BgZ:V1.2 AddendaInhoudelijkeGegevensBgZ2017: verschil tussen versies
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Regel 1.776: | Regel 1.776: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|SystolischeBloeddruk (SystolicBloodPressure) | |colspan="2"|SystolischeBloeddruk (SystolicBloodPressure) | ||
− | |style="background-color: white;"|130 mm[ | + | |style="background-color: white;"|130 mm[Hg] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|DiastolischeBloeddruk (DiastolicBloodPressure) | |colspan="2"|DiastolischeBloeddruk (DiastolicBloodPressure) | ||
− | |style="background-color: white;"|79 mm[ | + | |style="background-color: white;"|79 mm[Hg] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|BloeddrukDatumTijd (BloodPressureDateTime) | |colspan="2"|BloeddrukDatumTijd (BloodPressureDateTime) | ||
Regel 2.132: | Regel 2.132: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|SystolischeBloeddruk (SystolicBloodPressure) | |colspan="2"|SystolischeBloeddruk (SystolicBloodPressure) | ||
− | |style="background-color: white;"|120 mm[ | + | |style="background-color: white;"|120 mm[Hg] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|DiastolischeBloeddruk (DiastolicBloodPressure) | |colspan="2"|DiastolischeBloeddruk (DiastolicBloodPressure) | ||
− | |style="background-color: white;"|71 mm[ | + | |style="background-color: white;"|71 mm[Hg] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|BloeddrukDatumTijd (BloodPressureDateTime) | |colspan="2"|BloeddrukDatumTijd (BloodPressureDateTime) | ||
Regel 2.165: | Regel 2.165: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|SystolischeBloeddruk (SystolicBloodPressure) | |colspan="2"|SystolischeBloeddruk (SystolicBloodPressure) | ||
− | |style="background-color: white;"|140 mm[ | + | |style="background-color: white;"|140 mm[Hg] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|DiastolischeBloeddruk (DiastolicBloodPressure) | |colspan="2"|DiastolischeBloeddruk (DiastolicBloodPressure) | ||
− | |style="background-color: white;"|85 mm[ | + | |style="background-color: white;"|85 mm[Hg] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|BloeddrukDatumTijd (BloodPressureDateTime) | |colspan="2"|BloeddrukDatumTijd (BloodPressureDateTime) | ||
Regel 3.466: | Regel 3.466: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|SystolischeBloeddruk (SystolicBloodPressure) | |colspan="2"|SystolischeBloeddruk (SystolicBloodPressure) | ||
− | |style="background-color: white;"|150 mm[ | + | |style="background-color: white;"|150 mm[Hg] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|DiastolischeBloeddruk (DiastolicBloodPressure) | |colspan="2"|DiastolischeBloeddruk (DiastolicBloodPressure) | ||
− | |style="background-color: white;"|94 mm[ | + | |style="background-color: white;"|94 mm[Hg] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|BloeddrukDatumTijd (BloodPressureDateTime) | |colspan="2"|BloeddrukDatumTijd (BloodPressureDateTime) | ||
Regel 3.496: | Regel 3.496: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|SystolischeBloeddruk (SystolicBloodPressure) | |colspan="2"|SystolischeBloeddruk (SystolicBloodPressure) | ||
− | |style="background-color: white;"|130 mm[ | + | |style="background-color: white;"|130 mm[Hg] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|DiastolischeBloeddruk (DiastolicBloodPressure) | |colspan="2"|DiastolischeBloeddruk (DiastolicBloodPressure) | ||
− | |style="background-color: white;"|80 mm[ | + | |style="background-color: white;"|80 mm[Hg] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|BloeddrukDatumTijd (BloodPressureDateTime) | |colspan="2"|BloeddrukDatumTijd (BloodPressureDateTime) | ||
Regel 3.599: | Regel 3.599: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|SystolischeBloeddruk (SystolicBloodPressure) | |colspan="2"|SystolischeBloeddruk (SystolicBloodPressure) | ||
− | |style="background-color: white;"|120 mm[ | + | |style="background-color: white;"|120 mm[Hg] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|DiastolischeBloeddruk (DiastolicBloodPressure) | |colspan="2"|DiastolischeBloeddruk (DiastolicBloodPressure) | ||
− | |style="background-color: white;"|78 mm[ | + | |style="background-color: white;"|78 mm[Hg] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|BloeddrukDatumTijd (BloodPressureDateTime) | |colspan="2"|BloeddrukDatumTijd (BloodPressureDateTime) |
Versie van 9 dec 2022 07:26
1 Addenda voor inhoudelijke gegevens
Deze pagina bevat de gegevens voor de kwalificatiescenario's van de BgZ
2 Scenario 1: Patiënt A
2.1 Probleem (Problem) [bgz-patA-problem2]
Probleem (Problem) [bgz-patA-problem2] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999151 | |
ProbleemType (ProblemType) | Diagnosis (code = '282291009' in codeSystem 'SNOMED CT') | |
ProbleemNaam (ProblemName) | allergisch astma (code = '389145006' in codeSystem 'SNOMED CT') | |
ProbleemBeginDatum (ProblemStartDate) | 1999 | |
ProbleemEindDatum (ProblemEndDate) | 2000 | |
ProbleemStatus (ProblemStatus) | Inactive (code = '73425007' in codeSystem 'SNOMED CT') | |
VerificatieStatus (VerificationStatus) | Known absent (code = '410516002' in codeSystem 'SNOMED CT') | |
Toelichting (Comment) | Patiënt meende dat kortademigheid optrad als reactie op noten. |
2.2 Probleem (Problem) [bgz-patA-problem3]
Probleem (Problem) [bgz-patA-problem3] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999151 | |
ProbleemAnatomischeLocatie (ProblemAnatomicalLocation) | gehele long (code = '181216001' in codeSystem 'SNOMED CT') | |
ProbleemType (ProblemType) | Diagnosis (code = '282291009' in codeSystem 'SNOMED CT') | |
ProbleemNaam (ProblemName) | astma (code = '195967001' in codeSystem 'SNOMED CT') | |
ProbleemBeginDatum (ProblemStartDate) | 2000 | |
ProbleemStatus (ProblemStatus) | Active (code = '55561003' in codeSystem 'SNOMED CT') | |
VerificatieStatus (VerificationStatus) | Confirmed present (code = '410605003' in codeSystem 'SNOMED CT') | |
Toelichting (Comment) | Kortademig |
2.3 Probleem (Problem) [bgz-patA-problem4]
Probleem (Problem) [bgz-patA-problem4] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999151 | |
ProbleemAnatomischeLocatie (ProblemAnatomicalLocation) | geheel rechter uitwendig oor (code = '368567003' in codeSystem 'SNOMED CT') | |
ProbleemLateraliteit (ProblemLaterality) | Right (code = '24028007' in codeSystem 'SNOMED CT') | |
ProbleemType (ProblemType) | Functional Limitation (code = '248536006' in codeSystem 'SNOMED CT') | |
ProbleemNaam (ProblemName) | gehoorverlies (code = '15188001' in codeSystem 'SNOMED CT') | |
ProbleemBeginDatum (ProblemStartDate) | 8 maa 2012 | |
ProbleemStatus (ProblemStatus) | Active (code = '55561003' in codeSystem 'SNOMED CT') | |
VerificatieStatus (VerificationStatus) | Confirmed present (code = '410605003' in codeSystem 'SNOMED CT') | |
Toelichting (Comment) | Slechthorend door harde muziek |
2.4 Probleem (Problem) [bgz-patA-problem5]
Probleem (Problem) [bgz-patA-problem5] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999151 | |
ProbleemAnatomischeLocatie (ProblemAnatomicalLocation) | structuur van enkelgewricht (code = '70258002' in codeSystem 'SNOMED CT') | |
ProbleemLateraliteit (ProblemLaterality) | Left (code = '7771000' in codeSystem 'SNOMED CT') | |
ProbleemType (ProblemType) | Diagnosis (code = '282291009' in codeSystem 'SNOMED CT') | |
ProbleemNaam (ProblemName) | fractuur van enkel (code = '16114001' in codeSystem 'SNOMED CT') | |
ProbleemBeginDatum (ProblemStartDate) | T+1D | |
ProbleemStatus (ProblemStatus) | Active (code = '55561003' in codeSystem 'SNOMED CT') | |
VerificatieStatus (VerificationStatus) | Confirmed present (code = '410605003' in codeSystem 'SNOMED CT') | |
Toelichting (Comment) | Op een bal gaan staan tijdens het voetballen. |
2.5 Woonsituatie (LivingSituation) [bgz-patA-living]
Woonsituatie (LivingSituation) [bgz-patA-living] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999151 | |
Toelichting (Comment) | Geen lift | |
WoningType (HouseType) | Appartement of flatwoning (code = 'FLATW' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.13.1') |
2.6 DrugsGebruik (DrugUse) [bgz-patA-druguse]
DrugsGebruik (DrugUse) [bgz-patA-druguse] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999151 | ||
WaarnemingGebruik (ObservationOfUse) | |||
StartDatum (StartDate) | 1986 | ||
StopDatum (StopDate) | 1988 | ||
Hoeveelheid (Amount) | Eén keer per maand | ||
Toelichting (Comment) | Op feesten | ||
DrugsOfGeneesmiddelSoort (DrugOrMedicationType) | Methylenedioxymethamphetamine (substance) (code = '288459003' in codeSystem 'SNOMED CT') | ||
DrugsGebruikStatus (DrugUseStatus) | Misused drugs in past (finding) (code = '44870007' in codeSystem 'SNOMED CT') | ||
Toedieningsweg (RouteOfAdministration) | ORAAL (code = '9' in codeSystem 'G-Standaard TH007 Toedieningswegen') |
2.7 AlcoholGebruik (AlcoholUse) [bgz-patA-alcohol]
AlcoholGebruik (AlcoholUse) [bgz-patA-alcohol] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999151 | ||
Toelichting (Comment) | flesje bier | ||
AlcoholGebruikStatus (AlcoholUseStatus) | Current drinker of alcohol (finding) (code = '219006' in codeSystem 'SNOMED CT') | ||
WaarnemingGebruik (ObservationOfUse) | |||
StartDatum (StartDate) | 1984 | ||
Hoeveelheid (Amount) | 1 /d |
2.8 Contactpersoon (Contact) [bgz-patA-contactperson1]
Contactpersoon (Contact) [bgz-patA-contactperson1] | |||||
Gegevenselement | Waarde | ||||
referentie:Patient (reference:Patient) | 999999151 | ||||
Naamgegevens (NameInformation) | |||||
referentie:Naamgegevens (reference:NameInformation) | |||||
Voornamen (FirstNames) | Dirk | ||||
Initialen (Initials) | D. | ||||
Roepnaam (GivenName) | Dirk | ||||
Geslachtsnaam (LastName) | |||||
Achternaam (LastName) | Janse | ||||
Contactgegevens (ContactInformation) | |||||
referentie:Contactgegevens (reference:ContactInformation) | |||||
Telefoonnummers (TelephoneNumbers) | |||||
Telefoonnummer (TelephoneNumber) | +316-22668899 | ||||
TelecomType (TelecomType) | Mobile Phone (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
NummerSoort (NumberType) | Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
EmailAdressen (EmailAddresses) | |||||
EmailAdres (EmailAddress) | dirk.janse@test.nl | ||||
EmailSoort (EmailAddressType) | Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Adresgegevens (AddressInformation) | |||||
referentie:Adresgegevens (reference:AddressInformation) | |||||
Straat (Street) | Huweelstraat | ||||
Huisnummer (HouseNumber) | 15 | ||||
AanduidingBijNummer (HouseNumberIndication) | Tegenover (code = 'to' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.3') | ||||
