze katheter (code = '52124006' in codeSystem 'SNOMED CT') | ||||||
| Product omschrijving | centraal veneuze katheter | ||||||
| Toelichting | voor voeding | ||||||
| Infuus | |||||||
| Infuuskatheter | |||||||
| Medisch hulpmiddel | |||||||
| Product | |||||||
| Product type | Perifeer intraveneus infuus (code = '82449006' in codeSystem 'SNOMED CT') | ||||||
| Product omschrijving | voor medicatie | ||||||
| Uitscheiding | |||||||
| Stoma | |||||||
| Stoma type | eindstandige ileostoma (code = '311412005' in codeSystem 'SNOMED CT') | ||||||
| Toelichting | na subtotale darmresectie | ||||||
| Stoma | |||||||
| Stoma type | urostoma (code = '281601009' in codeSystem 'SNOMED CT') | ||||||