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1 Addenda voor inhoudelijke gegevens
Deze pagina bevat de gegevens voor de kwalificatiescenario's van de BgZ
2 Scenario 1: Patiënt A
2.1 Probleem (Problem) [bgz-patA-problem2]
Probleem (Problem) [bgz-patA-problem2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
ProbleemType (ProblemType)
|
Diagnosis (code = '282291009' in codeSystem 'SNOMED CT')
|
ProbleemNaam (ProblemName)
|
allergisch astma (code = '389145006' in codeSystem 'SNOMED CT')
|
ProbleemBeginDatum (ProblemStartDate)
|
1999
|
ProbleemEindDatum (ProblemEndDate)
|
2000
|
ProbleemStatus (ProblemStatus)
|
Inactive (code = '73425007' in codeSystem 'SNOMED CT')
|
VerificatieStatus (VerificationStatus)
|
Known absent (code = '410516002' in codeSystem 'SNOMED CT')
|
Toelichting (Comment)
|
Patiënt meende dat kortademigheid optrad als reactie op noten.
|
2.2 Probleem (Problem) [bgz-patA-problem3]
Probleem (Problem) [bgz-patA-problem3]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
ProbleemAnatomischeLocatie (ProblemAnatomicalLocation)
|
gehele long (code = '181216001' in codeSystem 'SNOMED CT')
|
ProbleemType (ProblemType)
|
Diagnosis (code = '282291009' in codeSystem 'SNOMED CT')
|
ProbleemNaam (ProblemName)
|
astma (code = '195967001' in codeSystem 'SNOMED CT')
|
ProbleemBeginDatum (ProblemStartDate)
|
2000
|
ProbleemStatus (ProblemStatus)
|
Active (code = '55561003' in codeSystem 'SNOMED CT')
|
VerificatieStatus (VerificationStatus)
|
Confirmed present (code = '410605003' in codeSystem 'SNOMED CT')
|
Toelichting (Comment)
|
Kortademig
|
2.3 Probleem (Problem) [bgz-patA-problem4]
Probleem (Problem) [bgz-patA-problem4]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
ProbleemAnatomischeLocatie (ProblemAnatomicalLocation)
|
geheel rechter uitwendig oor (code = '368567003' in codeSystem 'SNOMED CT')
|
ProbleemLateraliteit (ProblemLaterality)
|
Right (code = '24028007' in codeSystem 'SNOMED CT')
|
ProbleemType (ProblemType)
|
Functional Limitation (code = '248536006' in codeSystem 'SNOMED CT')
|
ProbleemNaam (ProblemName)
|
gehoorverlies (code = '15188001' in codeSystem 'SNOMED CT')
|
ProbleemBeginDatum (ProblemStartDate)
|
8 maa 2012
|
ProbleemStatus (ProblemStatus)
|
Active (code = '55561003' in codeSystem 'SNOMED CT')
|
VerificatieStatus (VerificationStatus)
|
Confirmed present (code = '410605003' in codeSystem 'SNOMED CT')
|
Toelichting (Comment)
|
Slechthorend door harde muziek
|
2.4 Probleem (Problem) [bgz-patA-problem5]
Probleem (Problem) [bgz-patA-problem5]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
ProbleemAnatomischeLocatie (ProblemAnatomicalLocation)
|
structuur van enkelgewricht (code = '70258002' in codeSystem 'SNOMED CT')
|
ProbleemLateraliteit (ProblemLaterality)
|
Left (code = '7771000' in codeSystem 'SNOMED CT')
|
ProbleemType (ProblemType)
|
Diagnosis (code = '282291009' in codeSystem 'SNOMED CT')
|
ProbleemNaam (ProblemName)
|
fractuur van enkel (code = '16114001' in codeSystem 'SNOMED CT')
|
ProbleemBeginDatum (ProblemStartDate)
|
T+1D
|
ProbleemStatus (ProblemStatus)
|
Active (code = '55561003' in codeSystem 'SNOMED CT')
|
VerificatieStatus (VerificationStatus)
|
Confirmed present (code = '410605003' in codeSystem 'SNOMED CT')
|
Toelichting (Comment)
|
Op een bal gaan staan tijdens het voetballen.
|
2.5 Woonsituatie (LivingSituation) [bgz-patA-living]
Woonsituatie (LivingSituation) [bgz-patA-living]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
Toelichting (Comment)
|
Geen lift
|
WoningType (HouseType)
|
Appartement of flatwoning (code = 'FLATW' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.13.1')
|
2.6 DrugsGebruik (DrugUse) [bgz-patA-druguse]
DrugsGebruik (DrugUse) [bgz-patA-druguse]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
WaarnemingGebruik (ObservationOfUse)
|
|
StartDatum (StartDate)
|
1986
|
StopDatum (StopDate)
|
1988
|
Hoeveelheid (Amount)
|
Eén keer per maand
|
Toelichting (Comment)
|
Op feesten
|
DrugsOfGeneesmiddelSoort (DrugOrMedicationType)
|
Methylenedioxymethamphetamine (substance) (code = '288459003' in codeSystem 'SNOMED CT')
|
DrugsGebruikStatus (DrugUseStatus)
|
Misused drugs in past (finding) (code = '44870007' in codeSystem 'SNOMED CT')
|
Toedieningsweg (RouteOfAdministration)
|
ORAAL (code = '9' in codeSystem 'G-Standaard TH007 Toedieningswegen')
|
2.7 AlcoholGebruik (AlcoholUse) [bgz-patA-alcohol]
AlcoholGebruik (AlcoholUse) [bgz-patA-alcohol]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
Toelichting (Comment)
|
flesje bier
|
AlcoholGebruikStatus (AlcoholUseStatus)
|
Current drinker of alcohol (finding) (code = '219006' in codeSystem 'SNOMED CT')
|
WaarnemingGebruik (ObservationOfUse)
|
|
StartDatum (StartDate)
|
1984
|
Hoeveelheid (Amount)
|
1 /d
|
2.8 Contactpersoon (Contact) [bgz-patA-contactperson1]
Contactpersoon (Contact) [bgz-patA-contactperson1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
Naamgegevens (NameInformation)
|
|
referentie:Naamgegevens (reference:NameInformation)
|
|
Voornamen (FirstNames)
|
Dirk
|
Initialen (Initials)
|
D.
|
Roepnaam (GivenName)
|
Dirk
|
Geslachtsnaam (LastName)
|
|
Achternaam (LastName)
|
Janse
|
Contactgegevens (ContactInformation)
|
|
referentie:Contactgegevens (reference:ContactInformation)
|
|
Telefoonnummers (TelephoneNumbers)
|
|
Telefoonnummer (TelephoneNumber)
|
+316-22668899
|
TelecomType (TelecomType)
|
Mobile Phone (code = 'MC' in codeSystem 'HL7 AddressUse')
|
NummerSoort (NumberType)
|
Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse')
|
EmailAdressen (EmailAddresses)
|
|
EmailAdres (EmailAddress)
|
dirk.janse@test.nl
|
EmailSoort (EmailAddressType)
|
Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse')
|
Adresgegevens (AddressInformation)
|
|
referentie:Adresgegevens (reference:AddressInformation)
|
|
Straat (Street)
|
Huweelstraat
|
Huisnummer (HouseNumber)
|
15
|
AanduidingBijNummer (HouseNumberIndication)
|
Tegenover (code = 'to' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.3')
|
Postcode (Postcode)
|
1248 CC
|
Woonplaats (PlaceOfResidence)
|
Barendrecht
|
Land (Country)
|
Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2')
|
AdresSoort (AddressType)
|
Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse')
|
Rol (Role)
|
Eerste relatie/contactpersoon (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472')
|
Relatie (Relationship)
|
Son (code = 'SONC' in codeSystem 'HL7 RoleCode')
|
2.9 BurgerlijkeStaatRC (MaritalStatusRC) [bgz-patA-marital]
BurgerlijkeStaatRC (MaritalStatusRC) [bgz-patA-marital]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
BurgerlijkeStaat (MaritalStatus)
|
Married (code = 'M' in codeSystem '2.16.840.1.113883.5.2')
|
2.10 Contactpersoon (Contact) [bgz-patA-contactperson2]
Contactpersoon (Contact) [bgz-patA-contactperson2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
Naamgegevens (NameInformation)
|
|
referentie:Naamgegevens (reference:NameInformation)
|
|
Voornamen (FirstNames)
|
Els
|
Initialen (Initials)
|
E.