Postcode (Postcode) | 1248 CC | ||||
Woonplaats (PlaceOfResidence) | Barendrecht | ||||
Land (Country) | Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2') | ||||
AdresSoort (AddressType) | Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Rol (Role) | Eerste relatie/contactpersoon (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472') | ||||
Relatie (Relationship) | Son (code = 'SONC' in codeSystem 'HL7 RoleCode') |
2.9 BurgerlijkeStaatRC (MaritalStatusRC) [bgz-patA-marital]
BurgerlijkeStaatRC (MaritalStatusRC) [bgz-patA-marital] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999151 | |
BurgerlijkeStaat (MaritalStatus) | Married (code = 'M' in codeSystem '2.16.840.1.113883.5.2') |
2.10 Contactpersoon (Contact) [bgz-patA-contactperson2]
Contactpersoon (Contact) [bgz-patA-contactperson2] | |||||
Gegevenselement | Waarde | ||||
referentie:Patient (reference:Patient) | 999999151 | ||||
Naamgegevens (NameInformation) | |||||
referentie:Naamgegevens (reference:NameInformation) | |||||
Voornamen (FirstNames) | Els | ||||
Initialen (Initials) | E. | ||||
Roepnaam (GivenName) | Els | ||||
Naamgebruik (NameUsage) | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam (LastName) | |||||
Voorvoegsels (Prefix) | de | ||||
Achternaam (LastName) | Groot | ||||
Contactgegevens (ContactInformation) | |||||
referentie:Contactgegevens (reference:ContactInformation) | |||||
Telefoonnummers (TelephoneNumbers) | |||||
Telefoonnummer (TelephoneNumber) | 06-12345678 | ||||
TelecomType (TelecomType) | Mobile Phone (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
NummerSoort (NumberType) | Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
EmailAdressen (EmailAddresses) | |||||
EmailAdres (EmailAddress) | Els.degroot@test.nl | ||||
EmailSoort (EmailAddressType) | Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Adresgegevens (AddressInformation) | |||||
referentie:Adresgegevens (reference:AddressInformation) | |||||
Straat (Street) | Gaaspelwede | ||||
Huisnummer (HouseNumber) | 16 | ||||
Postcode (Postcode) | 1247 BB | ||||
Woonplaats (PlaceOfResidence) | Hellevoetsluis | ||||
Land (Country) | Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2') | ||||
AdresSoort (AddressType) | Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Rol (Role) | Anders (code = '9' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472') | ||||
Relatie (Relationship) | Daughter in-law (code = 'DAUINLAW' in codeSystem 'HL7 RoleCode') |
2.11 Wilsverklaring (AdvanceDirective) [bgz-patA-advdir]
Wilsverklaring (AdvanceDirective) [bgz-patA-advdir] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999151 | ||
WilsverklaringType (LivingWillType) | Levenswensverklaring (code = 'LW' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.14.1') | ||
WilsverklaringDatum (LivingWillDate) | 16 sep 2012 | ||
Aandoening (Disorder) | |||
referentie:Probleem (reference:Problem) | zib-2017-bgz-patA-problem3 | ||
Vertegenwoordiger (Representative) | |||
referentie:Contactpersoon (reference:Contact) | zib-2017-bgz-patA-contactperson1 | ||
WilsverklaringDocument (LivingWillDocument) | ZHVtbXktd2lsc3ZlcmtsYXJpbmcgRGVubmlzIEphbnNlLnBkZg== | ||
Toelichting (Comment) | gescand document |
2.12 BehandelAanwijzing (TreatmentDirective) [bgz-patA-treatmentdir]
BehandelAanwijzing (TreatmentDirective) [bgz-patA-treatmentdir] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999151 | ||
Verificatie (Verification) | |||
Geverifieerd (Verified) | Ja | ||
GeverifieerdBij (VerifiedWith) | Patient (code = '116154003' in codeSystem 'SNOMED CT') | ||
VerificatieDatum (VerificationDate) | T+1D | ||
Behandeling (Treatment) | Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): MRI | ||
BehandelingToegestaan (TreatmentPermitted) | Ja, maar met beperkingen (code = 'JA_MAAR' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4') | ||
Beperkingen (Restrictions) | eerst overleg met de partner | ||
Toelichting (Comment) | voor behandeling "MRI"; beperking geldt tot aan ontslag uit het ziekenhuis | ||
Wilsverklaring (AdvanceDirective) | |||
referentie:Wilsverklaring (reference:AdvanceDirective) | zib-2017-bgz-patA-advdir |
2.13 FunctioneleOfMentaleStatus (FunctionalOrMentalStatus) [bgz-patA-funcment2]
FunctioneleOfMentaleStatus (FunctionalOrMentalStatus) [bgz-patA-funcment2] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999151 | |
StatusNaam (StatusName) | vermogen om zich te mobiliseren (code = '301438001' in codeSystem 'SNOMED CT') | |
StatusWaarde (StatusValue) | ernstig (code = '24484000' in codeSystem '2.16.840.1.113883.6.96 (ordinal = ) | |
StatusDatum (StatusDate) | T+1D | |
Toelichting (Comment) | Mag nog niet op loopgips steunen |
2.14 Alert (Alert) [bgz-patA-alert1]
Alert (Alert) [bgz-patA-alert1] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999151 | |
AlertNaam (AlertName) | Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): agressieve patiënt | |
BeginDatumTijd (StartDateTime) | 2016 | |
AlertType (AlertType) | alert (code = '74018-3' in codeSystem 'LOINC') |
2.15 Alert (Alert) [bgz-patA-alert2]
Alert (Alert) [bgz-patA-alert2] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999151 | |
AlertNaam (AlertName) | Methicillin resistant staphylococcus aureus carrier (code = '432415000' in codeSystem 'SNOMED CT') | |
AlertType (AlertType) | alert (code = '74018-3' in codeSystem 'LOINC') |
2.16 Verrichting (Procedure) [bgz-patA-procedure1]
Verrichting (Procedure) [bgz-patA-procedure1] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999151 | ||
VerrichtingStartDatum (ProcedureStartDate) | T+1D{14:00} | ||
VerrichtingEindDatum (ProcedureEndDate) | T+1D{15:00} | ||
VerrichtingAnatomischeLocatie (ProcedureAnatomicalLocation) | structuur van enkelgewricht (code = '70258002' in codeSystem 'SNOMED CT') | ||
VerrichtingLateraliteit (ProcedureLaterality) | Left (code = '7771000' in codeSystem 'SNOMED CT') | ||
Indicatie (Indication) | |||
referentie:Probleem (reference:Problem) | zib-2017-bgz-patA-problem5 | ||
VerrichtingType (ProcedureType) | externe fixatie van fractuur van malleolus (code = '111501000146106' in codeSystem 'SNOMED CT') | ||
Locatie (Location) | |||
referentie:Zorgaanbieder (reference:HealthcareProvider) | naam eigen ziekenhuis | ||
Uitvoerder (Performer) | |||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patA-healthProf2 | ||
Aanvrager (Requester) | |||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patA-healthProf3 |
2.17 Verrichting (Procedure) [bgz-patA-procedure2]
Verrichting (Procedure) [bgz-patA-procedure2] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999151 | ||
VerrichtingStartDatum (ProcedureStartDate) | T+2D{09:30} | ||
VerrichtingAnatomischeLocatie (ProcedureAnatomicalLocation) | structuur van enkelgewricht (code = '70258002' in codeSystem 'SNOMED CT') | ||
VerrichtingLateraliteit (ProcedureLaterality) | Left (code = '7771000' in codeSystem 'SNOMED CT') | ||
Indicatie (Indication) | |||
referentie:Probleem (reference:Problem) | zib-2017-bgz-patA-problem5 | ||
VerrichtingType (ProcedureType) | aanleggen van loopgips voor onderbeen (code = '122531000146102' in codeSystem 'SNOMED CT') | ||
Locatie (Location) | |||
referentie:Zorgaanbieder (reference:HealthcareProvider) | naam eigen ziekenhuis | ||
Aanvrager (Requester) | |||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patA-healthProf2 |
2.18 Contact (Encounter) [bgz-patA-encounter1]
Contact (Encounter) [bgz-patA-encounter1] | ||||
Gegevenselement | Waarde | |||
referentie:Patient (reference:Patient) | 999999151 | |||
ContactType (ContactType) | Emergency (code = 'EMER' in codeSystem 'HL7 ActCode') | |||
ContactMet (ContactWith) | ||||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patA-healthProf2 | |||
Locatie (Location) | ||||
referentie:Zorgaanbieder (reference:HealthcareProvider) | naam eigen ziekenhuis | |||
BeginDatumTijd (StartDateTime) | T+1D{11:00} | |||
EindDatumTijd (EndDateTime) | T+1D{13:30} | |||
RedenContact (ContactReason) | ||||
Probleem (Problem) | ||||
referentie:Probleem (reference:Problem) | zib-2017-bgz-patA-problem5 | |||
Herkomst (Origin) | Home (code = '264362003' in codeSystem 'SNOMED CT') |
2.19 Contact (Encounter) [bgz-patA-encounter2]
Contact (Encounter) [bgz-patA-encounter2] | ||||
Gegevenselement | Waarde | |||
referentie:Patient (reference:Patient) | 999999151 | |||
ContactType (ContactType) | Inpatient (code = 'IMP' in codeSystem 'HL7 ActCode') | |||
ContactMet (ContactWith) | ||||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patA-healthProf3 | |||
Locatie (Location) | ||||
referentie:Zorgaanbieder (reference:HealthcareProvider) | naam eigen ziekenhuis | |||
BeginDatumTijd (StartDateTime) | T+1D{13:30} | |||
EindDatumTijd (EndDateTime) | T+2D{12:00} | |||
RedenContact (ContactReason) | ||||
Verrichting (Procedure) | ||||
referentie:Verrichting (reference:Procedure) | zib-2017-bgz-patA-procedure1 | |||
Bestemming (Destination) | Rehabilitation hospital (code = '80522000' in codeSystem 'SNOMED CT') |
2.20 Contact (Encounter) [bgz-patA-encounter3]
Contact (Encounter) [bgz-patA-encounter3] | ||||
Gegevenselement | Waarde | |||
referentie:Patient (reference:Patient) | 999999151 | |||
ContactType (ContactType) | Ambulatory (code = 'AMB' in codeSystem 'HL7 ActCode') | |||
ContactMet (ContactWith) | ||||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patA-healthProf2 | |||
Locatie (Location) | ||||
referentie:Zorgaanbieder (reference:HealthcareProvider) | naam eigen ziekenhuis | |||
BeginDatumTijd (StartDateTime) | T+44D{09:00} | |||
RedenContact (ContactReason) | ||||
Verrichting (Procedure) | ||||
referentie:Verrichting (reference:Procedure) | zib-2017-bgz-patA-procedure1 |
2.21 Zorgverlener (HealthProfessional) [bgz-patA-healthProf2]
Zorgverlener (HealthProfessional) [bgz-patA-healthProf2] | |||||
Gegevenselement | Waarde | ||||
referentie:Patient (reference:Patient) | 999999151 | ||||
ZorgverlenerIdentificatienummer (HealthProfessionalIdentificationNumber) | 45678912 (in identificerend systeem: AGB-Z) | ||||
Naamgegevens (NameInformation) | |||||
referentie:Naamgegevens (reference:NameInformation) | |||||
Voornamen (FirstNames) | Jeroen Hendrik Robert | ||||
Initialen (Initials) | J.H.R. | ||||
Roepnaam (GivenName) | Jeroen | ||||
Naamgebruik (NameUsage) | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam (LastName) | |||||
Achternaam (LastName) | Peters | ||||
Specialisme (Specialty) | Orthopedisch chirurg (code = '01.032' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||
Adresgegevens (AddressInformation) | |||||
