mp:Vdraft Sandbox: verschil tussen versies
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− | {{ | + | {{DISPLAYTITLE:e-overdracht: addendum inhoudelijke gegevens}} |
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− | = | + | =Addenda voor inhoudelijke gegevens= |
− | + | <section begin=eovd-saa-tst-1.1-alle_zibs /> | |
− | + | ==Scenario Aanmeldbericht== | |
− | + | ||
− | + | === Administratieve gegevens=== | |
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− | === 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="7" | Administratieve gegevens |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="6" width="30%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Datum overplaatsing |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T + 1 dag |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Persoonsgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="47"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Patient |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="18"| |
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|-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="6"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Voornamen | |colspan="3"|Voornamen | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Erik |
|-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;"|E |
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|-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 | + | |rowspan="2"| |
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|-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;"|XXX_Altenborg |
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|-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="6"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Straat | |colspan="3"|Straat | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Knolweg |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Huisnummer | |colspan="3"|Huisnummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1000 |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Postcode | |colspan="3"|Postcode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|9999XA |
|-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;"|Stitswerd |
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|-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;"| | + | |style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Identificatienummer |
+ | |style="background-color: white;"|999911612 (in identificerend systeem: BSN) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Geboortedatum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|14 aug 1964 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Geslacht |
− | + | |style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |
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− | |style="background-color: white;"| | ||
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="6"|Betaler | |
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− | |colspan="6"|Betaler | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="7"| | |rowspan="7"| | ||
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Verzekeraar |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="5"| |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Verzekering |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan | + | |rowspan="3"| |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Eind datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T + 1 jaar |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verzekeringssoort |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Contactpersoon |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="18"| |
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|-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="7"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Voornamen | |colspan="3"|Voornamen | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Johanna |
|-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;"|J |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Roepnaam | |colspan="3"|Roepnaam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Hanna |
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|-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 | + | |rowspan="2"| |
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|-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;"|Bakker |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Contactgegevens | |colspan="5"|Contactgegevens | ||
Regel 262: | Regel 123: | ||
|-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;"|+31645678912 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Email adressen | |colspan="4"|Email adressen | ||
Regel 269: | Regel 130: | ||
|-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;"|jbakker@123net.nl |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Relatie |
+ | |style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Sturende organisatie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="16"| |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Zorgaanbieder |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="14"| |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Zorgaanbieder identificatienummer |
+ | |style="background-color: white;"|06590457 (in identificerend systeem: AGB-Z) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Organisatie naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|AB-zkh |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Organisatie locatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Noord |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Afdeling specialisme |
− | + | |style="background-color: white;"|Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |
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− | |style="background-color: white;"| | ||
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Contactgegevens | |colspan="5"|Contactgegevens | ||
Regel 351: | Regel 164: | ||
|-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;"|+31182435770 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Email adressen | |colspan="4"|Email adressen | ||
Regel 358: | Regel 171: | ||
|-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;"|neurologie@ABZ.nl |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Organisatie type |
+ | |style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Ontvangende organisatie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan | + | |rowspan="5"| |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Zorgaanbieder |
|-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="4"|Afdeling specialisme |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="4"|Organisatie type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060') |
+ | |} | ||
