MedMij:V1.0 Sandbox2: verschil tussen versies
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|style="background-color: white;"|bglz-1-3-verpleegkundigeinterventie-01 | |style="background-color: white;"|bglz-1-3-verpleegkundigeinterventie-01 | ||
|}<section end=verpleegkundig_zorgplan_ /> | |}<section end=verpleegkundig_zorgplan_ /> | ||
==Demografie en identificatie == | |||
<section begin=demografie_en_identificatie_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Demografie en identificatie | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="6" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Patient | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="38"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Fiona | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|F. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|XXX_Mutter | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Straat | |||
|style="background-color: white;"|Knolweg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Huisnummer | |||
|style="background-color: white;"|1001 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Postcode | |||
|style="background-color: white;"|9999XX | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Woonplaats | |||
|style="background-color: white;"|Stitswerd | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Land | |||
|style="background-color: white;"|Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Adres soort | |||
|style="background-color: white;"|Postadres (code = 'PST' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="10"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"|+31634567891 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telecom type | |||
|style="background-color: white;"|Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Nummer soort | |||
|style="background-color: white;"|Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email adres | |||
|style="background-color: white;"|fmutter@hotmail.com | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email soort | |||
|style="background-color: white;"|Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Identificatienummer | |||
|style="background-color: white;"|999911673 (in identificerend systeem: 2.16.840.1.113883.2.4.6.3) | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Geboortedatum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Geslacht | |||
|style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Meerling indicator | |||
|style="background-color: white;"|Nee | |||
|}<section end=demografie_en_identificatie_ /> | |||
==Behandelrestricties == | |||
<section begin=behandelrestricties_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Behandelrestricties | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="4" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Behandel aanwijzing | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Verificatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Geverifieerd | |||
|style="background-color: white;"|Ja | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Geverifieerd bij | |||
|style="background-color: white;"|Patiënt (code = '116154003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Verificatie datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Behandeling | |||
|style="background-color: white;"|Cardiopulmonaire resuscitatie (code = '89666000' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Behandeling toegestaan | |||
|style="background-color: white;"|Behandeling niet toegestaan en/of wenselijk (code = 'NEE' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Begin datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Wilsverklaring | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Wilsverklaring | |||
|style="background-color: white;"|bglz-1-1-wilsverklaring-01 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Wilsverklaring | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Wilsverklaring type | |||
|style="background-color: white;"|Niet reanimeren verklaring (code = 'NR' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.14.1') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Wilsverklaring datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Vertegenwoordiger | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Contactpersoon | |||
|style="background-color: white;"|bglz-1-1-contactpersoon-01 | |||
|}<section end=behandelrestricties_ /> | |||
==Contactpersonen == | |||
<section begin=contactpersonen_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Contactpersonen | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="6" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Contactpersoon | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="26"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Robert | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|R. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Prins | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="10"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"|06-34567891 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telecom type | |||
|style="background-color: white;"|Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Nummer soort | |||
|style="background-color: white;"|Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email adres | |||
|style="background-color: white;"|bprins@123net.nl | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email soort | |||
|style="background-color: white;"|Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Rol | |||
|style="background-color: white;"|Eerste relatie/contactpersoon (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Relatie | |||
|style="background-color: white;"|Zoon (code = 'SONC' in codeSystem 'HL7 RoleCode') | |||
|}<section end=contactpersonen_ /> | |||
==Klachten en diagnoses == | |||
<section begin=klachten_en_diagnoses_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Klachten en diagnoses | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="3" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem type | |||
|style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|ischemisch cerebrovasculair accident (code = '422504002' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"| | |||
|-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="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem type | |||
|style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|diabetes mellitus (code = '73211009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"| | |||
|-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="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem type | |||
|style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|probleem met zichzelf wassen en afdrogen (code = '288552005' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"| | |||
|-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="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem type | |||
|style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|probleem met zichzelf kleden (code = '284972002' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"| | |||
|-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="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem type | |||
|style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|probleem met lopen (code = '228158008' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"| | |||
|-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="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem type | |||
|style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|afasie (code = '87486003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"| | |||
|-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="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem type | |||
|style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|risico op decubitus (code = '285304000' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"| | |||
|-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="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem type | |||
|style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|overbelaste mantelzorg (code = '705044006' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|}<section end=klachten_en_diagnoses_ /> | |||
==Allergieen == | |||
<section begin=allergieen_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Allergieen | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="4" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Allergie intolerantie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Veroorzakende stof | |||
|style="background-color: white;"|pinda (code = '762952008' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Allergie status | |||
|style="background-color: white;"|Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Mate van kritiek zijn | |||
|style="background-color: white;"|Fataal (code = '399166001' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Toelichting | |||
|style="background-color: white;"|Na het eten van pinda's als student ontstond er een klinisch beeld van anafylaxie waarop de HA epipen heeft moeten toedienen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Reactie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Symptoom | |||
|style="background-color: white;"|Anafylaxie (code = '39579001' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Reactie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Symptoom | |||
|style="background-color: white;"|Angio-oedeem (code = '41291007' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Reactie beschrijving | |||
|style="background-color: white;"|Angio-oedeem van de tong, lippen en peri-orbitale regio met acute benauwdheid na het eten van pinda's. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Allergie intolerantie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Veroorzakende stof | |||
|style="background-color: white;"|nikkelsulfaat (code = '255848005' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Allergie status | |||
|style="background-color: white;"|Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Mate van kritiek zijn | |||
|style="background-color: white;"|Matig (code = '6736007' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Toelichting | |||
|style="background-color: white;"|Opgemerkt bij het dragen van nikkel bevattende sieraden. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Reactie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Symptoom | |||