|
Roepnaam (GivenName)
|
Els
|
Naamgebruik (NameUsage)
|
Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')
|
Geslachtsnaam (LastName)
|
|
Voorvoegsels (Prefix)
|
de
|
Achternaam (LastName)
|
Groot
|
Contactgegevens (ContactInformation)
|
|
referentie:Contactgegevens (reference:ContactInformation)
|
|
Telefoonnummers (TelephoneNumbers)
|
|
Telefoonnummer (TelephoneNumber)
|
06-12345678
|
TelecomType (TelecomType)
|
Mobile Phone (code = 'MC' in codeSystem 'HL7 AddressUse')
|
NummerSoort (NumberType)
|
Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse')
|
EmailAdressen (EmailAddresses)
|
|
EmailAdres (EmailAddress)
|
Els.degroot@test.nl
|
EmailSoort (EmailAddressType)
|
Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse')
|
Adresgegevens (AddressInformation)
|
|
referentie:Adresgegevens (reference:AddressInformation)
|
|
Straat (Street)
|
Gaaspelwede
|
Huisnummer (HouseNumber)
|
16
|
Postcode (Postcode)
|
1247 BB
|
Woonplaats (PlaceOfResidence)
|
Hellevoetsluis
|
Land (Country)
|
Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2')
|
AdresSoort (AddressType)
|
Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse')
|
Rol (Role)
|
Anders (code = '9' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472')
|
Relatie (Relationship)
|
Daughter in-law (code = 'DAUINLAW' in codeSystem 'HL7 RoleCode')
|
2.11 Wilsverklaring (AdvanceDirective) [bgz-patA-advdir]
Wilsverklaring (AdvanceDirective) [bgz-patA-advdir]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
WilsverklaringType (LivingWillType)
|
Levenswensverklaring (code = 'LW' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.14.1')
|
WilsverklaringDatum (LivingWillDate)
|
16 sep 2012
|
Aandoening (Disorder)
|
|
referentie:Probleem (reference:Problem)
|
zib-2017-bgz-patA-problem3
|
Vertegenwoordiger (Representative)
|
|
referentie:Contactpersoon (reference:Contact)
|
zib-2017-bgz-patA-contactperson1
|
WilsverklaringDocument (LivingWillDocument)
|
ZHVtbXktd2lsc3ZlcmtsYXJpbmcgRGVubmlzIEphbnNlLnBkZg==
|
Toelichting (Comment)
|
gescand document
|
2.12 BehandelAanwijzing (TreatmentDirective) [bgz-patA-treatmentdir]
BehandelAanwijzing (TreatmentDirective) [bgz-patA-treatmentdir]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
Verificatie (Verification)
|
|
Geverifieerd (Verified)
|
Ja
|
GeverifieerdBij (VerifiedWith)
|
Patient (code = '116154003' in codeSystem 'SNOMED CT')
|
VerificatieDatum (VerificationDate)
|
T+1D
|
Behandeling (Treatment)
|
Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): MRI
|
BehandelingToegestaan (TreatmentPermitted)
|
Ja, maar met beperkingen (code = 'JA_MAAR' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4')
|
Beperkingen (Restrictions)
|
eerst overleg met de partner
|
Toelichting (Comment)
|
voor behandeling "MRI"; beperking geldt tot aan ontslag uit het ziekenhuis
|
Wilsverklaring (AdvanceDirective)
|
|
referentie:Wilsverklaring (reference:AdvanceDirective)
|
zib-2017-bgz-patA-advdir
|
2.13 FunctioneleOfMentaleStatus (FunctionalOrMentalStatus) [bgz-patA-funcment2]
FunctioneleOfMentaleStatus (FunctionalOrMentalStatus) [bgz-patA-funcment2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
StatusNaam (StatusName)
|
vermogen om zich te mobiliseren (code = '301438001' in codeSystem 'SNOMED CT')
|
StatusWaarde (StatusValue)
|
ernstig (code = '24484000' in codeSystem '2.16.840.1.113883.6.96 (ordinal = )
|
StatusDatum (StatusDate)
|
T+1D
|
Toelichting (Comment)
|
Mag nog niet op loopgips steunen
|
2.14 Alert (Alert) [bgz-patA-alert1]
Alert (Alert) [bgz-patA-alert1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
AlertNaam (AlertName)
|
Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): agressieve patiënt
|
BeginDatumTijd (StartDateTime)
|
2016
|
AlertType (AlertType)
|
alert (code = '74018-3' in codeSystem 'LOINC')
|
2.15 Alert (Alert) [bgz-patA-alert2]
Alert (Alert) [bgz-patA-alert2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
AlertNaam (AlertName)
|
Methicillin resistant staphylococcus aureus carrier (code = '432415000' in codeSystem 'SNOMED CT')
|
AlertType (AlertType)
|
alert (code = '74018-3' in codeSystem 'LOINC')
|
2.16 Verrichting (Procedure) [bgz-patA-procedure1]
Verrichting (Procedure) [bgz-patA-procedure1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
VerrichtingStartDatum (ProcedureStartDate)
|
T+1D{14:00}
|
VerrichtingEindDatum (ProcedureEndDate)
|
T+1D{15:00}
|
VerrichtingAnatomischeLocatie (ProcedureAnatomicalLocation)
|
structuur van enkelgewricht (code = '70258002' in codeSystem 'SNOMED CT')
|
VerrichtingLateraliteit (ProcedureLaterality)
|
Left (code = '7771000' in codeSystem 'SNOMED CT')
|
Indicatie (Indication)
|
|
referentie:Probleem (reference:Problem)
|
zib-2017-bgz-patA-problem5
|
VerrichtingType (ProcedureType)
|
externe fixatie van fractuur van malleolus (code = '111501000146106' in codeSystem 'SNOMED CT')
|
Locatie (Location)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
naam eigen ziekenhuis
|
Uitvoerder (Performer)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patA-healthProf2
|
Aanvrager (Requester)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patA-healthProf3
|
2.17 Verrichting (Procedure) [bgz-patA-procedure2]
Verrichting (Procedure) [bgz-patA-procedure2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
VerrichtingStartDatum (ProcedureStartDate)
|
T+2D{09:30}
|
VerrichtingAnatomischeLocatie (ProcedureAnatomicalLocation)
|
structuur van enkelgewricht (code = '70258002' in codeSystem 'SNOMED CT')
|
VerrichtingLateraliteit (ProcedureLaterality)
|
Left (code = '7771000' in codeSystem 'SNOMED CT')
|
Indicatie (Indication)
|
|
referentie:Probleem (reference:Problem)
|
zib-2017-bgz-patA-problem5
|
VerrichtingType (ProcedureType)
|
aanleggen van loopgips voor onderbeen (code = '122531000146102' in codeSystem 'SNOMED CT')
|
Locatie (Location)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
naam eigen ziekenhuis
|
Aanvrager (Requester)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patA-healthProf2
|
2.18 Contact (Encounter) [bgz-patA-encounter1]
Contact (Encounter) [bgz-patA-encounter1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
ContactType (ContactType)
|
Emergency (code = 'EMER' in codeSystem 'HL7 ActCode')
|
ContactMet (ContactWith)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patA-healthProf2
|
Locatie (Location)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
naam eigen ziekenhuis
|
BeginDatumTijd (StartDateTime)
|
T+1D{11:00}
|
EindDatumTijd (EndDateTime)
|
T+1D{13:30}
|
RedenContact (ContactReason)
|
|
Probleem (Problem)
|
|
referentie:Probleem (reference:Problem)
|
zib-2017-bgz-patA-problem5
|
Herkomst (Origin)
|
Home (code = '264362003' in codeSystem 'SNOMED CT')
|
2.19 Contact (Encounter) [bgz-patA-encounter2]
Contact (Encounter) [bgz-patA-encounter2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
ContactType (ContactType)
|
Inpatient (code = 'IMP' in codeSystem 'HL7 ActCode')
|
ContactMet (ContactWith)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patA-healthProf3
|
Locatie (Location)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
naam eigen ziekenhuis
|
BeginDatumTijd (StartDateTime)
|
T+1D{13:30}
|
EindDatumTijd (EndDateTime)
|
T+2D{12:00}
|
RedenContact (ContactReason)
|
|
Verrichting (Procedure)
|
|
referentie:Verrichting (reference:Procedure)
|
zib-2017-bgz-patA-procedure1
|
Bestemming (Destination)
|
Rehabilitation hospital (code = '80522000' in codeSystem 'SNOMED CT')
|
2.20 Contact (Encounter) [bgz-patA-encounter3]
Contact (Encounter) [bgz-patA-encounter3]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
ContactType (ContactType)
|
Ambulatory (code = 'AMB' in codeSystem 'HL7 ActCode')
|
ContactMet (ContactWith)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patA-healthProf2
|
Locatie (Location)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
naam eigen ziekenhuis
|
BeginDatumTijd (StartDateTime)
|
T+44D{09:00}
|
RedenContact (ContactReason)
|
|
Verrichting (Procedure)
|
|
referentie:Verrichting (reference:Procedure)
|
zib-2017-bgz-patA-procedure1
|
2.21 Zorgverlener (HealthProfessional) [bgz-patA-healthProf2]
Zorgverlener (HealthProfessional) [bgz-patA-healthProf2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
ZorgverlenerIdentificatienummer (HealthProfessionalIdentificationNumber)
|
45678912 (in identificerend systeem: AGB-Z)
|
Naamgegevens (NameInformation)
|
|
referentie:Naamgegevens (reference:NameInformation)
|
|
Voornamen (FirstNames)
|
Jeroen Hendrik Robert
|
Initialen (Initials)
|
J.H.R.
|
Roepnaam (GivenName)
|
Jeroen
|
Naamgebruik (NameUsage)
|
Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')
|
Geslachtsnaam (LastName)
|
|
Achternaam (LastName)
|
Peters
|
Specialisme (Specialty)
|
Orthopedisch chirurg (code = '01.032' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)')
|
Adresgegevens (AddressInformation)
|
|
referentie:Adresgegevens (reference:AddressInformation)
|
|
Straat (Street)
|
Dr. Molewaterplein
|
Huisnummer (HouseNumber)
|
40
|
Postcode (Postcode)
|
3015 GD
|
Woonplaats (PlaceOfResidence)
|
Rotterdam
|
Gemeente (Municipality)
|
Rotterdam
|
Land (Country)
|
Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2')
|
AdresSoort (AddressType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
Contactgegevens (ContactInformation)
|
|
referentie:Contactgegevens (reference:ContactInformation)
|
|
Telefoonnummers (TelephoneNumbers)
|
|
Telefoonnummer (TelephoneNumber)
|
06-23412345
|
TelecomType (TelecomType)
|
Mobile Phone (code = 'MC' in codeSystem 'HL7 AddressUse')
|
NummerSoort (NumberType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
EmailAdressen (EmailAddresses)
|
|
EmailAdres (EmailAddress)
|
j.peters@hospital.nl
|
EmailSoort (EmailAddressType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
Zorgaanbieder (HealthcareProvider)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
naam eigen ziekenhuis
|
ZorgverlenersRol (HealthProfessionalRole)
|
Responsible Party (code = 'RESP' in codeSystem 'HL7 ParticipationType')
|
2.22 LaboratoriumUitslag (LaboratoryTestResult) [bgz-patA-labresult2]
LaboratoriumUitslag (LaboratoryTestResult) [bgz-patA-labresult2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
LaboratoriumTest (LaboratoryTest)
|
|
TestCode (TestCode)
|
Hemoglobine A1c [massa/volume] in bloed (code = '41995-2' in codeSystem 'LOINC')
|
TestDatumTijd (TestDateTime)
|
T+2D{09:00}
|
TestUitslag (TestResult)
|
8.9 mmol/L
|
TestUitslagStatus (TestResultStatus)
|
Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1')
|
ReferentieBovengrens (ReferenceRangeUpperLimit)
|
9.9 mmol/L
|
ReferentieOndergrens (ReferenceRangeLowerLimit)
|
7.4 mmol/L
|
Monster (Specimen)
|
|
Monsternummer (SpecimenId)
|
9877 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.25.4267.4)
|
Monstervolgnummer (SpecimenNumberExtension)
|
2
|
Containertype (ContainerType)
|
container voor bloed- of weefselopslag of -kweek (code = '700957004' in codeSystem 'SNOMED CT')
|
Monstermateriaal (SpecimenMaterial)
|
bloed (code = '87612001' in codeSystem 'SNOMED CT')
|
AfnameDatumTijd (CollectionDateTime)
|
T+2D{08:00}
|
AnatomischeLocatie (AnatomicalLocation)
|
gehele regio cubiti (code = '76248009' in codeSystem 'SNOMED CT')
|
Lateraliteit (Laterality)
|
Right (code = '24028007' in codeSystem 'SNOMED CT')
|
ResultaatType (ResultType)
|
Chemistry (code = '275711006' in codeSystem 'SNOMED CT')
|
2.23 LaboratoriumUitslag (LaboratoryTestResult) [bgz-patA-labresult1]
LaboratoriumUitslag (LaboratoryTestResult) [bgz-patA-labresult1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
LaboratoriumTest (LaboratoryTest)
|
|
TestCode (TestCode)
|
Hemoglobine A1c [massa/volume] in bloed (code = '41995-2' in codeSystem 'LOINC')
|
TestDatumTijd (TestDateTime)
|
T+1D{13:00}
|
TestUitslag (TestResult)
|
8.1 mmol/L
|
TestUitslagStatus (TestResultStatus)
|
Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1')
|
ReferentieBovengrens (ReferenceRangeUpperLimit)
|
9.9 mmol/L
|
ReferentieOndergrens (ReferenceRangeLowerLimit)
|
7.4 mmol/L
|
LaboratoriumTest (LaboratoryTest)
|
|
TestCode (TestCode)
|
Hematocriet [volumefractie] in bloed (code = '20570-8' in codeSystem 'LOINC')
|
TestDatumTijd (TestDateTime)
|
T+1D{13:00}
|
TestUitslag (TestResult)
|
0.39 L/L
|
TestUitslagStatus (TestResultStatus)
|
Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1')
|
ReferentieBovengrens (ReferenceRangeUpperLimit)
|
0.46 L/L
|
ReferentieOndergrens (ReferenceRangeLowerLimit)
|
0.36 L/L
|
LaboratoriumTest (LaboratoryTest)
|
|
TestCode (TestCode)
|
Leukocyten [aantal/volume] in bloed (code = '26464-8' in codeSystem 'LOINC')
|
TestDatumTijd (TestDateTime)
|
T+1D{13:00}
|
TestUitslag (TestResult)
|
6.6E+9 /L
|
TestUitslagStatus (TestResultStatus)
|
Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1')
|
ReferentieBovengrens (ReferenceRangeUpperLimit)
|
11.0E+9 /L
|
ReferentieOndergrens (ReferenceRangeLowerLimit)
|
4.0E+9 /L
|
Monster (Specimen)
|
|
Monsternummer (SpecimenId)
|
9876 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.25.4267.4)
|
Monstervolgnummer (SpecimenNumberExtension)
|
2
|
Containertype (ContainerType)
|
container voor bloed- of weefselopslag of -kweek (code = '700957004' in codeSystem 'SNOMED CT')
|
Monstermateriaal (SpecimenMaterial)
|
bloed (code = '87612001' in codeSystem 'SNOMED CT')
|
AfnameDatumTijd (CollectionDateTime)
|
T+1D{12:00}
|
AnatomischeLocatie (AnatomicalLocation)
|
gehele regio cubiti (code = '76248009' in codeSystem 'SNOMED CT')
|
Lateraliteit (Laterality)
|
Left (code = '7771000' in codeSystem 'SNOMED CT')
|
Onderzoek (PanelOrBattery)
|
Compleet bloedbeeld panel in bloed d.m.v. geautomatiseerde telling (code = '58410-2' in codeSystem 'LOINC')
|
ResultaatStatus (ResultStatus)
|
Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1')
|
ResultaatType (ResultType)
|
Chemistry (code = '275711006' in codeSystem 'SNOMED CT')
|
Aanvrager (Requester)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patA-healthProf3
|
2.24 Vaccinatie (Vaccination) [bgz-patA-vaccin1]
Vaccinatie (Vaccination) [bgz-patA-vaccin1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
ProductCode (ProductCode)
|
Tetanusvaccin (code = 'J07AM01' in codeSystem '2.16.840.1.113883.6.73')
|
Dosis (Dose)
|
2 ml
|
VaccinatieDatum (VaccinationDate)
|
3 apr 2019
|
GewensteDatumHervaccinatie (PreferedDateForRevaccination)
|
3 apr 2020
|
Toediener (Administrator)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patA-healthProf1
|
Toelichting (Comment)
|
Gebeten door een hond
|
2.25 Zorgverlener (HealthProfessional) [bgz-patA-healthProf3]
Zorgverlener (HealthProfessional) [bgz-patA-healthProf3]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
ZorgverlenerIdentificatienummer (HealthProfessionalIdentificationNumber)
|
12345678 (in identificerend systeem: AGB-Z)
|
Naamgegevens (NameInformation)
|
|
referentie:Naamgegevens (reference:NameInformation)
|
|
Voornamen (FirstNames)
|
Alfred Bart
|
Initialen (Initials)
|
A.B.
