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| Regel 5: | Regel 5: | ||
=Addenda voor inhoudelijke gegevens= | =Addenda voor inhoudelijke gegevens= | ||
==Scenario MM-1.0-LZB-1.3-v1== | |||
<section begin=MM-1.0-LZB-1.3-v1 /> | |||
=== Demografie en identificatie=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Demografie en identificatie | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="5" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Patient | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="32"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Fiona | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|F. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|XXX_Mutter | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Straat | |||
|style="background-color: white;"|Knolweg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Huisnummer | |||
|style="background-color: white;"|1001 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Postcode | |||
|style="background-color: white;"|9999XX | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Woonplaats | |||
|style="background-color: white;"|Stitswerd | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Land | |||
|style="background-color: white;"|Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Adres soort | |||
|style="background-color: white;"|Postadres (code = 'PST' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="10"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"|+31634567891 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telecom type | |||
|style="background-color: white;"|Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Nummer soort | |||
|style="background-color: white;"|Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email adres | |||
|style="background-color: white;"|fmutter@hotmail.com | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email soort | |||
|style="background-color: white;"|Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Identificatienummer | |||
|style="background-color: white;"|999911673 (in identificerend systeem: BSN) | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geboortedatum | |||
|style="background-color: white;"|8 feb 1964 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslacht | |||
|style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Meerling indicator | |||
|style="background-color: white;"|Nee | |||
|} | |||
=== 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 - met id: '<span id="bglz-1-3-probleem-01"/>bglz-1-3-probleem-01' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem anatomische locatie | |||
|style="background-color: white;"|hiel (code = '76853006' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem lateraliteit | |||
|style="background-color: white;"|Links (code = '7771000' in codeSystem 'SNOMED CT') | |||
|-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;"|decubitus (code = '399912005' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"|T + 1 maand | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|} | |||
=== 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="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Laboratorium test | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test code | |||
|style="background-color: white;"|cholesterol:mol/volume:moment:serum of plasma:kwantitatief: (code = '14647-2' in codeSystem 'LOINC') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test datum tijd | |||
|style="background-color: white;"|T om 15:00:00 uur | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test uitslag | |||
|style="background-color: white;"|5.5 mmol/l | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie bovengrens | |||
|style="background-color: white;"|1.8 mmol/l | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Interpretatie vlaggen | |||
|style="background-color: white;"|Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Toelichting | |||
|style="background-color: white;"|Volgens richtlijn herseninfarct: streven naar <1,8mmol/L | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Laboratorium uitslag | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Laboratorium test | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test code | |||
|style="background-color: white;"|cholesterol:mol/volume:moment:serum of plasma:kwantitatief: (code = '14647-2' in codeSystem 'LOINC') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test datum tijd | |||
|style="background-color: white;"|T + 1 maand om 16:00:00 uur | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test uitslag | |||
|style="background-color: white;"|1.7 mmol/l | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie bovengrens | |||
|style="background-color: white;"|1.8 mmol/l | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Interpretatie vlaggen | |||
|style="background-color: white;"|Onder referentiewaarde (code = '281300000' 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 | |||
|} | |||
=== Verpleegkundig zorgplan=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Verpleegkundig zorgplan | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="7" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Doelen en interventies | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="26"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Verpleegkundige interventie - met id: '<span id="bglz-1-3-verpleegkundigeinterventie-01"/>bglz-1-3-verpleegkundigeinterventie-01' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="24"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Interventie | |||
|style="background-color: white;"|aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Indicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem | |||
|style="background-color: white;"|Zie probleem met id: '[[#bglz-1-3-probleem-01|bglz-1-3-probleem-01]]' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Frequentie | |||
|style="background-color: white;"|1 per dag | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="8"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Product type | |||
|style="background-color: white;"|schuimverband (code = '448416005' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Anatomische locatie | |||
|style="background-color: white;"|hiel (code = '76853006' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Lateraliteit | |||
|style="background-color: white;"|Links (code = '7771000' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="8"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Product type | |||
|style="background-color: white;"|huidvervangende wondbedekkers (code = '465239008' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Anatomische locatie | |||
|style="background-color: white;"|hiel (code = '76853006' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Lateraliteit | |||
|style="background-color: white;"|Links (code = '7771000' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Uitkomsten | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Uitkomst van zorg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Zorgresultaat | |||
|style="background-color: white;"|Decubituswond is verbeterd van categorie 2 naar 1. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Verpleegkundige interventie | |||
|style="background-color: white;"|Zie verpleegkundige_interventie met id: '[[#bglz-1-3-verpleegkundigeinterventie-01|bglz-1-3-verpleegkundigeinterventie-01]]' | |||
|}<section end=MM-1.0-LZB-1.3-v1 /> | |||
==Scenario MM-2.0-LZB-1.1-v1== | |||
<section begin=MM-2.0-LZB-1.1-v1 /> | |||
=== Demografie en identificatie=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Demografie en identificatie | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="5" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Patient - met id: '<span id=""/>' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="32"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Fiona | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|F. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|XXX_Mutter | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Straat | |||
|style="background-color: white;"|Knolweg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Huisnummer | |||
|style="background-color: white;"|1001 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Postcode | |||
|style="background-color: white;"|9999XX | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Woonplaats | |||