+ | === Algemene patienten context=== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Algemene patienten context | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="30%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Juridische situatie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan | + | |rowspan="5"| |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|<span id="tst-1.1-juridischesituatie-01" title="Intern ID = tst-1.1-juridischesituatie-01">Juridische situatie tst-1.1-juridischesituatie-01</span> |
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|-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="2"| | + | |colspan="2"|Vertegenwoordiging |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Onder curatele stelling (code = '9' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.3') |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Datum aanvang |
− | + | |style="background-color: white;"|T - 1 jaar | |
− | |||
− | |style="background-color: white;"| | ||
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|} | |} | ||
− | === | + | === 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="5" | Medische context |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="4" width="30%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Medische diagnose |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="18"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
− | |||
− | |||
− | |||
− | |||
|-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"|Probleem naam |
+ | |style="background-color: white;"|ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Toelichting |
− | |style="background-color: white;"| | + | |style="background-color: white;"|niet bekend met neurologische klachten |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
|-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="2"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|neoplasma van colon (code = '126838000') |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Probleem naam |
+ | |style="background-color: white;"|oksel (code = '238600001' in codeSystem 'SNOMED Clinical Terms') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
− | |||
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|-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="2"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|inverse psoriasis (code = '238600001') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Voorgeschiedenis |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
|-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="2"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|diabetes mellitus (code = '73211009') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Let op |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="7"| | |rowspan="7"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Alert |
|-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="2"|Alert naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Alert |
|-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="2"|Alert naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Vrijheidsbeperking |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="9"| |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Vrijheidsbeperkende interventie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="7"| | |rowspan="7"| | ||
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Wilsbekwaam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Juridische situatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Zie [[#tst-1.1-juridischesituatie-01|Juridische situatie: tst-1.1-juridischesituatie-01]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Soort interventie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|geforceerd toedienen van voeding bij patiënt (code = '37041007' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Reden van toepassen |
− | |style="background-color: white;"| | + | |style="background-color: white;"|bevorderen van fysieke gezondheid (code = '121581000146106' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Instemming |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Instemming patiënt (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.6.1') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Begin |
− | + | |style="background-color: white;"|T - 50 dagen | |
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− | |style="background-color: white;"| | ||
|} | |} | ||
− | === | + | === 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="7" | Verpleegkundige context zorgplan |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="6" width="30%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Actuele patientproblemen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="64"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Patientprobleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="15"| |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|<span id="tst-1.1-patientprobleem-01" title="Intern ID = tst-1.1-patientprobleem-01">Probleem tst-1.1-patientprobleem-01</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="4"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|probleem met zichzelf wassen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Toelichting |
− | + | |style="background-color: white;"|meneer kan niet buigen | |
− | |||
− | | | ||
− | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verpleegkundige interventie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="8"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Interventie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED Clinical Terms') |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Indicatie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="2"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Zie [[#tst-1.1-patientprobleem-01|Probleem: tst-1.1-patientprobleem-01]] |
− | |||
− | |||
− | |||
− | |||
− | |||
− | | | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Uitvoerder |
− | |||
− | |||
− | |||
− | |||
|-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="2"|Zorgverlener |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Patientprobleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="11"| |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|<span id="tst-1.1-patientprobleem-02" title="Intern ID = tst-1.1-patientprobleem-02">Probleem tst-1.1-patientprobleem-02</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|probleem met zichzelf kleden (code = '284972002' in codeSystem 'Referentieset Nationale kernset patientproblemen') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verpleegkundige interventie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan | + | |rowspan="5"| |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="3"|Interventie | |
− | + | |style="background-color: white;"|ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms') | |
− | |colspan="3"| | ||
− | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Indicatie |
|-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="2"|Probleem |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Zie [[#tst-1.1-patientprobleem-02|Probleem: tst-1.1-patientprobleem-02]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Patientprobleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="22"| |
− | |||
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− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|<span id="tst-1.1-patientprobleem-03" title="Intern ID = tst-1.1-patientprobleem-03">Probleem tst-1.1-patientprobleem-03</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|decubitus (code = '399912005' in codeSystem 'Referentieset Nationale kernset patientproblemen') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem status |
− | + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |style="background-color: white;"| | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verpleegkundige interventie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="5"| |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="3"|Interventie | |
− | + | |style="background-color: white;"|aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED Clinical Terms') | |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |colspan=" | ||
− | |style="background-color: white;"| | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
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− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Indicatie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="2"| |
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Zie [[#tst-1.1-patientprobleem-03|Probleem: tst-1.1-patientprobleem-03]] |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
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− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verpleegkundige interventie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="10"| |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Interventie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED Clinical Terms') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Indicatie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="2"| |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Probleem |
+ | |style="background-color: white;"|Zie [[#tst-1.1-patientprobleem-03|Probleem: tst-1.1-patientprobleem-03]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Actie start datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 10 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Actie eind datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 1 dag |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Uitvoerder |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="2"| |
− | |||
− | |||
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− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Zorgverlener |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="6"|Patientprobleem | |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |colspan="6"| | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="11"| | |rowspan="11"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|<span id="tst-1.1-patientprobleem-04" title="Intern ID = tst-1.1-patientprobleem-04">Probleem tst-1.1-patientprobleem-04</span> |
|-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="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|loopt risico op delier (code = '430794006' in codeSystem 'Referentieset Nationale kernset patientproblemen') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') |
− | |||
− | |||
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− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verpleegkundige interventie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Interventie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|bevorderen van vochtinname (code = '113148007' in codeSystem 'SNOMED Clinical Terms') |
− | |||
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− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Indicatie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="2"| |
− | |||
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− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Zie [[#tst-1.1-patientprobleem-04|Probleem: tst-1.1-patientprobleem-04]] |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|} | |} | ||
− | === Verpleegkundige context | + | === 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="8" | Verpleegkundige context specificatie gezondheidstoestand |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="7" width="30%"| Gegevenselement |
|| Waarde | || Waarde | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="8"|Voedingvocht |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="32"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Sonde systeem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="9"| | |rowspan="9"| | ||
− | |||
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− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Sonde |
|-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=" | + | |colspan="5"|Medisch hulpmiddel |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="5"| |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Product |
|-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="2"|Product type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|PEJ sonde (code = '8911000146104' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Product omschrijving |
− | + | |style="background-color: white;"|PEJ sonde | |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Infuus |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="10"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="6"|Infuuskatheter | |
− | |||
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− | |colspan="6"| | ||
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− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="7"| | |rowspan="7"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Medisch hulpmiddel |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="5"| |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Product |
|-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"|Product type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Centraal veneuze katheter (code = '52124006' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Product omschrijving |
− | |style="background-color: white;"| | + | |style="background-color: white;"|centraal veneuze katheter |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Toelichting |
− | |style="background-color: white;"| | + | |style="background-color: white;"|voor voeding |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Infuus | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="9"| |
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Infuuskatheter |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="7"| | |rowspan="7"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Medisch hulpmiddel |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Product |
|-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="2"|Product type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Perifeer intraveneus infuus (code = '82449006' in codeSystem 'SNOMED CT') |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Product omschrijving |
+ | |style="background-color: white;"|voor medicatie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="8"|Uitscheiding |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan | + | |rowspan="8"| |
− | |||
− | |||
− | |||
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− | |||
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− | |||
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− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="7"| | + | |colspan="7"|Stoma |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
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− | |||
− | |||
|-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="5"|Stoma type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|eindstandige ileostoma (code = '311412005' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Toelichting |
− | |style="background-color: white;"| | + | |style="background-color: white;"|na subtotale darmresectie |
− | |||
− | |||
− | |||
− | |||
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− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Stoma |
|-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="5"|Stoma type |
− | + | |style="background-color: white;"|urostoma (code = '281601009' in codeSystem 'SNOMED CT') | |
− | + | |}<section end=eovd-saa-tst-1.1-alle_zibs /> | |
− | + | <section begin=eovd-saa-tst-1.1b-alle_zibs /> | |
− | + | ==Scenario Aanmeldbericht - overlap BgZ== | |
− | + | ||
− | + | === Administratieve gegevens=== | |
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− | |style="background-color: white;"| | ||
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− | === | ||
{| 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="7" | Administratieve gegevens |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="6" width="30%"| Gegevenselement |
|| Waarde | || Waarde | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="6"|Datum overplaatsing |
+ | |style="background-color: white;"|T + 1 dag | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Persoonsgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="47"| |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Patient |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="18"| |
− | |||
− | |||
− | |||
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− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Naamgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="6"| |
|-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;"|Erik |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Initialen |
+ | |style="background-color: white;"|E | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Geslachtsnaam |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="2"| |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="2"|Achternaam | |
− | + | |style="background-color: white;"|XXX_Altenborg | |
− | |||
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− | |||
− | |colspan=" | ||
− | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Adresgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="6"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Straat |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Knolweg |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Huisnummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1000 |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Postcode |
+ | |style="background-color: white;"|9999XA | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Woonplaats |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Stitswerd |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Adres soort |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Identificatienummer |
+ | |style="background-color: white;"|999911612 (in identificerend systeem: BSN) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Geboortedatum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|14 aug 1964 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Geslacht |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Betaler |
|-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=" | + | |colspan="5"|Verzekeraar |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="5"| |
− | |||
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− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Verzekering |
− | |||
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− | |||
|-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="2"|Eind datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T + 1 jaar |
− | |||
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− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verzekeringssoort |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') |
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Contactpersoon | |colspan="6"|Contactpersoon | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="18"| |
|-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="7"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Voornamen | |colspan="3"|Voornamen | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Johanna |
|-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;"|J |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Roepnaam | |colspan="3"|Roepnaam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Hanna |
− | |||
− | |||
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|-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 | + | |rowspan="2"| |
− | |||
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|-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;"|Bakker |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Contactgegevens | |colspan="5"|Contactgegevens | ||
Regel 2.093: | Regel 711: | ||
|-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;"|+31645678912 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Email adressen | |colspan="4"|Email adressen | ||
Regel 2.100: | Regel 718: | ||
|-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;"|jbakker@123net.nl |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Relatie | |colspan="4"|Relatie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Sturende organisatie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="16"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Zorgaanbieder |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="14"| |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Zorgaanbieder identificatienummer |
+ | |style="background-color: white;"|06590457 (in identificerend systeem: AGB-Z) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Organisatie naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|AB-zkh |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Organisatie locatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Noord |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="4"|Afdeling specialisme | |
− | + | |style="background-color: white;"|Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |
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− | |colspan="4"| | ||
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− | |style="background-color: white;"| | ||
