BgZ CDA Implementation Guide

1 Introduction

TODO

2 Actors involved

Persons		Systems
Name	Description	Name	Description
Referring medical specialist	Medical specialist who sends a BgZ along with a referral	EHR	Electronic health record
Receiving medical specialist	Medical specialist receives a BgZ along with a referral	EHR	Electronic health record

5 CDA templates

Section	Titel	Title	CDA Template
0	BgZ		Template CDA Basisgegevensset Zorg 2017 (BgZ)
1. Demografie en identificatie		Demographics and identification
	Patient	Patient
2. Financiële informatie		Financial information
	Betaler	Payer
3. Behandelrestricties		Treatment Directives
	BehandelAanwijzing	TreatmentDirective
	Wilsverklaring	AdvanceDirective
4. Contactpersonen		Contact persons
	Contactpersoon	ContactPerson
5. Functionele status		Functional Status
	Funct. OfMentaleStatus	FunctionalOrMentalStatus
6. Klachten en diagnoses		Complaints and diagnoses
	Probleem	Problem
7. Sociale anamnese		Social anamnesis
	Woonsituatie	LivingSituation
	DrugsGebruik	DrugUse
	AlcoholGebruik	AlcoholUse
	TabakGebruik	TobaccoUse
	Voedingsadvies	NutritionAdvice
8. Waarschuwingen		Alerts
	Alert	Alert
9. Allergieën		Allergies
	AllergieIntolerantie	AllergyIntolerance
10. Medicatie		Medication
	MedicatieGebruik2	MedicationUse2
	Medicatieafspraak	MedicationAgreement
	Toedieningsafspraak	AdministrationAgreement
11. Medische hulpmiddelen		Medical devices
	MedischHulpmiddel	MedicalDevice
12. Vaccinaties		Immunizations
	Vaccinatie	Vaccination
13. Vitale functies		Vital signs
	Bloeddruk	BloodPressure
	LichaamsGewicht	BodyWeight
	LichaamsLengte	BodyHeight
14. Uitslagen		Results
	LaboratoriumUitslag	LaboratoryTestResult
15. Verrichtingen		Procedures
	Verrichting	Procedure
16. Contacten		Encounters
	Contact	Encounter
17. Zorgplan		Care plan
	OverdrachtGeplandeZorgActiviteit	PlannedCareActivityForTransfer
18. Zorgverleners		Health professionals
	Zorgverlener	HealthProfessional
	Zorgaanbieder	HealthcareProvider