|
Roepnaam (GivenName)
|
Alfred
|
Naamgebruik (NameUsage)
|
Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')
|
Geslachtsnaam (LastName)
|
|
Achternaam (LastName)
|
Bakker
|
Specialisme (Specialty)
|
Spoedeisende hulp arts (code = '01.071' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)')
|
Adresgegevens (AddressInformation)
|
|
referentie:Adresgegevens (reference:AddressInformation)
|
|
Straat (Street)
|
Dr. Molewaterplein
|
Huisnummer (HouseNumber)
|
40
|
Postcode (Postcode)
|
3015 GD
|
Woonplaats (PlaceOfResidence)
|
Rotterdam
|
Gemeente (Municipality)
|
Rotterdam
|
Land (Country)
|
Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2')
|
AdresSoort (AddressType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
Contactgegevens (ContactInformation)
|
|
referentie:Contactgegevens (reference:ContactInformation)
|
|
Telefoonnummers (TelephoneNumbers)
|
|
Telefoonnummer (TelephoneNumber)
|
06-33334444
|
TelecomType (TelecomType)
|
Mobile Phone (code = 'MC' in codeSystem 'HL7 AddressUse')
|
NummerSoort (NumberType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
EmailAdressen (EmailAddresses)
|
|
EmailAdres (EmailAddress)
|
a.b.bakker@hospital.nl
|
EmailSoort (EmailAddressType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
Zorgaanbieder (HealthcareProvider)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
naam eigen ziekenhuis
|
ZorgverlenersRol (HealthProfessionalRole)
|
Attender (code = 'ATND' in codeSystem 'HL7 ParticipationType')
|
2.26 FunctioneleOfMentaleStatus (FunctionalOrMentalStatus) [bgz-patA-funcment1]
FunctioneleOfMentaleStatus (FunctionalOrMentalStatus) [bgz-patA-funcment1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
StatusNaam (StatusName)
|
gehoorverlies (code = '15188001' in codeSystem 'SNOMED CT')
|
StatusWaarde (StatusValue)
|
licht (code = '255604002' in codeSystem '2.16.840.1.113883.6.96 (ordinal = )
|
StatusDatum (StatusDate)
|
1 feb 2012
|
Toelichting (Comment)
|
Licht beperkend
|
Hulpmiddel (MedicalDevice)
|
|
referentie:MedischHulpmiddel (reference:MedicalDevice)
|
zib-2017-bgz-patA-medDevice1
|
2.27 Zorgverlener (HealthProfessional) [bgz-patA-healthProf1]
Zorgverlener (HealthProfessional) [bgz-patA-healthProf1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
ZorgverlenerIdentificatienummer (HealthProfessionalIdentificationNumber)
|
88776655 (in identificerend systeem: AGB-Z)
|
Naamgegevens (NameInformation)
|
|
referentie:Naamgegevens (reference:NameInformation)
|
|
Voornamen (FirstNames)
|
Ria Alexandra
|
Initialen (Initials)
|
R.A.
|
Roepnaam (GivenName)
|
Ria
|
Naamgebruik (NameUsage)
|
Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')
|
Geslachtsnaam (LastName)
|
|
Achternaam (LastName)
|
Slot
|
Specialisme (Specialty)
|
Huisarts (code = '01.015' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)')
|
Adresgegevens (AddressInformation)
|
|
referentie:Adresgegevens (reference:AddressInformation)
|
|
Straat (Street)
|
Talmastraat
|
Huisnummer (HouseNumber)
|
84
|
Huisnummerletter (HouseNumberLetter)
|
B
|
Postcode (Postcode)
|
3071 AS
|
Woonplaats (PlaceOfResidence)
|
Rotterdam
|
Gemeente (Municipality)
|
Rotterdam
|
Land (Country)
|
Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2')
|
AdresSoort (AddressType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
Contactgegevens (ContactInformation)
|
|
referentie:Contactgegevens (reference:ContactInformation)
|
|
Telefoonnummers (TelephoneNumbers)
|
|
Telefoonnummer (TelephoneNumber)
|
06-12345767
|
TelecomType (TelecomType)
|
Mobile Phone (code = 'MC' in codeSystem 'HL7 AddressUse')
|
NummerSoort (NumberType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
EmailAdressen (EmailAddresses)
|
|
EmailAdres (EmailAddress)
|
r.a.slot@huisarts.nl
|
EmailSoort (EmailAddressType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
Zorgaanbieder (HealthcareProvider)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
Huisartsenpraktijk Rotterdam
|
2.28 TabakGebruik (TobaccoUse) [bgz-patA-tobacco]
TabakGebruik (TobaccoUse) [bgz-patA-tobacco]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
Toelichting (Comment)
|
Havana
|
SoortTabakGebruik (TypeOfTobaccoUsed)
|
Cigar smoker (finding) (code = '59978006' in codeSystem 'SNOMED CT')
|
TabakGebruikStatus (TobaccoUseStatus)
|
Occasional cigarette smoker (finding) (code = '230059006' in codeSystem 'SNOMED CT')
|
WaarnemingGebruik (ObservationOfUse)
|
|
StartDatum (StartDate)
|
2001
|
Hoeveelheid (Amount)
|
1 {cigars}/wk
|
PackYears (PackYears)
|
6
|
2.29 MedischHulpmiddel (MedicalDevice) [bgz-patA-medDevice1]
MedischHulpmiddel (MedicalDevice) [bgz-patA-medDevice1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
Product (Product)
|
|
ProductID (ProductID)
|
9321502032612 (code = '9321502032612' in codeSystem '1.3.160')
|
ProductType (ProductType)
|
hoorapparaat (code = '360283003' in codeSystem 'SNOMED CT')
|
ProductOmschrijving (ProductDescription)
|
Gehoorapparaat
|
BeginDatum (StartDate)
|
8 maa 2012
|
Indicatie (Indication)
|
|
referentie:Probleem (reference:Problem)
|
zib-2017-bgz-patA-problem4
|
Toelichting (Comment)
|
Apparaat niet zichtbaar
|
AnatomischeLocatie (AnatomicalLocation)
|
geheel rechter uitwendig oor (code = '368567003' in codeSystem 'SNOMED CT')
|
Lateraliteit (Laterality)
|
Right (code = '24028007' in codeSystem 'SNOMED CT')
|
Locatie (Location)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
Huisartsenpraktijk Rotterdam
|
Zorgverlener (HealthProfessional)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patA-healthProf1
|
2.30 MedischHulpmiddel (MedicalDevice) [bgz-patA-medDevice2]
MedischHulpmiddel (MedicalDevice) [bgz-patA-medDevice2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
Product (Product)
|
|
ProductID (ProductID)
|
5055785706734 (code = '5055785706734' in codeSystem '1.3.160')
|
ProductType (ProductType)
|
rolstoel (code = '58938008' in codeSystem 'SNOMED CT')
|
ProductOmschrijving (ProductDescription)
|
Niet-gemotoriseerde rolstoel
|
BeginDatum (StartDate)
|
T+2D
|
Indicatie (Indication)
|
|
referentie:Probleem (reference:Problem)
|
zib-2017-bgz-patA-problem5
|
Locatie (Location)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
naam eigen ziekenhuis
|
Zorgverlener (HealthProfessional)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patA-healthProf2
|
2.31 Vaccinatie (Vaccination) [bgz-patA-vaccin2]
Vaccinatie (Vaccination) [bgz-patA-vaccin2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
ProductCode (ProductCode)
|
Hepatitis A+B-vaccin (code = 'J07BC20' in codeSystem '2.16.840.1.113883.6.73')
|
Dosis (Dose)
|
1 ml
|
VaccinatieDatum (VaccinationDate)
|
2 maa 2015
|
GewensteDatumHervaccinatie (PreferedDateForRevaccination)
|
2 apr 2015
|
Toediener (Administrator)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patA-healthProf1
|
Toelichting (Comment)
|
Reis door Indonesië
|
2.32 AllergieIntolerantie (AllergyIntolerance) [bgz-patA-allergy1]
AllergieIntolerantie (AllergyIntolerance) [bgz-patA-allergy1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
VeroorzakendeStof (CausativeAgent)
|
noten (code = '294904000' in codeSystem 'SNOMED CT')
|
AllergieCategorie (AllergyCategory)
|
Propensity to adverse reactions to food (code = '418471000' in codeSystem 'SNOMED CT')
|
AllergieStatus (AllergyStatus)
|
Active (code = 'active' in codeSystem 'HL7 ActStatus')
|
BeginDatumTijd (StartDateTime)
|
29 mei 1976
|
MateVanKritiekZijn (Criticality)
|
Severe (code = '24484000' in codeSystem 'SNOMED CT')
|
LaatsteReactieDatumTijd (LastReactionDateTime)
|
18 aug 2012
|
Toelichting (Comment)
|
Niet allergisch voor cashewnoten
|
Reactie (Reaction)
|
|
Symptoom (Symptom)
|
Anaphylaxis (code = '39579001' in codeSystem 'SNOMED CT')
|
SpecifiekeStof (SpecificSubstance)
|
pecannoot (code = '260189007' in codeSystem 'SNOMED CT')
|
ReactieBeschrijving (ReactionDescription)
|
Bewusteloos wegens wegvallen bloeddruk.