|style="background-color: white;"|Contactdermatitis (code = '40275004' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Reactie beschrijving | |||
|style="background-color: white;"|Last van jeuk, roodheid en irritatie op de contactplek van nikkel bevattende sieraden. | |||
|}<section end=allergieen_ /> | |||
==Uitslagen == | |||
<section begin=uitslagen_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Uitslagen | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="4" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Laboratorium uitslag | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="17"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Laboratorium test | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test code | |||
|style="background-color: white;"|Hemoglobine (code = '718-7' in codeSystem 'LOINC') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test datum tijd | |||
|style="background-color: white;"|13 jan 2018 15:00 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test uitslag | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie bovengrens | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie ondergrens | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Interpretatie vlaggen | |||
|style="background-color: white;"|Onder referentiewaarde (code = '281300000' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Laboratorium test | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test code | |||
|style="background-color: white;"|Hematocriet (code = '20570-8' in codeSystem 'LOINC') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test datum tijd | |||
|style="background-color: white;"|13 jan 2018 15:00 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test uitslag | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie bovengrens | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie ondergrens | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Onderzoek | |||
|style="background-color: white;"|hemoglobine & hematocriet panel (code = '24360-0' in codeSystem 'LOINC') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Laboratorium uitslag | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Laboratorium test | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test code | |||
|style="background-color: white;"|glucose 2 uur na maaltijd massa/volume serum of plasma (code = '1521-4' in codeSystem 'LOINC') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test datum tijd | |||
|style="background-color: white;"|13 jan 2018 15:00 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test uitslag | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie bovengrens | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie ondergrens | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Interpretatie vlaggen | |||
|style="background-color: white;"|Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Laboratorium uitslag | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Laboratorium test | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test code | |||
|style="background-color: white;"|cholesterol in LDL massa/volume serum of plasma (code = '13457-7' in codeSystem 'LOINC') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test datum tijd | |||
|style="background-color: white;"|13 jan 2018 15:00 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test uitslag | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie bovengrens | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Interpretatie vlaggen | |||
|style="background-color: white;"|Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Toelichting | |||
|style="background-color: white;"|Volgens richtlijn herseninfarct: streven naar <1,8mmol/l | |||
|}<section end=uitslagen_ /> | |||
==Verrichtingen == | |||
<section begin=verrichtingen_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Verrichtingen | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="4" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verrichting | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="16"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting start datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting eind datum | |||
|style="background-color: white;"| | |||
|-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;"|bglz-1-1-probleem-01 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting type | |||
|style="background-color: white;"|CT van hersenschedel (code = '0000075653' in codeSystem 'DHD Verrichtingenthesaurus') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Locatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgaanbieder | |||
|style="background-color: white;"|bglz-1-1-zorgaanbieder-01 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Uitvoerder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgverlener | |||
|style="background-color: white;"|bglz-1-1-zorgverlener-02 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Aanvrager | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgverlener | |||
|style="background-color: white;"|bglz-1-1-zorgverlener-02 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verrichting | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="16"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting start datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting eind datum | |||
|style="background-color: white;"| | |||
|-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;"|bglz-1-1-probleem-01 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting type | |||
|style="background-color: white;"|trombolyse van arteria cerebri anterior links (code = '0000088463' in codeSystem 'DHD Verrichtingenthesaurus') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Locatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgaanbieder | |||
|style="background-color: white;"|bglz-1-1-zorgaanbieder-01 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Uitvoerder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgverlener | |||
|style="background-color: white;"|bglz-1-1-zorgverlener-02 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Aanvrager | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgverlener | |||
|style="background-color: white;"|bglz-1-1-zorgverlener-02 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verrichting | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="15"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting start datum | |||
|style="background-color: white;"| | |||
|-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;"|bglz-1-1-probleem-05 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting type | |||
|style="background-color: white;"|Fysiotherapie - revalidatie (code = '0000064981' in codeSystem 'DHD Verrichtingenthesaurus') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Locatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgaanbieder | |||
|style="background-color: white;"|bglz-1-1-zorgaanbieder-01 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Uitvoerder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgverlener | |||
|style="background-color: white;"|bglz-1-1-zorgverlener-04 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Aanvrager | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgverlener | |||
|style="background-color: white;"|bglz-1-1-zorgverlener-02 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verrichting | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="15"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting start datum | |||
|style="background-color: white;"| | |||
|-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;"|bglz-1-1-probleem-06 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting type | |||
|style="background-color: white;"|Logopedie - individuele zitting afasie (code = '0000065289' in codeSystem 'DHD Verrichtingenthesaurus') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Locatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgaanbieder | |||
|style="background-color: white;"|bglz-1-1-zorgaanbieder-01 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Uitvoerder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgverlener | |||
|style="background-color: white;"|bglz-1-1-zorgverlener-05 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Aanvrager | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgverlener | |||
|style="background-color: white;"|bglz-1-1-zorgverlener-02 | |||
|}<section end=verrichtingen_ /> | |||
==Verpleegkundig zorgplan == | |||
<section begin=verpleegkundig_zorgplan_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Verpleegkundig zorgplan | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="6" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Doelen en interventies | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="83"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Verpleegkundige interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="16"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Interventie | |||
|style="background-color: white;"|ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Indicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem | |||
|style="background-color: white;"|bglz-1-1-probleem-03 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Behandeldoel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Behandeldoel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Gewenst zorgresultaat | |||
|style="background-color: white;"|wassen onafhankelijk | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Frequentie | |||
|style="background-color: white;"|1 per dag | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Uitvoerder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgverlener | |||
|style="background-color: white;"|bglz-1-1-zorgverlener-03 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Verpleegkundige interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="16"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Interventie | |||
|style="background-color: white;"|ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Indicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem | |||
|style="background-color: white;"|bglz-1-1-probleem-04 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Behandeldoel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Behandeldoel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Gewenst zorgresultaat | |||
|style="background-color: white;"|kleden onafhankelijk | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Frequentie | |||