referentie:Adresgegevens (reference:AddressInformation) | |||||
Straat (Street) | Dr. Molewaterplein | ||||
Huisnummer (HouseNumber) | 40 | ||||
Postcode (Postcode) | 3015 GD | ||||
Woonplaats (PlaceOfResidence) | Rotterdam | ||||
Gemeente (Municipality) | Rotterdam | ||||
Land (Country) | Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2') | ||||
AdresSoort (AddressType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
Contactgegevens (ContactInformation) | |||||
referentie:Contactgegevens (reference:ContactInformation) | |||||
Telefoonnummers (TelephoneNumbers) | |||||
Telefoonnummer (TelephoneNumber) | 06-23412345 | ||||
TelecomType (TelecomType) | Mobile Phone (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
NummerSoort (NumberType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
EmailAdressen (EmailAddresses) | |||||
EmailAdres (EmailAddress) | j.peters@hospital.nl | ||||
EmailSoort (EmailAddressType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
Zorgaanbieder (HealthcareProvider) | |||||
referentie:Zorgaanbieder (reference:HealthcareProvider) | naam eigen ziekenhuis | ||||
ZorgverlenersRol (HealthProfessionalRole) | Responsible Party (code = 'RESP' in codeSystem 'HL7 ParticipationType') |
2.22 LaboratoriumUitslag (LaboratoryTestResult) [bgz-patA-labresult2]
LaboratoriumUitslag (LaboratoryTestResult) [bgz-patA-labresult2] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999151 | ||
LaboratoriumTest (LaboratoryTest) | |||
TestCode (TestCode) | Hemoglobine A1c [massa/volume] in bloed (code = '41995-2' in codeSystem 'LOINC') | ||
TestDatumTijd (TestDateTime) | T+2D{09:00} | ||
TestUitslag (TestResult) | 8.9 mmol/L | ||
TestUitslagStatus (TestResultStatus) | Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1') | ||
ReferentieBovengrens (ReferenceRangeUpperLimit) | 9.9 mmol/L | ||
ReferentieOndergrens (ReferenceRangeLowerLimit) | 7.4 mmol/L | ||
Monster (Specimen) | |||
Monsternummer (SpecimenId) | 9877 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.25.4267.4) | ||
Monstervolgnummer (SpecimenNumberExtension) | 2 | ||
Containertype (ContainerType) | container voor bloed- of weefselopslag of -kweek (code = '700957004' in codeSystem 'SNOMED CT') | ||
Monstermateriaal (SpecimenMaterial) | bloed (code = '87612001' in codeSystem 'SNOMED CT') | ||
AfnameDatumTijd (CollectionDateTime) | T+2D{08:00} | ||
AnatomischeLocatie (AnatomicalLocation) | gehele regio cubiti (code = '76248009' in codeSystem 'SNOMED CT') | ||
Lateraliteit (Laterality) | Right (code = '24028007' in codeSystem 'SNOMED CT') | ||
ResultaatType (ResultType) | Chemistry (code = '275711006' in codeSystem 'SNOMED CT') |
2.23 LaboratoriumUitslag (LaboratoryTestResult) [bgz-patA-labresult1]
LaboratoriumUitslag (LaboratoryTestResult) [bgz-patA-labresult1] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999151 | ||
LaboratoriumTest (LaboratoryTest) | |||
TestCode (TestCode) | Hemoglobine A1c [massa/volume] in bloed (code = '41995-2' in codeSystem 'LOINC') | ||
TestDatumTijd (TestDateTime) | T+1D{13:00} | ||
TestUitslag (TestResult) | 8.1 mmol/L | ||
TestUitslagStatus (TestResultStatus) | Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1') | ||
ReferentieBovengrens (ReferenceRangeUpperLimit) | 9.9 mmol/L | ||
ReferentieOndergrens (ReferenceRangeLowerLimit) | 7.4 mmol/L | ||
LaboratoriumTest (LaboratoryTest) | |||
TestCode (TestCode) | Hematocriet [volumefractie] in bloed (code = '20570-8' in codeSystem 'LOINC') | ||
TestDatumTijd (TestDateTime) | T+1D{13:00} | ||
TestUitslag (TestResult) | 0.39 L/L | ||
TestUitslagStatus (TestResultStatus) | Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1') | ||
ReferentieBovengrens (ReferenceRangeUpperLimit) | 0.46 L/L | ||
ReferentieOndergrens (ReferenceRangeLowerLimit) | 0.36 L/L | ||
LaboratoriumTest (LaboratoryTest) | |||
TestCode (TestCode) | Leukocyten [aantal/volume] in bloed (code = '26464-8' in codeSystem 'LOINC') | ||
TestDatumTijd (TestDateTime) | T+1D{13:00} | ||
TestUitslag (TestResult) | 6.6E+9 /L | ||
TestUitslagStatus (TestResultStatus) | Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1') | ||
ReferentieBovengrens (ReferenceRangeUpperLimit) | 11.0E+9 /L | ||
ReferentieOndergrens (ReferenceRangeLowerLimit) | 4.0E+9 /L | ||
Monster (Specimen) | |||
Monsternummer (SpecimenId) | 9876 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.25.4267.4) | ||
Monstervolgnummer (SpecimenNumberExtension) | 2 | ||
Containertype (ContainerType) | container voor bloed- of weefselopslag of -kweek (code = '700957004' in codeSystem 'SNOMED CT') | ||
Monstermateriaal (SpecimenMaterial) | bloed (code = '87612001' in codeSystem 'SNOMED CT') | ||
AfnameDatumTijd (CollectionDateTime) | T+1D{12:00} | ||
AnatomischeLocatie (AnatomicalLocation) | gehele regio cubiti (code = '76248009' in codeSystem 'SNOMED CT') | ||
Lateraliteit (Laterality) | Left (code = '7771000' in codeSystem 'SNOMED CT') | ||
Onderzoek (PanelOrBattery) | Compleet bloedbeeld panel in bloed d.m.v. geautomatiseerde telling (code = '58410-2' in codeSystem 'LOINC') | ||
ResultaatStatus (ResultStatus) | Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1') | ||
ResultaatType (ResultType) | Chemistry (code = '275711006' in codeSystem 'SNOMED CT') | ||
Aanvrager (Requester) | |||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patA-healthProf3 |
2.24 Vaccinatie (Vaccination) [bgz-patA-vaccin1]
Vaccinatie (Vaccination) [bgz-patA-vaccin1] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999151 | ||
ProductCode (ProductCode) | Tetanusvaccin (code = 'J07AM01' in codeSystem '2.16.840.1.113883.6.73') | ||
Dosis (Dose) | 2 mL | ||
VaccinatieDatum (VaccinationDate) | 3 apr 2019 | ||
GewensteDatumHervaccinatie (PreferedDateForRevaccination) | 3 apr 2020 | ||
Toediener (Administrator) | |||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patA-healthProf1 | ||
Toelichting (Comment) | Gebeten door een hond |
2.25 Zorgverlener (HealthProfessional) [bgz-patA-healthProf3]
Zorgverlener (HealthProfessional) [bgz-patA-healthProf3] | |||||
Gegevenselement | Waarde | ||||
referentie:Patient (reference:Patient) | 999999151 | ||||
ZorgverlenerIdentificatienummer (HealthProfessionalIdentificationNumber) | 12345678 (in identificerend systeem: AGB-Z) | ||||
Naamgegevens (NameInformation) | |||||
referentie:Naamgegevens (reference:NameInformation) | |||||
Voornamen (FirstNames) | Alfred Bart | ||||
Initialen (Initials) | A.B. | ||||
Roepnaam (GivenName) | Alfred | ||||
Naamgebruik (NameUsage) | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam (LastName) | |||||
Achternaam (LastName) | Bakker | ||||
Specialisme (Specialty) | Spoedeisende hulp arts (code = '01.071' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||
Adresgegevens (AddressInformation) | |||||
referentie:Adresgegevens (reference:AddressInformation) | |||||
Straat (Street) | Dr. Molewaterplein | ||||
Huisnummer (HouseNumber) | 40 | ||||
Postcode (Postcode) | 3015 GD | ||||
Woonplaats (PlaceOfResidence) | Rotterdam | ||||
Gemeente (Municipality) | Rotterdam | ||||
Land (Country) | Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2') | ||||
AdresSoort (AddressType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
Contactgegevens (ContactInformation) | |||||
referentie:Contactgegevens (reference:ContactInformation) | |||||
Telefoonnummers (TelephoneNumbers) | |||||
Telefoonnummer (TelephoneNumber) | 06-33334444 | ||||
TelecomType (TelecomType) | Mobile Phone (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
NummerSoort (NumberType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
EmailAdressen (EmailAddresses) | |||||
EmailAdres (EmailAddress) | a.b.bakker@hospital.nl | ||||
EmailSoort (EmailAddressType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
Zorgaanbieder (HealthcareProvider) | |||||
referentie:Zorgaanbieder (reference:HealthcareProvider) | naam eigen ziekenhuis | ||||
ZorgverlenersRol (HealthProfessionalRole) | Attender (code = 'ATND' in codeSystem 'HL7 ParticipationType') |
2.26 FunctioneleOfMentaleStatus (FunctionalOrMentalStatus) [bgz-patA-funcment1]
FunctioneleOfMentaleStatus (FunctionalOrMentalStatus) [bgz-patA-funcment1] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999151 | ||
StatusNaam (StatusName) | gehoorverlies (code = '15188001' in codeSystem 'SNOMED CT') | ||
StatusWaarde (StatusValue) | licht (code = '255604002' in codeSystem '2.16.840.1.113883.6.96 (ordinal = ) | ||
StatusDatum (StatusDate) | 1 feb 2012 | ||
Toelichting (Comment) | Licht beperkend | ||
Hulpmiddel (MedicalDevice) | |||
referentie:MedischHulpmiddel (reference:MedicalDevice) | zib-2017-bgz-patA-medDevice1 |
2.27 Zorgverlener (HealthProfessional) [bgz-patA-healthProf1]
Zorgverlener (HealthProfessional) [bgz-patA-healthProf1] | |||||
Gegevenselement | Waarde | ||||
referentie:Patient (reference:Patient) | 999999151 | ||||
ZorgverlenerIdentificatienummer (HealthProfessionalIdentificationNumber) | 88776655 (in identificerend systeem: AGB-Z) | ||||
Naamgegevens (NameInformation) | |||||
referentie:Naamgegevens (reference:NameInformation) | |||||
Voornamen (FirstNames) | Ria Alexandra | ||||
Initialen (Initials) | R.A. | ||||
Roepnaam (GivenName) | Ria | ||||
Naamgebruik (NameUsage) | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam (LastName) | |||||
Achternaam (LastName) | Slot | ||||
Specialisme (Specialty) | Huisarts (code = '01.015' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||
Adresgegevens (AddressInformation) | |||||
referentie:Adresgegevens (reference:AddressInformation) | |||||
Straat (Street) | Talmastraat | ||||
Huisnummer (HouseNumber) | 84 | ||||
Huisnummerletter (HouseNumberLetter) | B | ||||
Postcode (Postcode) | 3071 AS | ||||
Woonplaats (PlaceOfResidence) | Rotterdam | ||||
Gemeente (Municipality) | Rotterdam | ||||
Land (Country) | Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2') | ||||
AdresSoort (AddressType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
Contactgegevens (ContactInformation) | |||||
referentie:Contactgegevens (reference:ContactInformation) | |||||
Telefoonnummers (TelephoneNumbers) | |||||
Telefoonnummer (TelephoneNumber) | 06-12345767 | ||||
TelecomType (TelecomType) | Mobile Phone (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
NummerSoort (NumberType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
EmailAdressen (EmailAddresses) | |||||
EmailAdres (EmailAddress) | r.a.slot@huisarts.nl | ||||
EmailSoort (EmailAddressType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
Zorgaanbieder (HealthcareProvider) | |||||
referentie:Zorgaanbieder (reference:HealthcareProvider) | Huisartsenpraktijk Rotterdam |