|style="background-color: white;"|Stitswerd | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Land | |||
|style="background-color: white;"|Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Adres soort | |||
|style="background-color: white;"|Postadres (code = 'PST' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="10"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"|+31634567891 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telecom type | |||
|style="background-color: white;"|Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Nummer soort | |||
|style="background-color: white;"|Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email adres | |||
|style="background-color: white;"|fmutter@hotmail.com | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email soort | |||
|style="background-color: white;"|Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Identificatienummer | |||
|style="background-color: white;"|999911673 (in identificerend systeem: BSN) | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geboortedatum | |||
|style="background-color: white;"|8 feb 1964 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslacht | |||
|style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Meerling indicator | |||
|style="background-color: white;"|Nee | |||
|} | |||
=== Behandelrestricties=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Behandelrestricties | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="4" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Behandel aanwijzing | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Verificatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Geverifieerd | |||
|style="background-color: white;"|Ja | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Geverifieerd bij | |||
|style="background-color: white;"|Patiënt (code = '116154003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Verificatie datum | |||
|style="background-color: white;"|T | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Behandeling | |||
|style="background-color: white;"|Cardiopulmonaire resuscitatie (code = '89666000' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Behandeling toegestaan | |||
|style="background-color: white;"|Behandeling niet toegestaan en/of wenselijk (code = 'NEE' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Begin datum | |||
|style="background-color: white;"|T | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Wilsverklaring | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Wilsverklaring | |||
|style="background-color: white;"|Zie wilsverklaring met id: '[[#bglz-1-1-wilsverklaring-01|bglz-1-1-wilsverklaring-01]]' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Wilsverklaring - met id: '<span id="bglz-1-1-wilsverklaring-01"/>bglz-1-1-wilsverklaring-01' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Wilsverklaring type | |||
|style="background-color: white;"|Niet reanimeren verklaring (code = 'NR' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.14.1') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Wilsverklaring datum | |||
|style="background-color: white;"|T | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Vertegenwoordiger | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Contactpersoon | |||
|style="background-color: white;"|Zie contactpersoon met id: '[[#bglz-1-1-contactpersoon-01|bglz-1-1-contactpersoon-01]]' | |||
|} | |||
=== Contactpersonen=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactpersonen | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="5" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactpersoon - met id: '<span id="bglz-1-1-contactpersoon-01"/>bglz-1-1-contactpersoon-01' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="22"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Robert | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|R. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Prins | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="10"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"|06-34567891 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telecom type | |||
|style="background-color: white;"|Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Nummer soort | |||
|style="background-color: white;"|Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email adres | |||
|style="background-color: white;"|bprins@123net.nl | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email soort | |||
|style="background-color: white;"|Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Rol | |||
|style="background-color: white;"|Eerste relatie/contactpersoon (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Relatie | |||
|style="background-color: white;"|Zoon (code = 'SONC' in codeSystem 'HL7 RoleCode') | |||
|} | |||
=== Klachten en diagnoses=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Klachten en diagnoses | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="3" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem - met id: '<span id="bglz-1-1-probleem-01"/>bglz-1-1-probleem-01' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem type | |||
|style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|ischemisch cerebrovasculair accident (code = '422504002' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"|T | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Toelichting | |||
|style="background-color: white;"|Niet bekend met neurologische klachten | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem - met id: '<span id="bglz-1-1-probleem-02"/>bglz-1-1-probleem-02' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem type | |||
|style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|diabetes mellitus (code = '73211009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"|T - 14 jaar | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem - met id: '<span id="bglz-1-1-probleem-03"/>bglz-1-1-probleem-03' | |||
|-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;"|T | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem - met id: '<span id="bglz-1-1-probleem-04"/>bglz-1-1-probleem-04' | |||
|-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;"|T | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem - met id: '<span id="bglz-1-1-probleem-05"/>bglz-1-1-probleem-05' | |||
|-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;"|T | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem - met id: '<span id="bglz-1-1-probleem-06"/>bglz-1-1-probleem-06' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem type | |||
|style="background-color: white;"|Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem naam | |||
|style="background-color: white;"|afasie (code = '87486003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem begin datum | |||
|style="background-color: white;"|T | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem - met id: '<span id="bglz-1-1-probleem-07"/>bglz-1-1-probleem-07' | |||
|-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;"|T | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem - met id: '<span id="bglz-1-1-probleem-08"/>bglz-1-1-probleem-08' | |||
|-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;"|T | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem status | |||
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
|} | |||
=== Allergieen=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Allergieen | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="4" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Allergie intolerantie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Veroorzakende stof | |||
|style="background-color: white;"|pinda (code = '762952008' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Allergie status | |||
|style="background-color: white;"|Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Mate van kritiek zijn | |||
|style="background-color: white;"|Fataal (code = '399166001' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Toelichting | |||
|style="background-color: white;"|Na het eten van pinda's als student ontstond er een klinisch beeld van anafylaxie waarop de HA epipen heeft moeten toedienen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Reactie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Symptoom | |||
|style="background-color: white;"|Anafylaxie (code = '39579001' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Reactie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Symptoom | |||