|
Ernst (Severity)
|
Severe (code = '24484000' in codeSystem 'SNOMED CT')
|
WijzeVanBlootstelling (RouteOfExposure)
|
oraal (code = '738956005' in codeSystem 'SNOMED CT')
|
ReactieTijdstip (ReactionTime)
|
18 aug 2012
|
2.33 AllergieIntolerantie (AllergyIntolerance) [bgz-patA-allergy2]
AllergieIntolerantie (AllergyIntolerance) [bgz-patA-allergy2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
VeroorzakendeStof (CausativeAgent)
|
penicillines (code = '035' in codeSystem 'G-Standaard TH122 Ongewenste groepen')
|
AllergieCategorie (AllergyCategory)
|
Propensity to adverse reactions to drug (code = '419511003' in codeSystem 'SNOMED CT')
|
AllergieStatus (AllergyStatus)
|
Active (code = 'active' in codeSystem 'HL7 ActStatus')
|
BeginDatumTijd (StartDateTime)
|
2009
|
MateVanKritiekZijn (Criticality)
|
Mild (code = '255604002' in codeSystem 'SNOMED CT')
|
LaatsteReactieDatumTijd (LastReactionDateTime)
|
2011
|
Toelichting (Comment)
|
Alleen voor amoxicilline
|
Reactie (Reaction)
|
|
Symptoom (Symptom)
|
Nausea and vomiting (code = '16932000' in codeSystem 'SNOMED CT')
|
SpecifiekeStof (SpecificSubstance)
|
Amoxicilline (code = '023167' in codeSystem 'G-Standaard SNK')
|
Ernst (Severity)
|
Mild (code = '255604002' in codeSystem 'SNOMED CT')
|
WijzeVanBlootstelling (RouteOfExposure)
|
oraal (code = '738956005' in codeSystem 'SNOMED CT')
|
2.34 AllergieIntolerantie (AllergyIntolerance) [bgz-patA-allergy3]
AllergieIntolerantie (AllergyIntolerance) [bgz-patA-allergy3]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
BSN 999999151
|
VeroorzakendeStof (CausativeAgent)
|
latex (code = '111088007' in codeSystem 'SNOMED CT')
|
AllergieCategorie (AllergyCategory)
|
Allergy to substance (code = '419199007' in codeSystem 'SNOMED CT')
|
AllergieStatus (AllergyStatus)
|
Completed (code = 'completed' in codeSystem 'HL7 ActStatus')
|
BeginDatumTijd (StartDateTime)
|
2006
|
MateVanKritiekZijn (Criticality)
|
Moderate (code = '6736007' in codeSystem 'SNOMED CT')
|
LaatsteReactieDatumTijd (LastReactionDateTime)
|
2012
|
Reactie (Reaction)
|
|
Symptoom (Symptom)
|
Itching of skin (code = '418363000' in codeSystem 'SNOMED CT')
|
ReactieBeschrijving (ReactionDescription)
|
Huidproblemen
|
Ernst (Severity)
|
Mild (code = '255604002' in codeSystem 'SNOMED CT')
|
WijzeVanBlootstelling (RouteOfExposure)
|
cutane route (code = '448598008' in codeSystem 'SNOMED CT')
|
2.35 Bloeddruk (BloodPressure) [bgz-patA-bloodpressure3]
Bloeddruk (BloodPressure) [bgz-patA-bloodpressure3]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
Meetmethode (MeasuringMethod)
|
Non-invasive (code = '22762002' in codeSystem 'SNOMED CT')
|
ManchetType (CuffType)
|
Standaard (code = 'STD' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.15.1')
|
MeetLocatie (MeasuringLocation)
|
Right upper arm structure (code = '368209003' in codeSystem 'SNOMED CT')
|
DiastolischEindpunt (DiastolicEndpoint)
|
Phase 4 (code = '255271000' in codeSystem 'SNOMED CT')
|
SystolischeBloeddruk (SystolicBloodPressure)
|
130 mm[hg]
|
DiastolischeBloeddruk (DiastolicBloodPressure)
|
79 mm[hg]
|
BloeddrukDatumTijd (BloodPressureDateTime)
|
T+3D{10:00}
|
2.36 Lichaamsgewicht (BodyWeight) [bgz-patA-bodyweight1]
Lichaamsgewicht (BodyWeight) [bgz-patA-bodyweight1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
GewichtWaarde (WeightValue)
|
79 kg
|
GewichtDatumTijd (WeightDateTime)
|
T+1D
|
Kleding (Clothing)
|
Fully dressed (code = 'FULL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1')
|
2.37 Lichaamsgewicht (BodyWeight) [bgz-patA-bodyweight2]
Lichaamsgewicht (BodyWeight) [bgz-patA-bodyweight2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
GewichtWaarde (WeightValue)
|
78 kg
|
GewichtDatumTijd (WeightDateTime)
|
T+2D
|
Kleding (Clothing)
|
Fully dressed (code = 'FULL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1')
|
2.38 Lichaamslengte (BodyHeight) [bgz-patA-bodyheight]
Lichaamslengte (BodyHeight) [bgz-patA-bodyheight]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
LengteWaarde (HeightValue)
|
183 cm
|
LengteDatumTijd (HeightDateTime)
|
1 nov 2018
|
Positie (Position)
|
Orthostatic body position (code = '10904000' in codeSystem 'SNOMED CT')
|
2.39 Patient (Patient) [bgz-patA]
Patient (Patient) [bgz-patA]
|
Gegevenselement
|
Waarde
|
Naamgegevens (NameInformation)
|
|
referentie:Naamgegevens (reference:NameInformation)
|
|
Voornamen (FirstNames)
|
Dennis
|
Initialen (Initials)
|
D.
|
Roepnaam (GivenName)
|
Dennis
|
Naamgebruik (NameUsage)
|
Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')
|
Geslachtsnaam (LastName)
|
|
Achternaam (LastName)
|
Janse
|
Adresgegevens (AddressInformation)
|
|
referentie:Adresgegevens (reference:AddressInformation)
|
|
Straat (Street)
|
Huweelstraat
|
Huisnummer (HouseNumber)
|
15
|
AanduidingBijNummer (HouseNumberIndication)
|
Tegenover (code = 'to' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.3')
|
Postcode (Postcode)
|
1248 CC
|
Woonplaats (PlaceOfResidence)
|
Barendrecht
|
Land (Country)
|
Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2')
|
AdditioneleInformatie (AdditionalInformation)
|
Tijdelijk adres
|
AdresSoort (AddressType)
|
Tempory Address (code = 'TMP' in codeSystem 'HL7 AddressUse')
|
Contactgegevens (ContactInformation)
|
|
referentie:Contactgegevens (reference:ContactInformation)
|
|
Telefoonnummers (TelephoneNumbers)
|
|
Telefoonnummer (TelephoneNumber)
|
+316-11122233
|
TelecomType (TelecomType)
|
Mobile Phone (code = 'MC' in codeSystem 'HL7 AddressUse')
|
NummerSoort (NumberType)
|
Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse')
|
EmailAdressen (EmailAddresses)
|
|
EmailAdres (EmailAddress)
|
djanse@test.nl
|
EmailSoort (EmailAddressType)
|
Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse')
|
Identificatienummer (PatientIdentificationNumber)
|
999999151 (in identificerend systeem: BSN)
|
Geboortedatum (DateOfBirth)
|
2 feb 1950
|
Geslacht (Gender)
|
Male (code = 'M' in codeSystem 'HL7 AdministrativeGender')
|
MeerlingIndicator (MultipleBirthIndicator)
|
Nee
|
OverlijdensIndicator (DeathIndicator)
|
Nee
|
2.40 Betaler (Payer) [bgz-patA-payer]
Betaler (Payer) [bgz-patA-payer]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
Verzekeraar (InsuranceCompany)
|
|
Verzekering (Insurance)
|
|
BeginDatumTijd (StartDateTime)
|
T-182D
|
EindDatumTijd (EndDateTime)
|
T+183D
|
Verzekeringssoort (InsuranceType)
|
Aanvullend verzekerd (code = 'A' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1')
|
IdentificatieNummer (IdentificationNumber)
|
3343 (in identificerend systeem: 2.16.840.1.113883.2.4.6.4)
|
OrganisatieNaam (OrganizationName)
|
ONVZ Zorgverzekeraar
|
VerzekerdeNummer (InsurantNumber)
|
88664422
|
Adresgegevens (AddressInformation)
|
|
referentie:Adresgegevens (reference:AddressInformation)
|
|
Straat (Street)
|
De Molen
|
Huisnummer (HouseNumber)
|
66
|
AanduidingBijNummer (HouseNumberIndication)
|
Tegenover (code = 'to' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.3')
|
Postcode (Postcode)
|
3990 GD
|
Woonplaats (PlaceOfResidence)
|
Houten
|
Gemeente (Municipality)
|
Houten
|
Land (Country)
|
Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2')
|
AdresSoort (AddressType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
Contactgegevens (ContactInformation)
|
|
referentie:Contactgegevens (reference:ContactInformation)
|
|
Telefoonnummers (TelephoneNumbers)
|
|
Telefoonnummer (TelephoneNumber)
|
030-6396222
|
TelecomType (TelecomType)
|
Land Line (code = 'LL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.22.1')
|
NummerSoort (NumberType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
EmailAdressen (EmailAddresses)
|
|
EmailAdres (EmailAddress)
|
vd@onvz.nl
|
EmailSoort (EmailAddressType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
2.41 FunctioneleOfMentaleStatus (FunctionalOrMentalStatus) [bgz-patA-funcment3]
FunctioneleOfMentaleStatus (FunctionalOrMentalStatus) [bgz-patA-funcment3]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
StatusNaam (StatusName)
|
sombere stemming (code = '366979004' in codeSystem 'SNOMED CT')
|
StatusWaarde (StatusValue)
|
ernstig (code = '24484000' in codeSystem '2.16.840.1.113883.6.96 (ordinal = )
|
StatusDatum (StatusDate)
|
2010
|
Toelichting (Comment)
|
Met name in wintermaanden
|
2.42 Probleem (Problem) [bgz-patA-problem1]
Probleem (Problem) [bgz-patA-problem1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
ProbleemType (ProblemType)
|
Symptom (code = '418799008' in codeSystem 'SNOMED CT')
|
ProbleemNaam (ProblemName)
|
dyspneu (code = '267036007' in codeSystem 'SNOMED CT')
|
ProbleemBeginDatum (ProblemStartDate)
|
1999
|
ProbleemStatus (ProblemStatus)
|
Active (code = '55561003' in codeSystem 'SNOMED CT')
|
VerificatieStatus (VerificationStatus)
|
Confirmed present (code = '410605003' in codeSystem 'SNOMED CT')
|
2.43 Bloeddruk (BloodPressure) [bgz-patA-bloodpressure2]
Bloeddruk (BloodPressure) [bgz-patA-bloodpressure2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
Meetmethode (MeasuringMethod)
|
Non-invasive (code = '22762002' in codeSystem 'SNOMED CT')
|
MeetLocatie (MeasuringLocation)
|
Right upper arm structure (code = '368209003' in codeSystem 'SNOMED CT')
|
SystolischeBloeddruk (SystolicBloodPressure)
|
120 mm[hg]
|
DiastolischeBloeddruk (DiastolicBloodPressure)
|
71 mm[hg]
|
BloeddrukDatumTijd (BloodPressureDateTime)
|
T+2D{09:00}
|
Houding (Position)
|
Sitting position (code = '33586001' in codeSystem 'SNOMED CT')
|
2.44 Bloeddruk (BloodPressure) [bgz-patA-bloodpressure1]
Bloeddruk (BloodPressure) [bgz-patA-bloodpressure1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999151
|
Meetmethode (MeasuringMethod)
|
Non-invasive (code = '22762002' in codeSystem 'SNOMED CT')
|
ManchetType (CuffType)
|
Groot (code = 'L' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.15.1')
|
DiastolischEindpunt (DiastolicEndpoint)
|
Phase 4 (code = '255271000' in codeSystem 'SNOMED CT')
|
SystolischeBloeddruk (SystolicBloodPressure)
|
140 mm[hg]
|
DiastolischeBloeddruk (DiastolicBloodPressure)
|
85 mm[hg]
|
BloeddrukDatumTijd (BloodPressureDateTime)
|
T+1D{11:05}
|
3 Scenario 1: Patiënt B
3.1 Vaccinatie (Vaccination) [bgz-patB-vaccin]
Vaccinatie (Vaccination) [bgz-patB-vaccin]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
ProductCode (ProductCode)
|
rabiësvaccin (code = 'J07BG01' in codeSystem '2.16.840.1.113883.6.73')
|
Dosis (Dose)
|
1 ml
|
VaccinatieDatum (VaccinationDate)
|
3 jan 2017
|
Toediener (Administrator)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patB-healthProf1
|
Toelichting (Comment)
|
fietsreis naar Vietnam
|
3.2 Patient (Patient) [bgz-patB]
Patient (Patient) [bgz-patB]
|
Gegevenselement
|
Waarde
|
Naamgegevens (NameInformation)
|
|
referentie:Naamgegevens (reference:NameInformation)
|
|
Voornamen (FirstNames)
|
Maria Francisca
|
Initialen (Initials)
|
M.F.