|style="background-color: white;"|2 per dag | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Uitvoerder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgverlener | |||
|style="background-color: white;"|bglz-1-1-zorgverlener-03 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Verpleegkundige interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="15"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Interventie | |||
|style="background-color: white;"|patiënt mobiliseren (code = '62013009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Indicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem | |||
|style="background-color: white;"|bglz-1-1-probleem-05 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Behandeldoel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Behandeldoel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Gewenst zorgresultaat | |||
|style="background-color: white;"|lopen met hulp | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Uitvoerder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgverlener | |||
|style="background-color: white;"|bglz-1-1-zorgverlener-03 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Verpleegkundige interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="15"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Interventie | |||
|style="background-color: white;"|wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Indicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem | |||
|style="background-color: white;"|bglz-1-1-probleem-07 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Behandeldoel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Behandeldoel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Gewenst zorgresultaat | |||
|style="background-color: white;"|huid blijft intact | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Uitvoerder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgverlener | |||
|style="background-color: white;"|bglz-1-1-zorgverlener-03 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Verpleegkundige interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="15"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Interventie | |||
|style="background-color: white;"|ondersteuning voor verzorger (code = '386229000' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Indicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Probleem | |||
|style="background-color: white;"|bglz-1-1-probleem-08 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Behandeldoel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Behandeldoel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Gewenst zorgresultaat | |||
|style="background-color: white;"|zorgtaken voor echtgenoot worden gecontinueerd | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Uitvoerder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgverlener | |||
|style="background-color: white;"|bglz-1-1-zorgverlener-03 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Uitkomsten | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="31"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Uitkomst van zorg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgresultaat | |||
|style="background-color: white;"|Wassen met hulp. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verpleegkundige interventie | |||
|style="background-color: white;"|bglz-1-1-verpleegkundigeinterventie-01 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Uitkomst van zorg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgresultaat | |||
|style="background-color: white;"|Kleden met hulp. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verpleegkundige interventie | |||
|style="background-color: white;"|bglz-1-1-verpleegkundigeinterventie-02 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Uitkomst van zorg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgresultaat | |||
|style="background-color: white;"|Lopen geheel afhankelijk. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verpleegkundige interventie | |||
|style="background-color: white;"|bglz-1-1-verpleegkundigeinterventie-03 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Uitkomst van zorg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgresultaat | |||
|style="background-color: white;"|Huid is intact zonder decubitus wonden. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verpleegkundige interventie | |||
|style="background-color: white;"|bglz-1-1-verpleegkundigeinterventie-04 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Uitkomst van zorg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgresultaat | |||
|style="background-color: white;"|Thuiszorg is aangevraagd voor continuering van zorgtaken en huishoudelijke hulp. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verpleegkundige interventie | |||
|style="background-color: white;"|bglz-1-1-verpleegkundigeinterventie-05 | |||
|}<section end=verpleegkundig_zorgplan_ /> | |||
==Zorgsetting == | |||
<section begin=zorgsetting_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Zorgsetting | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="7" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Huisarts | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="22"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="20"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="11"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Laura | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|L. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Lanen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam partner | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Voorvoegsels partner | |||
|style="background-color: white;"|van | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam partner | |||
|style="background-color: white;"|Oosten | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Specialisme | |||
|style="background-color: white;"|Huisarts (code = '01.015' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgaanbieder | |||
|style="background-color: white;"|Huisartsenpraktijk | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Zorgverleners rol | |||
|style="background-color: white;"|Verwijzer (code = 'REF' in codeSystem 'HL7 ParticipationType') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Hoofdbehandelaar | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="18"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="16"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-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;"|Niels | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|N. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Helmond | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Specialisme | |||
|style="background-color: white;"|Neuroloog (code = '01.026' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgaanbieder | |||
|style="background-color: white;"|bglz-1-1-zorgaanbieder-01 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Zorgverleners rol | |||
|style="background-color: white;"|Hoofdbehandelaar (code = 'RESP' in codeSystem 'HL7 ParticipationType') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Overige behandelaars | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="49"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="15"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-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;"|Petra Johanna | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|P.J. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Vreeswijk | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Specialisme | |||
|style="background-color: white;"|Verpleegkundige (code = '30.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgaanbieder | |||
|style="background-color: white;"|bglz-1-1-zorgaanbieder-01 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="15"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-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;"|Thomas | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|T. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Janssen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Specialisme | |||
|style="background-color: white;"|Fysiotherapeut (code = '04.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgaanbieder | |||
|style="background-color: white;"|bglz-1-1-zorgaanbieder-01 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="15"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-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;"|Hilda | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|H. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Bruinsma | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Specialisme | |||
|style="background-color: white;"|Logopedist (code = '91.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgaanbieder | |||
|style="background-color: white;"|bglz-1-1-zorgaanbieder-01 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="28"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Organisatie naam | |||
|style="background-color: white;"|AA-zkh | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Organisatie locatie | |||
|style="background-color: white;"|Noord | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|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="7"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="10"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Telefoonnummer | |||
|style="background-color: white;"|+31182435768 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Telecom type | |||
|style="background-color: white;"|Vast telefoonnummer (code = 'LL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.22.1') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Nummer soort | |||
|style="background-color: white;"|Zakelijk telefoonnummer (code = 'WP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Email adres | |||
|style="background-color: white;"|neurologie@AAZ.nl | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Email soort | |||
|style="background-color: white;"|Zakelijk e-mailadres (code = 'WP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Straat | |||
|style="background-color: white;"|De Weststraat | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Huisnummer | |||
|style="background-color: white;"|3 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Postcode | |||
|style="background-color: white;"|9999PK | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Woonplaats | |||
