mp:Vdraft Sandbox: verschil tussen versies
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{{DISPLAYTITLE:Sturen overdrachtsbericht volwassenen 4.0 - dekkingsgraad scenario's}} | |||
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= | =Dekkingsgraad scenario's voor Sturen overdrachtsbericht volwassenen 4.0= | ||
De volgende scenario's zijn meegenomen: | |||
* Test Overdracht volwassene 1.1(id: eOvd-SOV-tst-1.1-alle_zibs) | |||
* Test Overdracht 1.10b(id: eOvd-SOV-tst-1.10b-AGBcodes) | |||
=== | * Test Overdracht 1.11b(id: eOvd-SOV-tst-1.11b-URAzorgaanbieders) | ||
* Test Overdracht 1.1b(id: eOvd-SOV-tst-1.1b-alle_zibs) | |||
* Test Overdracht 1.2b(id: eOvd-SOV-tst-1.2b-naam_adres_contact) | |||
* Test Overdracht 1.3b(id: eOvd-SOV-tst-1.3b-betaler) | |||
* Test Overdracht 1.4b(id: eOvd-SOV-tst-1.4b-woningtype_other) | |||
* Test Overdracht 1.5(id: eOvd-SOV-tst-1.5-zwangerschap) | |||
* Test Overdracht 1.6(id: eOvd-SOV-tst-1.6-interventie-ggz) | |||
* Test Overdracht 1.7(id: eOvd-SOV-tst-1.7-interventie-wzd) | |||
* Test Overdracht 1.8(id: eOvd-SOV-tst-1.8-uitscheiding) | |||
* Test Overdracht 1.9b(id: eOvd-SOV-tst-1.9b-AGBcodes) | |||
Zie voor de inhoud van deze scenario's: [[TODO]]. Onderstaande tabel toont de unieke waarden voor ieder veld. Lege velden worden niet geraakt door de meegenomen bovenstaande scenario's. | |||
=== Administratieve gegevens === | |||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Administratieve gegevens | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="7" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Datum overplaatsing | |||
|style="background-color: white;"|<br/>T + 1 dag<br/><br/>T + 10 dagen<br/><br/>T + 2 dagen<br/><br/>T + 5 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Persoonsgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="113"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Patient | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="46"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="15"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Naamgegevens | |colspan="5"|Naamgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="13"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|<br/>Erik<br/><br/>Claire<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Initialen | |colspan="3"|Initialen | ||
|style="background-color: white;"|M | |style="background-color: white;"|<br/>E<br/><br/>M.<br/><br/>C<br/><br/>M<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Roepnaam | |||
|style="background-color: white;"|<br/>Françoise<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|<br/>Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geslachtsnaam | |colspan="4"|Geslachtsnaam | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Voorvoegsels | |||
|style="background-color: white;"|<br/>van<br/><br/>van de<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Achternaam | |colspan="2"|Achternaam | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>XXX_Altenborg<br/><br/>XXX_Hondius<br/><br/>Clinteren<br/><br/>XXX_Ven<br/><br/>XXX_Birkholz<br/><br/>XXX_Quigleys<br/><br/>XXX_Arcken<br/><br/>XXX_Schouten-Baak<br/><br/>XXX_Koutrik<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam partner | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Voorvoegsels partner | |||
|style="background-color: white;"|<br/>van de<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam partner | |||
|style="background-color: white;"|<br/>Put<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="14"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Adresgegevens | |colspan="5"|Adresgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="12"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Straat | |colspan="3"|Straat | ||
|style="background-color: white;"|Knolweg | |style="background-color: white;"|<br/>Knolweg<br/><br/>Cremstraat<br/><br/>Magnolialaan<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Huisnummer | |colspan="3"|Huisnummer | ||
|style="background-color: white;"|1003 | |style="background-color: white;"|<br/>1000<br/><br/>7<br/><br/>1<br/><br/>1002<br/><br/>1003<br/><br/>1001<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Huisnummerletter | |||
|style="background-color: white;"|<br/>G<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Huisnummertoevoeging | |||
|style="background-color: white;"|<br/>I<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Aanduiding bij nummer | |||
|style="background-color: white;"|<br/>Bij (code = 'by' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.3')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Postcode | |colspan="3"|Postcode | ||
|style="background-color: white;"|9999ZA | |style="background-color: white;"|<br/>9999XA<br/><br/>1240AB<br/><br/>4100AA<br/><br/>9999ZZ<br/><br/>9999ZA<br/><br/>9999XX<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Woonplaats | |colspan="3"|Woonplaats | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>Stitswerd<br/><br/>Finsterwolderhamrink<br/><br/>Ruurlo<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Gemeente | |colspan="3"|Gemeente | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>Finsterwolderhamrink<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Land | |colspan="3"|Land | ||
|style="background-color: white;"|(code = ' | |style="background-color: white;"|<br/>Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)')<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Additionele informatie | |||
|style="background-color: white;"|<br/>tijdelijk adres<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Adres soort | |colspan="3"|Adres soort | ||
|style="background-color: white;"|Postadres (code = 'PST' in codeSystem 'HL7 AddressUse') | |style="background-color: white;"|<br/>Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse')<br/><br/>Postadres (code = 'PST' in codeSystem 'HL7 AddressUse')<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Contactgegevens | |colspan="5"|Contactgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="7"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Telefoonnummers | |colspan="4"|Telefoonnummers | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"|<br/>+31634567891<br/><br/>+31612121212<br/><br/>+31709131313<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email adres | |||
|style="background-color: white;"|<br/>evertaltenborg@hotmail.com<br/><br/>claire@vanclinteren.nl<br/><br/>clinteren@planeet.nl<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Identificatienummer | |||
|style="background-color: white;"|<br/>999911612 (in identificerend systeem: BSN)<br/><br/>999900079 (in identificerend systeem: BSN)<br/><br/>999999072 (in identificerend systeem: BSN)<br/><br/>999900018 (in identificerend systeem: BSN)<br/><br/>999900031 (in identificerend systeem: BSN)<br/><br/>999900912 (in identificerend systeem: BSN)<br/><br/>999900043 (in identificerend systeem: BSN)<br/><br/>999900055 (in identificerend systeem: BSN)<br/><br/>999900067 (in identificerend systeem: BSN)<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Geboortedatum | |||
|style="background-color: white;"|<br/>14 aug 1964<br/><br/>18 sep 1963<br/><br/>1 jul 1950<br/><br/>5 nov 1963<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Geslacht | |||
|style="background-color: white;"|<br/>Man (code = 'M' in codeSystem 'HL7 AdministrativeGender')<br/><br/>Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Meerling indicator | |||
|style="background-color: white;"|<br/>Nee<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Betaler | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="19"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Betaler persoon | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Betaler naam | |||
|style="background-color: white;"|<br/>J. Rijk<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Bankgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Bank naam | |||
|style="background-color: white;"|<br/>ING<br/><br/>Triodos<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Bankcode | |||
|style="background-color: white;"|<br/>INGBNL2A<br/><br/>TRIONL2U<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Rekeningnummer | |||
|style="background-color: white;"|<br/>NL98INGB0003856625<br/><br/>NL98TRIO0254712320<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Verzekeraar | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verzekering | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Begin datum tijd | |||
|style="background-color: white;"|<br/>T + 25 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Eind datum tijd | |||
|style="background-color: white;"|<br/>T + 1 jaar<br/><br/>T + 250 dagen<br/><br/>T + 390 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verzekeringssoort | |||
|style="background-color: white;"|<br/>Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1')<br/><br/>Aanvullend verzekerd (code = 'A' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Identificatie nummer | |||
|style="background-color: white;"|<br/>9664 (in identificerend systeem: 2.16.840.1.113883.2.4.6.4)<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Organisatie naam | |||
|style="background-color: white;"|<br/>Trias<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Verzekerde nummer | |||
|style="background-color: white;"|<br/>12345678<br/><br/>22345678<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Contactpersoon | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="44"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="15"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|<br/>Johanna<br/><br/>Johannes<br/><br/>Hendrike<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|<br/>J<br/><br/>H<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Roepnaam | |||
|style="background-color: white;"|<br/>Hanna<br/><br/>Hans<br/><br/>Riek<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|<br/>Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Voorvoegsels | |||
|style="background-color: white;"|<br/>van<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|<br/>Bakker<br/><br/>Dijk<br/><br/>Smit<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam partner | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Voorvoegsels partner | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam partner | |||
|style="background-color: white;"|<br/>Timmerman<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Telefoonnummer | |colspan="2"|Telefoonnummer | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>+31645678912<br/><br/>+31612121212<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Email adres | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>jbakker@123net.nl<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="14"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Straat | |||
|style="background-color: white;"|<br/>Vincent van Goghplantsoen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Huisnummer | |||
|style="background-color: white;"|<br/>1<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Huisnummerletter | |||
|style="background-color: white;"|<br/>C<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Huisnummertoevoeging | |||
|style="background-color: white;"|<br/>II<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Aanduiding bij nummer | |||
|style="background-color: white;"|<br/>Bij (code = 'by' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.3')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Postcode | |||
|style="background-color: white;"|<br/>9999AA<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Woonplaats | |||
|style="background-color: white;"|<br/>Hoogmade<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Gemeente | |||
|style="background-color: white;"|<br/>Kaag en Braassem<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Land | |||
|style="background-color: white;"|<br/>Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Additionele informatie | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Adres soort | |||
|style="background-color: white;"|<br/>Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Rol | |||
|style="background-color: white;"|<br/>Eerste relatie/contactpersoon (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472')<br/><br/>Wettelijke vertegenwoordiger (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Relatie | |||
|style="background-color: white;"|<br/>Dochter (code = 'DAUC' in codeSystem 'HL7 RoleCode')<br/><br/>Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Sturende organisatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="61"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="31"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Zorgaanbieder identificatienummer | |||
|style="background-color: white;"|<br/>06590457 (in identificerend systeem: AGB-Z)<br/><br/>06121212 (in identificerend systeem: AGB-Z)<br/><br/>00123456 (in identificerend systeem: URA)<br/><br/>06343434 (in identificerend systeem: AGB-Z)<br/><br/>75616161 (in identificerend systeem: AGB-Z)<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Organisatie naam | |||
|style="background-color: white;"|<br/>AB-zkh<br/><br/>EF-zkh<br/><br/>GH-zkh<br/><br/>CD-zkh<br/><br/>HomeCare<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Organisatie locatie | |||
|style="background-color: white;"|<br/>Noord<br/><br/>Zuid<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Afdeling specialisme | |||
|style="background-color: white;"|<br/>Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/><br/>Medisch specialisten, longziekten (code = '0322' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/><br/>Medisch specialisten, urologie (code = '0306' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"|<br/>+31182435770<br/><br/>+311182435000<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Email adressen | |colspan="4"|Email adressen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email adres | |||
|style="background-color: white;"|<br/>neurologie@ABZ.nl<br/><br/>longziekten@cdz.nl<br/><br/>info@cdz.nl<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="14"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Straat | |||
|style="background-color: white;"|<br/>Knolweg<br/><br/>Raapweg<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Huisnummer | |||
|style="background-color: white;"|<br/>10<br/><br/>3<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Huisnummerletter | |||
|style="background-color: white;"|<br/>D<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Huisnummertoevoeging | |||
|style="background-color: white;"|<br/>II<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Aanduiding bij nummer | |||
|style="background-color: white;"|<br/>Bij (code = 'by' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.3')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Postcode | |||
|style="background-color: white;"|<br/>9999PO<br/><br/>9999PQ<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Woonplaats | |||
|style="background-color: white;"|<br/>Stitswerd<br/><br/>Bolsward<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Gemeente | |||
|style="background-color: white;"|<br/>Súdwest-Fryslân<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Land | |||
|style="background-color: white;"|<br/>Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Additionele informatie | |||
|style="background-color: white;"|<br/>tijdelijk adres<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Adres soort | |||
|style="background-color: white;"|<br/>Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Organisatie type | |||
|style="background-color: white;"|<br/>Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060')<br/><br/>Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="27"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Zorgverlener identificatienummer | |||
|style="background-color: white;"|<br/>21616161616 (in identificerend systeem: 2.16.528.1.1007.5.1)<br/><br/>91343434 (in identificerend systeem: AGB-Z)<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="15"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|<br/>Charlotte Maria<br/><br/>Ronald<br/><br/>Amanda<br/><br/>Bart<br/><br/>Veerle<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|<br/>C. M.<br/><br/>C.M.<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Roepnaam | |||
|style="background-color: white;"|<br/>Lotte<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|<br/>Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Voorvoegsels | |||
|style="background-color: white;"|<br/>van<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|<br/>Bruinsma<br/><br/>Tuinman<br/><br/>Kwikzilver<br/><br/>Ieperen<br/><br/>Moorman<br/><br/>Henneman<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam partner | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Voorvoegsels partner | |||
|style="background-color: white;"|<br/>de<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam partner | |||
|style="background-color: white;"|<br/>Smet<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Specialisme | |||
|style="background-color: white;"|<br/>Verpleegkundigen, niet nader gespecificeerd (code = '9100' in codeSystem 'Vektis AGB-medische specialismen')<br/><br/>Gespecialiseerd verpleegkundige, transfer (code = '9108' in codeSystem 'Vektis AGB-medische specialismen')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Telefoonnummer | |||
|style="background-color: white;"|<br/>+31687654321<br/><br/>+31182435770<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Email adres | |||
|style="background-color: white;"|<br/>transfervpk@cdz.nl<br/><br/>info@cdz.nl<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Ontvangende organisatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="61"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="31"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Zorgaanbieder identificatienummer | |||
|style="background-color: white;"|<br/>75131313 (in identificerend systeem: AGB-Z)<br/><br/>75616161 (in identificerend systeem: AGB-Z)<br/><br/>01234567 (in identificerend systeem: URA)<br/><br/>75131313 (in identificerend systeem: URA)<br/><br/>75565656 (in identificerend systeem: AGB-Z)<br/><br/>06121212 (in identificerend systeem: URA)<br/><br/>75727272 (in identificerend systeem: AGB-Z)<br/><br/>47707070 (in identificerend systeem: AGB-Z)<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Organisatie naam | |||
|style="background-color: white;"|<br/>ThuiszorgOrg<br/><br/>HomeCare<br/><br/>WijkZorg<br/><br/>WijkverplegingOrg<br/><br/>AB-zkh<br/><br/>St. Geestelijk Welzijn<br/><br/>St. Zonnehof<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Organisatie locatie | |||
|style="background-color: white;"|<br/>Noord<br/><br/>Zuid<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Afdeling specialisme | |||
|style="background-color: white;"|<br/>Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/><br/>Medisch specialisten, obstetrie en gynaecologie (code = '0307' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"|<br/>+31182435780<br/><br/>+31182435000<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Email adres | |colspan="2"|Email adres | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>info@thuiszorgorg.nl<br/><br/>intake@wijkverplegingorg.nl<br/><br/>info@wijkverplegingorg.nl<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="14"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Straat | |||
|style="background-color: white;"|<br/>Hoofdstraat<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Huisnummer | |||
|style="background-color: white;"|<br/>50<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Huisnummerletter | |||
|style="background-color: white;"|<br/>D<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Huisnummertoevoeging | |||
|style="background-color: white;"|<br/>III<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Aanduiding bij nummer | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Postcode | |||
|style="background-color: white;"|<br/>9999PT<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Woonplaats | |||
|style="background-color: white;"|<br/>Stitswerd<br/><br/>Drachten<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Gemeente | |||
|style="background-color: white;"|<br/>Smallingerland<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Land | |||
|style="background-color: white;"|<br/>Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Additionele informatie | |||
|style="background-color: white;"|<br/>tijdelijk adres<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Adres soort | |||
|style="background-color: white;"|<br/>Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Organisatie type | |||
|style="background-color: white;"|<br/>Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060')<br/><br/>Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060')<br/><br/>Geestelijke Gezondheidszorg (code = 'G5' in codeSystem '2.16.840.1.113883.2.4.15.1060')<br/><br/>Verpleeghuis (code = 'R5' in codeSystem '2.16.840.1.113883.2.4.15.1060')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="27"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Zorgverlener identificatienummer | |||
|style="background-color: white;"|<br/>21717171717 (in identificerend systeem: 2.16.528.1.1007.5.1)<br/><br/>91020202 (in identificerend systeem: AGB-Z)<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="15"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="13"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Voornamen | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>Mark<br/><br/>Annemarie<br/><br/>Johan<br/><br/>Kevin<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Initialen | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>M.P.<br/><br/>H.J.<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| | |colspan="3"|Roepnaam | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>Han<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|<br/>Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Voorvoegsels | |||
|style="background-color: white;"|<br/>van<br/><br/>de<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|<br/>Laren<br/><br/>Spoel<br/><br/>Groot<br/><br/>Kuiper<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam partner | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Voorvoegsels partner | |||
|style="background-color: white;"|<br/>van<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam partner | |||
|style="background-color: white;"|<br/>Donderen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Specialisme | |||
|style="background-color: white;"|<br/>Verpleegkundigen, niet nader gespecificeerd (code = '9100' in codeSystem 'Vektis AGB-medische specialismen')<br/><br/>Gespecialiseerd verpleegkundige, transfer (code = '9108' in codeSystem 'Vektis AGB-medische specialismen')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Telefoonnummer | |||
|style="background-color: white;"|<br/>+31678787878<br/><br/>+31182435000<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Email adres | |||
|style="background-color: white;"|<br/>han@wijkverplegingorg.nl<br/><br/>info@wijkverplegingorg.nl<br/> | |||
|} | |} | ||
=== | === Algemene patienten context === | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="10" | Algemene patienten context | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="9" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Gezinssituatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="17"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Gezinssituatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="15"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Burgerlijke staat | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Burgerlijke staat rc | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Burgerlijke staat | |||
|style="background-color: white;"|<br/>Gehuwd (code = 'M' in codeSystem '2.16.840.1.113883.5.2')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Gezinssamenstelling | |||
|style="background-color: white;"|<br/>Samenwonend met partner (code = '408821002' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Aantal kinderen | |||
|style="background-color: white;"|<br/>3<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Aantal kinderen inwonend | |||
|style="background-color: white;"|<br/>0<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgtaak | |||
|style="background-color: white;"|<br/>zorgt voor zijn vrouw die slecht ter been is<br/><br/>zorgt voor de hond<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Kind | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Geboortedatum | |||
|style="background-color: white;"|<br/>T - 30 jaar<br/><br/>T - 25 jaar<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Inwonend | |||
|style="background-color: white;"|<br/>Nee<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"|<br/>kinderen wonen ver weg en kunnen niet helpen bij dagelijkse zorg aan echtgenote<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Juridische situatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Juridische situatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Juridische status | |||
|style="background-color: white;"|<br/>Rechterlijke machtiging (code = 'RM' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.2')<br/><br/>Besluit tot opname en verblijf (code = 'OPM' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.2')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Vertegenwoordiging | |||
|style="background-color: white;"|<br/>Onder curatele stelling (code = '9' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.3')<br/><br/>Mentorschap (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.3')<br/><br/>Zaakwaarneming (code = '10' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.3')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Datum aanvang | |||
|style="background-color: white;"|<br/>T - 1 jaar<br/><br/>T - 3 dagen<br/><br/>T - 6 maanden<br/><br/>T - 5 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Datum einde | |||
|style="background-color: white;"|<br/>T + 3 maanden<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Woonomgeving | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Woonsituatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"|<br/>woning is op derde verdieping, is gelijkvloers en er is een lift aanwezig<br/><br/>woont tijdelijk in hotel<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Woning type | |||
|style="background-color: white;"|<br/>Appartement of flatwoning (code = 'FLATW' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.13.1')<br/><br/>Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): hotel<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Levensovertuiging | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Levensovertuiging rc | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Levensovertuiging | |||
|style="background-color: white;"|<br/>Geen geloof (code = 'GeenGeloof' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Wilsverklaring | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="8"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Wilsverklaring type | |||
|style="background-color: white;"|<br/>Verklaring donorschap (code = 'DO' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.14.1')<br/><br/>Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Wil niet gevaccineerd worden<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Wilsverklaring datum | |||
|style="background-color: white;"|<br/>T - 4 jaar<br/><br/>T - 1 jaar<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Vertegenwoordiger | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactpersoon | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Wilsverklaring document | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"|<br/>wilsverklaring bevindt zich in de portemonnee.<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Sociale omgeving | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="73"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Participatie in maatschappij | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Sociaal netwerk | |||
|style="background-color: white;"|<br/>heeft veel contact met collega's en buren<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Vrijetijdsbesteding | |||
|style="background-color: white;"|<br/>gitaar spelen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Arbeidssituatie | |||
|style="background-color: white;"|<br/>werkt als administratief medewerker bij gemeente<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"|<br/>heeft tijdelijk contract<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Hulp van anderen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="65"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Hulpverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="59"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="23"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Voornamen | |||
|style="background-color: white;"|<br/>Therese<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Initialen | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Roepnaam | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Naamgebruik | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voorvoegsels | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Achternaam | |||
|style="background-color: white;"|<br/>Roep<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Geslachtsnaam partner | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voorvoegsels partner | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Achternaam partner | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Telefoonnummer | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Email adres | |||
|style="background-color: white;"|<br/>thereseroep@zzp.nl<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Mantelzorger | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="27"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactpersoon | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="25"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| | |colspan="3"|Voornamen | ||
|style="background-color: white;"|1 | |style="background-color: white;"|<br/>Marriet<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|<br/>M.<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Roepnaam | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"|<br/>Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Voorvoegsels | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"|<br/>Blauw<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam partner | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Voorvoegsels partner | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam partner | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| | |colspan="4"|Email adressen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Email adres | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Rol | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>Buur (code = '19' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472')<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Relatie | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Zorgaanbieder identificatienummer | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Organisatie naam | |||
|style="background-color: white;"|<br/>WijZorgen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Organisatie locatie | |||
|style="background-color: white;"|<br/>Stitswerd<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Organisatie type | |||
|style="background-color: white;"|<br/>Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Aard | |||
|style="background-color: white;"|<br/>helpt met ondersteuning echtgenote als meneer er niet is<br/><br/>ondersteuning bij wassen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Frequentie | |||
|style="background-color: white;"|<br/>zo vaak als nodig<br/><br/>dagelijks<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Soort hulp | |||
|style="background-color: white;"|<br/>Mantelzorg (code = '386229000' in codeSystem 'SNOMED CT')<br/><br/>Professionele thuiszorg (code = '60689008' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"|<br/>niet in het weekend<br/><br/>alleen in het weekend<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Communicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="8"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Taalvaardigheid | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Communicatie taal | |||
|style="background-color: white;"|<br/>Nederlands (code = 'nl' in codeSystem 'ISO 639-1: Codes for the representation of names of languages -- Part 1: Alpha-2 code')<br/><br/>Limburgs (code = 'li' in codeSystem 'ISO 639-1: Codes for the representation of names of languages -- Part 1: Alpha-2 code')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Taalvaardigheid begrijpen | |||
|style="background-color: white;"|<br/>Redelijk (code = 'F' in codeSystem '2.16.840.1.113883.5.61')<br/><br/>Goed (code = 'G' in codeSystem '2.16.840.1.113883.5.61')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Taalvaardigheid spreken | |||
|style="background-color: white;"|<br/>Slecht (code = 'P' in codeSystem '2.16.840.1.113883.5.61')<br/><br/>Redelijk (code = 'F' in codeSystem '2.16.840.1.113883.5.61')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Taalvaardigheid lezen | |||
|style="background-color: white;"|<br/>Redelijk (code = 'F' in codeSystem '2.16.840.1.113883.5.61')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"|<br/>t.g.v. CVA nu moeite met begrijpen, spreken gaat ook moeilijk i.v.m. afasie<br/><br/>opgegroeid in Zuid-Limburg<br/> | |||
|} | |} | ||
=== | === Medische context === | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="9" | Medische context | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="8" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Behandelaar | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="55"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="53"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgverlener identificatienummer | |||
|style="background-color: white;"|<br/>03898989 (in identificerend systeem: AGB-Z)<br/><br/>03454545 (in identificerend systeem: AGB-Z)<br/><br/>04232323 (in identificerend systeem: AGB-Z)<br/><br/>03171717 (in identificerend systeem: AGB-Z)<br/><br/>01171717 (in identificerend systeem: AGB-Z)<br/><br/>03848484 (in identificerend systeem: AGB-Z)<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Voornamen | |||
|style="background-color: white;"|<br/>Joshua<br/><br/>G.<br/><br/>Elizabeth<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Initialen | |||
|style="background-color: white;"|<br/>J. P.<br/><br/>K.<br/><br/>M.<br/><br/>P.<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Roepnaam | |||
|style="background-color: white;"|<br/>Beth<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgebruik | |||
|style="background-color: white;"|<br/>Geslachtsnaam partner (code = 'NL2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Voorvoegsels | |||
|style="background-color: white;"|<br/>van<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Achternaam | |||
|style="background-color: white;"|<br/>Helmond<br/><br/>Spijkerman<br/><br/>Bronsgeest<br/><br/>Dooremaal<br/><br/>Oosterhout<br/><br/>Eindhoven<br/><br/>Boomsma<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Geslachtsnaam partner | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Voorvoegsels partner | |||
|style="background-color: white;"|<br/>ter<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Achternaam partner | |||
|style="background-color: white;"|<br/>Balkt<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Specialisme | |||
|style="background-color: white;"|<br/>Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/><br/>Medisch specialisten, gastro-enterologie (maag-darm-lever-arts) (code = '0318' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/><br/>Fysiotherapeuten, fysiotherapie (code = '0401' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/><br/>Medisch specialisten, obstetrie en gynaecologie (code = '0307' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/><br/>Huisartsen, niet nader gespecificeerd (code = '0100' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/><br/>Medisch specialisten, urologie (code = '0306' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummer | |||
|style="background-color: white;"|<br/>+31665656565<br/><br/>+31201212121<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adres | |||
|style="background-color: white;"|<br/>beth@fysio.nl<br/><br/>info@fysio.nl<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="27"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Zorgaanbieder identificatienummer | |||
|style="background-color: white;"|<br/>06590457 (in identificerend systeem: AGB-Z)<br/><br/>04121212 (in identificerend systeem: AGB-Z)<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Organisatie naam | |||
|style="background-color: white;"|<br/>AB-zkh<br/><br/>FysioOrg<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Organisatie locatie | |||
|style="background-color: white;"|<br/>Noord<br/><br/>West<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Afdeling specialisme | |||
|style="background-color: white;"|<br/>Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/><br/>Medisch specialisten, gastro-enterologie (maag-darm-lever-arts) (code = '0318' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/><br/>Fysiotherapeuten, fysiotherapie (code = '0401' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Telefoonnummer | |||
|style="background-color: white;"|<br/>+31182435770<br/><br/>+31795232323<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Email adres | |||
|style="background-color: white;"|<br/>neurologie@ABZ.nl<br/><br/>maagleverdarm@ABZ.nl<br/><br/>info@fysio.nl<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Straat | |||
|style="background-color: white;"|<br/>Knolweg<br/><br/>Kastanjelaan<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Huisnummer | |||
|style="background-color: white;"|<br/>10<br/><br/>13<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Huisnummerletter | |||
|style="background-color: white;"|<br/>D<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Huisnummertoevoeging | |||
|style="background-color: white;"|<br/>IV<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Aanduiding bij nummer | |||
|style="background-color: white;"|<br/>Tegenover (code = 'to' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.3')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Postcode | |||
|style="background-color: white;"|<br/>9999PO<br/><br/>3434CV<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Woonplaats | |||
|style="background-color: white;"|<br/>Stitswerd<br/><br/>Monnickendam<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Gemeente | |||
|style="background-color: white;"|<br/>Waterland<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Land | |||
|style="background-color: white;"|<br/>Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Additionele informatie | |||
|style="background-color: white;"|<br/>gaat binnenkort verhuizen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Adres soort | |||
|style="background-color: white;"|<br/>Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Organisatie type | |||
|style="background-color: white;"|<br/>Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060')<br/><br/>Zelfstandig behandelcentrum (code = 'Z4' in codeSystem '2.16.840.1.113883.2.4.15.1060')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Medische diagnose | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="10"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Probleem anatomische locatie | |||
|style="background-color: white;"|<br/>oksel (code = '91470000' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Probleem lateraliteit | |||
|style="background-color: white;"|<br/>Rechts en links (code = '51440002' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Probleem type | |||
|style="background-color: white;"|<br/>Diagnose (code = '282291009' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Probleem naam | |||
|style="background-color: white;"|<br/>ischemisch cerebrovasculair accident (code = '422504002' in codeSystem 'SNOMED CT')<br/><br/>neoplasma van colon (code = '126838000')<br/><br/>inverse psoriasis (code = '238600001')<br/><br/>ziekte van Parkinson (code = '49049000' in codeSystem 'SNOMED CT')<br/><br/>zwangerschapsgeïnduceerde hypertensie (code = '48194001' in codeSystem 'SNOMED CT')<br/><br/>niet-organische psychose (code = '191525009' in codeSystem 'SNOMED CT')<br/><br/>delier (code = '2776000' in codeSystem 'SNOMED CT')<br/><br/>fistel tussen blaas en sigmoïd (code = '197861003')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Probleem begin datum | |||
|style="background-color: white;"|<br/>T - 100 dagen<br/><br/>T - 150 dagen<br/><br/>T - 10 jaar<br/><br/>T - 30 dagen<br/><br/>T - 10 dagen<br/><br/>T - 5 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Probleem eind datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Probleem status | |||
|style="background-color: white;"|<br/>Actueel (code = '55561003' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Verificatie status | |||
|style="background-color: white;"|<br/>Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Toelichting | |||
|style="background-color: white;"|<br/>niet bekend met neurologische klachten<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Voorgeschiedenis | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="10"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Probleem anatomische locatie | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Probleem lateraliteit | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Probleem type | |||
|style="background-color: white;"|<br/>Diagnose (code = '282291009' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Probleem naam | |||
|style="background-color: white;"|<br/>diabetes mellitus (code = '73211009')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Probleem begin datum | |||
|style="background-color: white;"|<br/>T - 12 jaar<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Probleem eind datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Probleem status | |||
|style="background-color: white;"|<br/>Actueel (code = '55561003' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Verificatie status | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Allergie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="18"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Allergie intolerantie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="16"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Veroorzakende stof | |||
|style="background-color: white;"|<br/>nikkelsulfaat (code = '255848005' in codeSystem 'SNOMED CT')<br/><br/>pollen (code = '256259004')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Allergie categorie | |||
|style="background-color: white;"|<br/>Stof of product (code = '419199007' in codeSystem 'SNOMED CT')<br/><br/>Omgeving (code = '426232007' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Allergie status | |||
|style="background-color: white;"|<br/>Actief (code = 'active' in codeSystem 'HL7 ActStatus')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Begin datum tijd | |||
|style="background-color: white;"|<br/>T - 10 jaar<br/><br/>T - 500 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Mate van kritiek zijn | |||
|style="background-color: white;"|<br/>Matig (code = '6736007' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Laatste reactie datum tijd | |||
|style="background-color: white;"|<br/>T - 99 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Toelichting | |||
|style="background-color: white;"|<br/>opgemerkt bij het dragen van nikkel bevattende sieraden.<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Reactie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Symptoom | |||
|style="background-color: white;"|<br/>Contactdermatitis (code = '40275004' in codeSystem 'SNOMED CT')<br/><br/>Overgevoeligheidsreactie van de bovenste luchtwegen (code = '490008' in codeSystem 'SNOMED CT')<br/><br/>Kortademigheid (code = '267036007' in codeSystem 'SNOMED CT')<br/><br/>Koorts (code = '386661006' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Specifieke stof | |||
|style="background-color: white;"|<br/>graspollen (code = '256277009')<br/><br/>pollen van paprikaplant (code = '110181000146104')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Reactie beschrijving | |||
|style="background-color: white;"|<br/>last van jeuk, roodheid en irritatie op de contactplek van nikkel bevattende sieraden.<br/><br/>veelvuldig niezen<br/><br/>ernstige benauwdheid en koorts<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Ernst | |||
|style="background-color: white;"|<br/>Matig (code = '6736007' in codeSystem 'SNOMED CT')<br/><br/>Ernstig (code = '24484000' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Wijze van blootstelling | |||
|style="background-color: white;"|<br/>intra-epidermale route (code = '448077001' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Reactie tijdstip | |||
|style="background-color: white;"|<br/>T - 99 dagen<br/><br/>T - 200 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Let op | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Alert | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Alert naam | |||
|style="background-color: white;"|<br/>Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT')<br/><br/>Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Begin datum tijd | |||
|style="background-color: white;"|<br/>T - 20 dagen<br/><br/>T - 10 jaar<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Alert type | |||
|style="background-color: white;"|<br/>waarschuwing (code = '74018-3' in codeSystem 'LOINC')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Vrijheidsbeperking | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="11"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Vrijheidsbeperkende interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Wilsbekwaam | |||
|style="background-color: white;"|<br/>Ja<br/><br/>Nee<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Wilsbekwaam toelichting | |||
|style="background-color: white;"|<br/>wegens psychose<br/><br/>Kan eigen situatie niet beoordelen<br/><br/>Kan zich niet orienteren<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Juridische situatie | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Soort interventie | |||
|style="background-color: white;"|<br/>geforceerd toedienen van voeding bij patiënt (code = '37041007' in codeSystem 'SNOMED CT')<br/><br/>geslotendeurprocedure (code = '225210009' in codeSystem 'SNOMED CT')<br/><br/>separeren in extra beveiligde kamer (code = '124041000146108' in codeSystem 'SNOMED CT')<br/><br/>constante supervisie met camera (code = '121411000146104' in codeSystem 'SNOMED CT')<br/><br/>constante supervisie met elektronisch traceringsmiddel (code = '121451000146100' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Reden van toepassen | |||
|style="background-color: white;"|<br/>bevorderen van fysieke gezondheid (code = '121581000146106' in codeSystem 'SNOMED CT')<br/><br/>afwenden van situatie die kan resulteren in toebrengen van schade aan zichzelf of aan anderen (code = '121481000146105' in codeSystem 'SNOMED CT')<br/><br/>afwenden van crisissituatie (code = '121491000146107' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Instemming | |||
|style="background-color: white;"|<br/>Instemming patiënt (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.6.1')<br/><br/>Geen instemming patiënt (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.6.1')<br/><br/>Instemming wettelijke vertegenwoordiger (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.6.1')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Begin | |||
|style="background-color: white;"|<br/>T - 50 dagen<br/><br/>T + 1 dag<br/><br/>T - 4 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Einde | |||
|style="background-color: white;"|<br/>T + 3 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Meetwaarden | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="64"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Bloeddruk | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="11"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Meetmethode | |||
|style="background-color: white;"|<br/>Niet-invasief (code = '22762002' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Manchet type | |||
|style="background-color: white;"|<br/>Standaard (code = 'STD' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.15.1')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Meet locatie | |||
|style="background-color: white;"|<br/>Rechter bovenarm (code = '368209003' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Diastolisch eindpunt | |||
|style="background-color: white;"|<br/>Fase V (code = '255272007' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Systolische bloeddruk | |||
|style="background-color: white;"|<br/>170 mmhg<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Diastolische bloeddruk | |||
|style="background-color: white;"|<br/>90 mmhg<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Gemiddelde bloeddruk | |||
|style="background-color: white;"|<br/>110 mmhg<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Bloeddruk datum tijd | |||
|style="background-color: white;"|<br/>T - 20 dagen om 14:45 uur<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Toelichting | |||
|style="background-color: white;"|<br/>meneer gebruikt medicatie<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Houding | |||
|style="background-color: white;"|<br/>Liggende positie (code = '102538003' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Polsfrequentie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Polsfrequentie waarde | |||
|style="background-color: white;"|<br/>90<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Polsfrequentie datum tijd | |||
|style="background-color: white;"|<br/>T - 5 dagen om 14:45 uur<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Toelichting | |||
|style="background-color: white;"|<br/>is altijd sportief geweest<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Pols regelmatigheid | |||
|style="background-color: white;"|<br/>Polsslag regelmatig (code = '271636001' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Lichaamstemperatuur | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Temperatuur waarde | |||
|style="background-color: white;"|<br/>36.8 ºc<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Temperatuur datum tijd | |||
|style="background-color: white;"|<br/>T - 4 dagen om 07 uur<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Toelichting | |||
|style="background-color: white;"|<br/>voeten voelen heel koud aan<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Temperatuur type | |||
|style="background-color: white;"|<br/>Tympanische temperatuur (code = '415974002' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Ademhaling | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="26"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Ademfrequentie | |||
|style="background-color: white;"|<br/>18 /min<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Ademhaling datum tijd | |||
|style="background-color: white;"|<br/>T - 3 dagen om 14:45 uur<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Ritme | |||
|style="background-color: white;"|<br/>Abnormaal ademhalingsritme (code = '85617008' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Diepte | |||
|style="background-color: white;"|<br/>Normale ademhalingsdiepte (code = '301284009' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Afwijkend ademhalingspatroon | |||
|style="background-color: white;"|<br/>Apneu (code = '1023001' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Extra zuurstof toediening | |||
|style="background-color: white;"|<br/>Ja<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Toelichting | |||
|style="background-color: white;"|<br/>meneer lijkt angstig<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toegediende zuurstof | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="17"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Flow rate | |||
|style="background-color: white;"|<br/>2 l/min<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Fi o2 | |||
|style="background-color: white;"|<br/>0.29 l<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Toediening hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="11"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Product id | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Product type | |||
|style="background-color: white;"|<br/>Neusbril (code = '336623009' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Product omschrijving | |||
|style="background-color: white;"|<br/>neusbril<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Begin datum | |colspan="3"|Begin datum | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| | |colspan="3"|Toelichting | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| | |colspan="3"|Anatomische locatie | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Lateraliteit | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Zorgverlener | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="8"|Lichaamsgewicht | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |colspan="6"|Gewicht waarde | ||
|style="background-color: white;"|<br/>74 kg<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Toelichting | |||
|style="background-color: white;"|<br/>meneer volgt afvaldieet<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Gewicht datum tijd | |||
|style="background-color: white;"|<br/>T - 5 dagen om 14:30 uur<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Kleding | |||
|style="background-color: white;"|<br/>Volledig gekleed, inclusief schoenen (code = 'FULL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Lichaamslengte | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Lengte waarde | |||
|style="background-color: white;"|<br/>170 cm<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Lengte datum tijd | |||
|style="background-color: white;"|<br/>T - 5 dagen om 14:30 uur<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Toelichting | |||
|style="background-color: white;"|<br/>zonder schoenen aan<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Positie | |||
|style="background-color: white;"|<br/>Staande positie (code = '10904000' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Pijnscore | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Pijn score | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Pijnscore waarde | |||
|style="background-color: white;"|<br/>2<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Pijnscore datum tijd | |||
|style="background-color: white;"|<br/>T - 5 dagen om 14:45 uur<br/><br/>T - 1 dag om 12:30 uur<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Pijn meetmethode | |||
|style="background-color: white;"|<br/>NRS (code = 'NRS' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.9.1')<br/><br/>VAS10 (code = 'VAS10' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.9.1')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Anatomische locatie | |||
|style="background-color: white;"|<br/>gehele voet (code = '302545001' in codeSystem 'SNOMED Clinical Terms')<br/><br/>structuur van rug exclusief nek (code = '77568009' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|Lateraliteit | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>Links (code = '7771000' in codeSystem 'SNOMED CT')<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|Toelichting | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>Af en toe pijn, maar niet belemmerend bij het lopen<br/> | ||
|} | |} | ||
=== | === Verpleegkundige context zorgplan === | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="11" | Verpleegkundige context zorgplan | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="10" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| | |colspan="10"|Verpleegkundig zorgplan ongestructureerd | ||
|style="background-color: white;"|10 | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Actuele patientproblemen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="69"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Patientprobleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="67"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Probleem anatomische locatie | |||
|style="background-color: white;"|<br/>hiel (code = '76853006' in codeSystem 'SNOMED Clinical Terms')<br/><br/>structuur van rug exclusief nek (code = '77568009' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Probleem lateraliteit | |||
|style="background-color: white;"|<br/>Links (code = '7771000' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Probleem type | |||
|style="background-color: white;"|<br/>Diagnose (code = '282291009' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Probleem naam | |||
|style="background-color: white;"|<br/>probleem met zichzelf wassen en afdrogen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen')<br/><br/>probleem met zichzelf kleden (code = '284972002' in codeSystem 'Referentieset Nationale kernset patientproblemen')<br/><br/>decubitus (code = '399912005' in codeSystem 'Referentieset Nationale kernset patientproblemen')<br/><br/>loopt risico op delier (code = '430794006' in codeSystem 'Referentieset Nationale kernset patientproblemen')<br/><br/>pijn (bevinding) (code = '22253000' in codeSystem 'Referentieset Nationale kernset patientproblemen')<br/><br/>fysieke agressie (code = '248004009' in codeSystem 'Referentieset Nationale kernset patientproblemen')<br/><br/>acute verwardheid (code = '130987000' in codeSystem 'Referentieset Nationale kernset patientproblemen')<br/><br/>incontinentie voor feces (code = '72042002' in codeSystem 'Referentieset Nationale kernset patientproblemen')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Probleem begin datum | |||
|style="background-color: white;"|<br/>T - 100 dagen<br/><br/>T - 90 dagen<br/><br/>T - 5 dagen<br/><br/>T - 10 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Probleem eind datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Probleem status | |||
|style="background-color: white;"|<br/>Actueel (code = '55561003' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"|<br/>meneer kan niet buigen<br/><br/>vastgesteld met DOS score<br/><br/>bij lopen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Verpleegkundige interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="55"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Interventie | |||
|style="background-color: white;"|<br/>ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED Clinical Terms')<br/><br/>ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms')<br/><br/>aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED Clinical Terms')<br/><br/>wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED Clinical Terms')<br/><br/>bevorderen van vochtinname (code = '113148007' in codeSystem 'SNOMED Clinical Terms')<br/><br/>afleiden (code = '414039005' in codeSystem 'SNOMED Clinical Terms')<br/><br/>rustige en geruststellende houding aannemen (code = '225980008' in codeSystem 'SNOMED Clinical Terms')<br/><br/>omgevingsstimuli minimaliseren (code = '710978006' in codeSystem 'SNOMED Clinical Terms')<br/><br/>zorg bij fecale incontinentie (code = '386223004' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Indicatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Probleem | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Behandeldoel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Gewenst zorgresultaat | |||
|style="background-color: white;"|<br/>wassen onafhankelijk<br/><br/>kleden onafhankelijk<br/><br/>wondlengte < 1cm, wondbreedte < 1 cm<br/><br/>vochtinname > 1,5 liter/dag<br/><br/>Veilige omgeving is gerealiseerd voor patient/ naasten; duur VBI beperken<br/><br/>DOSS < 3<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Actie start datum tijd | |||
|style="background-color: white;"|<br/>T - 90 dagen<br/><br/>T - 10 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Actie eind datum tijd | |||
|style="background-color: white;"|<br/>T - 1 dag<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Frequentie | |||
|style="background-color: white;"|<br/>1 /dag<br/><br/>3 /dag<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Interval | |||
|style="background-color: white;"|<br/>4 uur<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="8"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Product id | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Product type | |||
|style="background-color: white;"|<br/>schuimverband (code = '448416005' in codeSystem 'SNOMED Clinical Terms')<br/><br/>huidvervangende wondbedekkers (code = '465239008' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product omschrijving | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgverlener | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Instructie | |||
|style="background-color: white;"|<br/>let op: valrisico<br/><br/>Graag er op toezien dat meneer > 1,5 liter per dag drinkt<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Uitvoerder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="31"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgverlener | |||
|style="background-color: white;"|<br/>Ja<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Verzorger | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="27"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactpersoon | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="25"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Roepnaam | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Voorvoegsels | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam partner | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Voorvoegsels partner | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam partner | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email adres | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Rol | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Relatie | |||
|style="background-color: white;"|<br/>Echtgenoot (code = 'HUSB' in codeSystem 'HL7 RoleCode')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Patient | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Zorgresultaat | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Uitkomst van zorg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Zorgresultaat | |||
|style="background-color: white;"|<br/>doel deels behaald: kan nog niet rug wassen<br/><br/>doel deels behaald, kan nog niet zelf veters strikken<br/><br/>zie pijnscore<br/><br/>doel is behaald<br/><br/>DOSS = 2<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Verpleegkundige interventie | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Afspraken patient | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="69"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Contact | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="67"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Contact type | |||
|style="background-color: white;"|<br/>Poliklinisch (code = 'AMB' in codeSystem 'HL7 ActCode')<br/><br/>Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): telefonisch<br/><br/>Thuis (code = 'HH' in codeSystem 'HL7 ActCode')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Contact met | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="27"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Zorgverlener | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="25"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgverlener identificatienummer | |||
|style="background-color: white;"|<br/>03686868 (in identificerend systeem: AGB-Z)<br/><br/>03676767 (in identificerend systeem: AGB-Z)<br/><br/>88131313 (in identificerend systeem: AGB-Z)<br/><br/>67676767 (in identificerend systeem: AGB-Z)<br/><br/>01454545 (in identificerend systeem: AGB-Z)<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Voornamen | |||
|style="background-color: white;"|<br/>Joshua<br/><br/>Nicolaas<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Initialen | |||
|style="background-color: white;"|<br/>J.P.<br/><br/>F.<br/><br/>J.<br/><br/>W.<br/><br/>N.<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Roepnaam | |||
|style="background-color: white;"|<br/>Klaas<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgebruik | |||
|style="background-color: white;"|<br/>Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Voorvoegsels | |||
|style="background-color: white;"|<br/>van<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Achternaam | |||
|style="background-color: white;"|<br/>Helmond<br/><br/>Snijder<br/><br/>Drooglever<br/><br/>Bloem<br/><br/>Pinxteren<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Geslachtsnaam partner | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Voorvoegsels partner | |||
|style="background-color: white;"|<br/>de<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Achternaam partner | |||
|style="background-color: white;"|<br/>Mol<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Specialisme | |||
|style="background-color: white;"|<br/>Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/><br/>Medisch specialisten, neurochirurgie (code = '0308' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/><br/>Medisch specialisten, inwendige geneeskunde (code = '0313' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/><br/>Ergotherapeut (code = '90.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)')<br/><br/>Huisartsen, niet nader gespecificeerd (code = '0100' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummer | |||
|style="background-color: white;"|<br/>+31616161616<br/><br/>+31612121212<br/><br/>+31689898989<br/><br/>+31203232323<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adres | |||
|style="background-color: white;"|<br/>bloem@ergotherapie.nl<br/><br/>snijder@poli.nl<br/><br/>klaas@huisartspraktijk.nl<br/><br/>info@huisartspraktijk.nl<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Locatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="29"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Zorgaanbieder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="27"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgaanbieder identificatienummer | |||
|style="background-color: white;"|<br/>06590457 (in identificerend systeem: AGB-Z)<br/><br/>01565656 (in identificerend systeem: AGB-Z)<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Organisatie naam | |||
|style="background-color: white;"|<br/>AB-zkh<br/><br/>Huisartspraktijk de Huisarts<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Organisatie locatie | |||
|style="background-color: white;"|<br/>Noord<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Afdeling specialisme | |||
|style="background-color: white;"|<br/>Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/><br/>Huisartsen, niet nader gespecificeerd (code = '0100' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummer | |||
|style="background-color: white;"|<br/>+31182435770<br/><br/>+31203232323<br/><br/>+31203232000<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|Email adressen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Email adres | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>neurologie@ABZ.nl<br/><br/>info@huisartspraktijk.nl<br/><br/>assistente@huisartspraktijk.nl<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Adresgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| | |colspan="5"|Straat | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>Knolweg<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Huisnummer | |||
|style="background-color: white;"|<br/>10<br/><br/>100<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Huisnummerletter | |||
|style="background-color: white;"|<br/>a<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Huisnummertoevoeging | |||
|style="background-color: white;"|<br/>III<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Aanduiding bij nummer | |||
|style="background-color: white;"|<br/>Bij (code = 'by' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.3')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Postcode | |||
|style="background-color: white;"|<br/>9999PO<br/><br/>4000KK<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Woonplaats | |||
|style="background-color: white;"|<br/>Stitswerd<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Gemeente | |||
|style="background-color: white;"|<br/>Het Hogeland<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Land | |||
|style="background-color: white;"|<br/>Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Additionele informatie | |||
|style="background-color: white;"|<br/>bedrijfsgebouw "De Stits"<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Adres soort | |||
|style="background-color: white;"|<br/>Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Organisatie type | |||
|style="background-color: white;"|<br/>Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060')<br/><br/>Huisartspraktijk (zelfstandig of groepspraktijk) (code = 'Z3' in codeSystem '2.16.840.1.113883.2.4.15.1060')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Begin datum tijd | |||
|style="background-color: white;"|<br/>T + 5 dagen om 10 uur<br/><br/>T + 20 dagen om 15:15 uur<br/><br/>T + 12 dagen om 15:15 uur<br/><br/>T + 5 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Eind datum tijd | |||
|style="background-color: white;"|<br/>T + 5 dagen om 10:30 uur<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Reden contact | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Reden contact tekst | |||
|style="background-color: white;"|<br/>Controle voortgang revalidatie<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Probleem | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Afwijkende uitslag | |||
|style="background-color: white;"|<br/>hoge PSA waarde<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Wensen en behoeften patient enof naasten | |||
|style="background-color: white;"|<br/>meneer wil zo snel mogelijk weer zelfstandig kunnen functioneren en zijn vrouw kunnen verzorgen<br/> | |||
|} | |} | ||
=== | === Verpleegkundige context specificatie gezondheidstoestand === | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="12" | Verpleegkundige context specificatie gezondheidstoestand | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="11" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="12"|Zelfzorg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="156"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Vermogen tot drinken | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Drinken | |||
|style="background-color: white;"|<br/>Hulp nodig (code = '16681000146102' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '')<br/><br/>Onafhankelijk (code = '19841000146104' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Drink beperkingen | |||
|style="background-color: white;"|<br/>Bereiden (openen/uitschenken) (code = '286506008' in codeSystem 'SNOMED CT')<br/><br/>Vastpakken (code = '307071002' in codeSystem 'SNOMED CT')<br/><br/>Naar mond brengen (code = '288876009' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Vermogen tot eten | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Begin datum | |rowspan="3"| | ||
|style="background-color: white;"| | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="9"|Eten | |||
|style="background-color: white;"|<br/>Hulp nodig (code = '129033007' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '1')<br/><br/>Onafhankelijk (code = '165224005' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '0')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Eet beperkingen | |||
|style="background-color: white;"|<br/>Snijden/openen (code = '289078003' in codeSystem 'SNOMED CT')<br/><br/>Eetgerei hanteren (code = '289046006' in codeSystem 'SNOMED CT')<br/><br/>Naar de mond brengen (code = '289010002' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Vermogen tot mondverzorging | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="16"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Verzorgen tanden | |||
|style="background-color: white;"|<br/>Hulp nodig (code = '16671000146104' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Prothese | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="11"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product id | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product type | |||
|style="background-color: white;"|<br/>Gebitsprothese (code = '27606000' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Product omschrijving | |||
|style="background-color: white;"|<br/>Gebitsprothese bovenkaak<br/><br/>Gebitsprothese onderkaak<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Begin datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Anatomische locatie | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Lateraliteit | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Vermogen tot zich wassen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Zich wassen | |||
|style="background-color: white;"|<br/>Hulp nodig (code = '16621000146103' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '')<br/><br/>Onafhankelijk (code = '19831000146107' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Te wassen lichaamsdeel | |||
|style="background-color: white;"|<br/>Onderlichaam (code = '362875007' in codeSystem 'SNOMED CT')<br/><br/>Bovenlichaam (code = '362874006' in codeSystem 'SNOMED CT')<br/><br/>Gezicht (code = '302549007' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Vermogen tot zich kleden | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Zich kleden | |||
|style="background-color: white;"|<br/>Hulp nodig (code = '129039006' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '')<br/><br/>Onafhankelijk (code = '129035000' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Te kleden lichaamsdeel | |||
|style="background-color: white;"|<br/>Onderlichaam (code = '362875007' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Vermogen tot uiterlijke verzorging | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Uiterlijke verzorging | |||
|style="background-color: white;"|<br/>Hulp nodig (code = '27941000146109' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Vermogen tot toiletgang | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toiletgebruik | |||
|style="background-color: white;"|<br/>Onafhankelijk (code = '129062008' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '0')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Zorg bij menstruatie | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Vermogen tot zelfstandig medicatiegebruik | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="56"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Zelfstandig medicatiegebruik | |||
|style="background-color: white;"|<br/>Hulp nodig (code = '27921000146103' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Hulp bij toediening | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="53"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Verpleegkundige interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="51"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="7"|Interventie | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>bevorderen van therapietrouw met behulp van medicijndispenser (code = '710153008' in codeSystem 'SNOMED Clinical Terms')<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="8"|Behandeldoel | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|Gewenst zorgresultaat | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>therapietrouw<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="7"|Actie start datum tijd | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
| | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
=== | |colspan="7"|Actie eind datum tijd | ||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|style="background-color: # | |colspan="7"|Frequentie | ||
|-style="background-color: # | |style="background-color: white;"|<br/>2 /d<br/> | ||
|colspan=" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|| | |colspan="7"|Interval | ||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="8"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Product id | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Product type | |||
|style="background-color: white;"|<br/>medicatierol (code = '713308004' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product omschrijving | |||
|style="background-color: white;"|<br/>baxterrol<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgverlener | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Instructie | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Uitvoerder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="30"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="6"|Zorgverlener | ||
|style="background-color: white;"| | |||
| | |||
| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="7"|Verzorger | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="27"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactpersoon | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="25"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Naamgegevens | |colspan="5"|Naamgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="13"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Initialen | |colspan="3"|Initialen | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Roepnaam | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Naamgebruik | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geslachtsnaam | |colspan="4"|Geslachtsnaam | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Voorvoegsels | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam partner | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Voorvoegsels partner | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Achternaam partner | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Contactgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Telefoonnummers | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email adres | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Rol | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Relatie | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Vermogen tot verpleegtechnische handelingen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="56"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Verpleegkundige interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="53"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Verpleegkundige interventie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="51"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Interventie | |||
|style="background-color: white;"|<br/>Stoma care procedure (code = '225194008' in codeSystem 'SNOMED Clinical Terms')<br/><br/>vervangen van verband (code = '18949003' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Behandeldoel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="6"|Gewenst zorgresultaat | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>goede hygiene met betrekking tot stoma<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Actie start datum tijd | |||
|style="background-color: white;"|<br/>T - 6 dagen<br/><br/>T - 1 dag<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Actie eind datum tijd | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Frequentie | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Interval | |||
|style="background-color: white;"|<br/>2 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="8"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Product id | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Product type | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product omschrijving | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Zorgverlener | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Instructie | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Uitvoerder | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="30"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Verzorger | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="27"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Contactpersoon | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="25"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|Naamgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Voornamen | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="3"|Initialen | ||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| | |colspan="3"|Roepnaam | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| | |colspan="3"|Naamgebruik | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Voorvoegsels | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Achternaam | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Geslachtsnaam partner | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Voorvoegsels partner | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Achternaam partner | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Contactgegevens | |colspan="5"|Contactgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="7"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Telefoonnummers | |colspan="4"|Telefoonnummers | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Telefoonnummer | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Email adressen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Email adres | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Rol | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Relatie | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Patient | |||
|style="background-color: white;"|<br/>Ja<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"|<br/>toezicht bij uitvoer, en instructie hygiënisch werken<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Verrichten vpkhandeling | |||
|style="background-color: white;"|<br/>Hulp nodig (code = '27931000146101' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Toelichting zelfzorg | |||
|style="background-color: white;"|<br/>kan zich steeds beter redden met wassen en kleden, knoopjes dichtdoen en schoenen met hulp. Ileostoma instructies gestart.<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="12"|Mobiliteit | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="23"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Mobiliteit | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="21"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Lopen | |||
|style="background-color: white;"|<br/>Hulp nodig (code = '16581000146103' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Traplopen | |||
|style="background-color: white;"|<br/>Volledig afhankelijk (code = '301589003' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Houding veranderen | |||
|style="background-color: white;"|<br/>Onafhankelijk (code = '19821000146105' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Houding handhaven | |||
|style="background-color: white;"|<br/>Onafhankelijk (code = '19811000146100' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Uitvoeren transfer | |||
|style="background-color: white;"|<br/>Hulp nodig (code = '714917003' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="11"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product id | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product type | |||
|style="background-color: white;"|<br/>rollator (code = '404946006' in codeSystem 'SNOMED Clinical Terms')<br/><br/>rolstoel (code = '58938008' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Product omschrijving | |||
|style="background-color: white;"|<br/>rollator<br/><br/>rolstoel<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Begin datum | |||
|style="background-color: white;"|<br/>T - 1 jaar<br/><br/>T - 1 maand<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"|<br/>voor langere afstanden<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Anatomische locatie | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Lateraliteit | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toelichting | |||
|style="background-color: white;"|<br/>lopen is stuk verbeterd, rechter been minder krachtig<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="12"|Voedingvocht | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="111"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Voedingsadvies | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="9"|Dieet type | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>suikervrij, diabetes dieet<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Consistentie | |||
|style="background-color: white;"|<br/>dik vloeibaar<br/><br/>solide<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toelichting | |||
|style="background-color: white;"|<br/>eet naar eigen keuze minder vlees<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Snaqscore | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Gewichtsverlies score | |||
|style="background-color: white;"|<br/>LossAverage (code = 'G1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.5.1 (ordinal = '2')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Eetlust score | |||
|style="background-color: white;"|<br/>Eetlust (code = 'B0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.5.2 (ordinal = '0')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Voedings score | |||
|style="background-color: white;"|<br/>GeenVoeding (code = 'Z0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.5.3 (ordinal = '0')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Totaal score | |||
|style="background-color: white;"|<br/>2<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Snaqscore datum tijd | |||
|style="background-color: white;"|<br/>T - 6 dagen om 17 uur<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toelichting | |||
|style="background-color: white;"|<br/>geen verminderde eetlust ondanks chemotherapie<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Snaqrc score | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="8"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Gewichtsverlies score | |||
|style="background-color: white;"|<br/>LossHigh (code = 'G2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.19.1 (ordinal = '2')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Eetlust score | |||
|style="background-color: white;"|<br/>Eetlust (code = 'B0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.19.2 (ordinal = '0')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Bmiscore | |||
|style="background-color: white;"|<br/>Gezond (code = 'B0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.19.3 (ordinal = '0')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Hulp bij eten | |||
|style="background-color: white;"|<br/>Onafhankelijk (code = '165224005' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '0')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Totaal score | |||
|style="background-color: white;"|<br/>2<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Snaqrc score datum tijd | |||
|style="background-color: white;"|<br/>T - 6 dagen om 17 uur<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toelichting | |||