|
Roepnaam (GivenName)
|
Maria
|
Naamgebruik (NameUsage)
|
Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')
|
Geslachtsnaam (LastName)
|
|
Voorvoegsels (Prefix)
|
van 't
|
Achternaam (LastName)
|
Hoen
|
GeslachtsnaamPartner (LastNamePartner)
|
|
AchternaamPartner (PartnerLastName)
|
Verheul
|
Adresgegevens (AddressInformation)
|
|
referentie:Adresgegevens (reference:AddressInformation)
|
|
Straat (Street)
|
Steenstraat
|
Huisnummer (HouseNumber)
|
143
|
Huisnummerletter (HouseNumberLetter)
|
A
|
Huisnummertoevoeging (HouseNumberAddition)
|
II
|
Postcode (Postcode)
|
6584 YZ
|
Woonplaats (PlaceOfResidence)
|
Molenhoek
|
Gemeente (Municipality)
|
Mook en Middelaar
|
Land (Country)
|
Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2')
|
AdresSoort (AddressType)
|
Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse')
|
Contactgegevens (ContactInformation)
|
|
referentie:Contactgegevens (reference:ContactInformation)
|
|
Telefoonnummers (TelephoneNumbers)
|
|
Telefoonnummer (TelephoneNumber)
|
+316-10101010
|
TelecomType (TelecomType)
|
Mobile Phone (code = 'MC' in codeSystem 'HL7 AddressUse')
|
NummerSoort (NumberType)
|
Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse')
|
EmailAdressen (EmailAddresses)
|
|
EmailAdres (EmailAddress)
|
francisca@maria.org
|
EmailSoort (EmailAddressType)
|
Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse')
|
Identificatienummer (PatientIdentificationNumber)
|
999999092 (in identificerend systeem: BSN)
|
Geboortedatum (DateOfBirth)
|
16 apr 1956
|
Geslacht (Gender)
|
Female (code = 'F' in codeSystem 'HL7 AdministrativeGender')
|
MeerlingIndicator (MultipleBirthIndicator)
|
Ja
|
OverlijdensIndicator (DeathIndicator)
|
Nee
|
3.3 BurgerlijkeStaatRC (MaritalStatusRC) [bgz-patB-marital]
BurgerlijkeStaatRC (MaritalStatusRC) [bgz-patB-marital]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
BurgerlijkeStaat (MaritalStatus)
|
Domestic partner (code = 'T' in codeSystem '2.16.840.1.113883.5.2')
|
3.4 Betaler (Payer) [bgz-patB-payer]
Betaler (Payer) [bgz-patB-payer]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
Verzekeraar (InsuranceCompany)
|
|
Verzekering (Insurance)
|
|
BeginDatumTijd (StartDateTime)
|
T-182D
|
EindDatumTijd (EndDateTime)
|
T+183D
|
Verzekeringssoort (InsuranceType)
|
Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1')
|
IdentificatieNummer (IdentificationNumber)
|
3313 (in identificerend systeem: 2.16.840.1.113883.2.4.6.4)
|
OrganisatieNaam (OrganizationName)
|
Interpolis Zorgverzekeringen N.V.
|
VerzekerdeNummer (InsurantNumber)
|
98765432
|
Adresgegevens (AddressInformation)
|
|
referentie:Adresgegevens (reference:AddressInformation)
|
|
Straat (Street)
|
Spoorlaan
|
Huisnummer (HouseNumber)
|
298
|
Postcode (Postcode)
|
5017 JZ
|
Woonplaats (PlaceOfResidence)
|
Tilburg
|
Land (Country)
|
Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2')
|
AdresSoort (AddressType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
Contactgegevens (ContactInformation)
|
|
referentie:Contactgegevens (reference:ContactInformation)
|
|
Telefoonnummers (TelephoneNumbers)
|
|
Telefoonnummer (TelephoneNumber)
|
0134622025
|
TelecomType (TelecomType)
|
Land Line (code = 'LL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.22.1')
|
NummerSoort (NumberType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
EmailAdressen (EmailAddresses)
|
|
EmailAdres (EmailAddress)
|
info@interpolis.nl
|
EmailSoort (EmailAddressType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
3.5 Wilsverklaring (AdvanceDirective) [bgz-patB-advdir]
Wilsverklaring (AdvanceDirective) [bgz-patB-advdir]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
WilsverklaringType (LivingWillType)
|
Niet reanimeren verklaring (code = 'NR' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.14.1')
|
WilsverklaringDatum (LivingWillDate)
|
7 jul 2007
|
WilsverklaringDocument (LivingWillDocument)
|
ZHVtbXktd2lsc3ZlcmtsYXJpbmcgTWFyaWEgdmFuICd0IEhvZW4ucGRm
|
3.6 BehandelAanwijzing (TreatmentDirective) [bgz-patB-treatmentdir]
BehandelAanwijzing (TreatmentDirective) [bgz-patB-treatmentdir]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
Verificatie (Verification)
|
|
Geverifieerd (Verified)
|
Ja
|
GeverifieerdBij (VerifiedWith)
|
Patient (code = '116154003' in codeSystem 'SNOMED CT')
|
VerificatieDatum (VerificationDate)
|
7 jul 2017
|
Behandeling (Treatment)
|
Cardiopulmonary resuscitation (procedure) (code = '89666000' in codeSystem 'SNOMED CT')
|
BehandelingToegestaan (TreatmentPermitted)
|
Nee (code = 'NEE' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4')
|
BeginDatum (StartDate)
|
7 jul 2007
|
Wilsverklaring (AdvanceDirective)
|
|
referentie:Wilsverklaring (reference:AdvanceDirective)
|
zib-2017-bgz-patB-advdir
|
3.7 Contactpersoon (Contact) [bgz-patB-contactperson1]
Contactpersoon (Contact) [bgz-patB-contactperson1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
Naamgegevens (NameInformation)
|
|
referentie:Naamgegevens (reference:NameInformation)
|
|
Voornamen (FirstNames)
|
Peter
|
Initialen (Initials)
|
P.
|
Roepnaam (GivenName)
|
Peer
|
Naamgebruik (NameUsage)
|
Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')
|
Geslachtsnaam (LastName)
|
|
Achternaam (LastName)
|
Verheul
|
GeslachtsnaamPartner (LastNamePartner)
|
|
VoorvoegselsPartner (PartnerPrefix)
|
van 't
|
AchternaamPartner (PartnerLastName)
|
Hoen
|
Contactgegevens (ContactInformation)
|
|
referentie:Contactgegevens (reference:ContactInformation)
|
|
Telefoonnummers (TelephoneNumbers)
|
|
Telefoonnummer (TelephoneNumber)
|
0611119999
|
TelecomType (TelecomType)
|
Mobile Phone (code = 'MC' in codeSystem 'HL7 AddressUse')
|
NummerSoort (NumberType)
|
Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse')
|
EmailAdressen (EmailAddresses)
|
|
EmailAdres (EmailAddress)
|
peer@verheul.org
|
EmailSoort (EmailAddressType)
|
Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse')
|
Adresgegevens (AddressInformation)
|
|
referentie:Adresgegevens (reference:AddressInformation)
|
|
Straat (Street)
|
Steenstraat
|
Huisnummer (HouseNumber)
|
143
|
Huisnummerletter (HouseNumberLetter)
|
A
|
Huisnummertoevoeging (HouseNumberAddition)
|
II
|
Postcode (Postcode)
|
6584 YZ
|
Woonplaats (PlaceOfResidence)
|
Molenhoek
|
Gemeente (Municipality)
|
Mook en Middelaar
|
Land (Country)
|
Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2')
|
AdresSoort (AddressType)
|
Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse')
|
Rol (Role)
|
Eerste relatie/contactpersoon (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472')
|
Relatie (Relationship)
|
Domestic partner (code = 'DOMPART' in codeSystem 'HL7 RoleCode')
|
3.8 Contactpersoon (Contact) [bgz-patB-contactperson2]
Contactpersoon (Contact) [bgz-patB-contactperson2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
Naamgegevens (NameInformation)
|
|
referentie:Naamgegevens (reference:NameInformation)
|
|
Voornamen (FirstNames)
|
Puck
|
Initialen (Initials)
|
P.
|
Geslachtsnaam (LastName)
|
|
Voorvoegsels (Prefix)
|
van 't
|
Achternaam (LastName)
|
Hoen
|
Adresgegevens (AddressInformation)
|
|
referentie:Adresgegevens (reference:AddressInformation)
|
|
Straat (Street)
|
Straatweg
|
Huisnummer (HouseNumber)
|
11
|
Postcode (Postcode)
|
1256 DC
|
Woonplaats (PlaceOfResidence)
|
Venlo
|
AdresSoort (AddressType)
|
Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse')
|
Rol (Role)
|
Tweede relatie/contactpersoon (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472')
|
Relatie (Relationship)
|
Daughter (code = 'DAUC' in codeSystem 'HL7 RoleCode')
|
3.9 FunctioneleOfMentaleStatus (FunctionalOrMentalStatus) [bgz-patB-funcment]
FunctioneleOfMentaleStatus (FunctionalOrMentalStatus) [bgz-patB-funcment]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
StatusNaam (StatusName)
|
spierzwakte van bovenste extremiteit (code = '713512009' in codeSystem 'SNOMED CT')
|
StatusWaarde (StatusValue)
|
matig (code = '6736007' in codeSystem '2.16.840.1.113883.6.96 (ordinal = )
|
StatusDatum (StatusDate)
|
2010
|
Toelichting (Comment)
|
krachtsvermindering rechterarm na CVA
|
Hulpmiddel (MedicalDevice)
|
|
referentie:MedischHulpmiddel (reference:MedicalDevice)
|
zib-2017-bgz-patB-medDevice
|
3.10 Probleem (Problem) [bgz-patB-problem1]
Probleem (Problem) [bgz-patB-problem1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
ProbleemType (ProblemType)
|
Diagnosis (code = '282291009' in codeSystem 'SNOMED CT')
|
ProbleemNaam (ProblemName)
|
hypertensieve aandoening (code = '38341003' in codeSystem 'SNOMED CT')
|
ProbleemBeginDatum (ProblemStartDate)
|
2004
|
ProbleemStatus (ProblemStatus)
|
Active (code = '55561003' in codeSystem 'SNOMED CT')
|
VerificatieStatus (VerificationStatus)
|
Confirmed present (code = '410605003' in codeSystem 'SNOMED CT')
|
3.11 Probleem (Problem) [bgz-patB-problem2]
Probleem (Problem) [bgz-patB-problem2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
ProbleemType (ProblemType)
|
Diagnosis (code = '282291009' in codeSystem 'SNOMED CT')
|
ProbleemNaam (ProblemName)
|
BRCA1-genmutatie positief (code = '412734009' in codeSystem 'SNOMED CT')
|
ProbleemBeginDatum (ProblemStartDate)
|
2005
|
ProbleemStatus (ProblemStatus)
|
Active (code = '55561003' in codeSystem 'SNOMED CT')
|
VerificatieStatus (VerificationStatus)
|
Confirmed present (code = '410605003' in codeSystem 'SNOMED CT')
|
3.12 Probleem (Problem) [bgz-patB-problem3]
Probleem (Problem) [bgz-patB-problem3]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
ProbleemType (ProblemType)
|
Complaint (code = '409586006' in codeSystem 'SNOMED CT')
|
ProbleemNaam (ProblemName)
|
postmenopauzale status (code = '76498008' in codeSystem 'SNOMED CT')
|
ProbleemBeginDatum (ProblemStartDate)
|
2009
|
ProbleemStatus (ProblemStatus)
|
Active (code = '55561003' in codeSystem 'SNOMED CT')
|
3.13 Probleem (Problem) [bgz-patB-problem4]
Probleem (Problem) [bgz-patB-problem4]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
ProbleemAnatomischeLocatie (ProblemAnatomicalLocation)
|
structuur van cerebrum (code = '83678007' in codeSystem 'SNOMED CT')
|
ProbleemLateraliteit (ProblemLaterality)
|
Left (code = '7771000' in codeSystem 'SNOMED CT')
|
ProbleemType (ProblemType)
|
Diagnosis (code = '282291009' in codeSystem 'SNOMED CT')
|
ProbleemNaam (ProblemName)
|
cerebraal infarct (code = '432504007' in codeSystem 'SNOMED CT')
|
ProbleemBeginDatum (ProblemStartDate)
|
1 jul 2010
|
ProbleemStatus (ProblemStatus)
|
Active (code = '55561003' in codeSystem 'SNOMED CT')
|
VerificatieStatus (VerificationStatus)
|
Confirmed present (code = '410605003' in codeSystem 'SNOMED CT')
|
3.14 Probleem (Problem) [bgz-patB-problem5]
Probleem (Problem) [bgz-patB-problem5]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
ProbleemAnatomischeLocatie (ProblemAnatomicalLocation)
|
structuur van rechter mamma (code = '73056007' in codeSystem 'SNOMED CT')
|
ProbleemLateraliteit (ProblemLaterality)
|
Right (code = '24028007' in codeSystem 'SNOMED CT')
|
ProbleemType (ProblemType)
|
Symptom (code = '418799008' in codeSystem 'SNOMED CT')
|
ProbleemNaam (ProblemName)
|
palpabele massa van mamma (code = '2271000146103' in codeSystem 'SNOMED CT')
|
ProbleemBeginDatum (ProblemStartDate)
|
4 maa 2019
|
ProbleemStatus (ProblemStatus)
|
Active (code = '55561003' in codeSystem 'SNOMED CT')
|
VerificatieStatus (VerificationStatus)
|
Suspected (code = '415684004' in codeSystem 'SNOMED CT')
|
3.15 Probleem (Problem) [bgz-patB-problem6]
Probleem (Problem) [bgz-patB-problem6]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
ProbleemAnatomischeLocatie (ProblemAnatomicalLocation)
|
structuur van rechter mamma (code = '73056007' in codeSystem 'SNOMED CT')
|
ProbleemLateraliteit (ProblemLaterality)
|
Right (code = '24028007' in codeSystem 'SNOMED CT')
|
ProbleemType (ProblemType)
|
Diagnosis (code = '282291009' in codeSystem 'SNOMED CT')
|
ProbleemNaam (ProblemName)
|
maligne neoplasma van mamma (code = '254837009' in codeSystem 'SNOMED CT')
|
ProbleemBeginDatum (ProblemStartDate)
|
28 maa 2019
|
ProbleemStatus (ProblemStatus)
|
Active (code = '55561003' in codeSystem 'SNOMED CT')
|
VerificatieStatus (VerificationStatus)
|
Confirmed present (code = '410605003' in codeSystem 'SNOMED CT')
|
3.16 Probleem (Problem) [bgz-patB-problem7]
Probleem (Problem) [bgz-patB-problem7]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
ProbleemAnatomischeLocatie (ProblemAnatomicalLocation)
|
structuur van rechter mamma (code = '73056007' in codeSystem 'SNOMED CT')
|
ProbleemLateraliteit (ProblemLaterality)
|
Right (code = '24028007' in codeSystem 'SNOMED CT')
|
ProbleemType (ProblemType)
|
Complication (code = '116223007' in codeSystem 'SNOMED CT')
|
ProbleemNaam (ProblemName)
|
postoperatieve wondinfectie (code = '58126003' in codeSystem 'SNOMED CT')
|
ProbleemBeginDatum (ProblemStartDate)
|
T+2D
|
ProbleemEindDatum (ProblemEndDate)
|
T+3D
|
ProbleemStatus (ProblemStatus)
|
Inactive (code = '73425007' in codeSystem 'SNOMED CT')
|
3.17 Woonsituatie (LivingSituation) [bgz-patB-living]
Woonsituatie (LivingSituation) [bgz-patB-living]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
WoningType (HouseType)
|
Eengezinswoning (code = 'EENGEZW' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.13.1')
|
3.18 DrugsGebruik (DrugUse) [bgz-patB-druguse]
DrugsGebruik (DrugUse) [bgz-patB-druguse]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
DrugsGebruikStatus (DrugUseStatus)
|
Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): onbekend
|
3.19 AlcoholGebruik (AlcoholUse) [bgz-patB-alcohol]
AlcoholGebruik (AlcoholUse) [bgz-patB-alcohol]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
Toelichting (Comment)
|
Mevrouw drinkt niet meer sinds ze weet dat ze drager BRCA1-genmutatie is.
|
AlcoholGebruikStatus (AlcoholUseStatus)
|
Ex-drinker (finding) (code = '82581004' in codeSystem 'SNOMED CT')
|
WaarnemingGebruik (ObservationOfUse)
|
|
StartDatum (StartDate)
|
1971
|
StopDatum (StopDate)
|
2005
|
Hoeveelheid (Amount)
|
14 {glasses}/wk
|
3.20 TabakGebruik (TobaccoUse) [bgz-patB-tobacco]
TabakGebruik (TobaccoUse) [bgz-patB-tobacco]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
TabakGebruikStatus (TobaccoUseStatus)
|
Ex-smoker (finding) (code = '8517006' in codeSystem 'SNOMED CT')
|
WaarnemingGebruik (ObservationOfUse)
|
|
StartDatum (StartDate)
|
1970
|
StopDatum (StopDate)
|
1980
|
3.21 Zorgverlener (HealthProfessional) [bgz-patB-healthProf2]
Zorgverlener (HealthProfessional) [bgz-patB-healthProf2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
ZorgverlenerIdentificatienummer (HealthProfessionalIdentificationNumber)
|
00141414 (in identificerend systeem: AGB-Z)
|
Naamgegevens (NameInformation)
|
|
referentie:Naamgegevens (reference:NameInformation)
|
|
Voornamen (FirstNames)
|
Johanna
|
Initialen (Initials)
|
J.
|
Roepnaam (GivenName)
|
Joke
|
Naamgebruik (NameUsage)
|
Unknown (code = 'UNK' in codeSystem 'HL7 NullFlavor')
|
Geslachtsnaam (LastName)
|
|
Voorvoegsels (Prefix)
|
de
|
Achternaam (LastName)
|
Bruin
|
Specialisme (Specialty)
|
Internist (code = '01.016' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)')
|
Adresgegevens (AddressInformation)
|
|
referentie:Adresgegevens (reference:AddressInformation)
|
|
Land (Country)
|
Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2')
|
AdresSoort (AddressType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
Contactgegevens (ContactInformation)
|
|
referentie:Contactgegevens (reference:ContactInformation)
|
|
Telefoonnummers (TelephoneNumbers)
|
|
Telefoonnummer (TelephoneNumber)
|
2768
|
TelecomType (TelecomType)
|
Pager (code = 'PG' in codeSystem 'HL7 AddressUse')
|
Zorgaanbieder (HealthcareProvider)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
naam eigen ziekenhuis
|
ZorgverlenersRol (HealthProfessionalRole)
|
Responsible Party (code = 'RESP' in codeSystem 'HL7 ParticipationType')
|
3.22 Zorgverlener (HealthProfessional) [bgz-patB-healthProf1]
Zorgverlener (HealthProfessional) [bgz-patB-healthProf1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
ZorgverlenerIdentificatienummer (HealthProfessionalIdentificationNumber)
|
00131313 (in identificerend systeem: AGB-Z)
|
Naamgegevens (NameInformation)
|
|
referentie:Naamgegevens (reference:NameInformation)
|
|
Voornamen (FirstNames)
|
Anna
|
Initialen (Initials)
|
A.
|
Roepnaam (GivenName)
|
Anna
|
Naamgebruik (NameUsage)
|
Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')
|
Geslachtsnaam (LastName)
|
|
Voorvoegsels (Prefix)
|
de
|
Achternaam (LastName)
|
Vries
|
GeslachtsnaamPartner (LastNamePartner)
|
|
AchternaamPartner (PartnerLastName)
|
Bijns
|
Specialisme (Specialty)
|
Huisarts (code = '01.015' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)')
|
Adresgegevens (AddressInformation)
|
|
referentie:Adresgegevens (reference:AddressInformation)
|
|
Straat (Street)
|
Dorpsstraat
|
Huisnummer (HouseNumber)
|
1
|
Postcode (Postcode)
|
6585 XY
|
Woonplaats (PlaceOfResidence)
|
Molenhoek
|
Gemeente (Municipality)
|
Mook en Middelaar
|
Land (Country)
|
Nederland (code = 'NL' in codeSystem '1.0.3166.1.2.2')
|
AdresSoort (AddressType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
Contactgegevens (ContactInformation)
|
|
referentie:Contactgegevens (reference:ContactInformation)
|
|
Telefoonnummers (TelephoneNumbers)
|
|
Telefoonnummer (TelephoneNumber)
|
077-1234567
|
TelecomType (TelecomType)
|
Land Line (code = 'LL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.22.1')
|
NummerSoort (NumberType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
EmailAdressen (EmailAddresses)
|
|
EmailAdres (EmailAddress)
|
Bijns.DeVries@HPMolenhoek.nl
|
EmailSoort (EmailAddressType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
Zorgaanbieder (HealthcareProvider)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
Huisartsenpraktijk Molenhoek
|
3.23 LaboratoriumUitslag (LaboratoryTestResult) [bgz-patB-labresult2]
LaboratoriumUitslag (LaboratoryTestResult) [bgz-patB-labresult2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
LaboratoriumTest (LaboratoryTest)
|
|
TestCode (TestCode)
|
CA15.3 [aanwezigheid] in serum of plasma (code = '2007-3' in codeSystem 'LOINC')
|
TestDatumTijd (TestDateTime)
|
T+2D{09:00}
|
TestUitslag (TestResult)
|
13 E/mL
|
TestUitslagStatus (TestResultStatus)
|
Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1')
|
Monster (Specimen)
|
|
Monstermateriaal (SpecimenMaterial)
|
serum of plasma (code = '122592007' in codeSystem 'SNOMED CT')
|
AfnameDatumTijd (CollectionDateTime)
|
T+2D{08:00}
|
ResultaatStatus (ResultStatus)
|
Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1')
|
ResultaatType (ResultType)
|
Chemistry (code = '275711006' in codeSystem 'SNOMED CT')
|
Aanvrager (Requester)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patB-healthProf2
|
3.24 LaboratoriumUitslag (LaboratoryTestResult) [bgz-patB-labresult1]
LaboratoriumUitslag (LaboratoryTestResult) [bgz-patB-labresult1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
LaboratoriumTest (LaboratoryTest)
|
|
TestCode (TestCode)
|
Monocyten [aantal/volume] in bloed (code = '26484-6' in codeSystem 'LOINC')
|
TestDatumTijd (TestDateTime)
|
T+1D{09:00}
|
TestUitslag (TestResult)
|
0.43E+9 /L
|
TestUitslagStatus (TestResultStatus)
|
Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1')
|
ReferentieBovengrens (ReferenceRangeUpperLimit)
|
1.00E+9 /L
|
ReferentieOndergrens (ReferenceRangeLowerLimit)
|
0.3E+9 /L
|
LaboratoriumTest (LaboratoryTest)
|
|
TestCode (TestCode)
|
Lymfocyten [aantal/volume] in bloed d.m.v. manuele telling (code = '732-8' in codeSystem 'LOINC')
|
TestDatumTijd (TestDateTime)
|
T+1D{09:00}
|
TestUitslag (TestResult)
|
0.86E+9 /L
|
TestUitslagStatus (TestResultStatus)
|
Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1')
|
ReferentieBovengrens (ReferenceRangeUpperLimit)
|
3.50E+9 /L
|
ReferentieOndergrens (ReferenceRangeLowerLimit)
|
1.00E+9 /L
|
InterpretatieVlaggen (ResultFlags)
|
Below reference range (code = '281300000' in codeSystem 'SNOMED CT')
|
LaboratoriumTest (LaboratoryTest)
|
|
TestCode (TestCode)
|
Lymfocyten.grote granulaire [aanwezigheid] in bloed (code = '59808-6' in codeSystem 'LOINC')
|
TestDatumTijd (TestDateTime)
|
T+1D{09:00}
|
TestUitslag (TestResult)
|
+
|
TestUitslagStatus (TestResultStatus)
|
Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1')
|
Monster (Specimen)
|
|
Monstermateriaal (SpecimenMaterial)
|
Serum (code = '67922002' in codeSystem 'SNOMED CT')
|
AfnameDatumTijd (CollectionDateTime)
|
T+1D{08:00}
|
Afnameprocedure (CollectionMethod)
|
venapunctie voor bloedtest (code = '28520004' in codeSystem 'SNOMED CT')
|
ResultaatStatus (ResultStatus)
|
Final (code = 'final' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.16.1')
|
ResultaatType (ResultType)
|
Hematology (code = '252275004' in codeSystem 'SNOMED CT')
|
Aanvrager (Requester)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patB-healthProf2
|
3.25 Lichaamslengte (BodyHeight) [bgz-patB-bodyheight]
Lichaamslengte (BodyHeight) [bgz-patB-bodyheight]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
LengteWaarde (HeightValue)
|
176 cm
|
LengteDatumTijd (HeightDateTime)
|
4 maa 2019
|
Positie (Position)
|
Orthostatic body position (code = '10904000' in codeSystem 'SNOMED CT')
|
3.26 Lichaamsgewicht (BodyWeight) [bgz-patB-bodyweight2]
Lichaamsgewicht (BodyWeight) [bgz-patB-bodyweight2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
GewichtWaarde (WeightValue)
|
54 kg
|
GewichtDatumTijd (WeightDateTime)
|
T+1D{07:30}
|
Kleding (Clothing)
|
Minimal dressed (code = 'MINIMAL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1')
|
3.27 Lichaamsgewicht (BodyWeight) [bgz-patB-bodyweight1]
Lichaamsgewicht (BodyWeight) [bgz-patB-bodyweight1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
GewichtWaarde (WeightValue)
|
68 kg
|
GewichtDatumTijd (WeightDateTime)
|
4 maa 2019
|
Kleding (Clothing)
|
Minimal dressed (code = 'MINIMAL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1')
|
3.28 Bloeddruk (BloodPressure) [bgz-patB-bloodpressure3]
Bloeddruk (BloodPressure) [bgz-patB-bloodpressure3]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
Meetmethode (MeasuringMethod)
|
Non-invasive (code = '22762002' in codeSystem 'SNOMED CT')
|
ManchetType (CuffType)
|
Standaard (code = 'STD' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.15.1')
|
MeetLocatie (MeasuringLocation)
|
Left upper arm structure (code = '368208006' in codeSystem 'SNOMED CT')
|
SystolischeBloeddruk (SystolicBloodPressure)
|
150 mm[hg]
|
DiastolischeBloeddruk (DiastolicBloodPressure)
|
94 mm[hg]
|
BloeddrukDatumTijd (BloodPressureDateTime)
|
T+2D{16:15}
|
3.29 Bloeddruk (BloodPressure) [bgz-patB-bloodpressure2]
Bloeddruk (BloodPressure) [bgz-patB-bloodpressure2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
Meetmethode (MeasuringMethod)
|
Non-invasive (code = '22762002' in codeSystem 'SNOMED CT')
|
ManchetType (CuffType)
|
Standaard (code = 'STD' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.15.1')
|
MeetLocatie (MeasuringLocation)
|
Left upper arm structure (code = '368208006' in codeSystem 'SNOMED CT')
|
SystolischeBloeddruk (SystolicBloodPressure)
|
130 mm[hg]
|
DiastolischeBloeddruk (DiastolicBloodPressure)
|
80 mm[hg]
|
BloeddrukDatumTijd (BloodPressureDateTime)
|
T+2D{07:45}
|
3.30 Zorgverlener (HealthProfessional) [bgz-patB-healthProf3]
Zorgverlener (HealthProfessional) [bgz-patB-healthProf3]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
ZorgverlenerIdentificatienummer (HealthProfessionalIdentificationNumber)
|
00151515 (in identificerend systeem: AGB-Z)
|
Naamgegevens (NameInformation)
|
|
referentie:Naamgegevens (reference:NameInformation)
|
|
Voornamen (FirstNames)
|
Antonius Franciscus
|
Initialen (Initials)
|
A.F.
|
Roepnaam (GivenName)
|
Ton
|
Naamgebruik (NameUsage)
|
Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')
|
Geslachtsnaam (LastName)
|
|
Achternaam (LastName)
|
Zoomers
|
Specialisme (Specialty)
|
Chirurg (code = '01.014' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)')
|
Contactgegevens (ContactInformation)
|
|
referentie:Contactgegevens (reference:ContactInformation)
|
|
Telefoonnummers (TelephoneNumbers)
|
|
Telefoonnummer (TelephoneNumber)
|
2769
|
TelecomType (TelecomType)
|
Pager (code = 'PG' in codeSystem 'HL7 AddressUse')
|
Zorgaanbieder (HealthcareProvider)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
naam eigen ziekenhuis
|
ZorgverlenersRol (HealthProfessionalRole)
|
Performer (code = 'PRF' in codeSystem 'HL7 ParticipationType')
|
3.31 Bloeddruk (BloodPressure) [bgz-patB-bloodpressure1]
Bloeddruk (BloodPressure) [bgz-patB-bloodpressure1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
Meetmethode (MeasuringMethod)
|
Non-invasive (code = '22762002' in codeSystem 'SNOMED CT')
|
ManchetType (CuffType)
|
Standaard (code = 'STD' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.15.1')
|
MeetLocatie (MeasuringLocation)
|
Left upper arm structure (code = '368208006' in codeSystem 'SNOMED CT')
|
SystolischeBloeddruk (SystolicBloodPressure)
|
120 mm[hg]
|
DiastolischeBloeddruk (DiastolicBloodPressure)
|
78 mm[hg]
|
BloeddrukDatumTijd (BloodPressureDateTime)
|
T+1D{07:15}
|
3.32 Contact (Encounter) [bgz-patB-encounter1]
Contact (Encounter) [bgz-patB-encounter1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
ContactType (ContactType)
|
Inpatient (code = 'IMP' in codeSystem 'HL7 ActCode')
|
ContactMet (ContactWith)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
behandelend arts
|
Locatie (Location)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
naam eigen ziekenhuis
|
BeginDatumTijd (StartDateTime)
|
T+1D{07:00}
|
EindDatumTijd (EndDateTime)
|
T+2D{09:00}
|
RedenContact (ContactReason)
|
|
Verrichting (Procedure)
|
|
referentie:Verrichting (reference:Procedure)
|
zib-2017-bgz-patB-procedure3
|
Herkomst (Origin)
|
Home (code = '264362003' in codeSystem 'SNOMED CT')
|
Bestemming (Destination)
|
Home (code = '264362003' in codeSystem 'SNOMED CT')
|
3.33 Verrichting (Procedure) [bgz-patB-procedure1]
Verrichting (Procedure) [bgz-patB-procedure1]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
VerrichtingStartDatum (ProcedureStartDate)
|
1 jul 2010
|
VerrichtingEindDatum (ProcedureEndDate)
|
1 jul 2020
|
Indicatie (Indication)
|
|
referentie:Probleem (reference:Problem)
|
zib-2017-bgz-patB-problem4
|
VerrichtingType (ProcedureType)
|
intraveneuze trombolyse (code = '77381000146102' in codeSystem 'SNOMED CT')
|
Locatie (Location)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
VieCuri
|
Uitvoerder (Performer)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
|
Aanvrager (Requester)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patB-healthProf1
|
3.34 Verrichting (Procedure) [bgz-patB-procedure2]
Verrichting (Procedure) [bgz-patB-procedure2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
VerrichtingStartDatum (ProcedureStartDate)
|
2 jul 2010
|
VerrichtingEindDatum (ProcedureEndDate)
|
2 jul 2020
|
VerrichtingAnatomischeLocatie (ProcedureAnatomicalLocation)
|
structuur van intracranieel bloedvat (code = '281138005' in codeSystem 'SNOMED CT')
|
Indicatie (Indication)
|
|
referentie:Probleem (reference:Problem)
|
zib-2017-bgz-patB-problem4
|
VerrichtingType (ProcedureType)
|
mechanische trombectomie van linker arteria carotis interna (code = '84581000146105' in codeSystem 'SNOMED CT')
|
VerrichtingMethode (ProcedureMethod)
|
fluoroscopisch geleide percutane mechanische trombectomie van sinus durae matris (code = '439625002' in codeSystem 'SNOMED CT')
|
Locatie (Location)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
naam eigen ziekenhuis
|
Uitvoerder (Performer)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patB-healthProf4
|
3.35 Verrichting (Procedure) [bgz-patB-procedure3]
Verrichting (Procedure) [bgz-patB-procedure3]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
VerrichtingStartDatum (ProcedureStartDate)
|
T+1D{10:00}
|
VerrichtingEindDatum (ProcedureEndDate)
|
T+1D{12:00}
|
VerrichtingAnatomischeLocatie (ProcedureAnatomicalLocation)
|
structuur van mamma (code = '76752008' in codeSystem 'SNOMED CT')
|
VerrichtingLateraliteit (ProcedureLaterality)
|
Right (code = '24028007' in codeSystem 'SNOMED CT')
|
Indicatie (Indication)
|
|
referentie:Probleem (reference:Problem)
|
zib-2017-bgz-patB-problem6
|
VerrichtingType (ProcedureType)
|
eenvoudige mastectomie (code = '172043006' in codeSystem 'SNOMED CT')
|
Locatie (Location)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
naam eigen ziekenhuis
|
Uitvoerder (Performer)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patB-healthProf3
|
Aanvrager (Requester)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patB-healthProf2
|
3.36 Verrichting (Procedure) [bgz-patB-procedure4]
Verrichting (Procedure) [bgz-patB-procedure4]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
VerrichtingStartDatum (ProcedureStartDate)
|
T+2D{17:45}
|
VerrichtingAnatomischeLocatie (ProcedureAnatomicalLocation)
|
structuur van mamma (code = '76752008' in codeSystem 'SNOMED CT')
|
VerrichtingLateraliteit (ProcedureLaterality)
|
Right (code = '24028007' in codeSystem 'SNOMED CT')
|
Indicatie (Indication)
|
|
referentie:Probleem (reference:Problem)
|
zib-2017-bgz-patB-problem7
|
VerrichtingType (ProcedureType)
|
incisie en drainage van diep abces (code = '103751000146104' in codeSystem 'SNOMED CT')
|
Locatie (Location)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
naam eigen ziekenhuis
|
3.37 Contact (Encounter) [bgz-patB-encounter2]
Contact (Encounter) [bgz-patB-encounter2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
ContactType (ContactType)
|
Emergency (code = 'EMER' in codeSystem 'HL7 ActCode')
|
Locatie (Location)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
naam eigen ziekenhuis
|
BeginDatumTijd (StartDateTime)
|
T+2D{16:00}
|
EindDatumTijd (EndDateTime)
|
T+2D{17:00}
|
RedenContact (ContactReason)
|
|
Probleem (Problem)
|
|
referentie:Probleem (reference:Problem)
|
zib-2017-bgz-patB-problem7
|
Herkomst (Origin)
|
Home (code = '264362003' in codeSystem 'SNOMED CT')
|
3.38 Contact (Encounter) [bgz-patB-encounter3]
Contact (Encounter) [bgz-patB-encounter3]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
ContactType (ContactType)
|
Inpatient (code = 'IMP' in codeSystem 'HL7 ActCode')
|
ContactMet (ContactWith)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patB-healthProf3
|
Locatie (Location)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
naam eigen ziekenhuis
|
BeginDatumTijd (StartDateTime)
|
T+2D{17:00}
|
EindDatumTijd (EndDateTime)
|
T+3D{10:00}
|
RedenContact (ContactReason)
|
|
Verrichting (Procedure)
|
|
referentie:Verrichting (reference:Procedure)
|
zib-2017-bgz-patB-procedure4
|
Bestemming (Destination)
|
Home (code = '264362003' in codeSystem 'SNOMED CT')
|
3.39 Zorgverlener (HealthProfessional) [bgz-patB-healthProf4]
Zorgverlener (HealthProfessional) [bgz-patB-healthProf4]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
ZorgverlenerIdentificatienummer (HealthProfessionalIdentificationNumber)
|
00161616 (in identificerend systeem: AGB-Z)
|
Naamgegevens (NameInformation)
|
|
referentie:Naamgegevens (reference:NameInformation)
|
|
Voornamen (FirstNames)
|
Horst
|
Initialen (Initials)
|
H.
|
Roepnaam (GivenName)
|
Horst
|
Naamgebruik (NameUsage)
|
Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')
|
Geslachtsnaam (LastName)
|
|
Achternaam (LastName)
|
Bontrager
|
Specialisme (Specialty)
|
Neurochirurg (code = '01.025' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)')
|
Adresgegevens (AddressInformation)
|
|
referentie:Adresgegevens (reference:AddressInformation)
|
|
Straat (Street)
|
Nimweger Strasse
|
Huisnummer (HouseNumber)
|
285
|
Postcode (Postcode)
|
47560
|
Gemeente (Municipality)
|
Kranenburg
|
Land (Country)
|
Duitsland (code = 'DE' in codeSystem '1.0.3166.1.2.2')
|
AdresSoort (AddressType)
|
Primary Home (code = 'HP' in codeSystem 'HL7 AddressUse')
|
Contactgegevens (ContactInformation)
|
|
referentie:Contactgegevens (reference:ContactInformation)
|
|
Telefoonnummers (TelephoneNumbers)
|
|
Telefoonnummer (TelephoneNumber)
|
024-1234567
|
TelecomType (TelecomType)
|
Land Line (code = 'LL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.22.1')
|
NummerSoort (NumberType)
|
Work Place (code = 'WP' in codeSystem 'HL7 AddressUse')
|
Zorgaanbieder (HealthcareProvider)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
naam eigen ziekenhuis
|
ZorgverlenersRol (HealthProfessionalRole)
|
Performer (code = 'PRF' in codeSystem 'HL7 ParticipationType')
|
3.40 Voedingsadvies (NutritionAdvice) [bgz-patB-nutrition]
Voedingsadvies (NutritionAdvice) [bgz-patB-nutrition]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
DieetType (DietType)
|
eiwitrijk
|
Toelichting (Comment)
|
In verband met lage spiermassa
|
3.41 Alert (Alert) [bgz-patB-alert2]
Alert (Alert) [bgz-patB-alert2]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
Conditie (Condition)
|
|
referentie:Probleem (reference:Problem)
|
zib-2017-bgz-patB-problem4
|
BeginDatumTijd (StartDateTime)
|
4 maa 2010
|
AlertType (AlertType)
|
condition (code = '75323-6' in codeSystem 'LOINC')
|
3.42 AllergieIntolerantie (AllergyIntolerance) [bgz-patB-allergy]
AllergieIntolerantie (AllergyIntolerance) [bgz-patB-allergy]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999900092
|
VeroorzakendeStof (CausativeAgent)
|
wespengif (code = '256440004' in codeSystem 'SNOMED CT')
|
AllergieCategorie (AllergyCategory)
|
Allergy to substance (code = '419199007' in codeSystem 'SNOMED CT')
|
AllergieStatus (AllergyStatus)
|
Completed (code = 'completed' in codeSystem 'HL7 ActStatus')
|
BeginDatumTijd (StartDateTime)
|
1980-08
|
MateVanKritiekZijn (Criticality)
|
Severe (code = '24484000' in codeSystem 'SNOMED CT')
|
LaatsteReactieDatumTijd (LastReactionDateTime)
|
2 aug 2015
|
Toelichting (Comment)
|
Patiënt heeft succesvolle desensitisatie ondergaan.
|
Reactie (Reaction)
|
|
Symptoom (Symptom)
|
Anaphylaxis (code = '39579001' in codeSystem 'SNOMED CT')
|
ReactieBeschrijving (ReactionDescription)
|
Sterk verlaagde bloeddruk en ademfrequentie.
|
Ernst (Severity)
|
Severe (code = '24484000' in codeSystem 'SNOMED CT')
|
3.43 MedischHulpmiddel (MedicalDevice) [bgz-patB-medDevice]
MedischHulpmiddel (MedicalDevice) [bgz-patB-medDevice]
|
Gegevenselement
|
Waarde
|
referentie:Patient (reference:Patient)
|
999999092
|
Product (Product)
|
|
ProductID (ProductID)
|
Moving arm support (code = '7350030255912' in codeSystem '1.3.160')
|
ProductType (ProductType)
|
positioneringssteun voor arm (code = '462914001' in codeSystem 'SNOMED CT')
|
ProductOmschrijving (ProductDescription)
|
armondersteuning bij eten en drinken en computerwerk
|
BeginDatum (StartDate)
|
3 feb 2016
|
Toelichting (Comment)
|
Vanwege spierzwakte rechterarm
|
AnatomischeLocatie (AnatomicalLocation)
|
structuur van bovenste extremiteit (code = '53120007' in codeSystem 'SNOMED CT')
|
Lateraliteit (Laterality)
|
Right (code = '24028007' in codeSystem 'SNOMED CT')
|
Locatie (Location)
|
|
referentie:Zorgaanbieder (reference:HealthcareProvider)
|
Huisartsenpraktijk Molenhoek
|
Zorgverlener (HealthProfessional)
|
|
referentie:Zorgverlener (reference:HealthProfessional)
|
zib-2017-bgz-patB-healthProf1
|
-->