|style="background-color: white;"|Stitswerd | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Land | |||
|style="background-color: white;"|Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Adres soort | |||
|style="background-color: white;"|Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Organisatie type | |||
|style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||
|}<section end=zorgsetting_ /> | |||
==Demografie en identificatie == | |||
<section begin=demografie_en_identificatie_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Demografie en identificatie | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="6" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Patient | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="38"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Fiona | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|F. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|XXX_Mutter | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Straat | |||
|style="background-color: white;"|Knolweg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Huisnummer | |||
|style="background-color: white;"|1001 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Postcode | |||
|style="background-color: white;"|9999XX | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Woonplaats | |||
|style="background-color: white;"|Stitswerd | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Land | |||
|style="background-color: white;"|Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Adres soort | |||
|style="background-color: white;"|Postadres (code = 'PST' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="10"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"|+31634567891 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telecom type | |||
|style="background-color: white;"|Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Nummer soort | |||
|style="background-color: white;"|Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email adres | |||
|style="background-color: white;"|fmutter@hotmail.com | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email soort | |||
|style="background-color: white;"|Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Identificatienummer | |||
|style="background-color: white;"|999911673 (in identificerend systeem: 2.16.840.1.113883.2.4.6.3) | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Geboortedatum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Geslacht | |||
|style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Meerling indicator | |||
|style="background-color: white;"|Nee | |||
|}<section end=demografie_en_identificatie_ /> | |||
==Behandelrestricties == | |||
<section begin=behandelrestricties_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Behandelrestricties | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="4" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Behandel aanwijzing | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Verificatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Geverifieerd | |||
|style="background-color: white;"|Ja | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Geverifieerd bij | |||
|style="background-color: white;"|Patiënt (code = '116154003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Verificatie datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Behandeling | |||
|style="background-color: white;"|Cardiopulmonaire resuscitatie (code = '89666000' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Behandeling toegestaan | |||
|style="background-color: white;"|Behandeling niet toegestaan en/of wenselijk (code = 'NEE' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Begin datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Wilsverklaring | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Wilsverklaring | |||
|style="background-color: white;"|bglz-0-1-wilsverklaring-01 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Wilsverklaring | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Wilsverklaring type | |||
|style="background-color: white;"|Niet reanimeren verklaring (code = 'NR' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.14.1') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Wilsverklaring datum | |||
|style="background-color: white;"| | |||
|}<section end=behandelrestricties_ /> | |||
==Klachten en diagnoses == | |||
<section begin=klachten_en_diagnoses_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Klachten en diagnoses | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="3" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem type | |||
|style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|ischemisch cerebrovasculair accident (code = '422504002' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"| | |||
|-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="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem type | |||
|style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|diabetes mellitus (code = '73211009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"| | |||
|-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="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem type | |||
|style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|probleem met zichzelf wassen en afdrogen (code = '288552005' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"| | |||
|-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="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem type | |||
|style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|probleem met zichzelf kleden (code = '284972002' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"| | |||
|-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="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem type | |||
|style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|probleem met lopen (code = '228158008' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"| | |||
|-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="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem type | |||
|style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|afasie (code = '87486003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"| | |||
|-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="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem type | |||
|style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|risico op decubitus (code = '285304000' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"| | |||
|-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="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem type | |||
|style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|overbelaste mantelzorg (code = '705044006' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|}<section end=klachten_en_diagnoses_ /> | |||
==Allergieen == | |||
<section begin=allergieen_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Allergieen | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="4" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Allergie intolerantie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Veroorzakende stof | |||
|style="background-color: white;"|pinda (code = '762952008' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Allergie status | |||
|style="background-color: white;"|Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Mate van kritiek zijn | |||
|style="background-color: white;"|Fataal (code = '399166001' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Toelichting | |||
|style="background-color: white;"|Na het eten van pinda's als student ontstond er een klinisch beeld van anafylaxie waarop de HA epipen heeft moeten toedienen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Reactie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Symptoom | |||
|style="background-color: white;"|Anafylaxie (code = '39579001' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Reactie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Symptoom | |||
|style="background-color: white;"|Angio-oedeem (code = '41291007' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Reactie beschrijving | |||
|style="background-color: white;"|Angio-oedeem van de tong, lippen en peri-orbitale regio met acute benauwdheid na het eten van pinda's. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Allergie intolerantie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Veroorzakende stof | |||
|style="background-color: white;"|nikkelsulfaat (code = '255848005' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Allergie status | |||
|style="background-color: white;"|Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Mate van kritiek zijn | |||
|style="background-color: white;"|Matig (code = '6736007' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Toelichting | |||
|style="background-color: white;"|Opgemerkt bij het dragen van nikkel bevattende sieraden. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Reactie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Symptoom | |||
|style="background-color: white;"|Contactdermatitis (code = '40275004' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Reactie beschrijving | |||
|style="background-color: white;"|Last van jeuk, roodheid en irritatie op de contactplek van nikkel bevattende sieraden. | |||
|}<section end=allergieen_ /> | |||
==Uitslagen == | |||
<section begin=uitslagen_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Uitslagen | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="4" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Laboratorium uitslag | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="17"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Laboratorium test | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test code | |||
|style="background-color: white;"|Hemoglobine (code = '718-7' in codeSystem 'LOINC') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test datum tijd | |||
|style="background-color: white;"|13 jan 2018 15:00 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test uitslag | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie bovengrens | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie ondergrens | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Interpretatie vlaggen | |||
|style="background-color: white;"|Onder referentiewaarde (code = '281300000' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Laboratorium test | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test code | |||
|style="background-color: white;"|Hematocriet (code = '20570-8' in codeSystem 'LOINC') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test datum tijd | |||
|style="background-color: white;"|13 jan 2018 15:00 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test uitslag | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie bovengrens | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie ondergrens | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Onderzoek | |||
|style="background-color: white;"|hemoglobine & hematocriet panel (code = '24360-0' in codeSystem 'LOINC') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Laboratorium uitslag | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Laboratorium test | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test code | |||
|style="background-color: white;"|glucose 2 uur na maaltijd massa/volume serum of plasma (code = '1521-4' in codeSystem 'LOINC') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test datum tijd | |||
|style="background-color: white;"|13 jan 2018 15:00 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test uitslag | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie bovengrens | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie ondergrens | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Interpretatie vlaggen | |||
|style="background-color: white;"|Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Laboratorium uitslag | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Laboratorium test | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test code | |||
|style="background-color: white;"|cholesterol in LDL massa/volume serum of plasma (code = '13457-7' in codeSystem 'LOINC') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test datum tijd | |||
|style="background-color: white;"|13 jan 2018 15:00 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test uitslag | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie bovengrens | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Interpretatie vlaggen | |||
|style="background-color: white;"|Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Toelichting | |||
|style="background-color: white;"|Volgens richtlijn herseninfarct: streven naar <1,8mmol/l | |||
|}<section end=uitslagen_ /> | |||
==Verrichtingen == | |||
<section begin=verrichtingen_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Verrichtingen | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="4" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verrichting | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting start datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting eind datum | |||
|style="background-color: white;"| | |||
|-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;"|bglz-0-1-probleem-01 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting type | |||
|style="background-color: white;"|CT van hersenschedel (code = '0000075653' in codeSystem 'DHD Verrichtingenthesaurus') | |||
|-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;"|bglz-0-1-zorgverlener-02 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Aanvrager | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgverlener | |||
|style="background-color: white;"|bglz-0-1-zorgverlener-02 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verrichting | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting start datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting eind datum | |||
|style="background-color: white;"| | |||
|-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;"|bglz-0-1-probleem-01 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting type | |||
|style="background-color: white;"|trombolyse van arteria cerebri anterior links (code = '0000088463' in codeSystem 'DHD Verrichtingenthesaurus') | |||
|-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;"|bglz-0-1-zorgverlener-02 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Aanvrager | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgverlener | |||
|style="background-color: white;"|bglz-0-1-zorgverlener-02 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verrichting | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting start datum | |||
|style="background-color: white;"| | |||
|-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;"|bglz-0-1-probleem-05 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting type | |||
|style="background-color: white;"|Fysiotherapie - revalidatie (code = '0000064981' in codeSystem 'DHD Verrichtingenthesaurus') | |||
|-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;"|bglz-0-1-zorgverlener-04 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Aanvrager | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgverlener | |||
|style="background-color: white;"|bglz-0-1-zorgverlener-02 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verrichting | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting start datum | |||
|style="background-color: white;"| | |||
|-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;"|bglz-0-1-probleem-06 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting type | |||
|style="background-color: white;"|Logopedie - individuele zitting afasie (code = '0000065289' in codeSystem 'DHD Verrichtingenthesaurus') | |||
|-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;"|bglz-0-1-zorgverlener-05 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Aanvrager | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgverlener | |||
|style="background-color: white;"|bglz-0-1-zorgverlener-02 | |||
|}<section end=verrichtingen_ /> | |||
==Zorgsetting == | |||
<section begin=zorgsetting_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Zorgsetting | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="7" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Huisarts | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="22"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="20"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="11"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Laura | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|L. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Lanen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam partner | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Voorvoegsels partner | |||
|style="background-color: white;"|van | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam partner | |||
|style="background-color: white;"|Oosten | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Specialisme | |||
|style="background-color: white;"|Huisarts (code = '01.015' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgaanbieder | |||
|style="background-color: white;"|Huisartsenpraktijk | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Zorgverleners rol | |||
|style="background-color: white;"|Verwijzer (code = 'REF' in codeSystem 'HL7 ParticipationType') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Hoofdbehandelaar | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="15"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-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;"|Niels | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|N. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Helmond | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Specialisme | |||
|style="background-color: white;"|Neuroloog (code = '01.026' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Zorgverleners rol | |||
|style="background-color: white;"|Hoofdbehandelaar (code = 'RESP' in codeSystem 'HL7 ParticipationType') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Overige behandelaars | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="40"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-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;"|Petra Johanna | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|P.J. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Vreeswijk | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Specialisme | |||
|style="background-color: white;"|Verpleegkundige (code = '30.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-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;"|Thomas | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|T. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Janssen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Specialisme | |||
|style="background-color: white;"|Fysiotherapeut (code = '04.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-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;"|Hilda | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|H. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Bruinsma | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Specialisme | |||
|style="background-color: white;"|Logopedist (code = '91.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||
|}<section end=zorgsetting_ /> | |||
==Demografie en identificatie == | |||
<section begin=demografie_en_identificatie_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Demografie en identificatie | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="6" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Patient | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="38"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-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;"|Gea | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|G. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|XXX_Valk | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Straat | |||
|style="background-color: white;"|Knolweg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Huisnummer | |||
|style="background-color: white;"|1003 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Postcode | |||
|style="background-color: white;"|9999ZA | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Woonplaats | |||
|style="background-color: white;"|Stitswerd | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Land | |||
|style="background-color: white;"|Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Adres soort | |||
|style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="10"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"|+31645678912 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telecom type | |||
|style="background-color: white;"|Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Nummer soort | |||
|style="background-color: white;"|Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email adres | |||
|style="background-color: white;"|gvalk@hotmail.com | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email soort | |||
|style="background-color: white;"|Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Identificatienummer | |||
|style="background-color: white;"|999911697 (in identificerend systeem: 2.16.840.1.113883.2.4.6.3) | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Geboortedatum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Geslacht | |||
|style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Meerling indicator | |||
|style="background-color: white;"|Ja | |||
|}<section end=demografie_en_identificatie_ /> | |||
[[Categorie:Kwalificatie]] | [[Categorie:Kwalificatie]] | ||
Versie van 22 aug 2019 11:37
__NUMBEREDHEADINGS__ {{#customtitle:Beschikbaarstellen basisgegevens langdurige zorg: addendum inhoudelijke gegevens kwalificatie}}

Addenda voor inhoudelijke gegevens
Demografie en identificatie
| Demografie en identificatie | ||||||
| Gegevenselement | Waarde | |||||
| Patient | ||||||
| Naamgegevens | ||||||
| Naamgegevens | ||||||
| Voornamen | Fiona | |||||
| Initialen | F. | |||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||||
| Geslachtsnaam | ||||||
| Achternaam | XXX_Mutter | |||||
| Adresgegevens | ||||||
| Adresgegevens | ||||||
| Straat | Knolweg | |||||
| Huisnummer | 1001 | |||||
| Postcode | 9999XX | |||||
| Woonplaats | Stitswerd | |||||
| Land | Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | |||||
| Adres soort | Postadres (code = 'PST' in codeSystem 'HL7 AddressUse') | |||||
| Contactgegevens | ||||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31634567891 | |||||
| Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | |||||
| Nummer soort | Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | |||||
| Email adressen | ||||||
| Email adres | fmutter@hotmail.com | |||||
| Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | |||||
| Identificatienummer | 999911673 (in identificerend systeem: 2.16.840.1.113883.2.4.6.3) | |||||
| Geboortedatum | ||||||
| Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |||||
| Meerling indicator | Nee | |||||
Klachten en diagnoses
| Klachten en diagnoses | |||
| Gegevenselement | Waarde | ||
| Probleem | |||
| Probleem anatomische locatie | hiel (code = '76853006' in codeSystem 'SNOMED CT') | ||
| Probleem lateraliteit | Links (code = '7771000' in codeSystem 'SNOMED CT') | ||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | decubitus (code = '399912005' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Uitslagen
| Uitslagen | ||||
| Gegevenselement | Waarde | |||
| Laboratorium uitslag | ||||
| Laboratorium test | ||||
| Test code | cholesterol in LDL massa/volume serum of plasma (code = '13457-7' in codeSystem 'LOINC') | |||
| Test datum tijd | 13 jan 2018 15:00 | |||
| Test uitslag | ||||
| Referentie bovengrens | ||||
| Interpretatie vlaggen | Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
| Toelichting | Volgens richtlijn herseninfarct: streven naar <1,8mmol/l | |||
| Laboratorium uitslag | ||||
| Laboratorium test | ||||
| Test code | cholesterol in LDL massa/volume serum of plasma (code = '13457-7' in codeSystem 'LOINC') | |||
| Test datum tijd | 21 feb 2018 16:00 | |||
| Test uitslag | ||||
| Referentie bovengrens | ||||
| Interpretatie vlaggen | Onder referentiewaarde (code = '281300000' in codeSystem 'SNOMED CT') | |||
| Toelichting | Volgens richtlijn herseninfarct: streven naar <1,8mmol/l | |||
Verpleegkundig zorgplan
| Verpleegkundig zorgplan | |||||||
| Gegevenselement | Waarde | ||||||
| Doelen en interventies | |||||||
| Verpleegkundige interventie | |||||||
| Interventie | aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED CT') | ||||||
| Indicatie | |||||||
| Probleem | bglz-1-3-probleem-01 | ||||||
| Frequentie | 1 per dag | ||||||
| Medisch hulpmiddel | |||||||
| Medisch hulpmiddel | |||||||
| Product | |||||||
| Product type | schuimverband (code = '448416005' in codeSystem 'SNOMED CT') | ||||||
| Anatomische locatie | hiel (code = '76853006' in codeSystem 'SNOMED CT') | ||||||
| Lateraliteit | Links (code = '7771000' in codeSystem 'SNOMED CT') | ||||||
| Medisch hulpmiddel | |||||||
| Medisch hulpmiddel | |||||||
| Product | |||||||
| Product type | huidvervangende wondbedekkers (code = '465239008' in codeSystem 'SNOMED CT') | ||||||
| Anatomische locatie | hiel (code = '76853006' in codeSystem 'SNOMED CT') | ||||||
| Lateraliteit | Links (code = '7771000' in codeSystem 'SNOMED CT') | ||||||
| Uitvoerder | |||||||
| Zorgverlener | |||||||
| Zorgverlener | zie Zorgsetting: Overige behandelaars - verpleegkundige | ||||||
| Uitkomsten | |||||||
| Uitkomst van zorg | |||||||
| Zorgresultaat | Decubituswond is verbeterd van categorie 2 naar 1. | ||||||
| Interventie | |||||||
| Verpleegkundige interventie | bglz-1-3-verpleegkundigeinterventie-01 | ||||||
Demografie en identificatie
| Demografie en identificatie | ||||||
| Gegevenselement | Waarde | |||||
| Patient | ||||||
| Naamgegevens | ||||||
| Naamgegevens | ||||||
| Voornamen | Fiona | |||||
| Initialen | F. | |||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||||
| Geslachtsnaam | ||||||
| Achternaam | XXX_Mutter | |||||
| Adresgegevens | ||||||
| Adresgegevens | ||||||
| Straat | Knolweg | |||||
| Huisnummer | 1001 | |||||
| Postcode | 9999XX | |||||
| Woonplaats | Stitswerd | |||||
| Land | Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | |||||
| Adres soort | Postadres (code = 'PST' in codeSystem 'HL7 AddressUse') | |||||
| Contactgegevens | ||||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31634567891 | |||||
| Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | |||||
| Nummer soort | Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | |||||
| Email adressen | ||||||
| Email adres | fmutter@hotmail.com | |||||
| Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | |||||
| Identificatienummer | 999911673 (in identificerend systeem: 2.16.840.1.113883.2.4.6.3) | |||||
| Geboortedatum | ||||||
| Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |||||
| Meerling indicator | Nee | |||||
Behandelrestricties
| Behandelrestricties | ||||
| Gegevenselement | Waarde | |||
| Behandel aanwijzing | ||||
| Verificatie | ||||
| Geverifieerd | Ja | |||
| Geverifieerd bij | Patiënt (code = '116154003' in codeSystem 'SNOMED CT') | |||
| Verificatie datum | ||||
| Behandeling | Cardiopulmonaire resuscitatie (code = '89666000' in codeSystem 'SNOMED CT') | |||
| Behandeling toegestaan | Behandeling niet toegestaan en/of wenselijk (code = 'NEE' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4') | |||
| Begin datum | ||||
| Wilsverklaring | ||||
| Wilsverklaring | bglz-1-1-wilsverklaring-01 | |||
| Wilsverklaring | ||||
| Wilsverklaring type | Niet reanimeren verklaring (code = 'NR' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.14.1') | |||
| Wilsverklaring datum | ||||
| Vertegenwoordiger | ||||
| Contactpersoon | bglz-1-1-contactpersoon-01 | |||
Contactpersonen
| Contactpersonen | ||||||
| Gegevenselement | Waarde | |||||
| Contactpersoon | ||||||
| Naamgegevens | ||||||
| Naamgegevens | ||||||
| Voornamen | Robert | |||||
| Initialen | R. | |||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||||
| Geslachtsnaam | ||||||
| Achternaam | Prins | |||||
| Contactgegevens | ||||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | 06-34567891 | |||||
| Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | |||||
| Nummer soort | Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | |||||
| Email adressen | ||||||
| Email adres | bprins@123net.nl | |||||
| Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | |||||
| Rol | Eerste relatie/contactpersoon (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472') | |||||
| Relatie | Zoon (code = 'SONC' in codeSystem 'HL7 RoleCode') | |||||
Klachten en diagnoses
| Klachten en diagnoses | |||
| Gegevenselement | Waarde | ||
| Probleem | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | ischemisch cerebrovasculair accident (code = '422504002' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Toelichting | Niet bekend met neurologische klachten | ||
| Probleem | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | diabetes mellitus (code = '73211009' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | probleem met zichzelf wassen en afdrogen (code = '288552005' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | probleem met zichzelf kleden (code = '284972002' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | probleem met lopen (code = '228158008' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | afasie (code = '87486003' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | risico op decubitus (code = '285304000' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | overbelaste mantelzorg (code = '705044006' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Allergieen
| Allergieen | ||||
| Gegevenselement | Waarde | |||
| Allergie intolerantie | ||||
| Veroorzakende stof | pinda (code = '762952008' in codeSystem 'SNOMED CT') | |||
| Allergie status | Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||
| Mate van kritiek zijn | Fataal (code = '399166001' in codeSystem 'SNOMED CT') | |||
| Toelichting | Na het eten van pinda's als student ontstond er een klinisch beeld van anafylaxie waarop de HA epipen heeft moeten toedienen | |||
| Reactie | ||||
| Symptoom | Anafylaxie (code = '39579001' in codeSystem 'SNOMED CT') | |||
| Reactie | ||||
| Symptoom | Angio-oedeem (code = '41291007' in codeSystem 'SNOMED CT') | |||
| Reactie beschrijving | Angio-oedeem van de tong, lippen en peri-orbitale regio met acute benauwdheid na het eten van pinda's. | |||
| Allergie intolerantie | ||||
| Veroorzakende stof | nikkelsulfaat (code = '255848005' in codeSystem 'SNOMED CT') | |||
| Allergie status | Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||
| Mate van kritiek zijn | Matig (code = '6736007' in codeSystem 'SNOMED CT') | |||
| Toelichting | Opgemerkt bij het dragen van nikkel bevattende sieraden. | |||
| Reactie | ||||
| Symptoom | Contactdermatitis (code = '40275004' in codeSystem 'SNOMED CT') | |||
| Reactie beschrijving | Last van jeuk, roodheid en irritatie op de contactplek van nikkel bevattende sieraden. | |||
Uitslagen
| Uitslagen | ||||
| Gegevenselement | Waarde | |||
| Laboratorium uitslag | ||||
| Laboratorium test | ||||
| Test code | Hemoglobine (code = '718-7' in codeSystem 'LOINC') | |||
| Test datum tijd | 13 jan 2018 15:00 | |||
| Test uitslag | ||||
| Referentie bovengrens | ||||
| Referentie ondergrens | ||||
| Interpretatie vlaggen | Onder referentiewaarde (code = '281300000' in codeSystem 'SNOMED CT') | |||
| Laboratorium test | ||||
| Test code | Hematocriet (code = '20570-8' in codeSystem 'LOINC') | |||
| Test datum tijd | 13 jan 2018 15:00 | |||
| Test uitslag | ||||
| Referentie bovengrens | ||||
| Referentie ondergrens | ||||
| Onderzoek | hemoglobine & hematocriet panel (code = '24360-0' in codeSystem 'LOINC') | |||
| Laboratorium uitslag | ||||
| Laboratorium test | ||||
| Test code | glucose 2 uur na maaltijd massa/volume serum of plasma (code = '1521-4' in codeSystem 'LOINC') | |||
| Test datum tijd | 13 jan 2018 15:00 | |||
| Test uitslag | ||||
| Referentie bovengrens | ||||
| Referentie ondergrens | ||||
| Interpretatie vlaggen | Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
| Laboratorium uitslag | ||||
| Laboratorium test | ||||
| Test code | cholesterol in LDL massa/volume serum of plasma (code = '13457-7' in codeSystem 'LOINC') | |||
| Test datum tijd | 13 jan 2018 15:00 | |||
| Test uitslag | ||||
| Referentie bovengrens | ||||
| Interpretatie vlaggen | Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
| Toelichting | Volgens richtlijn herseninfarct: streven naar <1,8mmol/l | |||
Verrichtingen
| Verrichtingen | ||||
| Gegevenselement | Waarde | |||
| Verrichting | ||||
| Verrichting start datum | ||||
| Verrichting eind datum | ||||
| Indicatie | ||||
| Probleem | bglz-1-1-probleem-01 | |||
| Verrichting type | CT van hersenschedel (code = '0000075653' in codeSystem 'DHD Verrichtingenthesaurus') | |||
| Locatie | ||||
| Zorgaanbieder | bglz-1-1-zorgaanbieder-01 | |||
| Uitvoerder | ||||
| Zorgverlener | bglz-1-1-zorgverlener-02 | |||
| Aanvrager | ||||
| Zorgverlener | bglz-1-1-zorgverlener-02 | |||
| Verrichting | ||||
| Verrichting start datum | ||||
| Verrichting eind datum | ||||
| Indicatie | ||||
| Probleem | bglz-1-1-probleem-01 | |||
| Verrichting type | trombolyse van arteria cerebri anterior links (code = '0000088463' in codeSystem 'DHD Verrichtingenthesaurus') | |||
| Locatie | ||||
| Zorgaanbieder | bglz-1-1-zorgaanbieder-01 | |||
| Uitvoerder | ||||
| Zorgverlener | bglz-1-1-zorgverlener-02 | |||
| Aanvrager | ||||
| Zorgverlener | bglz-1-1-zorgverlener-02 | |||
| Verrichting | ||||
| Verrichting start datum | ||||
| Indicatie | ||||
| Probleem | bglz-1-1-probleem-05 | |||
| Verrichting type | Fysiotherapie - revalidatie (code = '0000064981' in codeSystem 'DHD Verrichtingenthesaurus') | |||
| Locatie | ||||
| Zorgaanbieder | bglz-1-1-zorgaanbieder-01 | |||
| Uitvoerder | ||||
| Zorgverlener | bglz-1-1-zorgverlener-04 | |||
| Aanvrager | ||||
| Zorgverlener | bglz-1-1-zorgverlener-02 | |||
| Verrichting | ||||
| Verrichting start datum | ||||
| Indicatie | ||||
| Probleem | bglz-1-1-probleem-06 | |||
| Verrichting type | Logopedie - individuele zitting afasie (code = '0000065289' in codeSystem 'DHD Verrichtingenthesaurus') | |||
| Locatie | ||||
| Zorgaanbieder | bglz-1-1-zorgaanbieder-01 | |||
| Uitvoerder | ||||
| Zorgverlener | bglz-1-1-zorgverlener-05 | |||
| Aanvrager | ||||
| Zorgverlener | bglz-1-1-zorgverlener-02 | |||
Verpleegkundig zorgplan
| Verpleegkundig zorgplan | ||||||
| Gegevenselement | Waarde | |||||
| Doelen en interventies | ||||||
| Verpleegkundige interventie | ||||||
| Interventie | ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED CT') | |||||
| Indicatie | ||||||
| Probleem | bglz-1-1-probleem-03 | |||||
| Behandeldoel | ||||||
| Behandeldoel | ||||||
| Gewenst zorgresultaat | wassen onafhankelijk | |||||
| Frequentie | 1 per dag | |||||
| Uitvoerder | ||||||
| Zorgverlener | ||||||
| Zorgverlener | bglz-1-1-zorgverlener-03 | |||||
| Verpleegkundige interventie | ||||||
| Interventie | ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED CT') | |||||
| Indicatie | ||||||
| Probleem | bglz-1-1-probleem-04 | |||||
| Behandeldoel | ||||||
| Behandeldoel | ||||||
| Gewenst zorgresultaat | kleden onafhankelijk | |||||
| Frequentie | 2 per dag | |||||
| Uitvoerder | ||||||
| Zorgverlener | ||||||
| Zorgverlener | bglz-1-1-zorgverlener-03 | |||||
| Verpleegkundige interventie | ||||||
| Interventie | patiënt mobiliseren (code = '62013009' in codeSystem 'SNOMED CT') | |||||
| Indicatie | ||||||
| Probleem | bglz-1-1-probleem-05 | |||||
| Behandeldoel | ||||||
| Behandeldoel | ||||||
| Gewenst zorgresultaat | lopen met hulp | |||||
| Uitvoerder | ||||||
| Zorgverlener | ||||||
| Zorgverlener | bglz-1-1-zorgverlener-03 | |||||
| Verpleegkundige interventie | ||||||
| Interventie | wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED CT') | |||||
| Indicatie | ||||||
| Probleem | bglz-1-1-probleem-07 | |||||
| Behandeldoel | ||||||
| Behandeldoel | ||||||
| Gewenst zorgresultaat | huid blijft intact | |||||
| Uitvoerder | ||||||
| Zorgverlener | ||||||
| Zorgverlener | bglz-1-1-zorgverlener-03 | |||||
| Verpleegkundige interventie | ||||||
| Interventie | ondersteuning voor verzorger (code = '386229000' in codeSystem 'SNOMED CT') | |||||
| Indicatie | ||||||
| Probleem | bglz-1-1-probleem-08 | |||||
| Behandeldoel | ||||||
| Behandeldoel | ||||||
| Gewenst zorgresultaat | zorgtaken voor echtgenoot worden gecontinueerd | |||||
| Uitvoerder | ||||||
| Zorgverlener | ||||||
| Zorgverlener | bglz-1-1-zorgverlener-03 | |||||
| Uitkomsten | ||||||
| Uitkomst van zorg | ||||||
| Zorgresultaat | Wassen met hulp. | |||||
| Interventie | ||||||
| Verpleegkundige interventie | bglz-1-1-verpleegkundigeinterventie-01 | |||||
| Uitkomst van zorg | ||||||
| Zorgresultaat | Kleden met hulp. | |||||
| Interventie | ||||||
| Verpleegkundige interventie | bglz-1-1-verpleegkundigeinterventie-02 | |||||
| Uitkomst van zorg | ||||||
| Zorgresultaat | Lopen geheel afhankelijk. | |||||
| Interventie | ||||||
| Verpleegkundige interventie | bglz-1-1-verpleegkundigeinterventie-03 | |||||
| Uitkomst van zorg | ||||||
| Zorgresultaat | Huid is intact zonder decubitus wonden. | |||||
| Interventie | ||||||
| Verpleegkundige interventie | bglz-1-1-verpleegkundigeinterventie-04 | |||||
| Uitkomst van zorg | ||||||
| Zorgresultaat | Thuiszorg is aangevraagd voor continuering van zorgtaken en huishoudelijke hulp. | |||||
| Interventie | ||||||
| Verpleegkundige interventie | bglz-1-1-verpleegkundigeinterventie-05 | |||||
Zorgsetting
| Zorgsetting | |||||||
| Gegevenselement | Waarde | ||||||
| Huisarts | |||||||
| Zorgverlener | |||||||
| Naamgegevens | |||||||
| Naamgegevens | |||||||
| Voornamen | Laura | ||||||
| Initialen | L. | ||||||
| Naamgebruik | Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||||
| Geslachtsnaam | |||||||
| Achternaam | Lanen | ||||||
| Geslachtsnaam partner | |||||||
| Voorvoegsels partner | van | ||||||
| Achternaam partner | Oosten | ||||||
| Specialisme | Huisarts (code = '01.015' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||||
| Zorgaanbieder | |||||||
| Zorgaanbieder | Huisartsenpraktijk | ||||||
| Zorgverleners rol | Verwijzer (code = 'REF' in codeSystem 'HL7 ParticipationType') | ||||||
| Hoofdbehandelaar | |||||||
| Zorgverlener | |||||||
| Naamgegevens | |||||||
| Naamgegevens | |||||||
| Voornamen | Niels | ||||||
| Initialen | N. | ||||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||||
| Geslachtsnaam | |||||||
| Achternaam | Helmond | ||||||
| Specialisme | Neuroloog (code = '01.026' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||||
| Zorgaanbieder | |||||||
| Zorgaanbieder | bglz-1-1-zorgaanbieder-01 | ||||||
| Zorgverleners rol | Hoofdbehandelaar (code = 'RESP' in codeSystem 'HL7 ParticipationType') | ||||||
| Overige behandelaars | |||||||
| Zorgverlener | |||||||
| Naamgegevens | |||||||
| Naamgegevens | |||||||
| Voornamen | Petra Johanna | ||||||
| Initialen | P.J. | ||||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||||
| Geslachtsnaam | |||||||
| Achternaam | Vreeswijk | ||||||
| Specialisme | Verpleegkundige (code = '30.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||||
| Zorgaanbieder | |||||||
| Zorgaanbieder | bglz-1-1-zorgaanbieder-01 | ||||||
| Zorgverlener | |||||||
| Naamgegevens | |||||||
| Naamgegevens | |||||||
| Voornamen | Thomas | ||||||
| Initialen | T. | ||||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||||
| Geslachtsnaam | |||||||
| Achternaam | Janssen | ||||||
| Specialisme | Fysiotherapeut (code = '04.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||||
| Zorgaanbieder | |||||||
| Zorgaanbieder | bglz-1-1-zorgaanbieder-01 | ||||||
| Zorgverlener | |||||||
| Naamgegevens | |||||||
| Naamgegevens | |||||||
| Voornamen | Hilda | ||||||
| Initialen | H. | ||||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||||
| Geslachtsnaam | |||||||
| Achternaam | Bruinsma | ||||||
| Specialisme | Logopedist (code = '91.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||||
| Zorgaanbieder | |||||||
| Zorgaanbieder | bglz-1-1-zorgaanbieder-01 | ||||||
| Zorgaanbieder | |||||||
| Organisatie naam | AA-zkh | ||||||
| Organisatie locatie | Noord | ||||||
| Afdeling specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT (Vektis Zorgverlenersspecificatie (subberoepsgroep))') | ||||||
| Contactgegevens | |||||||
| Contactgegevens | |||||||
| Telefoonnummers | |||||||
| Telefoonnummer | +31182435768 | ||||||
| Telecom type | Vast telefoonnummer (code = 'LL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.22.1') | ||||||
| Nummer soort | Zakelijk telefoonnummer (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||||
| Email adressen | |||||||
| Email adres | neurologie@AAZ.nl | ||||||
| Email soort | Zakelijk e-mailadres (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||||
| Adresgegevens | |||||||
| Adresgegevens | |||||||
| Straat | De Weststraat | ||||||
| Huisnummer | 3 | ||||||
| Postcode | 9999PK | ||||||
| Woonplaats | Stitswerd | ||||||
| Land | Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | ||||||
| Adres soort | Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||||
| Organisatie type | Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | ||||||
Demografie en identificatie
| Demografie en identificatie | ||||||
| Gegevenselement | Waarde | |||||
| Patient | ||||||
| Naamgegevens | ||||||
| Naamgegevens | ||||||
| Voornamen | Fiona | |||||
| Initialen | F. | |||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||||
| Geslachtsnaam | ||||||
| Achternaam | XXX_Mutter | |||||
| Adresgegevens | ||||||
| Adresgegevens | ||||||
| Straat | Knolweg | |||||
| Huisnummer | 1001 | |||||
| Postcode | 9999XX | |||||
| Woonplaats | Stitswerd | |||||
| Land | Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | |||||
| Adres soort | Postadres (code = 'PST' in codeSystem 'HL7 AddressUse') | |||||
| Contactgegevens | ||||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31634567891 | |||||
| Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | |||||
| Nummer soort | Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | |||||
| Email adressen | ||||||
| Email adres | fmutter@hotmail.com | |||||
| Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | |||||
| Identificatienummer | 999911673 (in identificerend systeem: 2.16.840.1.113883.2.4.6.3) | |||||
| Geboortedatum | ||||||
| Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |||||
| Meerling indicator | Nee | |||||
Behandelrestricties
| Behandelrestricties | ||||
| Gegevenselement | Waarde | |||
| Behandel aanwijzing | ||||
| Verificatie | ||||
| Geverifieerd | Ja | |||
| Geverifieerd bij | Patiënt (code = '116154003' in codeSystem 'SNOMED CT') | |||
| Verificatie datum | ||||
| Behandeling | Cardiopulmonaire resuscitatie (code = '89666000' in codeSystem 'SNOMED CT') | |||
| Behandeling toegestaan | Behandeling niet toegestaan en/of wenselijk (code = 'NEE' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4') | |||
| Begin datum | ||||
| Wilsverklaring | ||||
| Wilsverklaring | bglz-0-1-wilsverklaring-01 | |||
| Wilsverklaring | ||||
| Wilsverklaring type | Niet reanimeren verklaring (code = 'NR' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.14.1') | |||
| Wilsverklaring datum | ||||
Klachten en diagnoses
| Klachten en diagnoses | |||
| Gegevenselement | Waarde | ||
| Probleem | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | ischemisch cerebrovasculair accident (code = '422504002' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Toelichting | Niet bekend met neurologische klachten | ||
| Probleem | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | diabetes mellitus (code = '73211009' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | probleem met zichzelf wassen en afdrogen (code = '288552005' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | probleem met zichzelf kleden (code = '284972002' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | probleem met lopen (code = '228158008' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | afasie (code = '87486003' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | risico op decubitus (code = '285304000' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | overbelaste mantelzorg (code = '705044006' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Allergieen
| Allergieen | ||||
| Gegevenselement | Waarde | |||
| Allergie intolerantie | ||||
| Veroorzakende stof | pinda (code = '762952008' in codeSystem 'SNOMED CT') | |||
| Allergie status | Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||
| Mate van kritiek zijn | Fataal (code = '399166001' in codeSystem 'SNOMED CT') | |||
| Toelichting | Na het eten van pinda's als student ontstond er een klinisch beeld van anafylaxie waarop de HA epipen heeft moeten toedienen | |||
| Reactie | ||||
| Symptoom | Anafylaxie (code = '39579001' in codeSystem 'SNOMED CT') | |||
| Reactie | ||||
| Symptoom | Angio-oedeem (code = '41291007' in codeSystem 'SNOMED CT') | |||
| Reactie beschrijving | Angio-oedeem van de tong, lippen en peri-orbitale regio met acute benauwdheid na het eten van pinda's. | |||
| Allergie intolerantie | ||||
| Veroorzakende stof | nikkelsulfaat (code = '255848005' in codeSystem 'SNOMED CT') | |||
| Allergie status | Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||
| Mate van kritiek zijn | Matig (code = '6736007' in codeSystem 'SNOMED CT') | |||
| Toelichting | Opgemerkt bij het dragen van nikkel bevattende sieraden. | |||
| Reactie | ||||
| Symptoom | Contactdermatitis (code = '40275004' in codeSystem 'SNOMED CT') | |||
| Reactie beschrijving | Last van jeuk, roodheid en irritatie op de contactplek van nikkel bevattende sieraden. | |||
Uitslagen
| Uitslagen | ||||
| Gegevenselement | Waarde | |||
| Laboratorium uitslag | ||||
| Laboratorium test | ||||
| Test code | Hemoglobine (code = '718-7' in codeSystem 'LOINC') | |||
| Test datum tijd | 13 jan 2018 15:00 | |||
| Test uitslag | ||||
| Referentie bovengrens | ||||
| Referentie ondergrens | ||||
| Interpretatie vlaggen | Onder referentiewaarde (code = '281300000' in codeSystem 'SNOMED CT') | |||
| Laboratorium test | ||||
| Test code | Hematocriet (code = '20570-8' in codeSystem 'LOINC') | |||
| Test datum tijd | 13 jan 2018 15:00 | |||
| Test uitslag | ||||
| Referentie bovengrens | ||||
| Referentie ondergrens | ||||
| Onderzoek | hemoglobine & hematocriet panel (code = '24360-0' in codeSystem 'LOINC') | |||
| Laboratorium uitslag | ||||
| Laboratorium test | ||||
| Test code | glucose 2 uur na maaltijd massa/volume serum of plasma (code = '1521-4' in codeSystem 'LOINC') | |||
| Test datum tijd | 13 jan 2018 15:00 | |||
| Test uitslag | ||||
| Referentie bovengrens | ||||
| Referentie ondergrens | ||||
| Interpretatie vlaggen | Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
| Laboratorium uitslag | ||||
| Laboratorium test | ||||
| Test code | cholesterol in LDL massa/volume serum of plasma (code = '13457-7' in codeSystem 'LOINC') | |||
| Test datum tijd | 13 jan 2018 15:00 | |||
| Test uitslag | ||||
| Referentie bovengrens | ||||
| Interpretatie vlaggen | Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
| Toelichting | Volgens richtlijn herseninfarct: streven naar <1,8mmol/l | |||
Verrichtingen
| Verrichtingen | ||||
| Gegevenselement | Waarde | |||
| Verrichting | ||||
| Verrichting start datum | ||||
| Verrichting eind datum | ||||
| Indicatie | ||||
| Probleem | bglz-0-1-probleem-01 | |||
| Verrichting type | CT van hersenschedel (code = '0000075653' in codeSystem 'DHD Verrichtingenthesaurus') | |||
| Uitvoerder | ||||
| Zorgverlener | bglz-0-1-zorgverlener-02 | |||
| Aanvrager | ||||
| Zorgverlener | bglz-0-1-zorgverlener-02 | |||
| Verrichting | ||||
| Verrichting start datum | ||||
| Verrichting eind datum | ||||
| Indicatie | ||||
| Probleem | bglz-0-1-probleem-01 | |||
| Verrichting type | trombolyse van arteria cerebri anterior links (code = '0000088463' in codeSystem 'DHD Verrichtingenthesaurus') | |||
| Uitvoerder | ||||
| Zorgverlener | bglz-0-1-zorgverlener-02 | |||
| Aanvrager | ||||
| Zorgverlener | bglz-0-1-zorgverlener-02 | |||
| Verrichting | ||||
| Verrichting start datum | ||||
| Indicatie | ||||
| Probleem | bglz-0-1-probleem-05 | |||
| Verrichting type | Fysiotherapie - revalidatie (code = '0000064981' in codeSystem 'DHD Verrichtingenthesaurus') | |||
| Uitvoerder | ||||
| Zorgverlener | bglz-0-1-zorgverlener-04 | |||
| Aanvrager | ||||
| Zorgverlener | bglz-0-1-zorgverlener-02 | |||
| Verrichting | ||||
| Verrichting start datum | ||||
| Indicatie | ||||
| Probleem | bglz-0-1-probleem-06 | |||
| Verrichting type | Logopedie - individuele zitting afasie (code = '0000065289' in codeSystem 'DHD Verrichtingenthesaurus') | |||
| Uitvoerder | ||||
| Zorgverlener | bglz-0-1-zorgverlener-05 | |||
| Aanvrager | ||||
| Zorgverlener | bglz-0-1-zorgverlener-02 | |||
Zorgsetting
| Zorgsetting | |||||||
| Gegevenselement | Waarde | ||||||
| Huisarts | |||||||
| Zorgverlener | |||||||
| Naamgegevens | |||||||
| Naamgegevens | |||||||
| Voornamen | Laura | ||||||
| Initialen | L. | ||||||
| Naamgebruik | Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||||
| Geslachtsnaam | |||||||
| Achternaam | Lanen | ||||||
| Geslachtsnaam partner | |||||||
| Voorvoegsels partner | van | ||||||
| Achternaam partner | Oosten | ||||||
| Specialisme | Huisarts (code = '01.015' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||||
| Zorgaanbieder | |||||||
| Zorgaanbieder | Huisartsenpraktijk | ||||||
| Zorgverleners rol | Verwijzer (code = 'REF' in codeSystem 'HL7 ParticipationType') | ||||||
| Hoofdbehandelaar | |||||||
| Zorgverlener | |||||||
| Naamgegevens | |||||||
| Naamgegevens | |||||||
| Voornamen | Niels | ||||||
| Initialen | N. | ||||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||||
| Geslachtsnaam | |||||||
| Achternaam | Helmond | ||||||
| Specialisme | Neuroloog (code = '01.026' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||||
| Zorgverleners rol | Hoofdbehandelaar (code = 'RESP' in codeSystem 'HL7 ParticipationType') | ||||||
| Overige behandelaars | |||||||
| Zorgverlener | |||||||
| Naamgegevens | |||||||
| Naamgegevens | |||||||
| Voornamen | Petra Johanna | ||||||
| Initialen | P.J. | ||||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||||
| Geslachtsnaam | |||||||
| Achternaam | Vreeswijk | ||||||
| Specialisme | Verpleegkundige (code = '30.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||||
| Zorgverlener | |||||||
| Naamgegevens | |||||||
| Naamgegevens | |||||||
| Voornamen | Thomas | ||||||
| Initialen | T. | ||||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||||
| Geslachtsnaam | |||||||
| Achternaam | Janssen | ||||||
| Specialisme | Fysiotherapeut (code = '04.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||||
| Zorgverlener | |||||||
| Naamgegevens | |||||||
| Naamgegevens | |||||||
| Voornamen | Hilda | ||||||
| Initialen | H. | ||||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||||
| Geslachtsnaam | |||||||
| Achternaam | Bruinsma | ||||||
| Specialisme | Logopedist (code = '91.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||||
Demografie en identificatie
| Demografie en identificatie | ||||||
| Gegevenselement | Waarde | |||||
| Patient | ||||||
| Naamgegevens | ||||||
| Naamgegevens | ||||||
| Voornamen | Gea | |||||
| Initialen | G. | |||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||||
| Geslachtsnaam | ||||||
| Achternaam | XXX_Valk | |||||
| Adresgegevens | ||||||
| Adresgegevens | ||||||
| Straat | Knolweg | |||||
| Huisnummer | 1003 | |||||
| Postcode | 9999ZA | |||||
| Woonplaats | Stitswerd | |||||
| Land | Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | |||||
| Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||||
| Contactgegevens | ||||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31645678912 | |||||
| Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | |||||
| Nummer soort | Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | |||||
| Email adressen | ||||||
| Email adres | gvalk@hotmail.com | |||||
| Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | |||||
| Identificatienummer | 999911697 (in identificerend systeem: 2.16.840.1.113883.2.4.6.3) | |||||
| Geboortedatum | ||||||
| Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |||||
| Meerling indicator | Ja | |||||