|style="background-color: white;"|<br/>geen verminderde eetlust ondanks chemotherapie<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Snaq65score | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="8"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Gewichtsverlies score | |||
|style="background-color: white;"|<br/>LossLow (code = 'G0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.18.1 (ordinal = '0')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Bovenarm omtrek score | |||
|style="background-color: white;"|<br/>Normaal (code = 'A0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.18.4 (ordinal = '0')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Eetlust score | |||
|style="background-color: white;"|<br/>Eetlust (code = 'B0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.18.2 (ordinal = '0')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Inspannings score | |||
|style="background-color: white;"|<br/>Mogelijk (code = 'In0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.18.3 (ordinal = '0')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Totaal score | |||
|style="background-color: white;"|<br/>0<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Snaq65score datum tijd | |||
|style="background-color: white;"|<br/>T - 6 dagen om 17 uur<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toelichting | |||
|style="background-color: white;"|<br/>geen verminderde eetlust ondanks chemotherapie<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Mustscore | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Bmiscore | |||
|style="background-color: white;"|<br/>BMIHigh (code = 'B0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.4.1 (ordinal = '0')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Gewichtsverlies score | |||
|style="background-color: white;"|<br/>LossLow (code = 'G0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.4.2 (ordinal = '0')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Ziekte score | |||
|style="background-color: white;"|<br/>Ziek (code = 'Z1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.4.3 (ordinal = '2')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Totaal score | |||
|style="background-color: white;"|<br/>2<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Mustscore datum tijd | |||
|style="background-color: white;"|<br/>T - 12 dagen om 17 uur<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Vochtbalans | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Vocht totaal in | |||
|style="background-color: white;"|<br/>1400 ml<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Vocht totaal uit | |||
|style="background-color: white;"|<br/>1000 ml<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Vochtbalans starttijd | |||
|style="background-color: white;"|<br/>T - 6 dagen om 07 uur<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Vochtbalans stoptijd | |||
|style="background-color: white;"|<br/>T - 5 dagen om 07 uur<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Sonde systeem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="27"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Sonde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="11"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product id | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product type | |||
|style="background-color: white;"|<br/>Neus-maagsonde (code = '17102003' in codeSystem 'SNOMED CT')<br/><br/>PEJ sonde (code = '8911000146104' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Product omschrijving | |||
|style="background-color: white;"|<br/>neus- maagsonde<br/><br/>PEJ sonde<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Begin datum | |||
|style="background-color: white;"|<br/>T - 5 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Anatomische locatie | |||
|style="background-color: white;"|<br/>neusgat (code = '363538002' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Lateraliteit | |||
|style="background-color: white;"|<br/>Links (code = '7771000' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Sonde lengte | |||
|style="background-color: white;"|<br/>575 mm<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Product id | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Product type | |||
|style="background-color: white;"|<br/>enterale voedingspomp (code = '468664004' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Product omschrijving | |||
|style="background-color: white;"|<br/>enterale voedingspomp<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Begin datum | |||
|style="background-color: white;"|<br/>T - 5 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Zorgverlener | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toelichting | |||
|style="background-color: white;"|<br/>wegens misselijkheid door chemotherapie<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Infuus | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="35"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Infuuskatheter | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="11"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product id | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product type | |||
|style="background-color: white;"|<br/>Centraal veneuze katheter (code = '52124006' in codeSystem 'SNOMED CT')<br/><br/>Perifeer intraveneus infuus (code = '82449006' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Product omschrijving | |||
|style="background-color: white;"|<br/>centraal veneuze katheter<br/><br/>Perifeer intraveneus infuus<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Begin datum | |||
|style="background-color: white;"|<br/>T - 20 dagen<br/><br/>T - 15 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"|<br/>onder sleutelbeen links<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Anatomische locatie | |||
|style="background-color: white;"|<br/>structuur van vena subclavia (code = '9454009' in codeSystem 'SNOMED Clinical Terms')<br/><br/>onderarm (code = '14975008' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Lateraliteit | |||
|style="background-color: white;"|<br/>Links (code = '7771000' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toelichting | |||
|style="background-color: white;"|<br/>voor voeding<br/><br/>voor medicatie<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Lumen of lijn | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="18"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Lijn status | |||
|style="background-color: white;"|<br/>Lopend (code = 'LNP' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.12.1')<br/><br/>Afgedopt (code = 'DOP' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.12.1')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Lumen locatie | |||
|style="background-color: white;"|<br/>Distaal (code = '46053002' in codeSystem 'SNOMED CT')<br/><br/>Mediaal (code = '255561001' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toedienings systeem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="14"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Randapparaat | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="11"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Product id | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Product type | |||
|style="background-color: white;"|<br/>infuuspomp voor algemene doeleinden (code = '470575008' in codeSystem 'SNOMED Clinical Terms')<br/><br/>spuitpomp (code = '418657004' in codeSystem 'SNOMED Clinical Terms')<br/><br/>infuuspomp (code = '430033006' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Product omschrijving | |||
|style="background-color: white;"|<br/>infuuspomp<br/><br/>spuitpomp (infusor)<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Begin datum | |||
|style="background-color: white;"|<br/>T - 20 dagen<br/><br/>T - 14 dagen<br/><br/>T - 13 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Toelichting | |||
|style="background-color: white;"|<br/>voor heparine<br/><br/>voor NaCL/gluc<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Zorgverlener | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toedienings systeem toelichting | |||
|style="background-color: white;"|<br/>voor TPV<br/><br/>voor NaCL 0.9%<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="12"|Uitscheiding | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="79"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Blaasfunctie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="34"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Urine continentie | |||
|style="background-color: white;"|<br/>Af en toe een ongelukje (max. 1 keer per 24 uur) (code = '165233007' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '1')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Urostoma | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Stoma | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Urine katheter | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="11"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product id | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product type | |||
|style="background-color: white;"|<br/>Verblijfskatheter (code = '23973005' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Product omschrijving | |||
|style="background-color: white;"|<br/>Verblijfskatheter<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Begin datum | |||
|style="background-color: white;"|<br/>T - 5 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Anatomische locatie | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Lateraliteit | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Incontinentiemateriaal | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="11"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product id | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product type | |||
|style="background-color: white;"|<br/>inlegger voor incontinentiebroek (code = '470713005' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Product omschrijving | |||
|style="background-color: white;"|<br/>inlegger<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Begin datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Anatomische locatie | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Lateraliteit | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Darmfunctie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="21"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Feces continentie | |||
|style="background-color: white;"|<br/>Incontinent (code = '72042002' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '0')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Stoma | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Frequentie | |||
|style="background-color: white;"|<br/>2 per dag<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Defecatie consistentie | |||
|style="background-color: white;"|<br/>Helemaal vloeibaar (code = 'Type 7' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.3.1')<br/><br/>Zachte stukjes met gehavende randen (code = 'Type 6' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.3.1')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Defecatie kleur | |||
|style="background-color: white;"|<br/>Grijswit (code = '267056008' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Incontinentiemateriaal | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="11"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product id | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product type | |||
|style="background-color: white;"|<br/>opvangzak voor fecesincontinentie (code = '469627000' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Product omschrijving | |||
|style="background-color: white;"|<br/>opvangzak voor fecesincontinentie<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Begin datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Anatomische locatie | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Lateraliteit | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toelichting | |||
|style="background-color: white;"|<br/>stoma na subtotale darmresectie wegens coloncarcinoom<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Stoma | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="20"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Stoma type | |||
|style="background-color: white;"|<br/>eindstandige ileostoma (code = '311412005' in codeSystem 'SNOMED CT')<br/><br/>urostoma (code = '281601009' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Stoma materiaal | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="11"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Product | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product id | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product type | |||
|style="background-color: white;"|<br/>Ileostomy bag (code = '417136005' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Product omschrijving | |||
|style="background-color: white;"|<br/>stomazak voor ileostoma<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Begin datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Anatomische locatie | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Lateraliteit | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Anatomische locatie | |||
|style="background-color: white;"|<br/>onderbuik (code = '27033000' in codeSystem 'SNOMED Clinical Terms')<br/><br/>buikwand (code = '83908009' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Lateraliteit | |||
|style="background-color: white;"|<br/>Rechts (code = '24028007' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Aanleg datum | |||
|style="background-color: white;"|<br/>T - 12 dagen<br/><br/>T - 4 jaar<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toelichting | |||
|style="background-color: white;"|<br/>na subtotale darmresectie wegens coloncarcinoom<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="12"|Huid | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="63"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Brandwond | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Ontstaans datum | |||
|style="background-color: white;"|<br/>T - 2 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Uitgebreidheid | |||
|style="background-color: white;"|<br/>1 %<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Brandwond soort | |||
|style="background-color: white;"|<br/>Thermische brandwond (code = '105594005' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Anatomische locatie | |||
|style="background-color: white;"|<br/>onderarm (code = '362741001' in codeSystem 'SNOMED Clinical Terms')<br/><br/>handrug (code = '63125000' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Lateraliteit | |||
|style="background-color: white;"|<br/>Rechts (code = '24028007' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Dieptegraad | |||
|style="background-color: white;"|<br/>1e graad (code = '77140003' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '')<br/><br/>2e graad, oppervlakkig (code = '262587005' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toelichting | |||
|style="background-color: white;"|<br/>Meneer kreeg hete thee over zich heen, wond is ongeveer 2 bij 2 cm; geen verband nodig.<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Datum laatste verbandwissel | |||
|style="background-color: white;"|<br/>T - 1 dag<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Decubitus wond | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="11"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Decubitus categorie | |||
|style="background-color: white;"|<br/>Decubitus categorie 2 (code = '420324007' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '2')<br/><br/>Decubitus categorie 1 (code = '421076008' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '1')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Ontstaans datum | |||
|style="background-color: white;"|<br/>T - 2 dagen<br/><br/>T - 20 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Anatomische locatie | |||
|style="background-color: white;"|<br/>hiel (code = '76853006' in codeSystem 'SNOMED Clinical Terms')<br/><br/>stuitje (code = '182028002' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Lateraliteit | |||
|style="background-color: white;"|<br/>Links (code = '7771000' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Datum laatste verbandwissel | |||
|style="background-color: white;"|<br/>T - 1 dag<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Wondlengte | |||
|style="background-color: white;"|<br/>2 cm<br/><br/>3 cm<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Wondbreedte | |||
|style="background-color: white;"|<br/>2 cm<br/><br/>1 cm<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Wonddiepte | |||
|style="background-color: white;"|<br/>0.5 cm<br/><br/>0.2 cm<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Wond foto | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toelichting | |||
|style="background-color: white;"|<br/>Wond is niet geïnfecteerd.<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Huidaandoening | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="9"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Soort aandoening | |||
|style="background-color: white;"|<br/>Intertrigo/smetten (code = '58759008' in codeSystem 'SNOMED CT')<br/><br/>Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Inverse psoriasis<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Ontstaans datum | |||
|style="background-color: white;"|<br/>T - 6 dagen<br/><br/>T - 10 jaar<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Oorzaak | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="8"|Probleem | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Anatomische locatie | |||
|style="background-color: white;"|<br/>lies (code = '26893007' in codeSystem 'SNOMED Clinical Terms')<br/><br/>oksel (code = '91470000' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Lateraliteit | |||
|style="background-color: white;"|<br/>Rechts (code = '24028007' in codeSystem 'SNOMED CT')<br/><br/>Rechts en links (code = '51440002' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toelichting | |||
|style="background-color: white;"|<br/>Smetten zonder natten of infectie, inmiddels genezen.<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Wond | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="29"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Wond soort | |||
|style="background-color: white;"|<br/>Traumatische wond (code = '416462003' in codeSystem 'SNOMED CT')<br/><br/>Chirurgische wond (code = '112633009' in codeSystem 'SNOMED CT')<br/><br/>Oncologische ulcer (code = '94579000' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Wond weefsel | |||
|style="background-color: white;"|<br/>Rode wond (code = 'ROOD' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.7.2')<br/><br/>Graad II (code = 'GRAAD2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.7.1')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Wond infectie | |||
|style="background-color: white;"|<br/>Nee<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Wond vochtigheid | |||
|style="background-color: white;"|<br/>Droge wond (code = 'DROOG' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.7.3')<br/><br/>Vochtige wond (code = 'VOCHTIG' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.7.3')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Wond rand | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Wondlengte | |||
|style="background-color: white;"|<br/>2 cm<br/><br/>5 cm<br/><br/>1 cm<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Wondbreedte | |||
|style="background-color: white;"|<br/>4 cm<br/><br/>1 cm<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Wonddiepte | |||
|style="background-color: white;"|<br/>0.1 cm<br/><br/>4 cm<br/><br/>2 cm<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Anatomische locatie | |||
|style="background-color: white;"|<br/>knie (code = '72696002' in codeSystem 'SNOMED Clinical Terms')<br/><br/>onderbuik (code = '27033000' in codeSystem 'SNOMED Clinical Terms')<br/><br/>buikwand (code = '83908009' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Lateraliteit | |||
|style="background-color: white;"|<br/>Links (code = '7771000' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Wond ontstaansdatum | |||
|style="background-color: white;"|<br/>T - 12 dagen<br/><br/>T - 1 maand<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Datum laatste verbandwissel | |||
|style="background-color: white;"|<br/>T - 1 dag<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Drain | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="13"| | ||
|style="background-color: | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="9"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="11"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="8"|Product | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|Product id | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product type | |||
|style="background-color: white;"|<br/>wonddrain (code = '27033000' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Product omschrijving | |||
|style="background-color: white;"|<br/>wonddrain<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Begin datum | |||
|style="background-color: white;"|<br/>T - 12 dagen<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Anatomische locatie | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Lateraliteit | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="7"|Zorgverlener | ||
|style="background-color: white;"| | |style="background-color: white;"|referentie, zie bouwstenen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="9"|Wond foto | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="9"|Toelichting | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>oppervlakkige schaafwond na CVA, geen verband nodig<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="12"|Zintuigen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="36"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Functie horen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="16"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="9"|Hoor functie | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>Verminderde gehoorfunctie (code = '15188001' in codeSystem 'SNOMED CT')<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Horen hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="12"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="9"|Medisch hulpmiddel | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="10"| | |rowspan="10"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="8"|Product | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product id | |||
|style="background-color: white;"|<br/>012345678905 (code = '012345678905Global Trade Item Number (GTIN)')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product type | |||
|style="background-color: white;"|<br/>Gehoorapparaat (code = '6012004' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Product omschrijving | |||
|style="background-color: white;"|<br/>Gehoorapparaat<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Begin datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Anatomische locatie | |||
|style="background-color: white;"|<br/>Linkeroor (code = '89644007' in codeSystem 'SNOMED CT')<br/><br/>Rechteroor (code = '25577004' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Functie zien | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="17"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="9"|Visuele functie | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>Verminderd gezichtsvermogen (code = '397540003' in codeSystem 'SNOMED CT')<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="10"|Zien hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="13"| | ||
|style="background-color: | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="9"|Medisch hulpmiddel | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="11"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="8"|Product | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|Product id | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Product type | |||
|style="background-color: white;"|<br/>bril (code = '50121007' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Product omschrijving | |||
|style="background-color: white;"|<br/>bril<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Begin datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Toelichting | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Anatomische locatie | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Lateraliteit | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Zorgverlener | |||
|style="background-color: white;"|referentie, zie bouwstenen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toelichting | |||
|style="background-color: white;"|<br/>zonder bril bestaat verhoogd valrisico<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="12"|Ziektebeleving | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="6"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Ziektebeleving | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Ziekte inzicht van patient | |||
|style="background-color: white;"|<br/>meneer kan niet overzien wat de ziekte betekent in het dagelijkse leven<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Omgaan met ziekteproces door patient | |||
|style="background-color: white;"|<br/>meneer wil niet praten over de toekomst.<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="9"|Omgaan met ziekteproces door naasten | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>echtgenote maakt zich zorgen of zij de zorg voor meneer wel aan kan, omdat zij zelf ook slecht ter been is<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="12"|Mentale status | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="9"| | |rowspan="9"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Probleem | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Probleem type | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Probleem naam | |||
|style="background-color: white;"|<br/>gedaald bewustzijn (code = '443371007' in codeSystem 'SNOMED Clinical Terms')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="9"|Probleem begin datum | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>T - 22 dagen<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Probleem eind datum | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Probleem status | |||
|style="background-color: white;"|<br/>Actueel (code = '55561003' in codeSystem 'SNOMED CT')<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="9"|Toelichting | |||
|style="background-color: white;"|<br/>sinds cva, verminderde alertheid<br/> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="12"|Voortplanting | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="10"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="11"|Zwangerschap | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="8"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="9"|Zwanger | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>Ja<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="9"|Aterme datum | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>T + 120 dagen<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="9"|Datum laatste menstruatie | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>T - 170 dagen<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="9"|Zwangerschapsduur | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>160 dagen<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="9"|Graviditeit | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>1<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="9"|Pariteit | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>0<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="9"|Toelichting | ||
|style="background-color: white;"| | |style="background-color: white;"|<br/>Mevrouw is vaak misselijk in de ochtend.<br/> | ||
|} | |||
[[Categorie:Kwalificatie]] | |||
Versie van 6 dec 2021 11:01
__NUMBEREDHEADINGS__
|
Deze pagina is nog in bewerking |

Dekkingsgraad scenario's voor Sturen overdrachtsbericht volwassenen 4.0
De volgende scenario's zijn meegenomen:
- Test Overdracht volwassene 1.1(id: eOvd-SOV-tst-1.1-alle_zibs)
- Test Overdracht 1.10b(id: eOvd-SOV-tst-1.10b-AGBcodes)
- Test Overdracht 1.11b(id: eOvd-SOV-tst-1.11b-URAzorgaanbieders)
- Test Overdracht 1.1b(id: eOvd-SOV-tst-1.1b-alle_zibs)
- Test Overdracht 1.2b(id: eOvd-SOV-tst-1.2b-naam_adres_contact)
- Test Overdracht 1.3b(id: eOvd-SOV-tst-1.3b-betaler)
- Test Overdracht 1.4b(id: eOvd-SOV-tst-1.4b-woningtype_other)
- Test Overdracht 1.5(id: eOvd-SOV-tst-1.5-zwangerschap)
- Test Overdracht 1.6(id: eOvd-SOV-tst-1.6-interventie-ggz)
- Test Overdracht 1.7(id: eOvd-SOV-tst-1.7-interventie-wzd)
- Test Overdracht 1.8(id: eOvd-SOV-tst-1.8-uitscheiding)
- Test Overdracht 1.9b(id: eOvd-SOV-tst-1.9b-AGBcodes)
Zie voor de inhoud van deze scenario's: TODO. Onderstaande tabel toont de unieke waarden voor ieder veld. Lege velden worden niet geraakt door de meegenomen bovenstaande scenario's.
Administratieve gegevens
| Administratieve gegevens | |||||||
| Gegevenselement | Waarde | ||||||
| Datum overplaatsing | T + 1 dag T + 10 dagen T + 2 dagen T + 5 dagen | ||||||
| Persoonsgegevens | |||||||
| Patient | |||||||
| Naamgegevens | |||||||
| Naamgegevens | |||||||
| Voornamen | Erik Claire | ||||||
| Initialen | E M. C M | ||||||
| Roepnaam | Françoise | ||||||
| Naamgebruik | Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||||
| Geslachtsnaam | |||||||
| Voorvoegsels | van van de | ||||||
| Achternaam | XXX_Altenborg XXX_Hondius Clinteren XXX_Ven XXX_Birkholz XXX_Quigleys XXX_Arcken XXX_Schouten-Baak XXX_Koutrik | ||||||
| Geslachtsnaam partner | |||||||
| Voorvoegsels partner | van de | ||||||
| Achternaam partner | Put | ||||||
| Adresgegevens | |||||||
| Adresgegevens | |||||||
| Straat | Knolweg Cremstraat Magnolialaan | ||||||
| Huisnummer | 1000 7 1 1002 1003 1001 | ||||||
| Huisnummerletter | G | ||||||
| Huisnummertoevoeging | I | ||||||
| Aanduiding bij nummer | Bij (code = 'by' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.3') | ||||||
| Postcode | 9999XA 1240AB 4100AA 9999ZZ 9999ZA 9999XX | ||||||
| Woonplaats | Stitswerd Finsterwolderhamrink Ruurlo | ||||||
| Gemeente | Finsterwolderhamrink | ||||||
| Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||||||
| Additionele informatie | tijdelijk adres | ||||||
| Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') Postadres (code = 'PST' in codeSystem 'HL7 AddressUse') | ||||||
| Contactgegevens | |||||||
| Contactgegevens | |||||||
| Telefoonnummers | |||||||
| Telefoonnummer | +31634567891 +31612121212 +31709131313 | ||||||
| Email adressen | |||||||
| Email adres | evertaltenborg@hotmail.com claire@vanclinteren.nl clinteren@planeet.nl | ||||||
| Identificatienummer | 999911612 (in identificerend systeem: BSN) 999900079 (in identificerend systeem: BSN) 999999072 (in identificerend systeem: BSN) 999900018 (in identificerend systeem: BSN) 999900031 (in identificerend systeem: BSN) 999900912 (in identificerend systeem: BSN) 999900043 (in identificerend systeem: BSN) 999900055 (in identificerend systeem: BSN) 999900067 (in identificerend systeem: BSN) | ||||||
| Geboortedatum | 14 aug 1964 18 sep 1963 1 jul 1950 5 nov 1963 | ||||||
| Geslacht | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||||
| Meerling indicator | Nee | ||||||
| Betaler | |||||||
| Betaler persoon | |||||||
| Betaler naam | J. Rijk | ||||||
| Bankgegevens | |||||||
| Bank naam | ING Triodos | ||||||
| Bankcode | INGBNL2A TRIONL2U | ||||||
| Rekeningnummer | NL98INGB0003856625 NL98TRIO0254712320 | ||||||
| Verzekeraar | |||||||
| Verzekering | |||||||
| Begin datum tijd | T + 25 dagen | ||||||
| Eind datum tijd | T + 1 jaar T + 250 dagen T + 390 dagen | ||||||
| Verzekeringssoort | Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') Aanvullend verzekerd (code = 'A' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') | ||||||
| Identificatie nummer | 9664 (in identificerend systeem: 2.16.840.1.113883.2.4.6.4) | ||||||
| Organisatie naam | Trias | ||||||
| Verzekerde nummer | 12345678 22345678 | ||||||
| Contactpersoon | |||||||
| Naamgegevens | |||||||
| Naamgegevens | |||||||
| Voornamen | Johanna Johannes Hendrike | ||||||
| Initialen | J H | ||||||
| Roepnaam | Hanna Hans Riek | ||||||
| Naamgebruik | Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||||
| Geslachtsnaam | |||||||
| Voorvoegsels | van | ||||||
| Achternaam | Bakker Dijk Smit | ||||||
| Geslachtsnaam partner | |||||||
| Voorvoegsels partner | |||||||
| Achternaam partner | Timmerman | ||||||
| Contactgegevens | |||||||
| Contactgegevens | |||||||
| Telefoonnummers | |||||||
| Telefoonnummer | +31645678912 +31612121212 | ||||||
| Email adressen | |||||||
| Email adres | jbakker@123net.nl | ||||||
| Adresgegevens | |||||||
| Adresgegevens | |||||||
| Straat | Vincent van Goghplantsoen | ||||||
| Huisnummer | 1 | ||||||
| Huisnummerletter | C | ||||||
| Huisnummertoevoeging | II | ||||||
| Aanduiding bij nummer | Bij (code = 'by' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.3') | ||||||
| Postcode | 9999AA | ||||||
| Woonplaats | Hoogmade | ||||||
| Gemeente | Kaag en Braassem | ||||||
| Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||||||
| Additionele informatie | |||||||
| Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | ||||||
| Rol | Eerste relatie/contactpersoon (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472') Wettelijke vertegenwoordiger (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472') | ||||||
| Relatie | Dochter (code = 'DAUC' in codeSystem 'HL7 RoleCode') Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef | ||||||
| Sturende organisatie | |||||||
| Zorgaanbieder | |||||||
| Zorgaanbieder identificatienummer | 06590457 (in identificerend systeem: AGB-Z) 06121212 (in identificerend systeem: AGB-Z) 00123456 (in identificerend systeem: URA) 06343434 (in identificerend systeem: AGB-Z) 75616161 (in identificerend systeem: AGB-Z) | ||||||
| Organisatie naam | AB-zkh EF-zkh GH-zkh CD-zkh HomeCare | ||||||
| Organisatie locatie | Noord Zuid | ||||||
| Afdeling specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') Medisch specialisten, longziekten (code = '0322' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') Medisch specialisten, urologie (code = '0306' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | ||||||
| Contactgegevens | |||||||
| Contactgegevens | |||||||
| Telefoonnummers | |||||||
| Telefoonnummer | +31182435770 +311182435000 | ||||||
| Email adressen | |||||||
| Email adres | neurologie@ABZ.nl longziekten@cdz.nl info@cdz.nl | ||||||
| Adresgegevens | |||||||
| Adresgegevens | |||||||
| Straat | Knolweg Raapweg | ||||||
| Huisnummer | 10 3 | ||||||
| Huisnummerletter | D | ||||||
| Huisnummertoevoeging | II | ||||||
| Aanduiding bij nummer | Bij (code = 'by' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.3') | ||||||
| Postcode | 9999PO 9999PQ | ||||||
| Woonplaats | Stitswerd Bolsward | ||||||
| Gemeente | Súdwest-Fryslân | ||||||
| Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||||||
| Additionele informatie | tijdelijk adres | ||||||
| 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') Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060') | ||||||
| Zorgverlener | |||||||
| Zorgverlener identificatienummer | 21616161616 (in identificerend systeem: 2.16.528.1.1007.5.1) 91343434 (in identificerend systeem: AGB-Z) | ||||||
| Naamgegevens | |||||||
| Naamgegevens | |||||||
| Voornamen | Charlotte Maria Ronald Amanda Bart Veerle | ||||||
| Initialen | C. M. C.M. | ||||||
| Roepnaam | Lotte | ||||||
| Naamgebruik | Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||||
| Geslachtsnaam | |||||||
| Voorvoegsels | van | ||||||
| Achternaam | Bruinsma Tuinman Kwikzilver Ieperen Moorman Henneman | ||||||
| Geslachtsnaam partner | |||||||
| Voorvoegsels partner | de | ||||||
| Achternaam partner | Smet | ||||||
| Specialisme | Verpleegkundigen, niet nader gespecificeerd (code = '9100' in codeSystem 'Vektis AGB-medische specialismen') Gespecialiseerd verpleegkundige, transfer (code = '9108' in codeSystem 'Vektis AGB-medische specialismen') | ||||||
| Contactgegevens | |||||||
| Telefoonnummers | |||||||
| Telefoonnummer | +31687654321 +31182435770 | ||||||
| Email adressen | |||||||
| Email adres | transfervpk@cdz.nl info@cdz.nl | ||||||
| Ontvangende organisatie | |||||||
| Zorgaanbieder | |||||||
| Zorgaanbieder identificatienummer | 75131313 (in identificerend systeem: AGB-Z) 75616161 (in identificerend systeem: AGB-Z) 01234567 (in identificerend systeem: URA) 75131313 (in identificerend systeem: URA) 75565656 (in identificerend systeem: AGB-Z) 06121212 (in identificerend systeem: URA) 75727272 (in identificerend systeem: AGB-Z) 47707070 (in identificerend systeem: AGB-Z) | ||||||
| Organisatie naam | ThuiszorgOrg HomeCare WijkZorg WijkverplegingOrg AB-zkh St. Geestelijk Welzijn St. Zonnehof | ||||||
| Organisatie locatie | Noord Zuid | ||||||
| Afdeling specialisme | Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') Medisch specialisten, obstetrie en gynaecologie (code = '0307' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | ||||||
| Contactgegevens | |||||||
| Contactgegevens | |||||||
| Telefoonnummers | |||||||
| Telefoonnummer | +31182435780 +31182435000 | ||||||
| Email adressen | |||||||
| Email adres | info@thuiszorgorg.nl intake@wijkverplegingorg.nl info@wijkverplegingorg.nl | ||||||
| Adresgegevens | |||||||
| Adresgegevens | |||||||
| Straat | Hoofdstraat | ||||||
| Huisnummer | 50 | ||||||
| Huisnummerletter | D | ||||||
| Huisnummertoevoeging | III | ||||||
| Aanduiding bij nummer | |||||||
| Postcode | 9999PT | ||||||
| Woonplaats | Stitswerd Drachten | ||||||
| Gemeente | Smallingerland | ||||||
| Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||||||
| Additionele informatie | tijdelijk adres | ||||||
| Adres soort | Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||||
| Organisatie type | Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060') Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') Geestelijke Gezondheidszorg (code = 'G5' in codeSystem '2.16.840.1.113883.2.4.15.1060') Verpleeghuis (code = 'R5' in codeSystem '2.16.840.1.113883.2.4.15.1060') | ||||||
| Zorgverlener | |||||||
| Zorgverlener identificatienummer | 21717171717 (in identificerend systeem: 2.16.528.1.1007.5.1) 91020202 (in identificerend systeem: AGB-Z) | ||||||
| Naamgegevens | |||||||
| Naamgegevens | |||||||
| Voornamen | Mark Annemarie Johan Kevin | ||||||
| Initialen | M.P. H.J. | ||||||
| Roepnaam | Han | ||||||
| Naamgebruik | Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||||
| Geslachtsnaam | |||||||
| Voorvoegsels | van de | ||||||
| Achternaam | Laren Spoel Groot Kuiper | ||||||
| Geslachtsnaam partner | |||||||
| Voorvoegsels partner | van | ||||||
| Achternaam partner | Donderen | ||||||
| Specialisme | Verpleegkundigen, niet nader gespecificeerd (code = '9100' in codeSystem 'Vektis AGB-medische specialismen') Gespecialiseerd verpleegkundige, transfer (code = '9108' in codeSystem 'Vektis AGB-medische specialismen') | ||||||
| Contactgegevens | |||||||
| Telefoonnummers | |||||||
| Telefoonnummer | +31678787878 +31182435000 | ||||||
| Email adressen | |||||||
| Email adres | han@wijkverplegingorg.nl info@wijkverplegingorg.nl | ||||||
Algemene patienten context
| Algemene patienten context | |||||||||
| Gegevenselement | Waarde | ||||||||
| Gezinssituatie | |||||||||
| Gezinssituatie | |||||||||
| Burgerlijke staat | |||||||||
| Burgerlijke staat rc | |||||||||
| Burgerlijke staat | Gehuwd (code = 'M' in codeSystem '2.16.840.1.113883.5.2') | ||||||||
| Gezinssamenstelling | Samenwonend met partner (code = '408821002' in codeSystem 'SNOMED CT') | ||||||||
| Aantal kinderen | 3 | ||||||||
| Aantal kinderen inwonend | 0 | ||||||||
| Zorgtaak | zorgt voor zijn vrouw die slecht ter been is zorgt voor de hond | ||||||||
| Kind | |||||||||
| Geboortedatum | T - 30 jaar T - 25 jaar | ||||||||
| Inwonend | Nee | ||||||||
| Toelichting | kinderen wonen ver weg en kunnen niet helpen bij dagelijkse zorg aan echtgenote | ||||||||
| Juridische situatie | |||||||||
| Juridische situatie | |||||||||
| Juridische status | Rechterlijke machtiging (code = 'RM' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.2') Besluit tot opname en verblijf (code = 'OPM' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.2') | ||||||||
| Vertegenwoordiging | Onder curatele stelling (code = '9' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.3') Mentorschap (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.3') Zaakwaarneming (code = '10' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.3') | ||||||||
| Datum aanvang | T - 1 jaar T - 3 dagen T - 6 maanden T - 5 dagen | ||||||||
| Datum einde | T + 3 maanden | ||||||||
| Woonomgeving | |||||||||
| Woonsituatie | |||||||||
| Toelichting | woning is op derde verdieping, is gelijkvloers en er is een lift aanwezig woont tijdelijk in hotel | ||||||||
| Woning type | Appartement of flatwoning (code = 'FLATW' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.13.1') Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): hotel | ||||||||
| Levensovertuiging | |||||||||
| Levensovertuiging rc | |||||||||
| Levensovertuiging | Geen geloof (code = 'GeenGeloof' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4') | ||||||||
| Wilsverklaring | |||||||||
| Wilsverklaring type | Verklaring donorschap (code = 'DO' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.14.1') Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Wil niet gevaccineerd worden | ||||||||
| Wilsverklaring datum | T - 4 jaar T - 1 jaar | ||||||||
| Vertegenwoordiger | |||||||||
| Contactpersoon | referentie, zie bouwstenen | ||||||||
| Wilsverklaring document | |||||||||
| Toelichting | wilsverklaring bevindt zich in de portemonnee. | ||||||||
| Sociale omgeving | |||||||||
| Participatie in maatschappij | |||||||||
| Sociaal netwerk | heeft veel contact met collega's en buren | ||||||||
| Vrijetijdsbesteding | gitaar spelen | ||||||||
| Arbeidssituatie | werkt als administratief medewerker bij gemeente | ||||||||
| Toelichting | heeft tijdelijk contract | ||||||||
| Hulp van anderen | |||||||||
| Hulpverlener | |||||||||
| Zorgverlener | |||||||||
| Naamgegevens | |||||||||
| Voornamen | Therese | ||||||||
| Initialen | |||||||||
| Roepnaam | |||||||||
| Naamgebruik | |||||||||
| Geslachtsnaam | |||||||||
| Voorvoegsels | |||||||||
| Achternaam | Roep | ||||||||
| Geslachtsnaam partner | |||||||||
| Voorvoegsels partner | |||||||||
| Achternaam partner | |||||||||
| Contactgegevens | |||||||||
| Telefoonnummers | |||||||||
| Telefoonnummer | |||||||||
| Email adressen | |||||||||
| Email adres | thereseroep@zzp.nl | ||||||||
| Mantelzorger | |||||||||
| Contactpersoon | |||||||||
| Naamgegevens | |||||||||
| Voornamen | Marriet | ||||||||
| Initialen | M. | ||||||||
| Roepnaam | |||||||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||||||
| Geslachtsnaam | |||||||||
| Voorvoegsels | |||||||||
| Achternaam | Blauw | ||||||||
| Geslachtsnaam partner | |||||||||
| Voorvoegsels partner | |||||||||
| Achternaam partner | |||||||||
| Contactgegevens | |||||||||
| Telefoonnummers | |||||||||
| Telefoonnummer | |||||||||
| Email adressen | |||||||||
| Email adres | |||||||||
| Rol | Buur (code = '19' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472') | ||||||||
| Relatie | |||||||||
| Zorgaanbieder | |||||||||
| Zorgaanbieder identificatienummer | |||||||||
| Organisatie naam | WijZorgen | ||||||||
| Organisatie locatie | Stitswerd | ||||||||
| Organisatie type | Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060') | ||||||||
| Aard | helpt met ondersteuning echtgenote als meneer er niet is ondersteuning bij wassen | ||||||||
| Frequentie | zo vaak als nodig dagelijks | ||||||||
| Soort hulp | Mantelzorg (code = '386229000' in codeSystem 'SNOMED CT') Professionele thuiszorg (code = '60689008' in codeSystem 'SNOMED CT') | ||||||||
| Toelichting | niet in het weekend alleen in het weekend | ||||||||
| Communicatie | |||||||||
| Taalvaardigheid | |||||||||
| Communicatie taal | Nederlands (code = 'nl' in codeSystem 'ISO 639-1: Codes for the representation of names of languages -- Part 1: Alpha-2 code') Limburgs (code = 'li' in codeSystem 'ISO 639-1: Codes for the representation of names of languages -- Part 1: Alpha-2 code') | ||||||||
| Taalvaardigheid begrijpen | Redelijk (code = 'F' in codeSystem '2.16.840.1.113883.5.61') Goed (code = 'G' in codeSystem '2.16.840.1.113883.5.61') | ||||||||
| Taalvaardigheid spreken | Slecht (code = 'P' in codeSystem '2.16.840.1.113883.5.61') Redelijk (code = 'F' in codeSystem '2.16.840.1.113883.5.61') | ||||||||
| Taalvaardigheid lezen | Redelijk (code = 'F' in codeSystem '2.16.840.1.113883.5.61') | ||||||||
| Toelichting | t.g.v. CVA nu moeite met begrijpen, spreken gaat ook moeilijk i.v.m. afasie opgegroeid in Zuid-Limburg | ||||||||
Medische context
| Medische context | ||||||||
| Gegevenselement | Waarde | |||||||
| Behandelaar | ||||||||
| Zorgverlener | ||||||||
| Zorgverlener identificatienummer | 03898989 (in identificerend systeem: AGB-Z) 03454545 (in identificerend systeem: AGB-Z) 04232323 (in identificerend systeem: AGB-Z) 03171717 (in identificerend systeem: AGB-Z) 01171717 (in identificerend systeem: AGB-Z) 03848484 (in identificerend systeem: AGB-Z) | |||||||
| Naamgegevens | ||||||||
| Voornamen | Joshua G. Elizabeth | |||||||
| Initialen | J. P. K. M. P. | |||||||
| Roepnaam | Beth | |||||||
| Naamgebruik | Geslachtsnaam partner (code = 'NL2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||||||
| Geslachtsnaam | ||||||||
| Voorvoegsels | van | |||||||
| Achternaam | Helmond Spijkerman Bronsgeest Dooremaal Oosterhout Eindhoven Boomsma | |||||||
| Geslachtsnaam partner | ||||||||
| Voorvoegsels partner | ter | |||||||
| Achternaam partner | Balkt | |||||||
| Specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') Medisch specialisten, gastro-enterologie (maag-darm-lever-arts) (code = '0318' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') Fysiotherapeuten, fysiotherapie (code = '0401' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') Medisch specialisten, obstetrie en gynaecologie (code = '0307' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') Huisartsen, niet nader gespecificeerd (code = '0100' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') Medisch specialisten, urologie (code = '0306' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||||
| Contactgegevens | ||||||||
| Telefoonnummers | ||||||||
| Telefoonnummer | +31665656565 +31201212121 | |||||||
| Email adressen | ||||||||
| Email adres | beth@fysio.nl info@fysio.nl | |||||||
| Zorgaanbieder | ||||||||
| Zorgaanbieder identificatienummer | 06590457 (in identificerend systeem: AGB-Z) 04121212 (in identificerend systeem: AGB-Z) | |||||||
| Organisatie naam | AB-zkh FysioOrg | |||||||
| Organisatie locatie | Noord West | |||||||
| Afdeling specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') Medisch specialisten, gastro-enterologie (maag-darm-lever-arts) (code = '0318' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') Fysiotherapeuten, fysiotherapie (code = '0401' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||||
| Contactgegevens | ||||||||
| Telefoonnummers | ||||||||
| Telefoonnummer | +31182435770 +31795232323 | |||||||
| Email adressen | ||||||||
| Email adres | neurologie@ABZ.nl maagleverdarm@ABZ.nl info@fysio.nl | |||||||
| Adresgegevens | ||||||||
| Straat | Knolweg Kastanjelaan | |||||||
| Huisnummer | 10 13 | |||||||
| Huisnummerletter | D | |||||||
| Huisnummertoevoeging | IV | |||||||
| Aanduiding bij nummer | Tegenover (code = 'to' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.3') | |||||||
| Postcode | 9999PO 3434CV | |||||||
| Woonplaats | Stitswerd Monnickendam | |||||||
| Gemeente | Waterland | |||||||
| Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | |||||||
| Additionele informatie | gaat binnenkort verhuizen | |||||||
| 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') Zelfstandig behandelcentrum (code = 'Z4' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||||||
| Medische diagnose | ||||||||
| Probleem | ||||||||
| Probleem anatomische locatie | oksel (code = '91470000' in codeSystem 'SNOMED Clinical Terms') | |||||||
| Probleem lateraliteit | Rechts en links (code = '51440002' in codeSystem 'SNOMED CT') | |||||||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||||||
| Probleem naam | ischemisch cerebrovasculair accident (code = '422504002' in codeSystem 'SNOMED CT') neoplasma van colon (code = '126838000') inverse psoriasis (code = '238600001') ziekte van Parkinson (code = '49049000' in codeSystem 'SNOMED CT') zwangerschapsgeïnduceerde hypertensie (code = '48194001' in codeSystem 'SNOMED CT') niet-organische psychose (code = '191525009' in codeSystem 'SNOMED CT') delier (code = '2776000' in codeSystem 'SNOMED CT') fistel tussen blaas en sigmoïd (code = '197861003') | |||||||
| Probleem begin datum | T - 100 dagen T - 150 dagen T - 10 jaar T - 30 dagen T - 10 dagen T - 5 dagen | |||||||
| Probleem eind datum | ||||||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||||
| Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||||
| Toelichting | niet bekend met neurologische klachten | |||||||
| Voorgeschiedenis | ||||||||
| Probleem | ||||||||
| Probleem anatomische locatie | ||||||||
| Probleem lateraliteit | ||||||||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||||||
| Probleem naam | diabetes mellitus (code = '73211009') | |||||||
| Probleem begin datum | T - 12 jaar | |||||||
| Probleem eind datum | ||||||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||||
| Verificatie status | ||||||||
| Toelichting | ||||||||
| Allergie | ||||||||
| Allergie intolerantie | ||||||||
| Veroorzakende stof | nikkelsulfaat (code = '255848005' in codeSystem 'SNOMED CT') pollen (code = '256259004') | |||||||
| Allergie categorie | Stof of product (code = '419199007' in codeSystem 'SNOMED CT') Omgeving (code = '426232007' in codeSystem 'SNOMED CT') | |||||||
| Allergie status | Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||||||
| Begin datum tijd | T - 10 jaar T - 500 dagen | |||||||
| Mate van kritiek zijn | Matig (code = '6736007' in codeSystem 'SNOMED CT') | |||||||
| Laatste reactie datum tijd | T - 99 dagen | |||||||
| Toelichting | opgemerkt bij het dragen van nikkel bevattende sieraden. | |||||||
| Reactie | ||||||||
| Symptoom | Contactdermatitis (code = '40275004' in codeSystem 'SNOMED CT') Overgevoeligheidsreactie van de bovenste luchtwegen (code = '490008' in codeSystem 'SNOMED CT') Kortademigheid (code = '267036007' in codeSystem 'SNOMED CT') Koorts (code = '386661006' in codeSystem 'SNOMED CT') | |||||||
| Specifieke stof | graspollen (code = '256277009') pollen van paprikaplant (code = '110181000146104') | |||||||
| Reactie beschrijving | last van jeuk, roodheid en irritatie op de contactplek van nikkel bevattende sieraden. veelvuldig niezen ernstige benauwdheid en koorts | |||||||
| Ernst | Matig (code = '6736007' in codeSystem 'SNOMED CT') Ernstig (code = '24484000' in codeSystem 'SNOMED CT') | |||||||
| Wijze van blootstelling | intra-epidermale route (code = '448077001' in codeSystem 'SNOMED Clinical Terms') | |||||||
| Reactie tijdstip | T - 99 dagen T - 200 dagen | |||||||
| Let op | ||||||||
| Alert | ||||||||
| Alert naam | Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT') Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie | |||||||
| Begin datum tijd | T - 20 dagen T - 10 jaar | |||||||
| Alert type | waarschuwing (code = '74018-3' in codeSystem 'LOINC') | |||||||
| Vrijheidsbeperking | ||||||||
| Vrijheidsbeperkende interventie | ||||||||
| Wilsbekwaam | Ja Nee | |||||||
| Wilsbekwaam toelichting | wegens psychose Kan eigen situatie niet beoordelen Kan zich niet orienteren | |||||||
| Juridische situatie | referentie, zie bouwstenen | |||||||
| Soort interventie | geforceerd toedienen van voeding bij patiënt (code = '37041007' in codeSystem 'SNOMED CT') geslotendeurprocedure (code = '225210009' in codeSystem 'SNOMED CT') separeren in extra beveiligde kamer (code = '124041000146108' in codeSystem 'SNOMED CT') constante supervisie met camera (code = '121411000146104' in codeSystem 'SNOMED CT') constante supervisie met elektronisch traceringsmiddel (code = '121451000146100' in codeSystem 'SNOMED CT') | |||||||
| Reden van toepassen | bevorderen van fysieke gezondheid (code = '121581000146106' in codeSystem 'SNOMED CT') afwenden van situatie die kan resulteren in toebrengen van schade aan zichzelf of aan anderen (code = '121481000146105' in codeSystem 'SNOMED CT') afwenden van crisissituatie (code = '121491000146107' in codeSystem 'SNOMED CT') | |||||||
| Instemming | Instemming patiënt (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.6.1') Geen instemming patiënt (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.6.1') Instemming wettelijke vertegenwoordiger (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.6.1') | |||||||
| Begin | T - 50 dagen T + 1 dag T - 4 dagen | |||||||
| Einde | T + 3 dagen | |||||||
| Meetwaarden | ||||||||
| Bloeddruk | ||||||||
| Meetmethode | Niet-invasief (code = '22762002' in codeSystem 'SNOMED CT') | |||||||
| Manchet type | Standaard (code = 'STD' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.15.1') | |||||||
| Meet locatie | Rechter bovenarm (code = '368209003' in codeSystem 'SNOMED CT') | |||||||
| Diastolisch eindpunt | Fase V (code = '255272007' in codeSystem 'SNOMED CT') | |||||||
| Systolische bloeddruk | 170 mmhg | |||||||
| Diastolische bloeddruk | 90 mmhg | |||||||
| Gemiddelde bloeddruk | 110 mmhg | |||||||
| Bloeddruk datum tijd | T - 20 dagen om 14:45 uur | |||||||
| Toelichting | meneer gebruikt medicatie | |||||||
| Houding | Liggende positie (code = '102538003' in codeSystem 'SNOMED CT') | |||||||
| Polsfrequentie | ||||||||
| Polsfrequentie waarde | 90 | |||||||
| Polsfrequentie datum tijd | T - 5 dagen om 14:45 uur | |||||||
| Toelichting | is altijd sportief geweest | |||||||
| Pols regelmatigheid | Polsslag regelmatig (code = '271636001' in codeSystem 'SNOMED CT') | |||||||
| Lichaamstemperatuur | ||||||||
| Temperatuur waarde | 36.8 ºc | |||||||
| Temperatuur datum tijd | T - 4 dagen om 07 uur | |||||||
| Toelichting | voeten voelen heel koud aan | |||||||
| Temperatuur type | Tympanische temperatuur (code = '415974002' in codeSystem 'SNOMED CT') | |||||||
| Ademhaling | ||||||||
| Ademfrequentie | 18 /min | |||||||
| Ademhaling datum tijd | T - 3 dagen om 14:45 uur | |||||||
| Ritme | Abnormaal ademhalingsritme (code = '85617008' in codeSystem 'SNOMED CT') | |||||||
| Diepte | Normale ademhalingsdiepte (code = '301284009' in codeSystem 'SNOMED CT') | |||||||
| Afwijkend ademhalingspatroon | Apneu (code = '1023001' in codeSystem 'SNOMED CT') | |||||||
| Extra zuurstof toediening | Ja | |||||||
| Toelichting | meneer lijkt angstig | |||||||
| Toegediende zuurstof | ||||||||
| Flow rate | 2 l/min | |||||||
| Fi o2 | 0.29 l | |||||||
| Toediening hulpmiddel | ||||||||
| Medisch hulpmiddel | ||||||||
| Product | ||||||||
| Product id | ||||||||
| Product type | Neusbril (code = '336623009' in codeSystem 'SNOMED CT') | |||||||
| Product omschrijving | neusbril | |||||||
| Begin datum | ||||||||
| Toelichting | ||||||||
| Anatomische locatie | ||||||||
| Lateraliteit | ||||||||
| Zorgverlener | referentie, zie bouwstenen | |||||||
| Lichaamsgewicht | ||||||||
| Gewicht waarde | 74 kg | |||||||
| Toelichting | meneer volgt afvaldieet | |||||||
| Gewicht datum tijd | T - 5 dagen om 14:30 uur | |||||||
| Kleding | Volledig gekleed, inclusief schoenen (code = 'FULL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1') | |||||||
| Lichaamslengte | ||||||||
| Lengte waarde | 170 cm | |||||||
| Lengte datum tijd | T - 5 dagen om 14:30 uur | |||||||
| Toelichting | zonder schoenen aan | |||||||
| Positie | Staande positie (code = '10904000' in codeSystem 'SNOMED CT') | |||||||
| Pijnscore | ||||||||
| Pijn score | ||||||||
| Pijnscore waarde | 2 | |||||||
| Pijnscore datum tijd | T - 5 dagen om 14:45 uur T - 1 dag om 12:30 uur | |||||||
| Pijn meetmethode | NRS (code = 'NRS' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.9.1') VAS10 (code = 'VAS10' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.9.1') | |||||||
| Anatomische locatie | gehele voet (code = '302545001' in codeSystem 'SNOMED Clinical Terms') structuur van rug exclusief nek (code = '77568009' in codeSystem 'SNOMED Clinical Terms') | |||||||
| Lateraliteit | Links (code = '7771000' in codeSystem 'SNOMED CT') | |||||||
| Toelichting | Af en toe pijn, maar niet belemmerend bij het lopen | |||||||
Verpleegkundige context zorgplan
| Verpleegkundige context zorgplan | ||||||||||
| Gegevenselement | Waarde | |||||||||
| Verpleegkundig zorgplan ongestructureerd | ||||||||||
| Actuele patientproblemen | ||||||||||
| Patientprobleem | ||||||||||
| Probleem | ||||||||||
| Probleem anatomische locatie | hiel (code = '76853006' in codeSystem 'SNOMED Clinical Terms') structuur van rug exclusief nek (code = '77568009' in codeSystem 'SNOMED Clinical Terms') | |||||||||
| Probleem lateraliteit | Links (code = '7771000' in codeSystem 'SNOMED CT') | |||||||||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||||||||
| Probleem naam | probleem met zichzelf wassen en afdrogen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen') probleem met zichzelf kleden (code = '284972002' in codeSystem 'Referentieset Nationale kernset patientproblemen') decubitus (code = '399912005' in codeSystem 'Referentieset Nationale kernset patientproblemen') loopt risico op delier (code = '430794006' in codeSystem 'Referentieset Nationale kernset patientproblemen') pijn (bevinding) (code = '22253000' in codeSystem 'Referentieset Nationale kernset patientproblemen') fysieke agressie (code = '248004009' in codeSystem 'Referentieset Nationale kernset patientproblemen') acute verwardheid (code = '130987000' in codeSystem 'Referentieset Nationale kernset patientproblemen') incontinentie voor feces (code = '72042002' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||||||||
| Probleem begin datum | T - 100 dagen T - 90 dagen T - 5 dagen T - 10 dagen | |||||||||
| Probleem eind datum | ||||||||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||||||
| Toelichting | meneer kan niet buigen vastgesteld met DOS score bij lopen | |||||||||
| Verpleegkundige interventie | ||||||||||
| Interventie | ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED Clinical Terms') ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms') aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED Clinical Terms') wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED Clinical Terms') bevorderen van vochtinname (code = '113148007' in codeSystem 'SNOMED Clinical Terms') afleiden (code = '414039005' in codeSystem 'SNOMED Clinical Terms') rustige en geruststellende houding aannemen (code = '225980008' in codeSystem 'SNOMED Clinical Terms') omgevingsstimuli minimaliseren (code = '710978006' in codeSystem 'SNOMED Clinical Terms') zorg bij fecale incontinentie (code = '386223004' in codeSystem 'SNOMED Clinical Terms') | |||||||||
| Indicatie | ||||||||||
| Probleem | referentie, zie bouwstenen | |||||||||
| Behandeldoel | ||||||||||
| Gewenst zorgresultaat | wassen onafhankelijk kleden onafhankelijk wondlengte < 1cm, wondbreedte < 1 cm vochtinname > 1,5 liter/dag Veilige omgeving is gerealiseerd voor patient/ naasten; duur VBI beperken DOSS < 3 | |||||||||
| Actie start datum tijd | T - 90 dagen T - 10 dagen | |||||||||
| Actie eind datum tijd | T - 1 dag | |||||||||
| Frequentie | 1 /dag 3 /dag | |||||||||
| Interval | 4 uur | |||||||||
| Medisch hulpmiddel | ||||||||||
| Product | ||||||||||
| Product id | ||||||||||
| Product type | schuimverband (code = '448416005' in codeSystem 'SNOMED Clinical Terms') huidvervangende wondbedekkers (code = '465239008' in codeSystem 'SNOMED Clinical Terms') | |||||||||
| Product omschrijving | ||||||||||
| Toelichting | ||||||||||
| Zorgverlener | referentie, zie bouwstenen | |||||||||
| Instructie | let op: valrisico Graag er op toezien dat meneer > 1,5 liter per dag drinkt | |||||||||
| Uitvoerder | ||||||||||
| Zorgverlener | Ja | |||||||||
| Verzorger | ||||||||||
| Contactpersoon | ||||||||||
| Naamgegevens | ||||||||||
| Voornamen | ||||||||||
| Initialen | ||||||||||
| Roepnaam | ||||||||||
| Naamgebruik | ||||||||||
| Geslachtsnaam | ||||||||||
| Voorvoegsels | ||||||||||
| Achternaam | ||||||||||
| Geslachtsnaam partner | ||||||||||
| Voorvoegsels partner | ||||||||||
| Achternaam partner | ||||||||||
| Contactgegevens | ||||||||||
| Telefoonnummers | ||||||||||
| Telefoonnummer | ||||||||||
| Email adressen | ||||||||||
| Email adres | ||||||||||
| Rol | ||||||||||
| Relatie | Echtgenoot (code = 'HUSB' in codeSystem 'HL7 RoleCode') | |||||||||
| Patient | ||||||||||
| Toelichting | ||||||||||
| Zorgresultaat | ||||||||||
| Uitkomst van zorg | ||||||||||
| Zorgresultaat | doel deels behaald: kan nog niet rug wassen doel deels behaald, kan nog niet zelf veters strikken zie pijnscore doel is behaald DOSS = 2 | |||||||||
| Interventie | ||||||||||
| Verpleegkundige interventie | referentie, zie bouwstenen | |||||||||
| Afspraken patient | ||||||||||
| Contact | ||||||||||
| Contact type | Poliklinisch (code = 'AMB' in codeSystem 'HL7 ActCode') Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): telefonisch Thuis (code = 'HH' in codeSystem 'HL7 ActCode') | |||||||||
| Contact met | ||||||||||
| Zorgverlener | ||||||||||
| Zorgverlener identificatienummer | 03686868 (in identificerend systeem: AGB-Z) 03676767 (in identificerend systeem: AGB-Z) 88131313 (in identificerend systeem: AGB-Z) 67676767 (in identificerend systeem: AGB-Z) 01454545 (in identificerend systeem: AGB-Z) | |||||||||
| Naamgegevens | ||||||||||
| Voornamen | Joshua Nicolaas | |||||||||
| Initialen | J.P. F. J. W. N. | |||||||||
| Roepnaam | Klaas | |||||||||
| Naamgebruik | Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||||||||
| Geslachtsnaam | ||||||||||
| Voorvoegsels | van | |||||||||
| Achternaam | Helmond Snijder Drooglever Bloem Pinxteren | |||||||||
| Geslachtsnaam partner | ||||||||||
| Voorvoegsels partner | de | |||||||||
| Achternaam partner | Mol | |||||||||
| Specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') Medisch specialisten, neurochirurgie (code = '0308' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') Medisch specialisten, inwendige geneeskunde (code = '0313' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') Ergotherapeut (code = '90.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') Huisartsen, niet nader gespecificeerd (code = '0100' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||||||
| Contactgegevens | ||||||||||
| Telefoonnummers | ||||||||||
| Telefoonnummer | +31616161616 +31612121212 +31689898989 +31203232323 | |||||||||
| Email adressen | ||||||||||
| Email adres | bloem@ergotherapie.nl snijder@poli.nl klaas@huisartspraktijk.nl info@huisartspraktijk.nl | |||||||||
| Locatie | ||||||||||
| Zorgaanbieder | ||||||||||
| Zorgaanbieder identificatienummer | 06590457 (in identificerend systeem: AGB-Z) 01565656 (in identificerend systeem: AGB-Z) | |||||||||
| Organisatie naam | AB-zkh Huisartspraktijk de Huisarts | |||||||||
| Organisatie locatie | Noord | |||||||||
| Afdeling specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') Huisartsen, niet nader gespecificeerd (code = '0100' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||||||
| Contactgegevens | ||||||||||
| Telefoonnummers | ||||||||||
| Telefoonnummer | +31182435770 +31203232323 +31203232000 | |||||||||
| Email adressen | ||||||||||
| Email adres | neurologie@ABZ.nl info@huisartspraktijk.nl assistente@huisartspraktijk.nl | |||||||||
| Adresgegevens | ||||||||||
| Straat | Knolweg | |||||||||
| Huisnummer | 10 100 | |||||||||
| Huisnummerletter | a | |||||||||
| Huisnummertoevoeging | III | |||||||||
| Aanduiding bij nummer | Bij (code = 'by' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.3') | |||||||||
| Postcode | 9999PO 4000KK | |||||||||
| Woonplaats | Stitswerd | |||||||||
| Gemeente | Het Hogeland | |||||||||
| Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | |||||||||
| Additionele informatie | bedrijfsgebouw "De Stits" | |||||||||
| 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') Huisartspraktijk (zelfstandig of groepspraktijk) (code = 'Z3' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||||||||
| Begin datum tijd | T + 5 dagen om 10 uur T + 20 dagen om 15:15 uur T + 12 dagen om 15:15 uur T + 5 dagen | |||||||||
| Eind datum tijd | T + 5 dagen om 10:30 uur | |||||||||
| Reden contact | ||||||||||
| Reden contact tekst | Controle voortgang revalidatie | |||||||||
| Probleem | referentie, zie bouwstenen | |||||||||
| Afwijkende uitslag | hoge PSA waarde | |||||||||
| Wensen en behoeften patient enof naasten | meneer wil zo snel mogelijk weer zelfstandig kunnen functioneren en zijn vrouw kunnen verzorgen | |||||||||
Verpleegkundige context specificatie gezondheidstoestand
| Verpleegkundige context specificatie gezondheidstoestand | |||||||||||
| Gegevenselement | Waarde | ||||||||||
| Zelfzorg | |||||||||||
| Vermogen tot drinken | |||||||||||
| Drinken | Hulp nodig (code = '16681000146102' in codeSystem '2.16.840.1.113883.6.96 (ordinal = ) Onafhankelijk (code = '19841000146104' in codeSystem '2.16.840.1.113883.6.96 (ordinal = ) | ||||||||||
| Drink beperkingen | Bereiden (openen/uitschenken) (code = '286506008' in codeSystem 'SNOMED CT') Vastpakken (code = '307071002' in codeSystem 'SNOMED CT') Naar mond brengen (code = '288876009' in codeSystem 'SNOMED CT') | ||||||||||
| Vermogen tot eten | |||||||||||
| Eten | Hulp nodig (code = '129033007' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '1') Onafhankelijk (code = '165224005' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '0') | ||||||||||
| Eet beperkingen | Snijden/openen (code = '289078003' in codeSystem 'SNOMED CT') Eetgerei hanteren (code = '289046006' in codeSystem 'SNOMED CT') Naar de mond brengen (code = '289010002' in codeSystem 'SNOMED CT') | ||||||||||
| Vermogen tot mondverzorging | |||||||||||
| Verzorgen tanden | Hulp nodig (code = '16671000146104' in codeSystem 'SNOMED CT') | ||||||||||
| Prothese | |||||||||||
| Medisch hulpmiddel | |||||||||||
| Product | |||||||||||
| Product id | |||||||||||
| Product type | Gebitsprothese (code = '27606000' in codeSystem 'SNOMED CT') | ||||||||||
| Product omschrijving | Gebitsprothese bovenkaak Gebitsprothese onderkaak | ||||||||||
| Begin datum | |||||||||||
| Toelichting | |||||||||||
| Anatomische locatie | |||||||||||
| Lateraliteit | |||||||||||
| Zorgverlener | referentie, zie bouwstenen | ||||||||||
| Vermogen tot zich wassen | |||||||||||
| Zich wassen | Hulp nodig (code = '16621000146103' in codeSystem '2.16.840.1.113883.6.96 (ordinal = ) Onafhankelijk (code = '19831000146107' in codeSystem '2.16.840.1.113883.6.96 (ordinal = ) | ||||||||||
| Te wassen lichaamsdeel | Onderlichaam (code = '362875007' in codeSystem 'SNOMED CT') Bovenlichaam (code = '362874006' in codeSystem 'SNOMED CT') Gezicht (code = '302549007' in codeSystem 'SNOMED CT') | ||||||||||
| Vermogen tot zich kleden | |||||||||||
| Zich kleden | Hulp nodig (code = '129039006' in codeSystem '2.16.840.1.113883.6.96 (ordinal = ) Onafhankelijk (code = '129035000' in codeSystem '2.16.840.1.113883.6.96 (ordinal = ) | ||||||||||
| Te kleden lichaamsdeel | Onderlichaam (code = '362875007' in codeSystem 'SNOMED CT') | ||||||||||
| Vermogen tot uiterlijke verzorging | |||||||||||
| Uiterlijke verzorging | Hulp nodig (code = '27941000146109' in codeSystem '2.16.840.1.113883.6.96 (ordinal = ) | ||||||||||
| Vermogen tot toiletgang | |||||||||||
| Toiletgebruik | Onafhankelijk (code = '129062008' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '0') | ||||||||||
| Zorg bij menstruatie | |||||||||||
| Vermogen tot zelfstandig medicatiegebruik | |||||||||||
| Zelfstandig medicatiegebruik | Hulp nodig (code = '27921000146103' in codeSystem 'SNOMED CT') | ||||||||||
| Hulp bij toediening | |||||||||||
| Verpleegkundige interventie | |||||||||||
| Interventie | bevorderen van therapietrouw met behulp van medicijndispenser (code = '710153008' in codeSystem 'SNOMED Clinical Terms') | ||||||||||
| Behandeldoel | |||||||||||
| Gewenst zorgresultaat | therapietrouw | ||||||||||
| Actie start datum tijd | |||||||||||
| Actie eind datum tijd | |||||||||||
| Frequentie | 2 /d | ||||||||||
| Interval | |||||||||||
| Medisch hulpmiddel | |||||||||||
| Product | |||||||||||
| Product id | |||||||||||
| Product type | medicatierol (code = '713308004' in codeSystem 'SNOMED Clinical Terms') | ||||||||||
| Product omschrijving | baxterrol | ||||||||||
| Toelichting | |||||||||||
| Zorgverlener | referentie, zie bouwstenen | ||||||||||
| Instructie | |||||||||||
| Uitvoerder | |||||||||||
| Zorgverlener | |||||||||||
| Verzorger | |||||||||||
| Contactpersoon | |||||||||||
| Naamgegevens | |||||||||||
| Voornamen | |||||||||||
| Initialen | |||||||||||
| Roepnaam | |||||||||||
| Naamgebruik | |||||||||||
| Geslachtsnaam | |||||||||||
| Voorvoegsels | |||||||||||
| Achternaam | |||||||||||
| Geslachtsnaam partner | |||||||||||
| Voorvoegsels partner | |||||||||||
| Achternaam partner | |||||||||||
| Contactgegevens | |||||||||||
| Telefoonnummers | |||||||||||
| Telefoonnummer | |||||||||||
| Email adressen | |||||||||||
| Email adres | |||||||||||
| Rol | |||||||||||
| Relatie | |||||||||||
| Toelichting | |||||||||||
| Vermogen tot verpleegtechnische handelingen | |||||||||||
| Verpleegkundige interventie | |||||||||||
| Verpleegkundige interventie | |||||||||||
| Interventie | Stoma care procedure (code = '225194008' in codeSystem 'SNOMED Clinical Terms') vervangen van verband (code = '18949003' in codeSystem 'SNOMED Clinical Terms') | ||||||||||
| Behandeldoel | |||||||||||
| Gewenst zorgresultaat | goede hygiene met betrekking tot stoma | ||||||||||
| Actie start datum tijd | T - 6 dagen T - 1 dag | ||||||||||
| Actie eind datum tijd | |||||||||||
| Frequentie | |||||||||||
| Interval | 2 dagen | ||||||||||
| Medisch hulpmiddel | |||||||||||
| Product | |||||||||||
| Product id | |||||||||||
| Product type | |||||||||||
| Product omschrijving | |||||||||||
| Toelichting | |||||||||||
| Zorgverlener | referentie, zie bouwstenen | ||||||||||
| Instructie | |||||||||||
| Uitvoerder | |||||||||||
| Verzorger | |||||||||||
| Contactpersoon | |||||||||||
| Naamgegevens | |||||||||||
| Voornamen | |||||||||||
| Initialen | |||||||||||
| Roepnaam | |||||||||||
| Naamgebruik | |||||||||||
| Geslachtsnaam | |||||||||||
| Voorvoegsels | |||||||||||
| Achternaam | |||||||||||
| Geslachtsnaam partner | |||||||||||
| Voorvoegsels partner | |||||||||||
| Achternaam partner | |||||||||||
| Contactgegevens | |||||||||||
| Telefoonnummers | |||||||||||
| Telefoonnummer | |||||||||||
| Email adressen | |||||||||||
| Email adres | |||||||||||
| Rol | |||||||||||
| Relatie | |||||||||||
| Patient | Ja | ||||||||||
| Toelichting | toezicht bij uitvoer, en instructie hygiënisch werken | ||||||||||
| Verrichten vpkhandeling | Hulp nodig (code = '27931000146101' in codeSystem '2.16.840.1.113883.6.96 (ordinal = ) | ||||||||||
| Toelichting zelfzorg | kan zich steeds beter redden met wassen en kleden, knoopjes dichtdoen en schoenen met hulp. Ileostoma instructies gestart. | ||||||||||
| Mobiliteit | |||||||||||
| Mobiliteit | |||||||||||
| Lopen | Hulp nodig (code = '16581000146103' in codeSystem '2.16.840.1.113883.6.96 (ordinal = ) | ||||||||||
| Traplopen | Volledig afhankelijk (code = '301589003' in codeSystem '2.16.840.1.113883.6.96 (ordinal = ) | ||||||||||
| Houding veranderen | Onafhankelijk (code = '19821000146105' in codeSystem '2.16.840.1.113883.6.96 (ordinal = ) | ||||||||||
| Houding handhaven | Onafhankelijk (code = '19811000146100' in codeSystem '2.16.840.1.113883.6.96 (ordinal = ) | ||||||||||
| Uitvoeren transfer | Hulp nodig (code = '714917003' in codeSystem '2.16.840.1.113883.6.96 (ordinal = ) | ||||||||||
| Medisch hulpmiddel | |||||||||||
| Medisch hulpmiddel | |||||||||||
| Product | |||||||||||
| Product id | |||||||||||
| Product type | rollator (code = '404946006' in codeSystem 'SNOMED Clinical Terms') rolstoel (code = '58938008' in codeSystem 'SNOMED Clinical Terms') | ||||||||||
| Product omschrijving | rollator rolstoel | ||||||||||
| Begin datum | T - 1 jaar T - 1 maand | ||||||||||
| Toelichting | voor langere afstanden | ||||||||||
| Anatomische locatie | |||||||||||
| Lateraliteit | |||||||||||
| Zorgverlener | referentie, zie bouwstenen | ||||||||||
| Toelichting | lopen is stuk verbeterd, rechter been minder krachtig | ||||||||||
| Voedingvocht | |||||||||||
| Voedingsadvies | |||||||||||
| Dieet type | suikervrij, diabetes dieet | ||||||||||
| Consistentie | dik vloeibaar solide | ||||||||||
| Toelichting | eet naar eigen keuze minder vlees | ||||||||||
| Snaqscore | |||||||||||
| Gewichtsverlies score | LossAverage (code = 'G1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.5.1 (ordinal = '2') | ||||||||||
| Eetlust score | Eetlust (code = 'B0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.5.2 (ordinal = '0') | ||||||||||
| Voedings score | GeenVoeding (code = 'Z0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.5.3 (ordinal = '0') | ||||||||||
| Totaal score | 2 | ||||||||||
| Snaqscore datum tijd | T - 6 dagen om 17 uur | ||||||||||
| Toelichting | geen verminderde eetlust ondanks chemotherapie | ||||||||||
| Snaqrc score | |||||||||||
| Gewichtsverlies score | LossHigh (code = 'G2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.19.1 (ordinal = '2') | ||||||||||
| Eetlust score | Eetlust (code = 'B0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.19.2 (ordinal = '0') | ||||||||||
| Bmiscore | Gezond (code = 'B0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.19.3 (ordinal = '0') | ||||||||||
| Hulp bij eten | Onafhankelijk (code = '165224005' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '0') | ||||||||||
| Totaal score | 2 | ||||||||||
| Snaqrc score datum tijd | T - 6 dagen om 17 uur | ||||||||||
| Toelichting | geen verminderde eetlust ondanks chemotherapie | ||||||||||
| Snaq65score | |||||||||||
| Gewichtsverlies score | LossLow (code = 'G0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.18.1 (ordinal = '0') | ||||||||||
| Bovenarm omtrek score | Normaal (code = 'A0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.18.4 (ordinal = '0') | ||||||||||
| Eetlust score | Eetlust (code = 'B0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.18.2 (ordinal = '0') | ||||||||||
| Inspannings score | Mogelijk (code = 'In0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.18.3 (ordinal = '0') | ||||||||||
| Totaal score | 0 | ||||||||||
| Snaq65score datum tijd | T - 6 dagen om 17 uur | ||||||||||
| Toelichting | geen verminderde eetlust ondanks chemotherapie | ||||||||||
| Mustscore | |||||||||||
| Bmiscore | BMIHigh (code = 'B0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.4.1 (ordinal = '0') | ||||||||||
| Gewichtsverlies score | LossLow (code = 'G0' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.4.2 (ordinal = '0') | ||||||||||
| Ziekte score | Ziek (code = 'Z1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.4.3 (ordinal = '2') | ||||||||||
| Totaal score | 2 | ||||||||||
| Mustscore datum tijd | T - 12 dagen om 17 uur | ||||||||||
| Toelichting | |||||||||||
| Vochtbalans | |||||||||||
| Toelichting | |||||||||||
| Vocht totaal in | 1400 ml | ||||||||||
| Vocht totaal uit | 1000 ml | ||||||||||
| Vochtbalans starttijd | T - 6 dagen om 07 uur | ||||||||||
| Vochtbalans stoptijd | T - 5 dagen om 07 uur | ||||||||||
| Sonde systeem | |||||||||||
| Sonde | |||||||||||
| Medisch hulpmiddel | |||||||||||
| Product | |||||||||||
| Product id | |||||||||||
| Product type | Neus-maagsonde (code = '17102003' in codeSystem 'SNOMED CT') PEJ sonde (code = '8911000146104' in codeSystem 'SNOMED CT') | ||||||||||
| Product omschrijving | neus- maagsonde PEJ sonde | ||||||||||
| Begin datum | T - 5 dagen | ||||||||||
| Toelichting | |||||||||||
| Anatomische locatie | neusgat (code = '363538002' in codeSystem 'SNOMED Clinical Terms') | ||||||||||
| Lateraliteit | Links (code = '7771000' in codeSystem 'SNOMED CT') | ||||||||||
| Zorgverlener | referentie, zie bouwstenen | ||||||||||
| Sonde lengte | 575 mm | ||||||||||
| Medisch hulpmiddel | |||||||||||
| Product | |||||||||||
| Product id | |||||||||||
| Product type | enterale voedingspomp (code = '468664004' in codeSystem 'SNOMED Clinical Terms') | ||||||||||
| Product omschrijving | enterale voedingspomp | ||||||||||
| Begin datum | T - 5 dagen | ||||||||||
| Toelichting | |||||||||||
| Zorgverlener | referentie, zie bouwstenen | ||||||||||
| Toelichting | wegens misselijkheid door chemotherapie | ||||||||||
| Infuus | |||||||||||
| Infuuskatheter | |||||||||||
| Medisch hulpmiddel | |||||||||||
| Product | |||||||||||
| Product id | |||||||||||
| Product type | Centraal veneuze katheter (code = '52124006' in codeSystem 'SNOMED CT') Perifeer intraveneus infuus (code = '82449006' in codeSystem 'SNOMED CT') | ||||||||||
| Product omschrijving | centraal veneuze katheter Perifeer intraveneus infuus | ||||||||||
| Begin datum | T - 20 dagen T - 15 dagen | ||||||||||
| Toelichting | onder sleutelbeen links | ||||||||||
| Anatomische locatie | structuur van vena subclavia (code = '9454009' in codeSystem 'SNOMED Clinical Terms') onderarm (code = '14975008' in codeSystem 'SNOMED Clinical Terms') | ||||||||||
| Lateraliteit | Links (code = '7771000' in codeSystem 'SNOMED CT') | ||||||||||
| Zorgverlener | referentie, zie bouwstenen | ||||||||||
| Toelichting | voor voeding voor medicatie | ||||||||||
| Lumen of lijn | |||||||||||
| Lijn status | Lopend (code = 'LNP' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.12.1') Afgedopt (code = 'DOP' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.12.1') | ||||||||||
| Lumen locatie | Distaal (code = '46053002' in codeSystem 'SNOMED CT') Mediaal (code = '255561001' in codeSystem 'SNOMED CT') | ||||||||||
| Toedienings systeem | |||||||||||
| Randapparaat | |||||||||||
| Medisch hulpmiddel | |||||||||||
| Product | |||||||||||
| Product id | |||||||||||
| Product type | infuuspomp voor algemene doeleinden (code = '470575008' in codeSystem 'SNOMED Clinical Terms') spuitpomp (code = '418657004' in codeSystem 'SNOMED Clinical Terms') infuuspomp (code = '430033006' in codeSystem 'SNOMED Clinical Terms') | ||||||||||
| Product omschrijving | infuuspomp spuitpomp (infusor) | ||||||||||
| Begin datum | T - 20 dagen T - 14 dagen T - 13 dagen | ||||||||||
| Toelichting | voor heparine voor NaCL/gluc | ||||||||||
| Zorgverlener | referentie, zie bouwstenen | ||||||||||
| Toedienings systeem toelichting | voor TPV voor NaCL 0.9% | ||||||||||
| Uitscheiding | |||||||||||
| Blaasfunctie | |||||||||||
| Urine continentie | Af en toe een ongelukje (max. 1 keer per 24 uur) (code = '165233007' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '1') | ||||||||||
| Urostoma | |||||||||||
| Stoma | referentie, zie bouwstenen | ||||||||||
| Urine katheter | |||||||||||
| Medisch hulpmiddel | |||||||||||
| Product | |||||||||||
| Product id | |||||||||||
| Product type | Verblijfskatheter (code = '23973005' in codeSystem 'SNOMED CT') | ||||||||||
| Product omschrijving | Verblijfskatheter | ||||||||||
| Begin datum | T - 5 dagen | ||||||||||
| Toelichting | |||||||||||
| Anatomische locatie | |||||||||||
| Lateraliteit | |||||||||||
| Zorgverlener | referentie, zie bouwstenen | ||||||||||
| Incontinentiemateriaal | |||||||||||
| Medisch hulpmiddel | |||||||||||
| Product | |||||||||||
| Product id | |||||||||||
| Product type | inlegger voor incontinentiebroek (code = '470713005' in codeSystem 'SNOMED Clinical Terms') | ||||||||||
| Product omschrijving | inlegger | ||||||||||
| Begin datum | |||||||||||
| Toelichting | |||||||||||
| Anatomische locatie | |||||||||||
| Lateraliteit | |||||||||||
| Zorgverlener | referentie, zie bouwstenen | ||||||||||
| Toelichting | |||||||||||
| Darmfunctie | |||||||||||
| Feces continentie | Incontinent (code = '72042002' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '0') | ||||||||||
| Stoma | referentie, zie bouwstenen | ||||||||||
| Frequentie | 2 per dag | ||||||||||
| Defecatie consistentie | Helemaal vloeibaar (code = 'Type 7' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.3.1') Zachte stukjes met gehavende randen (code = 'Type 6' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.3.1') | ||||||||||
| Defecatie kleur | Grijswit (code = '267056008' in codeSystem 'SNOMED CT') | ||||||||||
| Incontinentiemateriaal | |||||||||||
| Medisch hulpmiddel | |||||||||||
| Product | |||||||||||
| Product id | |||||||||||
| Product type | opvangzak voor fecesincontinentie (code = '469627000' in codeSystem 'SNOMED Clinical Terms') | ||||||||||
| Product omschrijving | opvangzak voor fecesincontinentie | ||||||||||
| Begin datum | |||||||||||
| Toelichting | |||||||||||
| Anatomische locatie | |||||||||||
| Lateraliteit | |||||||||||
| Zorgverlener | referentie, zie bouwstenen | ||||||||||
| Toelichting | stoma na subtotale darmresectie wegens coloncarcinoom | ||||||||||
| Stoma | |||||||||||
| Stoma type | eindstandige ileostoma (code = '311412005' in codeSystem 'SNOMED CT') urostoma (code = '281601009' in codeSystem 'SNOMED CT') | ||||||||||
| Stoma materiaal | |||||||||||
| Medisch hulpmiddel | |||||||||||
| Product | |||||||||||
| Product id | |||||||||||
| Product type | Ileostomy bag (code = '417136005' in codeSystem 'SNOMED Clinical Terms') | ||||||||||
| Product omschrijving | stomazak voor ileostoma | ||||||||||
| Begin datum | |||||||||||
| Toelichting | |||||||||||
| Anatomische locatie | |||||||||||
| Lateraliteit | |||||||||||
| Zorgverlener | referentie, zie bouwstenen | ||||||||||
| Anatomische locatie | onderbuik (code = '27033000' in codeSystem 'SNOMED Clinical Terms') buikwand (code = '83908009' in codeSystem 'SNOMED Clinical Terms') | ||||||||||
| Lateraliteit | Rechts (code = '24028007' in codeSystem 'SNOMED CT') | ||||||||||
| Aanleg datum | T - 12 dagen T - 4 jaar | ||||||||||
| Toelichting | na subtotale darmresectie wegens coloncarcinoom | ||||||||||
| Huid | |||||||||||
| Brandwond | |||||||||||
| Ontstaans datum | T - 2 dagen | ||||||||||
| Uitgebreidheid | 1 % | ||||||||||
| Brandwond soort | Thermische brandwond (code = '105594005' in codeSystem 'SNOMED CT') | ||||||||||
| Anatomische locatie | onderarm (code = '362741001' in codeSystem 'SNOMED Clinical Terms') handrug (code = '63125000' in codeSystem 'SNOMED Clinical Terms') | ||||||||||
| Lateraliteit | Rechts (code = '24028007' in codeSystem 'SNOMED CT') | ||||||||||
| Dieptegraad | 1e graad (code = '77140003' in codeSystem '2.16.840.1.113883.6.96 (ordinal = ) 2e graad, oppervlakkig (code = '262587005' in codeSystem '2.16.840.1.113883.6.96 (ordinal = ) | ||||||||||
| Toelichting | Meneer kreeg hete thee over zich heen, wond is ongeveer 2 bij 2 cm; geen verband nodig. | ||||||||||
| Datum laatste verbandwissel | T - 1 dag | ||||||||||
| Decubitus wond | |||||||||||
| Decubitus categorie | Decubitus categorie 2 (code = '420324007' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '2') Decubitus categorie 1 (code = '421076008' in codeSystem '2.16.840.1.113883.6.96 (ordinal = '1') | ||||||||||
| Ontstaans datum | T - 2 dagen T - 20 dagen | ||||||||||
| Anatomische locatie | hiel (code = '76853006' in codeSystem 'SNOMED Clinical Terms') stuitje (code = '182028002' in codeSystem 'SNOMED Clinical Terms') | ||||||||||
| Lateraliteit | Links (code = '7771000' in codeSystem 'SNOMED CT') | ||||||||||
| Datum laatste verbandwissel | T - 1 dag | ||||||||||
| Wondlengte | 2 cm 3 cm | ||||||||||
| Wondbreedte | 2 cm 1 cm | ||||||||||
| Wonddiepte | 0.5 cm 0.2 cm | ||||||||||
| Wond foto | |||||||||||
| Toelichting | Wond is niet geïnfecteerd. | ||||||||||
| Huidaandoening | |||||||||||
| Soort aandoening | Intertrigo/smetten (code = '58759008' in codeSystem 'SNOMED CT') Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Inverse psoriasis | ||||||||||
| Ontstaans datum | T - 6 dagen T - 10 jaar | ||||||||||
| Oorzaak | |||||||||||
| Probleem | referentie, zie bouwstenen | ||||||||||
| Anatomische locatie | lies (code = '26893007' in codeSystem 'SNOMED Clinical Terms') oksel (code = '91470000' in codeSystem 'SNOMED Clinical Terms') | ||||||||||
| Lateraliteit | Rechts (code = '24028007' in codeSystem 'SNOMED CT') Rechts en links (code = '51440002' in codeSystem 'SNOMED CT') | ||||||||||
| Toelichting | Smetten zonder natten of infectie, inmiddels genezen. | ||||||||||
| Wond | |||||||||||
| Wond soort | Traumatische wond (code = '416462003' in codeSystem 'SNOMED CT') Chirurgische wond (code = '112633009' in codeSystem 'SNOMED CT') Oncologische ulcer (code = '94579000' in codeSystem 'SNOMED CT') | ||||||||||
| Wond weefsel | Rode wond (code = 'ROOD' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.7.2') Graad II (code = 'GRAAD2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.7.1') | ||||||||||
| Wond infectie | Nee | ||||||||||
| Wond vochtigheid | Droge wond (code = 'DROOG' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.7.3') Vochtige wond (code = 'VOCHTIG' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.7.3') | ||||||||||
| Wond rand | |||||||||||
| Wondlengte | 2 cm 5 cm 1 cm | ||||||||||
| Wondbreedte | 4 cm 1 cm | ||||||||||
| Wonddiepte | 0.1 cm 4 cm 2 cm | ||||||||||
| Anatomische locatie | knie (code = '72696002' in codeSystem 'SNOMED Clinical Terms') onderbuik (code = '27033000' in codeSystem 'SNOMED Clinical Terms') buikwand (code = '83908009' in codeSystem 'SNOMED Clinical Terms') | ||||||||||
| Lateraliteit | Links (code = '7771000' in codeSystem 'SNOMED CT') | ||||||||||
| Wond ontstaansdatum | T - 12 dagen T - 1 maand | ||||||||||
| Datum laatste verbandwissel | T - 1 dag | ||||||||||
| Drain | |||||||||||
| Medisch hulpmiddel | |||||||||||
| Product | |||||||||||
| Product id | |||||||||||
| Product type | wonddrain (code = '27033000' in codeSystem 'SNOMED Clinical Terms') | ||||||||||
| Product omschrijving | wonddrain | ||||||||||
| Begin datum | T - 12 dagen | ||||||||||
| Toelichting | |||||||||||
| Anatomische locatie | |||||||||||
| Lateraliteit | |||||||||||
| Zorgverlener | referentie, zie bouwstenen | ||||||||||
| Wond foto | |||||||||||
| Toelichting | oppervlakkige schaafwond na CVA, geen verband nodig | ||||||||||
| Zintuigen | |||||||||||
| Functie horen | |||||||||||
| Hoor functie | Verminderde gehoorfunctie (code = '15188001' in codeSystem 'SNOMED CT') | ||||||||||
| Horen hulpmiddel | |||||||||||
| Medisch hulpmiddel | |||||||||||
| Product | |||||||||||
| Product id | 012345678905 (code = '012345678905Global Trade Item Number (GTIN)') | ||||||||||
| Product type | Gehoorapparaat (code = '6012004' in codeSystem 'SNOMED CT') | ||||||||||
| Product omschrijving | Gehoorapparaat | ||||||||||
| Begin datum | |||||||||||
| Toelichting | |||||||||||
| Anatomische locatie | Linkeroor (code = '89644007' in codeSystem 'SNOMED CT') Rechteroor (code = '25577004' in codeSystem 'SNOMED CT') | ||||||||||
| Zorgverlener | referentie, zie bouwstenen | ||||||||||
| Toelichting | |||||||||||
| Functie zien | |||||||||||
| Visuele functie | Verminderd gezichtsvermogen (code = '397540003' in codeSystem 'SNOMED CT') | ||||||||||
| Zien hulpmiddel | |||||||||||
| Medisch hulpmiddel | |||||||||||
| Product | |||||||||||
| Product id | |||||||||||
| Product type | bril (code = '50121007' in codeSystem 'SNOMED CT') | ||||||||||
| Product omschrijving | bril | ||||||||||
| Begin datum | |||||||||||
| Toelichting | |||||||||||
| Anatomische locatie | |||||||||||
| Lateraliteit | |||||||||||
| Zorgverlener | referentie, zie bouwstenen | ||||||||||
| Toelichting | zonder bril bestaat verhoogd valrisico | ||||||||||
| Ziektebeleving | |||||||||||
| Ziektebeleving | |||||||||||
| Ziekte inzicht van patient | meneer kan niet overzien wat de ziekte betekent in het dagelijkse leven | ||||||||||
| Omgaan met ziekteproces door patient | meneer wil niet praten over de toekomst. | ||||||||||
| Omgaan met ziekteproces door naasten | echtgenote maakt zich zorgen of zij de zorg voor meneer wel aan kan, omdat zij zelf ook slecht ter been is | ||||||||||
| Mentale status | |||||||||||
| Probleem | |||||||||||
| Probleem type | |||||||||||
| Probleem naam | gedaald bewustzijn (code = '443371007' in codeSystem 'SNOMED Clinical Terms') | ||||||||||
| Probleem begin datum | T - 22 dagen | ||||||||||
| Probleem eind datum | |||||||||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||||||||||
| Toelichting | sinds cva, verminderde alertheid | ||||||||||
| Voortplanting | |||||||||||
| Zwangerschap | |||||||||||
| Zwanger | Ja | ||||||||||
| Aterme datum | T + 120 dagen | ||||||||||
| Datum laatste menstruatie | T - 170 dagen | ||||||||||
| Zwangerschapsduur | 160 dagen | ||||||||||
| Graviditeit | 1 | ||||||||||
| Pariteit | 0 | ||||||||||
| Toelichting | Mevrouw is vaak misselijk in de ochtend. | ||||||||||