|style="background-color: white;"|Angio-oedeem (code = '41291007' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Reactie beschrijving | |||
|style="background-color: white;"|Angio-oedeem van de tong, lippen en peri-orbitale regio met acute benauwdheid na het eten van pinda's. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Allergie intolerantie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Veroorzakende stof | |||
|style="background-color: white;"|nikkelsulfaat (code = '255848005' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Allergie status | |||
|style="background-color: white;"|Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Mate van kritiek zijn | |||
|style="background-color: white;"|Matig (code = '6736007' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Toelichting | |||
|style="background-color: white;"|Opgemerkt bij het dragen van nikkel bevattende sieraden. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Reactie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Symptoom | |||
|style="background-color: white;"|Contactdermatitis (code = '40275004' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Reactie beschrijving | |||
|style="background-color: white;"|Last van jeuk, roodheid en irritatie op de contactplek van nikkel bevattende sieraden. | |||
|} | |||
=== Uitslagen=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Uitslagen | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="4" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Laboratorium uitslag | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="17"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Laboratorium test | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test code | |||
|style="background-color: white;"|Hemoglobine (code = '718-7' in codeSystem 'LOINC') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test datum tijd | |||
|style="background-color: white;"|T om 15:00:00 uur | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test uitslag | |||
|style="background-color: white;"|11.0 g/dl | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie bovengrens | |||
|style="background-color: white;"|16.0 g/dl | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie ondergrens | |||
|style="background-color: white;"|12.0 g/dl | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Interpretatie vlaggen | |||
|style="background-color: white;"|Onder referentiewaarde (code = '281300000' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Laboratorium test | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test code | |||
|style="background-color: white;"|Hematocriet (code = '20570-8' in codeSystem 'LOINC') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test datum tijd | |||
|style="background-color: white;"|T om 15:00:00 uur | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test uitslag | |||
|style="background-color: white;"|47 % | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie bovengrens | |||
|style="background-color: white;"|51 % | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie ondergrens | |||
|style="background-color: white;"|39 % | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Onderzoek | |||
|style="background-color: white;"|hemoglobine & hematocriet panel (code = '24360-0' in codeSystem 'LOINC') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Laboratorium uitslag | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Laboratorium test | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test code | |||
|style="background-color: white;"|glucose 2 uur na maaltijd massa/volume serum of plasma (code = '1521-4' in codeSystem 'LOINC') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test datum tijd | |||
|style="background-color: white;"|T om 15:00:00 uur | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test uitslag | |||
|style="background-color: white;"|5.9 mg/dl | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie bovengrens | |||
|style="background-color: white;"|7.8 mg/dl | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie ondergrens | |||
|style="background-color: white;"|3.5 mg/dl | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Interpretatie vlaggen | |||
|style="background-color: white;"|Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Laboratorium uitslag | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Laboratorium test | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test code | |||
|style="background-color: white;"|cholesterol:mol/volume:moment:serum of plasma:kwantitatief: (code = '14647-2' in codeSystem 'LOINC') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test datum tijd | |||
|style="background-color: white;"|T om 15:00:00 uur | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Test uitslag | |||
|style="background-color: white;"|5.5 mmol/l | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Referentie bovengrens | |||
|style="background-color: white;"|1.8 mmol/l | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Interpretatie vlaggen | |||
|style="background-color: white;"|Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Toelichting | |||
|style="background-color: white;"|Volgens richtlijn herseninfarct: streven naar <1,8mmol/L | |||
|} | |||
=== Verrichtingen=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Verrichtingen | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="4" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verrichting | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="16"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting start datum | |||
|style="background-color: white;"|T | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting eind datum | |||
|style="background-color: white;"|T | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Indicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem | |||
|style="background-color: white;"|Zie probleem met id: '[[#bglz-1-1-probleem-01|bglz-1-1-probleem-01]]' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting type | |||
|style="background-color: white;"|computertomografie van hersenen (code = '34227000' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Locatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgaanbieder | |||
|style="background-color: white;"|Zie zorgaanbieder met id: '[[#bglz-1-1-zorgaanbieder-01|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;"|Zie zorgverlener met id: '[[#bglz-1-1-zorgverlener-02|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;"|Zie zorgverlener met id: '[[#bglz-1-1-zorgverlener-02|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;"|T | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting eind datum | |||
|style="background-color: white;"|T | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Indicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem | |||
|style="background-color: white;"|Zie probleem met id: '[[#bglz-1-1-probleem-01|bglz-1-1-probleem-01]]' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting type | |||
|style="background-color: white;"|percutane trombolyse van intracraniële arterie (code = '230935003' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Locatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgaanbieder | |||
|style="background-color: white;"|Zie zorgaanbieder met id: '[[#bglz-1-1-zorgaanbieder-01|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;"|Zie zorgverlener met id: '[[#bglz-1-1-zorgverlener-02|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;"|Zie zorgverlener met id: '[[#bglz-1-1-zorgverlener-02|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;"|T | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Indicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem | |||
|style="background-color: white;"|Zie probleem met id: '[[#bglz-1-1-probleem-05|bglz-1-1-probleem-05]]' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting type | |||
|style="background-color: white;"|fysiotherapie (code = '91251008' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Locatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgaanbieder | |||
|style="background-color: white;"|Zie zorgaanbieder met id: '[[#bglz-1-1-zorgaanbieder-01|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;"|Zie zorgverlener met id: '[[#bglz-1-1-zorgverlener-04|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;"|Zie zorgverlener met id: '[[#bglz-1-1-zorgverlener-02|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;"|T | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Indicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Probleem | |||
|style="background-color: white;"|Zie probleem met id: '[[#bglz-1-1-probleem-06|bglz-1-1-probleem-06]]' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting type | |||
|style="background-color: white;"|logopedische behandeling (code = '5154007' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Locatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Zorgaanbieder | |||
|style="background-color: white;"|Zie zorgaanbieder met id: '[[#bglz-1-1-zorgaanbieder-01|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;"|Zie zorgverlener met id: '[[#bglz-1-1-zorgverlener-05|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;"|Zie zorgverlener met id: '[[#bglz-1-1-zorgverlener-02|bglz-1-1-zorgverlener-02]]' | |||
|} | |||
=== 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 - met id: '<span id="bglz-1-1-verpleegkundigeinterventie-01"/>bglz-1-1-verpleegkundigeinterventie-01' | |||
|-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;"|Zie probleem met id: '[[#bglz-1-1-probleem-03|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;"|Zie zorgverlener met id: '[[#bglz-1-1-zorgverlener-03|bglz-1-1-zorgverlener-03]]' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Verpleegkundige interventie - met id: '<span id="bglz-1-1-verpleegkundigeinterventie-02"/>bglz-1-1-verpleegkundigeinterventie-02' | |||
|-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;"|Zie probleem met id: '[[#bglz-1-1-probleem-04|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;"|Zie zorgverlener met id: '[[#bglz-1-1-zorgverlener-03|bglz-1-1-zorgverlener-03]]' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Verpleegkundige interventie - met id: '<span id="bglz-1-1-verpleegkundigeinterventie-03"/>bglz-1-1-verpleegkundigeinterventie-03' | |||
|-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;"|Zie probleem met id: '[[#bglz-1-1-probleem-05|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;"|Zie zorgverlener met id: '[[#bglz-1-1-zorgverlener-03|bglz-1-1-zorgverlener-03]]' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Verpleegkundige interventie - met id: '<span id="bglz-1-1-verpleegkundigeinterventie-04"/>bglz-1-1-verpleegkundigeinterventie-04' | |||
|-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;"|Zie probleem met id: '[[#bglz-1-1-probleem-07|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;"|Zie zorgverlener met id: '[[#bglz-1-1-zorgverlener-03|bglz-1-1-zorgverlener-03]]' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Verpleegkundige interventie - met id: '<span id="bglz-1-1-verpleegkundigeinterventie-05"/>bglz-1-1-verpleegkundigeinterventie-05' | |||
|-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;"|Zie probleem met id: '[[#bglz-1-1-probleem-08|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;"|Zie zorgverlener met id: '[[#bglz-1-1-zorgverlener-03|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;"|Zie verpleegkundige_interventie met id: '[[#bglz-1-1-verpleegkundigeinterventie-01|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;"|Zie verpleegkundige_interventie met id: '[[#bglz-1-1-verpleegkundigeinterventie-02|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;"|Zie verpleegkundige_interventie met id: '[[#bglz-1-1-verpleegkundigeinterventie-03|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;"|Zie verpleegkundige_interventie met id: '[[#bglz-1-1-verpleegkundigeinterventie-04|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;"|Zie verpleegkundige_interventie met id: '[[#bglz-1-1-verpleegkundigeinterventie-05|bglz-1-1-verpleegkundigeinterventie-05]]' | |||
|} | |||
=== Zorgsetting=== | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Zorgsetting | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="6" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Huisarts | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgverlener - met id: '<span id="bglz-1-1-zorgverlener-01"/>bglz-1-1-zorgverlener-01' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="10"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Laura | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|L. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Lanen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Specialisme | |||
|style="background-color: white;"|Huisarts (code = '01.015' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgverleners rol | |||
|style="background-color: white;"|Verwijzer (code = 'REF' in codeSystem 'HL7 ParticipationType') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Hoofdbehandelaar | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="15"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgverlener - met id: '<span id="bglz-1-1-zorgverlener-02"/>bglz-1-1-zorgverlener-02' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Niels | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|N. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Helmond | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Specialisme | |||
|style="background-color: white;"|Neuroloog (code = '01.026' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Zorgaanbieder | |||
|style="background-color: white;"|Zie zorgaanbieder met id: '[[#bglz-1-1-zorgaanbieder-01|bglz-1-1-zorgaanbieder-01]]' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zorgverleners rol | |||
|style="background-color: white;"|Hoofdbehandelaar (code = 'RESP' in codeSystem 'HL7 ParticipationType') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Overige behandelaars | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="40"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgverlener - met id: '<span id="bglz-1-1-zorgverlener-03"/>bglz-1-1-zorgverlener-03' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Petra Johanna | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|P.J. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Vreeswijk | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Specialisme | |||
|style="background-color: white;"|Verpleegkundige (code = '30.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Zorgaanbieder | |||
|style="background-color: white;"|Zie zorgaanbieder met id: '[[#bglz-1-1-zorgaanbieder-01|bglz-1-1-zorgaanbieder-01]]' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgverlener - met id: '<span id="bglz-1-1-zorgverlener-04"/>bglz-1-1-zorgverlener-04' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Thomas | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|T. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Janssen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Specialisme | |||
|style="background-color: white;"|Fysiotherapeut (code = '04.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Zorgaanbieder | |||
|style="background-color: white;"|Zie zorgaanbieder met id: '[[#bglz-1-1-zorgaanbieder-01|bglz-1-1-zorgaanbieder-01]]' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgverlener - met id: '<span id="bglz-1-1-zorgverlener-05"/>bglz-1-1-zorgverlener-05' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Hilda | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|H. | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|Bruinsma | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Specialisme | |||
|style="background-color: white;"|Logopedist (code = '91.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Zorgaanbieder | |||
|style="background-color: white;"|Zie zorgaanbieder met id: '[[#bglz-1-1-zorgaanbieder-01|bglz-1-1-zorgaanbieder-01]]' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgaanbieder - met id: '<span id="bglz-1-1-zorgaanbieder-01"/>bglz-1-1-zorgaanbieder-01' | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="24"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Organisatie naam | |||
|style="background-color: white;"|AA-zkh | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Organisatie locatie | |||
|style="background-color: white;"|Noord | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Afdeling specialisme | |||
|style="background-color: white;"|Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT (Vektis Zorgverlenersspecificatie (subberoepsgroep))') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="10"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Telefoonnummer | |||
|style="background-color: white;"|+31182435768 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Telecom type | |||
|style="background-color: white;"|Vast telefoonnummer (code = 'LL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.22.1') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Nummer soort | |||
|style="background-color: white;"|Zakelijk telefoonnummer (code = 'WP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Email adres | |||
|style="background-color: white;"|neurologie@AAZ.nl | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Email soort | |||
|style="background-color: white;"|Zakelijk e-mailadres (code = 'WP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Straat | |||
|style="background-color: white;"|De Weststraat | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Huisnummer | |||
|style="background-color: white;"|3 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Postcode | |||
|style="background-color: white;"|9999PK | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Woonplaats | |||
|style="background-color: white;"|Stitswerd | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Land | |||
|style="background-color: white;"|Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Adres soort | |||
|style="background-color: white;"|Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Organisatie type | |||
|style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||
|}<section end=MM-2.0-LZB-1.1-v1 /> | |||
==Scenario MM-2.1-LZB-1.5-v1== | ==Scenario MM-2.1-LZB-1.5-v1== | ||
<section begin=MM-2.1-LZB-1.5-v1 /> | <section begin=MM-2.1-LZB-1.5-v1 /> | ||
Versie van 28 sep 2020 14:49
__NUMBEREDHEADINGS__

Addenda voor inhoudelijke gegevens
Scenario MM-1.0-LZB-1.3-v1
Demografie en identificatie
| Demografie en identificatie | |||||
| Gegevenselement | Waarde | ||||
| Patient | |||||
| Naamgegevens | |||||
| Voornamen | Fiona | ||||
| Initialen | F. | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Mutter | ||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1001 | ||||
| Postcode | 9999XX | ||||
| Woonplaats | Stitswerd | ||||
| Land | Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | ||||
| Adres soort | Postadres (code = 'PST' in codeSystem 'HL7 AddressUse') | ||||
| Contactgegevens | |||||
| Telefoonnummers | |||||
| Telefoonnummer | +31634567891 | ||||
| Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
| Nummer soort | Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
| Email adressen | |||||
| Email adres | fmutter@hotmail.com | ||||
| Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
| Identificatienummer | 999911673 (in identificerend systeem: BSN) | ||||
| Geboortedatum | 8 feb 1964 | ||||
| Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
| Meerling indicator | Nee | ||||
Klachten en diagnoses
| Klachten en diagnoses | |||
| Gegevenselement | Waarde | ||
| Probleem - met id: 'bglz-1-3-probleem-01' | |||
| Probleem anatomische locatie | hiel (code = '76853006' in codeSystem 'SNOMED CT') | ||
| Probleem lateraliteit | Links (code = '7771000' in codeSystem 'SNOMED CT') | ||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | decubitus (code = '399912005' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | T + 1 maand | ||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
Uitslagen
| Uitslagen | ||||
| Gegevenselement | Waarde | |||
| Laboratorium uitslag | ||||
| Laboratorium test | ||||
| Test code | cholesterol:mol/volume:moment:serum of plasma:kwantitatief: (code = '14647-2' in codeSystem 'LOINC') | |||
| Test datum tijd | T om 15:00:00 uur | |||
| Test uitslag | 5.5 mmol/l | |||
| Referentie bovengrens | 1.8 mmol/l | |||
| Interpretatie vlaggen | Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
| Toelichting | Volgens richtlijn herseninfarct: streven naar <1,8mmol/L | |||
| Laboratorium uitslag | ||||
| Laboratorium test | ||||
| Test code | cholesterol:mol/volume:moment:serum of plasma:kwantitatief: (code = '14647-2' in codeSystem 'LOINC') | |||
| Test datum tijd | T + 1 maand om 16:00:00 uur | |||
| Test uitslag | 1.7 mmol/l | |||
| Referentie bovengrens | 1.8 mmol/l | |||
| Interpretatie vlaggen | Onder referentiewaarde (code = '281300000' in codeSystem 'SNOMED CT') | |||
| Toelichting | Volgens richtlijn herseninfarct: streven naar <1,8mmol/L | |||
Verpleegkundig zorgplan
| Verpleegkundig zorgplan | |||||||
| Gegevenselement | Waarde | ||||||
| Doelen en interventies | |||||||
| Verpleegkundige interventie - met id: 'bglz-1-3-verpleegkundigeinterventie-01' | |||||||
| Interventie | aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED CT') | ||||||
| Indicatie | |||||||
| Probleem | Zie probleem met id: 'bglz-1-3-probleem-01' | ||||||
| Frequentie | 1 per dag | ||||||
| Medisch hulpmiddel | |||||||
| Medisch hulpmiddel | |||||||
| Product | |||||||
| Product type | schuimverband (code = '448416005' in codeSystem 'SNOMED CT') | ||||||
| Anatomische locatie | hiel (code = '76853006' in codeSystem 'SNOMED CT') | ||||||
| Lateraliteit | Links (code = '7771000' in codeSystem 'SNOMED CT') | ||||||
| Medisch hulpmiddel | |||||||
| Medisch hulpmiddel | |||||||
| Product | |||||||
| Product type | huidvervangende wondbedekkers (code = '465239008' in codeSystem 'SNOMED CT') | ||||||
| Anatomische locatie | hiel (code = '76853006' in codeSystem 'SNOMED CT') | ||||||
| Lateraliteit | Links (code = '7771000' in codeSystem 'SNOMED CT') | ||||||
| Uitkomsten | |||||||
| Uitkomst van zorg | |||||||
| Zorgresultaat | Decubituswond is verbeterd van categorie 2 naar 1. | ||||||
| Interventie | |||||||
| Verpleegkundige interventie | Zie verpleegkundige_interventie met id: 'bglz-1-3-verpleegkundigeinterventie-01' | ||||||
Scenario MM-2.0-LZB-1.1-v1
Demografie en identificatie
| Demografie en identificatie | |||||
| Gegevenselement | Waarde | ||||
| Patient - met id: '' | |||||
| Naamgegevens | |||||
| Voornamen | Fiona | ||||
| Initialen | F. | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Mutter | ||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1001 | ||||
| Postcode | 9999XX | ||||
| Woonplaats | Stitswerd | ||||
| Land | Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | ||||
| Adres soort | Postadres (code = 'PST' in codeSystem 'HL7 AddressUse') | ||||
| Contactgegevens | |||||
| Telefoonnummers | |||||
| Telefoonnummer | +31634567891 | ||||
| Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
| Nummer soort | Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
| Email adressen | |||||
| Email adres | fmutter@hotmail.com | ||||
| Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
| Identificatienummer | 999911673 (in identificerend systeem: BSN) | ||||
| Geboortedatum | 8 feb 1964 | ||||
| Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
| Meerling indicator | Nee | ||||
Behandelrestricties
| Behandelrestricties | ||||
| Gegevenselement | Waarde | |||
| Behandel aanwijzing | ||||
| Verificatie | ||||
| Geverifieerd | Ja | |||
| Geverifieerd bij | Patiënt (code = '116154003' in codeSystem 'SNOMED CT') | |||
| Verificatie datum | T | |||
| Behandeling | Cardiopulmonaire resuscitatie (code = '89666000' in codeSystem 'SNOMED CT') | |||
| Behandeling toegestaan | Behandeling niet toegestaan en/of wenselijk (code = 'NEE' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4') | |||
| Begin datum | T | |||
| Wilsverklaring | ||||
| Wilsverklaring | Zie wilsverklaring met id: 'bglz-1-1-wilsverklaring-01' | |||
| Wilsverklaring - met id: 'bglz-1-1-wilsverklaring-01' | ||||
| Wilsverklaring type | Niet reanimeren verklaring (code = 'NR' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.14.1') | |||
| Wilsverklaring datum | T | |||
| Vertegenwoordiger | ||||
| Contactpersoon | Zie contactpersoon met id: 'bglz-1-1-contactpersoon-01' | |||
Contactpersonen
| Contactpersonen | |||||
| Gegevenselement | Waarde | ||||
| Contactpersoon - met id: 'bglz-1-1-contactpersoon-01' | |||||
| Naamgegevens | |||||
| Voornamen | Robert | ||||
| Initialen | R. | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
| Geslachtsnaam | |||||
| Achternaam | Prins | ||||
| Contactgegevens | |||||
| Telefoonnummers | |||||
| Telefoonnummer | 06-34567891 | ||||
| Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
| Nummer soort | Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
| Email adressen | |||||
| Email adres | bprins@123net.nl | ||||
| Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
| Rol | Eerste relatie/contactpersoon (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472') | ||||
| Relatie | Zoon (code = 'SONC' in codeSystem 'HL7 RoleCode') | ||||
Klachten en diagnoses
| Klachten en diagnoses | |||
| Gegevenselement | Waarde | ||
| Probleem - met id: 'bglz-1-1-probleem-01' | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | ischemisch cerebrovasculair accident (code = '422504002' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | T | ||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Toelichting | Niet bekend met neurologische klachten | ||
| Probleem - met id: 'bglz-1-1-probleem-02' | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | diabetes mellitus (code = '73211009' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | T - 14 jaar | ||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem - met id: 'bglz-1-1-probleem-03' | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | probleem met zichzelf wassen en afdrogen (code = '288552005' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | T | ||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem - met id: 'bglz-1-1-probleem-04' | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | probleem met zichzelf kleden (code = '284972002' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | T | ||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem - met id: 'bglz-1-1-probleem-05' | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | probleem met lopen (code = '228158008' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | T | ||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem - met id: 'bglz-1-1-probleem-06' | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | afasie (code = '87486003' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | T | ||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem - met id: 'bglz-1-1-probleem-07' | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | risico op decubitus (code = '285304000' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | T | ||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem - met id: 'bglz-1-1-probleem-08' | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | overbelaste mantelzorg (code = '705044006' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | T | ||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
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 | T om 15:00:00 uur | |||
| Test uitslag | 11.0 g/dl | |||
| Referentie bovengrens | 16.0 g/dl | |||
| Referentie ondergrens | 12.0 g/dl | |||
| Interpretatie vlaggen | Onder referentiewaarde (code = '281300000' in codeSystem 'SNOMED CT') | |||
| Laboratorium test | ||||
| Test code | Hematocriet (code = '20570-8' in codeSystem 'LOINC') | |||
| Test datum tijd | T om 15:00:00 uur | |||
| Test uitslag | 47 % | |||
| Referentie bovengrens | 51 % | |||
| Referentie ondergrens | 39 % | |||
| Onderzoek | hemoglobine & hematocriet panel (code = '24360-0' in codeSystem 'LOINC') | |||
| Laboratorium uitslag | ||||
| Laboratorium test | ||||
| Test code | glucose 2 uur na maaltijd massa/volume serum of plasma (code = '1521-4' in codeSystem 'LOINC') | |||
| Test datum tijd | T om 15:00:00 uur | |||
| Test uitslag | 5.9 mg/dl | |||
| Referentie bovengrens | 7.8 mg/dl | |||
| Referentie ondergrens | 3.5 mg/dl | |||
| Interpretatie vlaggen | Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
| Laboratorium uitslag | ||||
| Laboratorium test | ||||
| Test code | cholesterol:mol/volume:moment:serum of plasma:kwantitatief: (code = '14647-2' in codeSystem 'LOINC') | |||
| Test datum tijd | T om 15:00:00 uur | |||
| Test uitslag | 5.5 mmol/l | |||
| Referentie bovengrens | 1.8 mmol/l | |||
| Interpretatie vlaggen | Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
| Toelichting | Volgens richtlijn herseninfarct: streven naar <1,8mmol/L | |||
Verrichtingen
| Verrichtingen | ||||
| Gegevenselement | Waarde | |||
| Verrichting | ||||
| Verrichting start datum | T | |||
| Verrichting eind datum | T | |||
| Indicatie | ||||
| Probleem | Zie probleem met id: 'bglz-1-1-probleem-01' | |||
| Verrichting type | computertomografie van hersenen (code = '34227000' in codeSystem 'SNOMED CT') | |||
| Locatie | ||||
| Zorgaanbieder | Zie zorgaanbieder met id: 'bglz-1-1-zorgaanbieder-01' | |||
| Uitvoerder | ||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-1-1-zorgverlener-02' | |||
| Aanvrager | ||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-1-1-zorgverlener-02' | |||
| Verrichting | ||||
| Verrichting start datum | T | |||
| Verrichting eind datum | T | |||
| Indicatie | ||||
| Probleem | Zie probleem met id: 'bglz-1-1-probleem-01' | |||
| Verrichting type | percutane trombolyse van intracraniële arterie (code = '230935003' in codeSystem 'SNOMED CT') | |||
| Locatie | ||||
| Zorgaanbieder | Zie zorgaanbieder met id: 'bglz-1-1-zorgaanbieder-01' | |||
| Uitvoerder | ||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-1-1-zorgverlener-02' | |||
| Aanvrager | ||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-1-1-zorgverlener-02' | |||
| Verrichting | ||||
| Verrichting start datum | T | |||
| Indicatie | ||||
| Probleem | Zie probleem met id: 'bglz-1-1-probleem-05' | |||
| Verrichting type | fysiotherapie (code = '91251008' in codeSystem 'SNOMED CT') | |||
| Locatie | ||||
| Zorgaanbieder | Zie zorgaanbieder met id: 'bglz-1-1-zorgaanbieder-01' | |||
| Uitvoerder | ||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-1-1-zorgverlener-04' | |||
| Aanvrager | ||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-1-1-zorgverlener-02' | |||
| Verrichting | ||||
| Verrichting start datum | T | |||
| Indicatie | ||||
| Probleem | Zie probleem met id: 'bglz-1-1-probleem-06' | |||
| Verrichting type | logopedische behandeling (code = '5154007' in codeSystem 'SNOMED CT') | |||
| Locatie | ||||
| Zorgaanbieder | Zie zorgaanbieder met id: 'bglz-1-1-zorgaanbieder-01' | |||
| Uitvoerder | ||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-1-1-zorgverlener-05' | |||
| Aanvrager | ||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-1-1-zorgverlener-02' | |||
Verpleegkundig zorgplan
| Verpleegkundig zorgplan | ||||||
| Gegevenselement | Waarde | |||||
| Doelen en interventies | ||||||
| Verpleegkundige interventie - met id: 'bglz-1-1-verpleegkundigeinterventie-01' | ||||||
| Interventie | ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED CT') | |||||
| Indicatie | ||||||
| Probleem | Zie probleem met id: 'bglz-1-1-probleem-03' | |||||
| Behandeldoel | ||||||
| Behandeldoel | ||||||
| Gewenst zorgresultaat | wassen onafhankelijk | |||||
| Frequentie | 1 per dag | |||||
| Uitvoerder | ||||||
| Zorgverlener | ||||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-1-1-zorgverlener-03' | |||||
| Verpleegkundige interventie - met id: 'bglz-1-1-verpleegkundigeinterventie-02' | ||||||
| Interventie | ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED CT') | |||||
| Indicatie | ||||||
| Probleem | Zie probleem met id: 'bglz-1-1-probleem-04' | |||||
| Behandeldoel | ||||||
| Behandeldoel | ||||||
| Gewenst zorgresultaat | kleden onafhankelijk | |||||
| Frequentie | 2 per dag | |||||
| Uitvoerder | ||||||
| Zorgverlener | ||||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-1-1-zorgverlener-03' | |||||
| Verpleegkundige interventie - met id: 'bglz-1-1-verpleegkundigeinterventie-03' | ||||||
| Interventie | patiënt mobiliseren (code = '62013009' in codeSystem 'SNOMED CT') | |||||
| Indicatie | ||||||
| Probleem | Zie probleem met id: 'bglz-1-1-probleem-05' | |||||
| Behandeldoel | ||||||
| Behandeldoel | ||||||
| Gewenst zorgresultaat | lopen met hulp | |||||
| Uitvoerder | ||||||
| Zorgverlener | ||||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-1-1-zorgverlener-03' | |||||
| Verpleegkundige interventie - met id: 'bglz-1-1-verpleegkundigeinterventie-04' | ||||||
| Interventie | wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED CT') | |||||
| Indicatie | ||||||
| Probleem | Zie probleem met id: 'bglz-1-1-probleem-07' | |||||
| Behandeldoel | ||||||
| Behandeldoel | ||||||
| Gewenst zorgresultaat | huid blijft intact | |||||
| Uitvoerder | ||||||
| Zorgverlener | ||||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-1-1-zorgverlener-03' | |||||
| Verpleegkundige interventie - met id: 'bglz-1-1-verpleegkundigeinterventie-05' | ||||||
| Interventie | ondersteuning voor verzorger (code = '386229000' in codeSystem 'SNOMED CT') | |||||
| Indicatie | ||||||
| Probleem | Zie probleem met id: 'bglz-1-1-probleem-08' | |||||
| Behandeldoel | ||||||
| Behandeldoel | ||||||
| Gewenst zorgresultaat | zorgtaken voor echtgenoot worden gecontinueerd | |||||
| Uitvoerder | ||||||
| Zorgverlener | ||||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-1-1-zorgverlener-03' | |||||
| Uitkomsten | ||||||
| Uitkomst van zorg | ||||||
| Zorgresultaat | Wassen met hulp. | |||||
| Interventie | ||||||
| Verpleegkundige interventie | Zie verpleegkundige_interventie met id: 'bglz-1-1-verpleegkundigeinterventie-01' | |||||
| Uitkomst van zorg | ||||||
| Zorgresultaat | Kleden met hulp. | |||||
| Interventie | ||||||
| Verpleegkundige interventie | Zie verpleegkundige_interventie met id: 'bglz-1-1-verpleegkundigeinterventie-02' | |||||
| Uitkomst van zorg | ||||||
| Zorgresultaat | Lopen geheel afhankelijk. | |||||
| Interventie | ||||||
| Verpleegkundige interventie | Zie verpleegkundige_interventie met id: 'bglz-1-1-verpleegkundigeinterventie-03' | |||||
| Uitkomst van zorg | ||||||
| Zorgresultaat | Huid is intact zonder decubitus wonden. | |||||
| Interventie | ||||||
| Verpleegkundige interventie | Zie verpleegkundige_interventie met id: 'bglz-1-1-verpleegkundigeinterventie-04' | |||||
| Uitkomst van zorg | ||||||
| Zorgresultaat | Thuiszorg is aangevraagd voor continuering van zorgtaken en huishoudelijke hulp. | |||||
| Interventie | ||||||
| Verpleegkundige interventie | Zie verpleegkundige_interventie met id: 'bglz-1-1-verpleegkundigeinterventie-05' | |||||
Zorgsetting
| Zorgsetting | ||||||
| Gegevenselement | Waarde | |||||
| Huisarts | ||||||
| Zorgverlener - met id: 'bglz-1-1-zorgverlener-01' | ||||||
| Naamgegevens | ||||||
| Voornamen | Laura | |||||
| Initialen | L. | |||||
| Geslachtsnaam | ||||||
| Achternaam | Lanen | |||||
| Specialisme | Huisarts (code = '01.015' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
| Zorgverleners rol | Verwijzer (code = 'REF' in codeSystem 'HL7 ParticipationType') | |||||
| Hoofdbehandelaar | ||||||
| Zorgverlener - met id: 'bglz-1-1-zorgverlener-02' | ||||||
| Naamgegevens | ||||||
| Voornamen | Niels | |||||
| Initialen | N. | |||||
| Geslachtsnaam | ||||||
| Achternaam | Helmond | |||||
| Specialisme | Neuroloog (code = '01.026' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
| Zorgaanbieder | ||||||
| Zorgaanbieder | Zie zorgaanbieder met id: 'bglz-1-1-zorgaanbieder-01' | |||||
| Zorgverleners rol | Hoofdbehandelaar (code = 'RESP' in codeSystem 'HL7 ParticipationType') | |||||
| Overige behandelaars | ||||||
| Zorgverlener - met id: 'bglz-1-1-zorgverlener-03' | ||||||
| Naamgegevens | ||||||
| Voornamen | Petra Johanna | |||||
| Initialen | P.J. | |||||
| Geslachtsnaam | ||||||
| Achternaam | Vreeswijk | |||||
| Specialisme | Verpleegkundige (code = '30.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
| Zorgaanbieder | ||||||
| Zorgaanbieder | Zie zorgaanbieder met id: 'bglz-1-1-zorgaanbieder-01' | |||||
| Zorgverlener - met id: 'bglz-1-1-zorgverlener-04' | ||||||
| Naamgegevens | ||||||
| Voornamen | Thomas | |||||
| Initialen | T. | |||||
| Geslachtsnaam | ||||||
| Achternaam | Janssen | |||||
| Specialisme | Fysiotherapeut (code = '04.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
| Zorgaanbieder | ||||||
| Zorgaanbieder | Zie zorgaanbieder met id: 'bglz-1-1-zorgaanbieder-01' | |||||
| Zorgverlener - met id: 'bglz-1-1-zorgverlener-05' | ||||||
| Naamgegevens | ||||||
| Voornamen | Hilda | |||||
| Initialen | H. | |||||
| Geslachtsnaam | ||||||
| Achternaam | Bruinsma | |||||
| Specialisme | Logopedist (code = '91.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
| Zorgaanbieder | ||||||
| Zorgaanbieder | Zie zorgaanbieder met id: 'bglz-1-1-zorgaanbieder-01' | |||||
| Zorgaanbieder - met id: 'bglz-1-1-zorgaanbieder-01' | ||||||
| Organisatie naam | AA-zkh | |||||
| Organisatie locatie | Noord | |||||
| Afdeling specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT (Vektis Zorgverlenersspecificatie (subberoepsgroep))') | |||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31182435768 | |||||
| Telecom type | Vast telefoonnummer (code = 'LL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.22.1') | |||||
| Nummer soort | Zakelijk telefoonnummer (code = 'WP' in codeSystem 'HL7 AddressUse') | |||||
| Email adressen | ||||||
| Email adres | neurologie@AAZ.nl | |||||
| Email soort | Zakelijk e-mailadres (code = 'WP' in codeSystem 'HL7 AddressUse') | |||||
| Adresgegevens | ||||||
| Straat | De Weststraat | |||||
| Huisnummer | 3 | |||||
| Postcode | 9999PK | |||||
| Woonplaats | Stitswerd | |||||
| Land | Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | |||||
| Adres soort | Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | |||||
| Organisatie type | Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||||
Scenario MM-2.1-LZB-1.5-v1
Demografie en identificatie
| Demografie en identificatie | |||||
| Gegevenselement | Waarde | ||||
| Patient | |||||
| Naamgegevens | |||||
| Voornamen | Fiona | ||||
| Initialen | F. | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Mutter | ||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1001 | ||||
| Postcode | 9999XX | ||||
| Woonplaats | Stitswerd | ||||
| Land | Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | ||||
| Adres soort | Postadres (code = 'PST' in codeSystem 'HL7 AddressUse') | ||||
| Contactgegevens | |||||
| Telefoonnummers | |||||
| Telefoonnummer | +31634567891 | ||||
| Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
| Nummer soort | Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
| Email adressen | |||||
| Email adres | fmutter@hotmail.com | ||||
| Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
| Identificatienummer | 999911673 (in identificerend systeem: BSN) | ||||
| Geboortedatum | 8 feb 1964 | ||||
| Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
| Meerling indicator | Nee | ||||
Behandelrestricties
| Behandelrestricties | ||||
| Gegevenselement | Waarde | |||
| Behandel aanwijzing | ||||
| Verificatie | ||||
| Geverifieerd | Ja | |||
| Geverifieerd bij | Patiënt (code = '116154003' in codeSystem 'SNOMED CT') | |||
| Verificatie datum | T | |||
| Behandeling | Cardiopulmonaire resuscitatie (code = '89666000' in codeSystem 'SNOMED CT') | |||
| Behandeling toegestaan | Behandeling niet toegestaan en/of wenselijk (code = 'NEE' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4') | |||
| Begin datum | T | |||
| Wilsverklaring | ||||
| Wilsverklaring | Zie wilsverklaring met id: 'bglz-2.1-1.5-wilsverklaring-01' | |||
| Wilsverklaring - met id: 'bglz-2.1-1.5-wilsverklaring-01' | ||||
| Wilsverklaring type | Niet reanimeren verklaring (code = 'NR' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.14.1') | |||
| Wilsverklaring datum | T | |||
| Vertegenwoordiger | ||||
| Contactpersoon | Zie contactpersoon met id: 'bglz-2.1-1.5-contactpersoon-01' | |||
Contactpersonen
| Contactpersonen | |||||
| Gegevenselement | Waarde | ||||
| Contactpersoon - met id: 'bglz-2.1-1.5-contactpersoon-01' | |||||
| Naamgegevens | |||||
| Voornamen | Robert | ||||
| Initialen | R. | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
| Geslachtsnaam | |||||
| Achternaam | Prins | ||||
| Contactgegevens | |||||
| Telefoonnummers | |||||
| Telefoonnummer | 06-34567891 | ||||
| Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
| Nummer soort | Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
| Email adressen | |||||
| Email adres | bprins@123net.nl | ||||
| Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
| Rol | Eerste relatie/contactpersoon (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472') | ||||
| Relatie | Zoon (code = 'SONC' in codeSystem 'HL7 RoleCode') | ||||
Klachten en diagnoses
| Klachten en diagnoses | |||
| Gegevenselement | Waarde | ||
| Probleem - met id: 'bglz-2.1-1.5-probleem-01' | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | ischemisch cerebrovasculair accident (code = '422504002' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | T | ||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Toelichting | Niet bekend met neurologische klachten | ||
| Probleem - met id: 'bglz-2.1-1.5-probleem-02' | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | diabetes mellitus (code = '73211009' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | T - 14 jaar | ||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem - met id: 'bglz-2.1-1.5-probleem-03' | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | probleem met zichzelf wassen en afdrogen (code = '288552005' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | T | ||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem - met id: 'bglz-2.1-1.5-probleem-04' | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | probleem met zichzelf kleden (code = '284972002' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | T | ||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem - met id: 'bglz-2.1-1.5-probleem-05' | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | probleem met lopen (code = '228158008' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | T | ||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem - met id: 'bglz-2.1-1.5-probleem-06' | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | afasie (code = '87486003' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | T | ||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem - met id: 'bglz-2.1-1.5-probleem-07' | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | risico op decubitus (code = '285304000' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | T | ||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| Probleem - met id: 'bglz-2.1-1.5-probleem-08' | |||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | ||
| Probleem naam | overbelaste mantelzorg (code = '705044006' in codeSystem 'SNOMED CT') | ||
| Probleem begin datum | T | ||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
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 | T om 15:00:00 uur | |||
| Test uitslag | 11.0 g/dl | |||
| Referentie bovengrens | 16.0 g/dl | |||
| Referentie ondergrens | 12.0 g/dl | |||
| Interpretatie vlaggen | Onder referentiewaarde (code = '281300000' in codeSystem 'SNOMED CT') | |||
| Laboratorium test | ||||
| Test code | Hematocriet (code = '20570-8' in codeSystem 'LOINC') | |||
| Test datum tijd | T om 15:00:00 uur | |||
| Test uitslag | 47 % | |||
| Referentie bovengrens | 51 % | |||
| Referentie ondergrens | 39 % | |||
| Onderzoek | hemoglobine & hematocriet panel (code = '24360-0' in codeSystem 'LOINC') | |||
| Laboratorium uitslag | ||||
| Laboratorium test | ||||
| Test code | glucose 2 uur na maaltijd massa/volume serum of plasma (code = '1521-4' in codeSystem 'LOINC') | |||
| Test datum tijd | T om 15:00:00 uur | |||
| Test uitslag | 5.9 mg/dl | |||
| Referentie bovengrens | 7.8 mg/dl | |||
| Referentie ondergrens | 3.5 mg/dl | |||
| Interpretatie vlaggen | Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
| Laboratorium uitslag | ||||
| Laboratorium test | ||||
| Test code | cholesterol:mol/volume:moment:serum of plasma:kwantitatief: (code = '14647-2' in codeSystem 'LOINC') | |||
| Test datum tijd | T om 15:00:00 uur | |||
| Test uitslag | 5.5 mmol/l | |||
| Referentie bovengrens | 1.8 mmol/l | |||
| Interpretatie vlaggen | Boven referentiewaarde (code = '281302008' in codeSystem 'SNOMED CT') | |||
| Toelichting | Volgens richtlijn herseninfarct: streven naar <1,8mmol/L | |||
Verrichtingen
| Verrichtingen | ||||
| Gegevenselement | Waarde | |||
| Verrichting | ||||
| Verrichting start datum | T | |||
| Verrichting eind datum | T | |||
| Indicatie | ||||
| Probleem | Zie probleem met id: 'bglz-2.1-1.5-probleem-01' | |||
| Verrichting type | computertomografie van hersenen (code = '34227000' in codeSystem 'SNOMED CT') | |||
| Locatie | ||||
| Zorgaanbieder | Zie zorgaanbieder met id: 'bglz-2.1-1.5-zorgaanbieder-01' | |||
| Uitvoerder | ||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-2.1-1.5-zorgverlener-02' | |||
| Aanvrager | ||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-2.1-1.5-zorgverlener-02' | |||
| Verrichting | ||||
| Verrichting start datum | T | |||
| Verrichting eind datum | T | |||
| Indicatie | ||||
| Probleem | Zie probleem met id: 'bglz-2.1-1.5-probleem-01' | |||
| Verrichting type | percutane trombolyse van intracraniële arterie (code = '230935003' in codeSystem 'SNOMED CT') | |||
| Locatie | ||||
| Zorgaanbieder | Zie zorgaanbieder met id: 'bglz-2.1-1.5-zorgaanbieder-01' | |||
| Uitvoerder | ||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-2.1-1.5-zorgverlener-02' | |||
| Aanvrager | ||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-2.1-1.5-zorgverlener-02' | |||
| Verrichting | ||||
| Verrichting start datum | T | |||
| Indicatie | ||||
| Probleem | Zie probleem met id: 'bglz-2.1-1.5-probleem-05' | |||
| Verrichting type | fysiotherapie (code = '91251008' in codeSystem 'SNOMED CT') | |||
| Locatie | ||||
| Zorgaanbieder | Zie zorgaanbieder met id: 'bglz-2.1-1.5-zorgaanbieder-01' | |||
| Uitvoerder | ||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-2.1-1.5-zorgverlener-04' | |||
| Aanvrager | ||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-2.1-1.5-zorgverlener-02' | |||
| Verrichting | ||||
| Verrichting start datum | T | |||
| Indicatie | ||||
| Probleem | Zie probleem met id: 'bglz-2.1-1.5-probleem-06' | |||
| Verrichting type | logopedische behandeling (code = '5154007' in codeSystem 'SNOMED CT') | |||
| Locatie | ||||
| Zorgaanbieder | Zie zorgaanbieder met id: 'bglz-2.1-1.5-zorgaanbieder-01' | |||
| Uitvoerder | ||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-2.1-1.5-zorgverlener-05' | |||
| Aanvrager | ||||
| Zorgverlener | Zie zorgverlener met id: 'bglz-2.1-1.5-zorgverlener-02' | |||
Verpleegkundig zorgplan ongestructureerd
| Verpleegkundig zorgplan ongestructureerd | ||
| Gegevenselement | Waarde | |
| Verpleegkundig zorgplan ongestructureerd | Verpleegkundig zorgplan in opgemaakte tekst | |
Zorgsetting
| Zorgsetting | ||||||
| Gegevenselement | Waarde | |||||
| Huisarts | ||||||
| Zorgverlener - met id: 'bglz-2.1-1.5-zorgverlener-01' | ||||||
| Naamgegevens | ||||||
| Voornamen | Laura | |||||
| Initialen | L. | |||||
| Geslachtsnaam | ||||||
| Achternaam | Lanen | |||||
| Specialisme | Huisarts (code = '01.015' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
| Zorgverleners rol | Verwijzer (code = 'REF' in codeSystem 'HL7 ParticipationType') | |||||
| Hoofdbehandelaar | ||||||
| Zorgverlener - met id: 'bglz-2.1-1.5-zorgverlener-02' | ||||||
| Naamgegevens | ||||||
| Voornamen | Niels | |||||
| Initialen | N. | |||||
| Geslachtsnaam | ||||||
| Achternaam | Helmond | |||||
| Specialisme | Neuroloog (code = '01.026' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
| Zorgaanbieder | ||||||
| Zorgaanbieder | Zie zorgaanbieder met id: 'bglz-2.1-1.5-zorgaanbieder-01' | |||||
| Zorgverleners rol | Hoofdbehandelaar (code = 'RESP' in codeSystem 'HL7 ParticipationType') | |||||
| Overige behandelaars | ||||||
| Zorgverlener - met id: 'bglz-2.1-1.5-zorgverlener-03' | ||||||
| Naamgegevens | ||||||
| Voornamen | Petra Johanna | |||||
| Initialen | P.J. | |||||
| Geslachtsnaam | ||||||
| Achternaam | Vreeswijk | |||||
| Specialisme | Verpleegkundige (code = '30.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
| Zorgaanbieder | ||||||
| Zorgaanbieder | Zie zorgaanbieder met id: 'bglz-2.1-1.5-zorgaanbieder-01' | |||||
| Zorgverlener - met id: 'bglz-2.1-1.5-zorgverlener-04' | ||||||
| Naamgegevens | ||||||
| Voornamen | Thomas | |||||
| Initialen | T. | |||||
| Geslachtsnaam | ||||||
| Achternaam | Janssen | |||||
| Specialisme | Fysiotherapeut (code = '04.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
| Zorgaanbieder | ||||||
| Zorgaanbieder | Zie zorgaanbieder met id: 'bglz-2.1-1.5-zorgaanbieder-01' | |||||
| Zorgverlener - met id: 'bglz-2.1-1.5-zorgverlener-05' | ||||||
| Naamgegevens | ||||||
| Voornamen | Hilda | |||||
| Initialen | H. | |||||
| Geslachtsnaam | ||||||
| Achternaam | Bruinsma | |||||
| Specialisme | Logopedist (code = '91.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | |||||
| Zorgaanbieder | ||||||
| Zorgaanbieder | Zie zorgaanbieder met id: 'bglz-2.1-1.5-zorgaanbieder-01' | |||||
| Zorgaanbieder - met id: 'bglz-2.1-1.5-zorgaanbieder-01' | ||||||
| Organisatie naam | AA-zkh | |||||
| Organisatie locatie | Noord | |||||
| Afdeling specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT (Vektis Zorgverlenersspecificatie (subberoepsgroep))') | |||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31182435768 | |||||
| Telecom type | Vast telefoonnummer (code = 'LL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.22.1') | |||||
| Nummer soort | Zakelijk telefoonnummer (code = 'WP' in codeSystem 'HL7 AddressUse') | |||||
| Email adressen | ||||||
| Email adres | neurologie@AAZ.nl | |||||
| Email soort | Zakelijk e-mailadres (code = 'WP' in codeSystem 'HL7 AddressUse') | |||||
| Adresgegevens | ||||||
| Straat | De Weststraat | |||||
| Huisnummer | 3 | |||||
| Postcode | 9999PK | |||||
| Woonplaats | Stitswerd | |||||
| Land | Nederland (code = '6030' in codeSystem '2.16.840.1.113883.2.4.4.16.34') | |||||
| Adres soort | Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | |||||
| Organisatie type | Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||||