2.28 TabakGebruik (TobaccoUse) [bgz-patA-tobacco]
TabakGebruik (TobaccoUse) [bgz-patA-tobacco] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999151 | ||
Toelichting (Comment) | Havana | ||
SoortTabakGebruik (TypeOfTobaccoUsed) | Cigar smoker (finding) (code = '59978006' in codeSystem 'SNOMED CT') | ||
TabakGebruikStatus (TobaccoUseStatus) | Occasional cigarette smoker (finding) (code = '230059006' in codeSystem 'SNOMED CT') | ||
WaarnemingGebruik (ObservationOfUse) | |||
StartDatum (StartDate) | 2001 | ||
Hoeveelheid (Amount) | 1 {cigars}/wk | ||
PackYears (PackYears) | 6 |
2.29 MedischHulpmiddel (MedicalDevice) [bgz-patA-medDevice1]
MedischHulpmiddel (MedicalDevice) [bgz-patA-medDevice1] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999151 | ||
Product (Product) | |||
ProductID (ProductID) | 9321502032612 (code = '9321502032612' in codeSystem '1.3.160') | ||
ProductType (ProductType) | hoorapparaat (code = '360283003' in codeSystem 'SNOMED CT') | ||
ProductOmschrijving (ProductDescription) | Gehoorapparaat | ||
BeginDatum (StartDate) | 8 maa 2012 | ||
Indicatie (Indication) | |||
referentie:Probleem (reference:Problem) | zib-2017-bgz-patA-problem4 | ||
Toelichting (Comment) | Apparaat niet zichtbaar | ||
AnatomischeLocatie (AnatomicalLocation) | geheel rechter uitwendig oor (code = '368567003' in codeSystem 'SNOMED CT') | ||
Lateraliteit (Laterality) | Right (code = '24028007' in codeSystem 'SNOMED CT') | ||
Locatie (Location) | |||
referentie:Zorgaanbieder (reference:HealthcareProvider) | Huisartsenpraktijk Rotterdam | ||
Zorgverlener (HealthProfessional) | |||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patA-healthProf1 |
2.30 MedischHulpmiddel (MedicalDevice) [bgz-patA-medDevice2]
MedischHulpmiddel (MedicalDevice) [bgz-patA-medDevice2] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999151 | ||
Product (Product) | |||
ProductID (ProductID) | 5055785706734 (code = '5055785706734' in codeSystem '1.3.160') | ||
ProductType (ProductType) | rolstoel (code = '58938008' in codeSystem 'SNOMED CT') | ||
ProductOmschrijving (ProductDescription) | Niet-gemotoriseerde rolstoel | ||
BeginDatum (StartDate) | T+2D | ||
Indicatie (Indication) | |||
referentie:Probleem (reference:Problem) | zib-2017-bgz-patA-problem5 | ||
Locatie (Location) | |||
referentie:Zorgaanbieder (reference:HealthcareProvider) | naam eigen ziekenhuis | ||
Zorgverlener (HealthProfessional) | |||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patA-healthProf2 |
2.31 Vaccinatie (Vaccination) [bgz-patA-vaccin2]
Vaccinatie (Vaccination) [bgz-patA-vaccin2] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999151 | ||
ProductCode (ProductCode) | Hepatitis A+B-vaccin (code = 'J07BC20' in codeSystem '2.16.840.1.113883.6.73') | ||
Dosis (Dose) | 1 mL | ||
VaccinatieDatum (VaccinationDate) | 2 maa 2015 | ||
GewensteDatumHervaccinatie (PreferedDateForRevaccination) | 2 apr 2015 | ||
Toediener (Administrator) | |||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patA-healthProf1 | ||
Toelichting (Comment) | Reis door Indonesië |
2.32 AllergieIntolerantie (AllergyIntolerance) [bgz-patA-allergy1]
AllergieIntolerantie (AllergyIntolerance) [bgz-patA-allergy1] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999151 | ||
VeroorzakendeStof (CausativeAgent) | noten (code = '294904000' in codeSystem 'SNOMED CT') | ||
AllergieCategorie (AllergyCategory) | Propensity to adverse reactions to food (code = '418471000' in codeSystem 'SNOMED CT') | ||
AllergieStatus (AllergyStatus) | Active (code = 'active' in codeSystem 'HL7 ActStatus') | ||
BeginDatumTijd (StartDateTime) | 29 mei 1976 | ||
MateVanKritiekZijn (Criticality) | Severe (code = '24484000' in codeSystem 'SNOMED CT') | ||
LaatsteReactieDatumTijd (LastReactionDateTime) | 18 aug 2012 | ||
Toelichting (Comment) | Niet allergisch voor cashewnoten | ||
Reactie (Reaction) | |||
Symptoom (Symptom) | Anaphylaxis (code = '39579001' in codeSystem 'SNOMED CT') | ||
SpecifiekeStof (SpecificSubstance) | pecannoot (code = '260189007' in codeSystem 'SNOMED CT') | ||
ReactieBeschrijving (ReactionDescription) | Bewusteloos wegens wegvallen bloeddruk. | ||
Ernst (Severity) | Severe (code = '24484000' in codeSystem 'SNOMED CT') | ||
WijzeVanBlootstelling (RouteOfExposure) | oraal (code = '738956005' in codeSystem 'SNOMED CT') | ||
ReactieTijdstip (ReactionTime) | 18 aug 2012 |
2.33 AllergieIntolerantie (AllergyIntolerance) [bgz-patA-allergy2]
AllergieIntolerantie (AllergyIntolerance) [bgz-patA-allergy2] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999151 | ||
VeroorzakendeStof (CausativeAgent) | penicillines (code = '035' in codeSystem 'G-Standaard TH122 Ongewenste groepen') | ||
AllergieCategorie (AllergyCategory) | Propensity to adverse reactions to drug (code = '419511003' in codeSystem 'SNOMED CT') | ||
AllergieStatus (AllergyStatus) | Active (code = 'active' in codeSystem 'HL7 ActStatus') | ||
BeginDatumTijd (StartDateTime) | 2009 | ||
MateVanKritiekZijn (Criticality) | Mild (code = '255604002' in codeSystem 'SNOMED CT') | ||
LaatsteReactieDatumTijd (LastReactionDateTime) | 2011 | ||
Toelichting (Comment) | Alleen voor amoxicilline | ||
Reactie (Reaction) | |||
Symptoom (Symptom) | Nausea and vomiting (code = '16932000' in codeSystem 'SNOMED CT') | ||
SpecifiekeStof (SpecificSubstance) | Amoxicilline (code = '023167' in codeSystem 'G-Standaard SNK') | ||
Ernst (Severity) | Mild (code = '255604002' in codeSystem 'SNOMED CT') | ||
WijzeVanBlootstelling (RouteOfExposure) | oraal (code = '738956005' in codeSystem 'SNOMED CT') |
2.34 AllergieIntolerantie (AllergyIntolerance) [bgz-patA-allergy3]
AllergieIntolerantie (AllergyIntolerance) [bgz-patA-allergy3] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | BSN 999999151 | ||
VeroorzakendeStof (CausativeAgent) | latex (code = '111088007' in codeSystem 'SNOMED CT') | ||
AllergieCategorie (AllergyCategory) | Allergy to substance (code = '419199007' in codeSystem 'SNOMED CT') | ||
AllergieStatus (AllergyStatus) | Completed (code = 'completed' in codeSystem 'HL7 ActStatus') | ||
BeginDatumTijd (StartDateTime) | 2006 | ||
MateVanKritiekZijn (Criticality) | Moderate (code = '6736007' in codeSystem 'SNOMED CT') | ||
LaatsteReactieDatumTijd (LastReactionDateTime) | 2012 | ||
Reactie (Reaction) | |||
Symptoom (Symptom) | Itching of skin (code = '418363000' in codeSystem 'SNOMED CT') | ||
ReactieBeschrijving (ReactionDescription) | Huidproblemen | ||
Ernst (Severity) | Mild (code = '255604002' in codeSystem 'SNOMED CT') | ||
WijzeVanBlootstelling (RouteOfExposure) | cutane route (code = '448598008' in codeSystem 'SNOMED CT') |
2.35 Bloeddruk (BloodPressure) [bgz-patA-bloodpressure3]
Bloeddruk (BloodPressure) [bgz-patA-bloodpressure3] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999151 | |
Meetmethode (MeasuringMethod) | Non-invasive (code = '22762002' in codeSystem 'SNOMED CT') | |
ManchetType (CuffType) | Standaard (code = 'STD' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.15.1') | |
MeetLocatie (MeasuringLocation) | Right upper arm structure (code = '368209003' in codeSystem 'SNOMED CT') | |
DiastolischEindpunt (DiastolicEndpoint) | Phase 4 (code = '255271000' in codeSystem 'SNOMED CT') | |
SystolischeBloeddruk (SystolicBloodPressure) | 130 mm[Hg] | |
DiastolischeBloeddruk (DiastolicBloodPressure) | 79 mm[Hg] | |
BloeddrukDatumTijd (BloodPressureDateTime) | T+3D{10:00} |
2.36 Lichaamsgewicht (BodyWeight) [bgz-patA-bodyweight1]
Lichaamsgewicht (BodyWeight) [bgz-patA-bodyweight1] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999151 | |
GewichtWaarde (WeightValue) | 79 kg | |
GewichtDatumTijd (WeightDateTime) | T+1D | |
Kleding (Clothing) | Fully dressed (code = 'FULL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1') |
2.37 Lichaamsgewicht (BodyWeight) [bgz-patA-bodyweight2]
Lichaamsgewicht (BodyWeight) [bgz-patA-bodyweight2] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999151 | |
GewichtWaarde (WeightValue) | 78 kg | |
GewichtDatumTijd (WeightDateTime) | T+2D | |
Kleding (Clothing) | Fully dressed (code = 'FULL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1') |
2.38 Lichaamslengte (BodyHeight) [bgz-patA-bodyheight]
Lichaamslengte (BodyHeight) [bgz-patA-bodyheight] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999151 | |
LengteWaarde (HeightValue) | 183 cm | |
LengteDatumTijd (HeightDateTime) | 1 nov 2018 | |
Positie (Position) | Orthostatic body position (code = '10904000' in codeSystem 'SNOMED CT') |
2.39 Patient (Patient) [bgz-patA]
Patient (Patient) [bgz-patA] | |||||
Gegevenselement | Waarde | ||||
Naamgegevens (NameInformation) | |||||
referentie:Naamgegevens (reference:NameInformation) | |||||
Voornamen (FirstNames) | Dennis | ||||
Initialen (Initials) | D. | ||||
Roepnaam (GivenName) | Dennis | ||||
Naamgebruik (NameUsage) | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam (LastName) | |||||
Achternaam (LastName) | Janse | ||||
Adresgegevens (AddressInformation) | |||||
referentie:Adresgegevens (reference:AddressInformation) | |||||
Straat (Street) | Huweelstraat | ||||
Huisnummer (HouseNumber) | 15 | ||||
AanduidingBijNummer (HouseNumberIndication) | Tegenover (code = 'to' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.3') | ||||
Postcode (Postcode) | 1248 CC | ||||
Woonplaats (PlaceOfResidence) | Barendrecht | ||||
Land (Country) | Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2') | ||||
AdditioneleInformatie (AdditionalInformation) | Tijdelijk adres | ||||
AdresSoort (AddressType) | Tempory Address (code = 'TMP' in codeSystem 'HL7 AddressUse') | ||||
Contactgegevens (ContactInformation) | |||||
referentie:Contactgegevens (reference:ContactInformation) | |||||
Telefoonnummers (TelephoneNumbers) | |||||
Telefoonnummer (TelephoneNumber) | +316-11122233 | ||||
TelecomType (TelecomType) | Mobile Phone (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
NummerSoort (NumberType) | Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
EmailAdressen (EmailAddresses) | |||||
EmailAdres (EmailAddress) | djanse@test.nl | ||||
EmailSoort (EmailAddressType) | Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Identificatienummer (PatientIdentificationNumber) | 999999151 (in identificerend systeem: BSN) | ||||
Geboortedatum (DateOfBirth) | 2 feb 1950 | ||||
Geslacht (Gender) | Male (code = 'M' in codeSystem 'HL7 AdministrativeGender') | ||||
MeerlingIndicator (MultipleBirthIndicator) | Nee | ||||
OverlijdensIndicator (DeathIndicator) | Nee |
2.40 Betaler (Payer) [bgz-patA-payer]
Betaler (Payer) [bgz-patA-payer] | |||||
Gegevenselement | Waarde | ||||
referentie:Patient (reference:Patient) | 999999151 | ||||
Verzekeraar (InsuranceCompany) | |||||
Verzekering (Insurance) | |||||
BeginDatumTijd (StartDateTime) | T-182D | ||||
EindDatumTijd (EndDateTime) | T+183D | ||||
Verzekeringssoort (InsuranceType) | Aanvullend verzekerd (code = 'A' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') | ||||
IdentificatieNummer (IdentificationNumber) | 3343 (in identificerend systeem: 2.16.840.1.113883.2.4.6.4) | ||||
OrganisatieNaam (OrganizationName) | ONVZ Zorgverzekeraar | ||||
VerzekerdeNummer (InsurantNumber) | 88664422 | ||||
Adresgegevens (AddressInformation) | |||||
referentie:Adresgegevens (reference:AddressInformation) | |||||
Straat (Street) | De Molen | ||||
Huisnummer (HouseNumber) | 66 | ||||
AanduidingBijNummer (HouseNumberIndication) | Tegenover (code = 'to' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.3') | ||||
Postcode (Postcode) | 3990 GD | ||||
Woonplaats (PlaceOfResidence) | Houten | ||||
Gemeente (Municipality) | Houten | ||||
Land (Country) | Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2') | ||||
AdresSoort (AddressType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
Contactgegevens (ContactInformation) | |||||
referentie:Contactgegevens (reference:ContactInformation) | |||||
Telefoonnummers (TelephoneNumbers) | |||||
Telefoonnummer (TelephoneNumber) | 030-6396222 | ||||
TelecomType (TelecomType) | Land Line (code = 'LL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.22.1') | ||||
NummerSoort (NumberType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
EmailAdressen (EmailAddresses) | |||||
EmailAdres (EmailAddress) | vd@onvz.nl | ||||
EmailSoort (EmailAddressType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') |
2.41 FunctioneleOfMentaleStatus (FunctionalOrMentalStatus) [bgz-patA-funcment3]
FunctioneleOfMentaleStatus (FunctionalOrMentalStatus) [bgz-patA-funcment3] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999151 | |
StatusNaam (StatusName) | sombere stemming (code = '366979004' in codeSystem 'SNOMED CT') | |
StatusWaarde (StatusValue) | ernstig (code = '24484000' in codeSystem '2.16.840.1.113883.6.96 (ordinal = ) | |
StatusDatum (StatusDate) | 2010 | |
Toelichting (Comment) | Met name in wintermaanden |
2.42 Probleem (Problem) [bgz-patA-problem1]
Probleem (Problem) [bgz-patA-problem1] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999151 | |
ProbleemType (ProblemType) | Symptom (code = '418799008' in codeSystem 'SNOMED CT') | |
ProbleemNaam (ProblemName) | dyspneu (code = '267036007' in codeSystem 'SNOMED CT') | |
ProbleemBeginDatum (ProblemStartDate) | 1999 | |
ProbleemStatus (ProblemStatus) | Active (code = '55561003' in codeSystem 'SNOMED CT') | |
VerificatieStatus (VerificationStatus) | Confirmed present (code = '410605003' in codeSystem 'SNOMED CT') |
2.43 Bloeddruk (BloodPressure) [bgz-patA-bloodpressure2]
Bloeddruk (BloodPressure) [bgz-patA-bloodpressure2] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999151 | |
Meetmethode (MeasuringMethod) | Non-invasive (code = '22762002' in codeSystem 'SNOMED CT') | |
MeetLocatie (MeasuringLocation) | Right upper arm structure (code = '368209003' in codeSystem 'SNOMED CT') | |
SystolischeBloeddruk (SystolicBloodPressure) | 120 mm[Hg] | |
DiastolischeBloeddruk (DiastolicBloodPressure) | 71 mm[Hg] | |
BloeddrukDatumTijd (BloodPressureDateTime) | T+2D{09:00} | |
Houding (Position) | Sitting position (code = '33586001' in codeSystem 'SNOMED CT') |
2.44 Bloeddruk (BloodPressure) [bgz-patA-bloodpressure1]
Bloeddruk (BloodPressure) [bgz-patA-bloodpressure1] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999151 | |
Meetmethode (MeasuringMethod) | Non-invasive (code = '22762002' in codeSystem 'SNOMED CT') | |
ManchetType (CuffType) | Groot (code = 'L' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.15.1') | |
DiastolischEindpunt (DiastolicEndpoint) | Phase 4 (code = '255271000' in codeSystem 'SNOMED CT') | |
SystolischeBloeddruk (SystolicBloodPressure) | 140 mm[Hg] | |
DiastolischeBloeddruk (DiastolicBloodPressure) | 85 mm[Hg] | |
BloeddrukDatumTijd (BloodPressureDateTime) | T+1D{11:05} |
3 Scenario 1: Patiënt B
3.1 Vaccinatie (Vaccination) [bgz-patB-vaccin]
Vaccinatie (Vaccination) [bgz-patB-vaccin] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999092 | ||
ProductCode (ProductCode) | rabiësvaccin (code = 'J07BG01' in codeSystem '2.16.840.1.113883.6.73') | ||
Dosis (Dose) | 1 mL | ||
VaccinatieDatum (VaccinationDate) | 3 jan 2017 | ||
Toediener (Administrator) | |||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patB-healthProf1 | ||
Toelichting (Comment) | fietsreis naar Vietnam |
3.2 Patient (Patient) [bgz-patB]
Patient (Patient) [bgz-patB] | |||||
Gegevenselement | Waarde | ||||
Naamgegevens (NameInformation) | |||||
referentie:Naamgegevens (reference:NameInformation) | |||||
Voornamen (FirstNames) | Maria Francisca | ||||
Initialen (Initials) | M.F. | ||||
Roepnaam (GivenName) | Maria | ||||
Naamgebruik (NameUsage) | Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam (LastName) | |||||
Voorvoegsels (Prefix) | van 't | ||||
Achternaam (LastName) | Hoen | ||||
GeslachtsnaamPartner (LastNamePartner) | |||||
AchternaamPartner (PartnerLastName) | Verheul | ||||
Adresgegevens (AddressInformation) | |||||
referentie:Adresgegevens (reference:AddressInformation) | |||||
Straat (Street) | Steenstraat | ||||
Huisnummer (HouseNumber) | 143 | ||||
Huisnummerletter (HouseNumberLetter) | A | ||||
Huisnummertoevoeging (HouseNumberAddition) | II | ||||
Postcode (Postcode) | 6584 YZ | ||||
Woonplaats (PlaceOfResidence) | Molenhoek | ||||
Gemeente (Municipality) | Mook en Middelaar | ||||
Land (Country) | Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2') | ||||
AdresSoort (AddressType) | Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Contactgegevens (ContactInformation) | |||||
referentie:Contactgegevens (reference:ContactInformation) | |||||
Telefoonnummers (TelephoneNumbers) | |||||
Telefoonnummer (TelephoneNumber) | +316-10101010 | ||||
TelecomType (TelecomType) | Mobile Phone (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
NummerSoort (NumberType) | Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
EmailAdressen (EmailAddresses) | |||||
EmailAdres (EmailAddress) | francisca@maria.org | ||||
EmailSoort (EmailAddressType) | Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Identificatienummer (PatientIdentificationNumber) | 999999092 (in identificerend systeem: BSN) | ||||
Geboortedatum (DateOfBirth) | 16 apr 1956 | ||||
Geslacht (Gender) | Female (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
MeerlingIndicator (MultipleBirthIndicator) | Ja | ||||
OverlijdensIndicator (DeathIndicator) | Nee |
3.3 BurgerlijkeStaatRC (MaritalStatusRC) [bgz-patB-marital]
BurgerlijkeStaatRC (MaritalStatusRC) [bgz-patB-marital] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999092 | |
BurgerlijkeStaat (MaritalStatus) | Domestic partner (code = 'T' in codeSystem '2.16.840.1.113883.5.2') |
3.4 Betaler (Payer) [bgz-patB-payer]
Betaler (Payer) [bgz-patB-payer] | |||||
Gegevenselement | Waarde | ||||
referentie:Patient (reference:Patient) | 999999092 | ||||
Verzekeraar (InsuranceCompany) | |||||
Verzekering (Insurance) | |||||
BeginDatumTijd (StartDateTime) | T-182D | ||||
EindDatumTijd (EndDateTime) | T+183D | ||||
Verzekeringssoort (InsuranceType) | Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') | ||||
IdentificatieNummer (IdentificationNumber) | 3313 (in identificerend systeem: 2.16.840.1.113883.2.4.6.4) | ||||
OrganisatieNaam (OrganizationName) | Interpolis Zorgverzekeringen N.V. | ||||
VerzekerdeNummer (InsurantNumber) | 98765432 | ||||
Adresgegevens (AddressInformation) | |||||
referentie:Adresgegevens (reference:AddressInformation) | |||||
Straat (Street) | Spoorlaan | ||||
Huisnummer (HouseNumber) | 298 | ||||
Postcode (Postcode) | 5017 JZ | ||||
Woonplaats (PlaceOfResidence) | Tilburg | ||||
Land (Country) | Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2') | ||||
AdresSoort (AddressType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
Contactgegevens (ContactInformation) | |||||
referentie:Contactgegevens (reference:ContactInformation) | |||||
Telefoonnummers (TelephoneNumbers) | |||||
Telefoonnummer (TelephoneNumber) | 0134622025 | ||||
TelecomType (TelecomType) | Land Line (code = 'LL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.22.1') | ||||
NummerSoort (NumberType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
EmailAdressen (EmailAddresses) | |||||
EmailAdres (EmailAddress) | info@interpolis.nl | ||||
EmailSoort (EmailAddressType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') |
3.5 Wilsverklaring (AdvanceDirective) [bgz-patB-advdir]
Wilsverklaring (AdvanceDirective) [bgz-patB-advdir] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999900092 | |
WilsverklaringType (LivingWillType) | Niet reanimeren verklaring (code = 'NR' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.14.1') | |
WilsverklaringDatum (LivingWillDate) | 7 jul 2007 | |
WilsverklaringDocument (LivingWillDocument) | ZHVtbXktd2lsc3ZlcmtsYXJpbmcgTWFyaWEgdmFuICd0IEhvZW4ucGRm |
3.6 BehandelAanwijzing (TreatmentDirective) [bgz-patB-treatmentdir]
BehandelAanwijzing (TreatmentDirective) [bgz-patB-treatmentdir] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999092 | ||
Verificatie (Verification) | |||
Geverifieerd (Verified) | Ja | ||
GeverifieerdBij (VerifiedWith) | Patient (code = '116154003' in codeSystem 'SNOMED CT') | ||
VerificatieDatum (VerificationDate) | 7 jul 2017 | ||
Behandeling (Treatment) | Cardiopulmonary resuscitation (procedure) (code = '89666000' in codeSystem 'SNOMED CT') | ||
BehandelingToegestaan (TreatmentPermitted) | Nee (code = 'NEE' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4') | ||
BeginDatum (StartDate) | 7 jul 2007 | ||
Wilsverklaring (AdvanceDirective) | |||
referentie:Wilsverklaring (reference:AdvanceDirective) | zib-2017-bgz-patB-advdir |
3.7 Contactpersoon (Contact) [bgz-patB-contactperson1]
Contactpersoon (Contact) [bgz-patB-contactperson1] | |||||
Gegevenselement | Waarde | ||||
referentie:Patient (reference:Patient) | 999900092 | ||||
Naamgegevens (NameInformation) | |||||
referentie:Naamgegevens (reference:NameInformation) | |||||
Voornamen (FirstNames) | Peter | ||||
Initialen (Initials) | P. | ||||
Roepnaam (GivenName) | Peer | ||||
Naamgebruik (NameUsage) | Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam (LastName) | |||||
Achternaam (LastName) | Verheul | ||||
GeslachtsnaamPartner (LastNamePartner) | |||||
VoorvoegselsPartner (PartnerPrefix) | van 't | ||||
AchternaamPartner (PartnerLastName) | Hoen | ||||
Contactgegevens (ContactInformation) | |||||
referentie:Contactgegevens (reference:ContactInformation) | |||||
Telefoonnummers (TelephoneNumbers) | |||||
Telefoonnummer (TelephoneNumber) | 0611119999 | ||||
TelecomType (TelecomType) | Mobile Phone (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
NummerSoort (NumberType) | Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
EmailAdressen (EmailAddresses) | |||||
EmailAdres (EmailAddress) | peer@verheul.org | ||||
EmailSoort (EmailAddressType) | Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Adresgegevens (AddressInformation) | |||||
referentie:Adresgegevens (reference:AddressInformation) | |||||
Straat (Street) | Steenstraat | ||||
Huisnummer (HouseNumber) | 143 | ||||
Huisnummerletter (HouseNumberLetter) | A | ||||
Huisnummertoevoeging (HouseNumberAddition) | II | ||||
Postcode (Postcode) | 6584 YZ | ||||
Woonplaats (PlaceOfResidence) | Molenhoek | ||||
Gemeente (Municipality) | Mook en Middelaar | ||||
Land (Country) | Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2') | ||||
AdresSoort (AddressType) | Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Rol (Role) | Eerste relatie/contactpersoon (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472') | ||||
Relatie (Relationship) | Domestic partner (code = 'DOMPART' in codeSystem 'HL7 RoleCode') |
3.8 Contactpersoon (Contact) [bgz-patB-contactperson2]
Contactpersoon (Contact) [bgz-patB-contactperson2] | |||||
Gegevenselement | Waarde | ||||
referentie:Patient (reference:Patient) | 999900092 | ||||
Naamgegevens (NameInformation) | |||||
referentie:Naamgegevens (reference:NameInformation) | |||||
Voornamen (FirstNames) | Puck | ||||
Initialen (Initials) | P. | ||||
Geslachtsnaam (LastName) | |||||
Voorvoegsels (Prefix) | van 't | ||||
Achternaam (LastName) | Hoen | ||||
Adresgegevens (AddressInformation) | |||||
referentie:Adresgegevens (reference:AddressInformation) | |||||
Straat (Street) | Straatweg | ||||
Huisnummer (HouseNumber) | 11 | ||||
Postcode (Postcode) | 1256 DC | ||||
Woonplaats (PlaceOfResidence) | Venlo | ||||
AdresSoort (AddressType) | Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Rol (Role) | Tweede relatie/contactpersoon (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472') | ||||
Relatie (Relationship) | Daughter (code = 'DAUC' in codeSystem 'HL7 RoleCode') |
3.9 FunctioneleOfMentaleStatus (FunctionalOrMentalStatus) [bgz-patB-funcment]
FunctioneleOfMentaleStatus (FunctionalOrMentalStatus) [bgz-patB-funcment] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999900092 | ||
StatusNaam (StatusName) | spierzwakte van bovenste extremiteit (code = '713512009' in codeSystem 'SNOMED CT') | ||
StatusWaarde (StatusValue) | matig (code = '6736007' in codeSystem '2.16.840.1.113883.6.96 (ordinal = ) | ||
StatusDatum (StatusDate) | 2010 | ||
Toelichting (Comment) | krachtsvermindering rechterarm na CVA | ||
Hulpmiddel (MedicalDevice) | |||
referentie:MedischHulpmiddel (reference:MedicalDevice) | zib-2017-bgz-patB-medDevice |
3.10 Probleem (Problem) [bgz-patB-problem1]
Probleem (Problem) [bgz-patB-problem1] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999092 | |
ProbleemType (ProblemType) | Diagnosis (code = '282291009' in codeSystem 'SNOMED CT') | |
ProbleemNaam (ProblemName) | hypertensieve aandoening (code = '38341003' in codeSystem 'SNOMED CT') | |
ProbleemBeginDatum (ProblemStartDate) | 2004 | |
ProbleemStatus (ProblemStatus) | Active (code = '55561003' in codeSystem 'SNOMED CT') | |
VerificatieStatus (VerificationStatus) | Confirmed present (code = '410605003' in codeSystem 'SNOMED CT') |
3.11 Probleem (Problem) [bgz-patB-problem2]
Probleem (Problem) [bgz-patB-problem2] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999092 | |
ProbleemType (ProblemType) | Diagnosis (code = '282291009' in codeSystem 'SNOMED CT') | |
ProbleemNaam (ProblemName) | BRCA1-genmutatie positief (code = '412734009' in codeSystem 'SNOMED CT') | |
ProbleemBeginDatum (ProblemStartDate) | 2005 | |
ProbleemStatus (ProblemStatus) | Active (code = '55561003' in codeSystem 'SNOMED CT') | |
VerificatieStatus (VerificationStatus) | Confirmed present (code = '410605003' in codeSystem 'SNOMED CT') |
3.12 Probleem (Problem) [bgz-patB-problem3]
Probleem (Problem) [bgz-patB-problem3] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999092 | |
ProbleemType (ProblemType) | Complaint (code = '409586006' in codeSystem 'SNOMED CT') | |
ProbleemNaam (ProblemName) | postmenopauzale status (code = '76498008' in codeSystem 'SNOMED CT') | |
ProbleemBeginDatum (ProblemStartDate) | 2009 | |
ProbleemStatus (ProblemStatus) | Active (code = '55561003' in codeSystem 'SNOMED CT') |
3.13 Probleem (Problem) [bgz-patB-problem4]
Probleem (Problem) [bgz-patB-problem4] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999092 | |
ProbleemAnatomischeLocatie (ProblemAnatomicalLocation) | structuur van cerebrum (code = '83678007' in codeSystem 'SNOMED CT') | |
ProbleemLateraliteit (ProblemLaterality) | Left (code = '7771000' in codeSystem 'SNOMED CT') | |
ProbleemType (ProblemType) | Diagnosis (code = '282291009' in codeSystem 'SNOMED CT') | |
ProbleemNaam (ProblemName) | cerebraal infarct (code = '432504007' in codeSystem 'SNOMED CT') | |
ProbleemBeginDatum (ProblemStartDate) | 1 jul 2010 | |
ProbleemStatus (ProblemStatus) | Active (code = '55561003' in codeSystem 'SNOMED CT') | |
VerificatieStatus (VerificationStatus) | Confirmed present (code = '410605003' in codeSystem 'SNOMED CT') |
3.14 Probleem (Problem) [bgz-patB-problem5]
Probleem (Problem) [bgz-patB-problem5] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999092 | |
ProbleemAnatomischeLocatie (ProblemAnatomicalLocation) | structuur van rechter mamma (code = '73056007' in codeSystem 'SNOMED CT') | |
ProbleemLateraliteit (ProblemLaterality) | Right (code = '24028007' in codeSystem 'SNOMED CT') | |
ProbleemType (ProblemType) | Symptom (code = '418799008' in codeSystem 'SNOMED CT') | |
ProbleemNaam (ProblemName) | palpabele massa van mamma (code = '2271000146103' in codeSystem 'SNOMED CT') | |
ProbleemBeginDatum (ProblemStartDate) | 4 maa 2019 | |
ProbleemStatus (ProblemStatus) | Active (code = '55561003' in codeSystem 'SNOMED CT') | |
VerificatieStatus (VerificationStatus) | Suspected (code = '415684004' in codeSystem 'SNOMED CT') |
3.15 Probleem (Problem) [bgz-patB-problem6]
Probleem (Problem) [bgz-patB-problem6] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999092 | |
ProbleemAnatomischeLocatie (ProblemAnatomicalLocation) | structuur van rechter mamma (code = '73056007' in codeSystem 'SNOMED CT') | |
ProbleemLateraliteit (ProblemLaterality) | Right (code = '24028007' in codeSystem 'SNOMED CT') | |
ProbleemType (ProblemType) | Diagnosis (code = '282291009' in codeSystem 'SNOMED CT') | |
ProbleemNaam (ProblemName) | maligne neoplasma van mamma (code = '254837009' in codeSystem 'SNOMED CT') | |
ProbleemBeginDatum (ProblemStartDate) | 28 maa 2019 | |
ProbleemStatus (ProblemStatus) | Active (code = '55561003' in codeSystem 'SNOMED CT') | |
VerificatieStatus (VerificationStatus) | Confirmed present (code = '410605003' in codeSystem 'SNOMED CT') |
3.16 Probleem (Problem) [bgz-patB-problem7]
Probleem (Problem) [bgz-patB-problem7] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999092 | |
ProbleemAnatomischeLocatie (ProblemAnatomicalLocation) | structuur van rechter mamma (code = '73056007' in codeSystem 'SNOMED CT') | |
ProbleemLateraliteit (ProblemLaterality) | Right (code = '24028007' in codeSystem 'SNOMED CT') | |
ProbleemType (ProblemType) | Complication (code = '116223007' in codeSystem 'SNOMED CT') | |
ProbleemNaam (ProblemName) | postoperatieve wondinfectie (code = '58126003' in codeSystem 'SNOMED CT') | |
ProbleemBeginDatum (ProblemStartDate) | T+2D | |
ProbleemEindDatum (ProblemEndDate) | T+3D | |
ProbleemStatus (ProblemStatus) | Inactive (code = '73425007' in codeSystem 'SNOMED CT') |
3.17 Woonsituatie (LivingSituation) [bgz-patB-living]
Woonsituatie (LivingSituation) [bgz-patB-living] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999092 | |
WoningType (HouseType) | Eengezinswoning (code = 'EENGEZW' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.13.1') |
3.18 DrugsGebruik (DrugUse) [bgz-patB-druguse]
DrugsGebruik (DrugUse) [bgz-patB-druguse] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999900092 | |
DrugsGebruikStatus (DrugUseStatus) | Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): onbekend |
3.19 AlcoholGebruik (AlcoholUse) [bgz-patB-alcohol]
AlcoholGebruik (AlcoholUse) [bgz-patB-alcohol] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999900092 | ||
Toelichting (Comment) | Mevrouw drinkt niet meer sinds ze weet dat ze drager BRCA1-genmutatie is. | ||
AlcoholGebruikStatus (AlcoholUseStatus) | Ex-drinker (finding) (code = '82581004' in codeSystem 'SNOMED CT') | ||
WaarnemingGebruik (ObservationOfUse) | |||
StartDatum (StartDate) | 1971 | ||
StopDatum (StopDate) | 2005 | ||
Hoeveelheid (Amount) | 14 {glasses}/wk |
3.20 TabakGebruik (TobaccoUse) [bgz-patB-tobacco]
TabakGebruik (TobaccoUse) [bgz-patB-tobacco] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999092 | ||
TabakGebruikStatus (TobaccoUseStatus) | Ex-smoker (finding) (code = '8517006' in codeSystem 'SNOMED CT') | ||
WaarnemingGebruik (ObservationOfUse) | |||
StartDatum (StartDate) | 1970 | ||
StopDatum (StopDate) | 1980 |
3.21 Zorgverlener (HealthProfessional) [bgz-patB-healthProf2]
Zorgverlener (HealthProfessional) [bgz-patB-healthProf2] | |||||
Gegevenselement | Waarde | ||||
referentie:Patient (reference:Patient) | 999900092 | ||||
ZorgverlenerIdentificatienummer (HealthProfessionalIdentificationNumber) | 00141414 (in identificerend systeem: AGB-Z) | ||||
Naamgegevens (NameInformation) | |||||
referentie:Naamgegevens (reference:NameInformation) | |||||
Voornamen (FirstNames) | Johanna | ||||
Initialen (Initials) | J. | ||||
Roepnaam (GivenName) | Joke | ||||
Naamgebruik (NameUsage) | Unknown (code = 'UNK' in codeSystem 'HL7 NullFlavor') | ||||
Geslachtsnaam (LastName) | |||||
Voorvoegsels (Prefix) | de | ||||
Achternaam (LastName) | Bruin | ||||
Specialisme (Specialty) | Internist (code = '01.016' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||
Adresgegevens (AddressInformation) | |||||
referentie:Adresgegevens (reference:AddressInformation) | |||||
Land (Country) | Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2') | ||||
AdresSoort (AddressType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
Contactgegevens (ContactInformation) | |||||
referentie:Contactgegevens (reference:ContactInformation) | |||||
Telefoonnummers (TelephoneNumbers) | |||||
Telefoonnummer (TelephoneNumber) | 2768 | ||||
TelecomType (TelecomType) | Pager (code = 'PG' in codeSystem 'HL7 AddressUse') | ||||
Zorgaanbieder (HealthcareProvider) | |||||
referentie:Zorgaanbieder (reference:HealthcareProvider) | naam eigen ziekenhuis | ||||
ZorgverlenersRol (HealthProfessionalRole) | Responsible Party (code = 'RESP' in codeSystem 'HL7 ParticipationType') |
3.22 Zorgverlener (HealthProfessional) [bgz-patB-healthProf1]
Zorgverlener (HealthProfessional) [bgz-patB-healthProf1] | |||||
Gegevenselement | Waarde | ||||
referentie:Patient (reference:Patient) | 999900092 | ||||
ZorgverlenerIdentificatienummer (HealthProfessionalIdentificationNumber) | 00131313 (in identificerend systeem: AGB-Z) | ||||
Naamgegevens (NameInformation) | |||||
referentie:Naamgegevens (reference:NameInformation) | |||||
Voornamen (FirstNames) | Anna | ||||
Initialen (Initials) | A. | ||||
Roepnaam (GivenName) | Anna | ||||
Naamgebruik (NameUsage) | Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam (LastName) | |||||
Voorvoegsels (Prefix) | de | ||||
Achternaam (LastName) | Vries | ||||
GeslachtsnaamPartner (LastNamePartner) | |||||
AchternaamPartner (PartnerLastName) | Bijns | ||||
Specialisme (Specialty) | Huisarts (code = '01.015' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||
Adresgegevens (AddressInformation) | |||||
referentie:Adresgegevens (reference:AddressInformation) | |||||
Straat (Street) | Dorpsstraat | ||||
Huisnummer (HouseNumber) | 1 | ||||
Postcode (Postcode) | 6585 XY | ||||
Woonplaats (PlaceOfResidence) | Molenhoek | ||||
Gemeente (Municipality) | Mook en Middelaar | ||||
Land (Country) | Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2') | ||||
AdresSoort (AddressType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
Contactgegevens (ContactInformation) | |||||
referentie:Contactgegevens (reference:ContactInformation) | |||||
Telefoonnummers (TelephoneNumbers) | |||||
Telefoonnummer (TelephoneNumber) | 077-1234567 | ||||
TelecomType (TelecomType) | Land Line (code = 'LL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.22.1') | ||||
NummerSoort (NumberType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
EmailAdressen (EmailAddresses) | |||||
EmailAdres (EmailAddress) | Bijns.DeVries@HPMolenhoek.nl | ||||
EmailSoort (EmailAddressType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
Zorgaanbieder (HealthcareProvider) | |||||
referentie:Zorgaanbieder (reference:HealthcareProvider) | Huisartsenpraktijk Molenhoek |
3.23 LaboratoriumUitslag (LaboratoryTestResult) [bgz-patB-labresult2]
LaboratoriumUitslag (LaboratoryTestResult) [bgz-patB-labresult2] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999092 | ||
LaboratoriumTest (LaboratoryTest) | |||
TestCode (TestCode) | CA15.3 [aanwezigheid] in serum of plasma (code = '2007-3' in codeSystem 'LOINC') | ||
TestDatumTijd (TestDateTime) | T+2D{09:00} | ||
TestUitslag (TestResult) | 13 E/mL | ||
TestUitslagStatus (TestResultStatus) | Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1') | ||
Monster (Specimen) | |||
Monstermateriaal (SpecimenMaterial) | serum of plasma (code = '122592007' in codeSystem 'SNOMED CT') | ||
AfnameDatumTijd (CollectionDateTime) | T+2D{08:00} | ||
ResultaatStatus (ResultStatus) | Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1') | ||
ResultaatType (ResultType) | Chemistry (code = '275711006' in codeSystem 'SNOMED CT') | ||
Aanvrager (Requester) | |||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patB-healthProf2 |
3.24 LaboratoriumUitslag (LaboratoryTestResult) [bgz-patB-labresult1]
LaboratoriumUitslag (LaboratoryTestResult) [bgz-patB-labresult1] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999900092 | ||
LaboratoriumTest (LaboratoryTest) | |||
TestCode (TestCode) | Monocyten [aantal/volume] in bloed (code = '26484-6' in codeSystem 'LOINC') | ||
TestDatumTijd (TestDateTime) | T+1D{09:00} | ||
TestUitslag (TestResult) | 0.43E+9 /L | ||
TestUitslagStatus (TestResultStatus) | Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1') | ||
ReferentieBovengrens (ReferenceRangeUpperLimit) | 1.00E+9 /L | ||
ReferentieOndergrens (ReferenceRangeLowerLimit) | 0.3E+9 /L | ||
LaboratoriumTest (LaboratoryTest) | |||
TestCode (TestCode) | Lymfocyten [aantal/volume] in bloed d.m.v. manuele telling (code = '732-8' in codeSystem 'LOINC') | ||
TestDatumTijd (TestDateTime) | T+1D{09:00} | ||
TestUitslag (TestResult) | 0.86E+9 /L | ||
TestUitslagStatus (TestResultStatus) | Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1') | ||
ReferentieBovengrens (ReferenceRangeUpperLimit) | 3.50E+9 /L | ||
ReferentieOndergrens (ReferenceRangeLowerLimit) | 1.00E+9 /L | ||
InterpretatieVlaggen (ResultFlags) | Below reference range (code = '281300000' in codeSystem 'SNOMED CT') | ||
LaboratoriumTest (LaboratoryTest) | |||
TestCode (TestCode) | Lymfocyten.grote granulaire [aanwezigheid] in bloed (code = '59808-6' in codeSystem 'LOINC') | ||
TestDatumTijd (TestDateTime) | T+1D{09:00} | ||
TestUitslag (TestResult) | + | ||
TestUitslagStatus (TestResultStatus) | Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1') | ||
Monster (Specimen) | |||
Monstermateriaal (SpecimenMaterial) | Serum (code = '67922002' in codeSystem 'SNOMED CT') | ||
AfnameDatumTijd (CollectionDateTime) | T+1D{08:00} | ||
Afnameprocedure (CollectionMethod) | venapunctie voor bloedtest (code = '28520004' in codeSystem 'SNOMED CT') | ||
ResultaatStatus (ResultStatus) | Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1') | ||
ResultaatType (ResultType) | Hematology (code = '252275004' in codeSystem 'SNOMED CT') | ||
Aanvrager (Requester) | |||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patB-healthProf2 |
3.25 Lichaamslengte (BodyHeight) [bgz-patB-bodyheight]
Lichaamslengte (BodyHeight) [bgz-patB-bodyheight] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999900092 | |
LengteWaarde (HeightValue) | 176 cm | |
LengteDatumTijd (HeightDateTime) | 4 maa 2019 | |
Positie (Position) | Orthostatic body position (code = '10904000' in codeSystem 'SNOMED CT') |
3.26 Lichaamsgewicht (BodyWeight) [bgz-patB-bodyweight2]
Lichaamsgewicht (BodyWeight) [bgz-patB-bodyweight2] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999900092 | |
GewichtWaarde (WeightValue) | 54 kg | |
GewichtDatumTijd (WeightDateTime) | T+1D{07:30} | |
Kleding (Clothing) | Minimal dressed (code = 'MINIMAL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1') |
3.27 Lichaamsgewicht (BodyWeight) [bgz-patB-bodyweight1]
Lichaamsgewicht (BodyWeight) [bgz-patB-bodyweight1] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999900092 | |
GewichtWaarde (WeightValue) | 68 kg | |
GewichtDatumTijd (WeightDateTime) | 4 maa 2019 | |
Kleding (Clothing) | Minimal dressed (code = 'MINIMAL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1') |
3.28 Bloeddruk (BloodPressure) [bgz-patB-bloodpressure3]
Bloeddruk (BloodPressure) [bgz-patB-bloodpressure3] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999900092 | |
Meetmethode (MeasuringMethod) | Non-invasive (code = '22762002' in codeSystem 'SNOMED CT') | |
ManchetType (CuffType) | Standaard (code = 'STD' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.15.1') | |
MeetLocatie (MeasuringLocation) | Left upper arm structure (code = '368208006' in codeSystem 'SNOMED CT') | |
SystolischeBloeddruk (SystolicBloodPressure) | 150 mm[Hg] | |
DiastolischeBloeddruk (DiastolicBloodPressure) | 94 mm[Hg] | |
BloeddrukDatumTijd (BloodPressureDateTime) | T+2D{16:15} |
3.29 Bloeddruk (BloodPressure) [bgz-patB-bloodpressure2]
Bloeddruk (BloodPressure) [bgz-patB-bloodpressure2] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999900092 | |
Meetmethode (MeasuringMethod) | Non-invasive (code = '22762002' in codeSystem 'SNOMED CT') | |
ManchetType (CuffType) | Standaard (code = 'STD' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.15.1') | |
MeetLocatie (MeasuringLocation) | Left upper arm structure (code = '368208006' in codeSystem 'SNOMED CT') | |
SystolischeBloeddruk (SystolicBloodPressure) | 130 mm[Hg] | |
DiastolischeBloeddruk (DiastolicBloodPressure) | 80 mm[Hg] | |
BloeddrukDatumTijd (BloodPressureDateTime) | T+2D{07:45} |
3.30 Zorgverlener (HealthProfessional) [bgz-patB-healthProf3]
Zorgverlener (HealthProfessional) [bgz-patB-healthProf3] | |||||
Gegevenselement | Waarde | ||||
referentie:Patient (reference:Patient) | 999900092 | ||||
ZorgverlenerIdentificatienummer (HealthProfessionalIdentificationNumber) | 00151515 (in identificerend systeem: AGB-Z) | ||||
Naamgegevens (NameInformation) | |||||
referentie:Naamgegevens (reference:NameInformation) | |||||
Voornamen (FirstNames) | Antonius Franciscus | ||||
Initialen (Initials) | A.F. | ||||
Roepnaam (GivenName) | Ton | ||||
Naamgebruik (NameUsage) | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam (LastName) | |||||
Achternaam (LastName) | Zoomers | ||||
Specialisme (Specialty) | Chirurg (code = '01.014' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||
Contactgegevens (ContactInformation) | |||||
referentie:Contactgegevens (reference:ContactInformation) | |||||
Telefoonnummers (TelephoneNumbers) | |||||
Telefoonnummer (TelephoneNumber) | 2769 | ||||
TelecomType (TelecomType) | Pager (code = 'PG' in codeSystem 'HL7 AddressUse') | ||||
Zorgaanbieder (HealthcareProvider) | |||||
referentie:Zorgaanbieder (reference:HealthcareProvider) | naam eigen ziekenhuis | ||||
ZorgverlenersRol (HealthProfessionalRole) | Performer (code = 'PRF' in codeSystem 'HL7 ParticipationType') |
3.31 Bloeddruk (BloodPressure) [bgz-patB-bloodpressure1]
Bloeddruk (BloodPressure) [bgz-patB-bloodpressure1] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999900092 | |
Meetmethode (MeasuringMethod) | Non-invasive (code = '22762002' in codeSystem 'SNOMED CT') | |
ManchetType (CuffType) | Standaard (code = 'STD' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.15.1') | |
MeetLocatie (MeasuringLocation) | Left upper arm structure (code = '368208006' in codeSystem 'SNOMED CT') | |
SystolischeBloeddruk (SystolicBloodPressure) | 120 mm[Hg] | |
DiastolischeBloeddruk (DiastolicBloodPressure) | 78 mm[Hg] | |
BloeddrukDatumTijd (BloodPressureDateTime) | T+1D{07:15} |
3.32 Contact (Encounter) [bgz-patB-encounter1]
Contact (Encounter) [bgz-patB-encounter1] | ||||
Gegevenselement | Waarde | |||
referentie:Patient (reference:Patient) | 999900092 | |||
ContactType (ContactType) | Inpatient (code = 'IMP' in codeSystem 'HL7 ActCode') | |||
ContactMet (ContactWith) | ||||
referentie:Zorgverlener (reference:HealthProfessional) | behandelend arts | |||
Locatie (Location) | ||||
referentie:Zorgaanbieder (reference:HealthcareProvider) | naam eigen ziekenhuis | |||
BeginDatumTijd (StartDateTime) | T+1D{07:00} | |||
EindDatumTijd (EndDateTime) | T+2D{09:00} | |||
RedenContact (ContactReason) | ||||
Verrichting (Procedure) | ||||
referentie:Verrichting (reference:Procedure) | zib-2017-bgz-patB-procedure3 | |||
Herkomst (Origin) | Home (code = '264362003' in codeSystem 'SNOMED CT') | |||
Bestemming (Destination) | Home (code = '264362003' in codeSystem 'SNOMED CT') |
3.33 Verrichting (Procedure) [bgz-patB-procedure1]
Verrichting (Procedure) [bgz-patB-procedure1] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999092 | ||
VerrichtingStartDatum (ProcedureStartDate) | 1 jul 2010 | ||
VerrichtingEindDatum (ProcedureEndDate) | 1 jul 2020 | ||
Indicatie (Indication) | |||
referentie:Probleem (reference:Problem) | zib-2017-bgz-patB-problem4 | ||
VerrichtingType (ProcedureType) | intraveneuze trombolyse (code = '77381000146102' in codeSystem 'SNOMED CT') | ||
Locatie (Location) | |||
referentie:Zorgaanbieder (reference:HealthcareProvider) | VieCuri | ||
Uitvoerder (Performer) | |||
referentie:Zorgverlener (reference:HealthProfessional) | |||
Aanvrager (Requester) | |||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patB-healthProf1 |
3.34 Verrichting (Procedure) [bgz-patB-procedure2]
Verrichting (Procedure) [bgz-patB-procedure2] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999092 | ||
VerrichtingStartDatum (ProcedureStartDate) | 2 jul 2010 | ||
VerrichtingEindDatum (ProcedureEndDate) | 2 jul 2020 | ||
VerrichtingAnatomischeLocatie (ProcedureAnatomicalLocation) | structuur van intracranieel bloedvat (code = '281138005' in codeSystem 'SNOMED CT') | ||
Indicatie (Indication) | |||
referentie:Probleem (reference:Problem) | zib-2017-bgz-patB-problem4 | ||
VerrichtingType (ProcedureType) | mechanische trombectomie van linker arteria carotis interna (code = '84581000146105' in codeSystem 'SNOMED CT') | ||
VerrichtingMethode (ProcedureMethod) | fluoroscopisch geleide percutane mechanische trombectomie van sinus durae matris (code = '439625002' in codeSystem 'SNOMED CT') | ||
Locatie (Location) | |||
referentie:Zorgaanbieder (reference:HealthcareProvider) | naam eigen ziekenhuis | ||
Uitvoerder (Performer) | |||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patB-healthProf4 |
3.35 Verrichting (Procedure) [bgz-patB-procedure3]
Verrichting (Procedure) [bgz-patB-procedure3] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999092 | ||
VerrichtingStartDatum (ProcedureStartDate) | T+1D{10:00} | ||
VerrichtingEindDatum (ProcedureEndDate) | T+1D{12:00} | ||
VerrichtingAnatomischeLocatie (ProcedureAnatomicalLocation) | structuur van mamma (code = '76752008' in codeSystem 'SNOMED CT') | ||
VerrichtingLateraliteit (ProcedureLaterality) | Right (code = '24028007' in codeSystem 'SNOMED CT') | ||
Indicatie (Indication) | |||
referentie:Probleem (reference:Problem) | zib-2017-bgz-patB-problem6 | ||
VerrichtingType (ProcedureType) | eenvoudige mastectomie (code = '172043006' in codeSystem 'SNOMED CT') | ||
Locatie (Location) | |||
referentie:Zorgaanbieder (reference:HealthcareProvider) | naam eigen ziekenhuis | ||
Uitvoerder (Performer) | |||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patB-healthProf3 | ||
Aanvrager (Requester) | |||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patB-healthProf2 |
3.36 Verrichting (Procedure) [bgz-patB-procedure4]
Verrichting (Procedure) [bgz-patB-procedure4] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999092 | ||
VerrichtingStartDatum (ProcedureStartDate) | T+2D{17:45} | ||
VerrichtingAnatomischeLocatie (ProcedureAnatomicalLocation) | structuur van mamma (code = '76752008' in codeSystem 'SNOMED CT') | ||
VerrichtingLateraliteit (ProcedureLaterality) | Right (code = '24028007' in codeSystem 'SNOMED CT') | ||
Indicatie (Indication) | |||
referentie:Probleem (reference:Problem) | zib-2017-bgz-patB-problem7 | ||
VerrichtingType (ProcedureType) | incisie en drainage van diep abces (code = '103751000146104' in codeSystem 'SNOMED CT') | ||
Locatie (Location) | |||
referentie:Zorgaanbieder (reference:HealthcareProvider) | naam eigen ziekenhuis |
3.37 Contact (Encounter) [bgz-patB-encounter2]
Contact (Encounter) [bgz-patB-encounter2] | ||||
Gegevenselement | Waarde | |||
referentie:Patient (reference:Patient) | 999900092 | |||
ContactType (ContactType) | Emergency (code = 'EMER' in codeSystem 'HL7 ActCode') | |||
Locatie (Location) | ||||
referentie:Zorgaanbieder (reference:HealthcareProvider) | naam eigen ziekenhuis | |||
BeginDatumTijd (StartDateTime) | T+2D{16:00} | |||
EindDatumTijd (EndDateTime) | T+2D{17:00} | |||
RedenContact (ContactReason) | ||||
Probleem (Problem) | ||||
referentie:Probleem (reference:Problem) | zib-2017-bgz-patB-problem7 | |||
Herkomst (Origin) | Home (code = '264362003' in codeSystem 'SNOMED CT') |
3.38 Contact (Encounter) [bgz-patB-encounter3]
Contact (Encounter) [bgz-patB-encounter3] | ||||
Gegevenselement | Waarde | |||
referentie:Patient (reference:Patient) | 999900092 | |||
ContactType (ContactType) | Inpatient (code = 'IMP' in codeSystem 'HL7 ActCode') | |||
ContactMet (ContactWith) | ||||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patB-healthProf3 | |||
Locatie (Location) | ||||
referentie:Zorgaanbieder (reference:HealthcareProvider) | naam eigen ziekenhuis | |||
BeginDatumTijd (StartDateTime) | T+2D{17:00} | |||
EindDatumTijd (EndDateTime) | T+3D{10:00} | |||
RedenContact (ContactReason) | ||||
Verrichting (Procedure) | ||||
referentie:Verrichting (reference:Procedure) | zib-2017-bgz-patB-procedure4 | |||
Bestemming (Destination) | Home (code = '264362003' in codeSystem 'SNOMED CT') |
3.39 Zorgverlener (HealthProfessional) [bgz-patB-healthProf4]
Zorgverlener (HealthProfessional) [bgz-patB-healthProf4] | |||||
Gegevenselement | Waarde | ||||
referentie:Patient (reference:Patient) | 999900092 | ||||
ZorgverlenerIdentificatienummer (HealthProfessionalIdentificationNumber) | 00161616 (in identificerend systeem: AGB-Z) | ||||
Naamgegevens (NameInformation) | |||||
referentie:Naamgegevens (reference:NameInformation) | |||||
Voornamen (FirstNames) | Horst | ||||
Initialen (Initials) | H. | ||||
Roepnaam (GivenName) | Horst | ||||
Naamgebruik (NameUsage) | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam (LastName) | |||||
Achternaam (LastName) | Bontrager | ||||
Specialisme (Specialty) | Neurochirurg (code = '01.025' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||
Adresgegevens (AddressInformation) | |||||
referentie:Adresgegevens (reference:AddressInformation) | |||||
Straat (Street) | Nimweger Strasse | ||||
Huisnummer (HouseNumber) | 285 | ||||
Postcode (Postcode) | 47560 | ||||
Gemeente (Municipality) | Kranenburg | ||||
Land (Country) | Duitsland (code = 'DE' in codeSystem '1.0.3166.1.2.2') | ||||
AdresSoort (AddressType) | Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Contactgegevens (ContactInformation) | |||||
referentie:Contactgegevens (reference:ContactInformation) | |||||
Telefoonnummers (TelephoneNumbers) | |||||
Telefoonnummer (TelephoneNumber) | 024-1234567 | ||||
TelecomType (TelecomType) | Land Line (code = 'LL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.22.1') | ||||
NummerSoort (NumberType) | Work Place (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
Zorgaanbieder (HealthcareProvider) | |||||
referentie:Zorgaanbieder (reference:HealthcareProvider) | naam eigen ziekenhuis | ||||
ZorgverlenersRol (HealthProfessionalRole) | Performer (code = 'PRF' in codeSystem 'HL7 ParticipationType') |
3.40 Voedingsadvies (NutritionAdvice) [bgz-patB-nutrition]
Voedingsadvies (NutritionAdvice) [bgz-patB-nutrition] | ||
Gegevenselement | Waarde | |
referentie:Patient (reference:Patient) | 999999092 | |
DieetType (DietType) | eiwitrijk | |
Toelichting (Comment) | In verband met lage spiermassa |
3.41 Alert (Alert) [bgz-patB-alert2]
Alert (Alert) [bgz-patB-alert2] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999900092 | ||
Conditie (Condition) | |||
referentie:Probleem (reference:Problem) | zib-2017-bgz-patB-problem4 | ||
BeginDatumTijd (StartDateTime) | 4 maa 2010 | ||
AlertType (AlertType) | condition (code = '75323-6' in codeSystem 'LOINC') |
3.42 AllergieIntolerantie (AllergyIntolerance) [bgz-patB-allergy]
AllergieIntolerantie (AllergyIntolerance) [bgz-patB-allergy] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999900092 | ||
VeroorzakendeStof (CausativeAgent) | wespengif (code = '256440004' in codeSystem 'SNOMED CT') | ||
AllergieCategorie (AllergyCategory) | Allergy to substance (code = '419199007' in codeSystem 'SNOMED CT') | ||
AllergieStatus (AllergyStatus) | Completed (code = 'completed' in codeSystem 'HL7 ActStatus') | ||
BeginDatumTijd (StartDateTime) | 1980-08 | ||
MateVanKritiekZijn (Criticality) | Severe (code = '24484000' in codeSystem 'SNOMED CT') | ||
LaatsteReactieDatumTijd (LastReactionDateTime) | 2 aug 2015 | ||
Toelichting (Comment) | Patiënt heeft succesvolle desensitisatie ondergaan. | ||
Reactie (Reaction) | |||
Symptoom (Symptom) | Anaphylaxis (code = '39579001' in codeSystem 'SNOMED CT') | ||
ReactieBeschrijving (ReactionDescription) | Sterk verlaagde bloeddruk en ademfrequentie. | ||
Ernst (Severity) | Severe (code = '24484000' in codeSystem 'SNOMED CT') |
3.43 MedischHulpmiddel (MedicalDevice) [bgz-patB-medDevice]
MedischHulpmiddel (MedicalDevice) [bgz-patB-medDevice] | |||
Gegevenselement | Waarde | ||
referentie:Patient (reference:Patient) | 999999092 | ||
Product (Product) | |||
ProductID (ProductID) | Moving arm support (code = '7350030255912' in codeSystem '1.3.160') | ||
ProductType (ProductType) | positioneringssteun voor arm (code = '462914001' in codeSystem 'SNOMED CT') | ||
ProductOmschrijving (ProductDescription) | armondersteuning bij eten en drinken en computerwerk | ||
BeginDatum (StartDate) | 3 feb 2016 | ||
Toelichting (Comment) | Vanwege spierzwakte rechterarm | ||
AnatomischeLocatie (AnatomicalLocation) | structuur van bovenste extremiteit (code = '53120007' in codeSystem 'SNOMED CT') | ||
Lateraliteit (Laterality) | Right (code = '24028007' in codeSystem 'SNOMED CT') | ||
Locatie (Location) | |||
referentie:Zorgaanbieder (reference:HealthcareProvider) | Huisartsenpraktijk Molenhoek | ||
Zorgverlener (HealthProfessional) | |||
referentie:Zorgverlener (reference:HealthProfessional) | zib-2017-bgz-patB-healthProf1 |
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