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Contactgegevens | |colspan="5"|Contactgegevens | ||
Regel 2.228: | Regel 752: | ||
|-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;"|+31182435770 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Email adressen | |colspan="4"|Email adressen | ||
Regel 2.235: | Regel 759: | ||
|-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;"|neurologie@ABZ.nl |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Organisatie type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') |
− | |||
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Ontvangende organisatie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="5"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Zorgaanbieder |
− | |||
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|-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="4"|Afdeling specialisme |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Organisatie type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060') |
− | | | + | |} |
− | + | === Medische context=== | |
− | + | ||
− | + | {| class="wikitable" width="85%" | |
− | | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Medische context |
− | + | |-style="background-color: #1F497D;; color: white; text-align:left;" | |
− | | | + | |colspan="4" width="30%"| Gegevenselement |
− | + | || Waarde | |
− | + | ||
− | |||
− | |||
− | |||
− | |-style=" | ||
− | |||
− | |||
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− | |colspan=" | ||
− | |||
− | |||
− | | | ||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Medische diagnose |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="18"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
|-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=" | + | |colspan="2"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Toelichting |
− | |style="background-color: white;"| | + | |style="background-color: white;"|niet bekend met neurologische klachten |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
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|-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="2"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|neoplasma van colon (code = '126838000') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
− | |||
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|-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="2"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|oksel (code = '238600001' in codeSystem 'SNOMED Clinical Terms') |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Probleem status |
+ | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
− | |||
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|-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="2"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|inverse psoriasis (code = '238600001') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Voorgeschiedenis |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="5"| |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
− | |||
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− | |||
|-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="2"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|diabetes mellitus (code = '73211009') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Let op |
|-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=" | + | |colspan="4"|Alert |
− | |||
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|-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="2"|Alert naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT') |
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− | + | |style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie | |
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Versie van 10 dec 2021 12:45
1 Addenda voor inhoudelijke gegevens
1.1 Scenario Aanmeldbericht
1.1.1 Administratieve gegevens
Administratieve gegevens | ||||||
Gegevenselement | Waarde | |||||
Datum overplaatsing | T + 1 dag | |||||
Persoonsgegevens | ||||||
Patient | ||||||
Naamgegevens | ||||||
Voornamen | Erik | |||||
Initialen | E | |||||
Geslachtsnaam | ||||||
Achternaam | XXX_Altenborg | |||||
Adresgegevens | ||||||
Straat | Knolweg | |||||
Huisnummer | 1000 | |||||
Postcode | 9999XA | |||||
Woonplaats | Stitswerd | |||||
Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||||
Identificatienummer | 999911612 (in identificerend systeem: BSN) | |||||
Geboortedatum | 14 aug 1964 | |||||
Geslacht | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |||||
Betaler | ||||||
Verzekeraar | ||||||
Verzekering | ||||||
Eind datum tijd | T + 1 jaar | |||||
Verzekeringssoort | Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') | |||||
Contactpersoon | ||||||
Naamgegevens | ||||||
Voornamen | Johanna | |||||
Initialen | J | |||||
Roepnaam | Hanna | |||||
Geslachtsnaam | ||||||
Achternaam | Bakker | |||||
Contactgegevens | ||||||
Telefoonnummers | ||||||
Telefoonnummer | +31645678912 | |||||
Email adressen | ||||||
Email adres | jbakker@123net.nl | |||||
Relatie | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef | |||||
Sturende organisatie | ||||||
Zorgaanbieder | ||||||
Zorgaanbieder identificatienummer | 06590457 (in identificerend systeem: AGB-Z) | |||||
Organisatie naam | AB-zkh | |||||
Organisatie locatie | Noord | |||||
Afdeling specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
Contactgegevens | ||||||
Telefoonnummers | ||||||
Telefoonnummer | +31182435770 | |||||
Email adressen | ||||||
Email adres | neurologie@ABZ.nl | |||||
Organisatie type | Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||||
Ontvangende organisatie | ||||||
Zorgaanbieder | ||||||
Afdeling specialisme | Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
Organisatie type | Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060') |
1.1.2 Algemene patienten context
Algemene patienten context | ||||
Gegevenselement | Waarde | |||
Juridische situatie | ||||
Juridische situatie tst-1.1-juridischesituatie-01 | ||||
Vertegenwoordiging | Onder curatele stelling (code = '9' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.3') | |||
Datum aanvang | T - 1 jaar |
1.1.3 Medische context
Medische context | ||||
Gegevenselement | Waarde | |||
Medische diagnose | ||||
Probleem | ||||
Probleem naam | ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT') | |||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
Toelichting | niet bekend met neurologische klachten | |||
Probleem | ||||
Probleem naam | neoplasma van colon (code = '126838000') | |||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
Probleem | ||||
Probleem naam | oksel (code = '238600001' in codeSystem 'SNOMED Clinical Terms') | |||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
Probleem | ||||
Probleem naam | inverse psoriasis (code = '238600001') | |||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
Voorgeschiedenis | ||||
Probleem | ||||
Probleem naam | diabetes mellitus (code = '73211009') | |||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
Let op | ||||
Alert | ||||
Alert naam | Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT') | |||
Alert | ||||
Alert naam | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie | |||
Vrijheidsbeperking | ||||
Vrijheidsbeperkende interventie | ||||
Wilsbekwaam | Ja | |||
Juridische situatie | Zie Juridische situatie: tst-1.1-juridischesituatie-01 | |||
Soort interventie | geforceerd toedienen van voeding bij patiënt (code = '37041007' in codeSystem 'SNOMED CT') | |||
Reden van toepassen | bevorderen van fysieke gezondheid (code = '121581000146106' 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') | |||
Begin | T - 50 dagen |
1.1.4 Verpleegkundige context zorgplan
Verpleegkundige context zorgplan | ||||||
Gegevenselement | Waarde | |||||
Actuele patientproblemen | ||||||
Patientprobleem | ||||||
Probleem tst-1.1-patientprobleem-01 | ||||||
Probleem naam | probleem met zichzelf wassen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
Toelichting | meneer kan niet buigen | |||||
Verpleegkundige interventie | ||||||
Interventie | ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED Clinical Terms') | |||||
Indicatie | ||||||
Probleem | Zie Probleem: tst-1.1-patientprobleem-01 | |||||
Uitvoerder | ||||||
Zorgverlener | Ja | |||||
Patientprobleem | ||||||
Probleem tst-1.1-patientprobleem-02 | ||||||
Probleem naam | probleem met zichzelf kleden (code = '284972002' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
Verpleegkundige interventie | ||||||
Interventie | ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms') | |||||
Indicatie | ||||||
Probleem | Zie Probleem: tst-1.1-patientprobleem-02 | |||||
Patientprobleem | ||||||
Probleem tst-1.1-patientprobleem-03 | ||||||
Probleem naam | decubitus (code = '399912005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
Verpleegkundige interventie | ||||||
Interventie | aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED Clinical Terms') | |||||
Indicatie | ||||||
Probleem | Zie Probleem: tst-1.1-patientprobleem-03 | |||||
Verpleegkundige interventie | ||||||
Interventie | wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED Clinical Terms') | |||||
Indicatie | ||||||
Probleem | Zie Probleem: tst-1.1-patientprobleem-03 | |||||
Actie start datum tijd | T - 10 dagen | |||||
Actie eind datum tijd | T - 1 dag | |||||
Uitvoerder | ||||||
Zorgverlener | Ja | |||||
Patientprobleem | ||||||
Probleem tst-1.1-patientprobleem-04 | ||||||
Probleem naam | loopt risico op delier (code = '430794006' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
Verpleegkundige interventie | ||||||
Interventie | bevorderen van vochtinname (code = '113148007' in codeSystem 'SNOMED Clinical Terms') | |||||
Indicatie | ||||||
Probleem | Zie Probleem: tst-1.1-patientprobleem-04 |
1.1.5 Verpleegkundige context specificatie gezondheidstoestand
Verpleegkundige context specificatie gezondheidstoestand | |||||||
Gegevenselement | Waarde | ||||||
Voedingvocht | |||||||
Sonde systeem | |||||||
Sonde | |||||||
Medisch hulpmiddel | |||||||
Product | |||||||
Product type | PEJ sonde (code = '8911000146104' in codeSystem 'SNOMED CT') | ||||||
Product omschrijving | PEJ sonde | ||||||
Infuus | |||||||
Infuuskatheter | |||||||
Medisch hulpmiddel | |||||||
Product | |||||||
Product type | Centraal veneuze katheter (code = '52124006' in codeSystem 'SNOMED CT') | ||||||
Product omschrijving | centraal veneuze katheter | ||||||
Toelichting | voor voeding | ||||||
Infuus | |||||||
Infuuskatheter | |||||||
Medisch hulpmiddel | |||||||
Product | |||||||
Product type | Perifeer intraveneus infuus (code = '82449006' in codeSystem 'SNOMED CT') | ||||||
Product omschrijving | voor medicatie | ||||||
Uitscheiding | |||||||
Stoma | |||||||
Stoma type | eindstandige ileostoma (code = '311412005' in codeSystem 'SNOMED CT') | ||||||
Toelichting | na subtotale darmresectie | ||||||
Stoma | |||||||
Stoma type | urostoma (code = '281601009' in codeSystem 'SNOMED CT') |
1.2 Scenario Aanmeldbericht - overlap BgZ
1.2.1 Administratieve gegevens
Administratieve gegevens | ||||||
Gegevenselement | Waarde | |||||
Datum overplaatsing | T + 1 dag | |||||
Persoonsgegevens | ||||||
Patient | ||||||
Naamgegevens | ||||||
Voornamen | Erik | |||||
Initialen | E | |||||
Geslachtsnaam | ||||||
Achternaam | XXX_Altenborg | |||||
Adresgegevens | ||||||
Straat | Knolweg | |||||
Huisnummer | 1000 | |||||
Postcode | 9999XA | |||||
Woonplaats | Stitswerd | |||||
Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||||
Identificatienummer | 999911612 (in identificerend systeem: BSN) | |||||
Geboortedatum | 14 aug 1964 | |||||
Geslacht | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |||||
Betaler | ||||||
Verzekeraar | ||||||
Verzekering | ||||||
Eind datum tijd | T + 1 jaar | |||||
Verzekeringssoort | Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') | |||||
Contactpersoon | ||||||
Naamgegevens | ||||||
Voornamen | Johanna | |||||
Initialen | J | |||||
Roepnaam | Hanna | |||||
Geslachtsnaam | ||||||
Achternaam | Bakker | |||||
Contactgegevens | ||||||
Telefoonnummers | ||||||
Telefoonnummer | +31645678912 | |||||
Email adressen | ||||||
Email adres | jbakker@123net.nl | |||||
Relatie | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef | |||||
Sturende organisatie | ||||||
Zorgaanbieder | ||||||
Zorgaanbieder identificatienummer | 06590457 (in identificerend systeem: AGB-Z) | |||||
Organisatie naam | AB-zkh | |||||
Organisatie locatie | Noord | |||||
Afdeling specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
Contactgegevens | ||||||
Telefoonnummers | ||||||
Telefoonnummer | +31182435770 | |||||
Email adressen | ||||||
Email adres | neurologie@ABZ.nl | |||||
Organisatie type | Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||||
Ontvangende organisatie | ||||||
Zorgaanbieder | ||||||
Afdeling specialisme | Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
Organisatie type | Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060') |
1.2.2 Medische context
Medische context | ||||
Gegevenselement | Waarde | |||
Medische diagnose | ||||
Probleem | ||||
Probleem naam | ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT') | |||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
Toelichting | niet bekend met neurologische klachten | |||
Probleem | ||||
Probleem naam | neoplasma van colon (code = '126838000') | |||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
Probleem | ||||
Probleem naam | oksel (code = '238600001' in codeSystem 'SNOMED Clinical Terms') | |||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
Probleem | ||||
Probleem naam | inverse psoriasis (code = '238600001') | |||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
Voorgeschiedenis | ||||
Probleem | ||||
Probleem naam | diabetes mellitus (code = '73211009') | |||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
Let op | ||||
Alert | ||||
Alert naam | Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT') | |||
Alert | ||||
Alert naam | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie |