vpk:V4.1 Testgegevens eOverdracht Aanmeldbericht addendum: verschil tussen versies
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| (8 tussenliggende versies door 4 gebruikers niet weergegeven) | |||
| Regel 1: | Regel 1: | ||
| − | + | __NUMBEREDHEADINGS__ | |
| − | + | {{DISPLAYTITLE:eOverdracht {{VersieInfo|eOverdracht|release=V4.1}}: addendum inhoudelijke gegevens aanmeldbericht}} | |
| − | {{DISPLAYTITLE: | ||
=Addenda voor inhoudelijke gegevens= | =Addenda voor inhoudelijke gegevens= | ||
| Regel 21: | Regel 20: | ||
|colspan="7"|Persoonsgegevens | |colspan="7"|Persoonsgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="65"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Patient | |colspan="6"|Patient | ||
| Regel 74: | Regel 73: | ||
|colspan="6"|Betaler | |colspan="6"|Betaler | ||
|-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="5"|Verzekeraar | |colspan="5"|Verzekeraar | ||
|-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="4"|Verzekering | |colspan="4"|Verzekering | ||
| Regel 89: | Regel 88: | ||
|colspan="2"|Verzekeringssoort | |colspan="2"|Verzekeringssoort | ||
|style="background-color: white;"|Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') | |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;;" | ||
| + | |colspan="3"|Verzekerde nummer | ||
| + | |style="background-color: white;"|12345678 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Contactpersoon | |colspan="6"|Contactpersoon | ||
| Regel 361: | Regel 363: | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="11" | Verpleegkundige context zorgplan |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| − | |colspan=" | + | |colspan="10" width="30%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="11"|Actuele patientproblemen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="95"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="10"|Patientprobleem |
|-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="9"|<span id="t-1-1-patientprobleem-01" title="Intern ID = t-1-1-patientprobleem-01">Probleem t-1-1-patientprobleem-01</span> |
|-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="7"|Probleem naam |
|style="background-color: white;"|probleem met zichzelf wassen en afdrogen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |style="background-color: white;"|probleem met zichzelf wassen en afdrogen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="7"|Probleem status |
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |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="7"|Toelichting |
|style="background-color: white;"|meneer kan niet buigen | |style="background-color: white;"|meneer kan niet buigen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="9"|Verpleegkundige interventie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="9"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="7"|Interventie |
|style="background-color: white;"|ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED Clinical Terms') | |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="8"|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="6"|Probleem |
|style="background-color: white;"|Zie [[#t-1-1-patientprobleem-01|Probleem: t-1-1-patientprobleem-01]] | |style="background-color: white;"|Zie [[#t-1-1-patientprobleem-01|Probleem: t-1-1-patientprobleem-01]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|Actie start datum tijd | ||
| + | |style="background-color: white;"|T - 90 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="8"|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="6"|Zorgverlener |
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="10"|Patientprobleem |
|-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="9"|<span id="t-1.1-patientprobleem-02" title="Intern ID = t-1.1-patientprobleem-02">Probleem t-1.1-patientprobleem-02</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="7"|Probleem naam |
|style="background-color: white;"|probleem met zichzelf kleden (code = '284972002' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |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="7"|Probleem status |
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |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="9"|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="7"|Interventie |
|style="background-color: white;"|ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms') | |style="background-color: white;"|ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="8"|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="6"|Probleem |
|style="background-color: white;"|Zie [[#t-1.1-patientprobleem-02|Probleem: t-1.1-patientprobleem-02]] | |style="background-color: white;"|Zie [[#t-1.1-patientprobleem-02|Probleem: t-1.1-patientprobleem-02]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="10"|Patientprobleem |
|-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="9"|<span id="t-1-1-patientprobleem-03" title="Intern ID = t-1-1-patientprobleem-03">Probleem t-1-1-patientprobleem-03</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="7"|Probleem naam |
|style="background-color: white;"|decubitus (code = '399912005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |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="7"|Probleem status |
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |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="9"|Verpleegkundige interventie |
|-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="7"|Interventie |
|style="background-color: white;"|aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED Clinical Terms') | |style="background-color: white;"|aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED Clinical Terms') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="8"|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="6"|Probleem |
|style="background-color: white;"|Zie [[#t-1-1-patientprobleem-03|Probleem: t-1-1-patientprobleem-03]] | |style="background-color: white;"|Zie [[#t-1-1-patientprobleem-03|Probleem: t-1-1-patientprobleem-03]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="5"|Verpleegkundige interventie | + | |colspan="8"|Medisch hulpmiddel |
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|Product | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Product type | ||
| + | |style="background-color: white;"|schuimverband (code = '448416005' in codeSystem 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="8"|Medisch hulpmiddel | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|Product | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Product type | ||
| + | |style="background-color: white;"|huidvervangende wondbedekkers (code = '465239008' in codeSystem 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="9"|Verpleegkundige interventie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="10"| | |rowspan="10"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="7"|Interventie |
|style="background-color: white;"|wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED Clinical Terms') | |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="8"|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="6"|Probleem |
|style="background-color: white;"|Zie [[#t-1-1-patientprobleem-03|Probleem: t-1-1-patientprobleem-03]] | |style="background-color: white;"|Zie [[#t-1-1-patientprobleem-03|Probleem: t-1-1-patientprobleem-03]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="7"|Actie start datum tijd |
|style="background-color: white;"|T - 10 dagen | |style="background-color: white;"|T - 10 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="7"|Actie eind datum tijd |
|style="background-color: white;"|T - 1 dag | |style="background-color: white;"|T - 1 dag | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="8"|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="6"|Zorgverlener |
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="10"|Patientprobleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="31"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="9"|<span id="t-1-1-patientprobleem-04" title="Intern ID = t-1-1-patientprobleem-04">Probleem t-1-1-patientprobleem-04</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="7"|Probleem naam |
|style="background-color: white;"|loopt risico op delier (code = '430794006' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |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="7"|Probleem status |
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|Toelichting | ||
| + | |style="background-color: white;"|vastgesteld met DOS score | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="9"|Verpleegkundige interventie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="24"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="7"|Interventie |
|style="background-color: white;"|bevorderen van vochtinname (code = '113148007' in codeSystem 'SNOMED Clinical Terms') | |style="background-color: white;"|bevorderen van vochtinname (code = '113148007' in codeSystem 'SNOMED Clinical Terms') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="8"|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="6"|Probleem |
|style="background-color: white;"|Zie [[#t-1-1-patientprobleem-04|Probleem: t-1-1-patientprobleem-04]] | |style="background-color: white;"|Zie [[#t-1-1-patientprobleem-04|Probleem: t-1-1-patientprobleem-04]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="8"|Uitvoerder | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="18"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|Verzorger | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="16"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Contactpersoon | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="14"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Naamgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Voornamen | ||
| + | |style="background-color: white;"|Gerda | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Naamgebruik | ||
| + | |style="background-color: white;"|Geslachtsnaam partner (code = 'NL2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Geslachtsnaam partner | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|Achternaam partner | ||
| + | |style="background-color: white;"|XXX_Altenborg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Contactgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Telefoonnummers | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|Telefoonnummer | ||
| + | |style="background-color: white;"|+31662626262 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Relatie | ||
| + | |style="background-color: white;"|Echtgenoot (code = 'HUSB' in codeSystem 'HL7 RoleCode') | ||
|} | |} | ||
=== Verpleegkundige context specificatie gezondheidstoestand=== | === Verpleegkundige context specificatie gezondheidstoestand=== | ||
| Regel 668: | Regel 741: | ||
|colspan="7"|Persoonsgegevens | |colspan="7"|Persoonsgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="29"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Patient | |colspan="6"|Patient | ||
| Regel 721: | Regel 794: | ||
|colspan="6"|Betaler | |colspan="6"|Betaler | ||
|-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="5"|Verzekeraar | |colspan="5"|Verzekeraar | ||
|-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="4"|Verzekering | |colspan="4"|Verzekering | ||
| Regel 736: | Regel 809: | ||
|colspan="2"|Verzekeringssoort | |colspan="2"|Verzekeringssoort | ||
|style="background-color: white;"|Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') | |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;;" | ||
| + | |colspan="3"|Verzekerde nummer | ||
| + | |style="background-color: white;"|12345678 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Sturende organisatie | |colspan="7"|Sturende organisatie | ||
| Regel 1.133: | Regel 1.209: | ||
{| 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="6" | Verpleegkundige context zorgplan |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| − | |colspan=" | + | |colspan="5" width="30%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="6"|Actuele patientproblemen |
|-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="5"|Patientprobleem |
|-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="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;"|probleem met zichzelf kleden (code = '284972002' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |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="2"|Probleem status |
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |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"|Verpleegkundige interventie |
|-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"|Interventie |
|style="background-color: white;"|ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms') | |style="background-color: white;"|ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms') | ||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
|}<section end=eovd-saa-tst-1.4-minimaal /> | |}<section end=eovd-saa-tst-1.4-minimaal /> | ||
Huidige versie van 30 apr 2024 om 15:51
Inhoud
1 Addenda voor inhoudelijke gegevens
1.1 Test Aanmelding 1.1
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') | |||||
| Verzekerde nummer | 12345678 | |||||
| Contactpersoon | ||||||
| Naamgegevens | ||||||
| Voornamen | Johanna | |||||
| Initialen | J | |||||
| Roepnaam | Hanna | |||||
| Geslachtsnaam | ||||||
| Achternaam | Bakker | |||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31645678912 | |||||
| Email adressen | ||||||
| Email adres | jbakker@123net.nl | |||||
| Rol | Eerste relatie/contactpersoon (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.11.22.472') | |||||
| Relatie | Dochter (code = 'DAUC' in codeSystem 'HL7 RoleCode') | |||||
| Contactpersoon | ||||||
| Naamgegevens | ||||||
| Voornamen | Johannes | |||||
| Roepnaam | Hans | |||||
| Geslachtsnaam | ||||||
| Voorvoegsels | van | |||||
| Achternaam | Dijk | |||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31612121212 | |||||
| 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 t-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 incident (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 | 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: t-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 t-1-1-patientprobleem-01 | ||||||||||
| Probleem naam | probleem met zichzelf wassen en afdrogen (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: t-1-1-patientprobleem-01 | |||||||||
| Actie start datum tijd | T - 90 dagen | |||||||||
| Uitvoerder | ||||||||||
| Zorgverlener | Ja | |||||||||
| Patientprobleem | ||||||||||
| Probleem t-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: t-1.1-patientprobleem-02 | |||||||||
| Patientprobleem | ||||||||||
| Probleem t-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: t-1-1-patientprobleem-03 | |||||||||
| Medisch hulpmiddel | ||||||||||
| Product | ||||||||||
| Product type | schuimverband (code = '448416005' in codeSystem 'SNOMED Clinical Terms') | |||||||||
| Medisch hulpmiddel | ||||||||||
| Product | ||||||||||
| Product type | huidvervangende wondbedekkers (code = '465239008' in codeSystem 'SNOMED Clinical Terms') | |||||||||
| Verpleegkundige interventie | ||||||||||
| Interventie | wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED Clinical Terms') | |||||||||
| Indicatie | ||||||||||
| Probleem | Zie Probleem: t-1-1-patientprobleem-03 | |||||||||
| Actie start datum tijd | T - 10 dagen | |||||||||
| Actie eind datum tijd | T - 1 dag | |||||||||
| