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}}

Naar nictiz.nl
Naar nictiz.nl

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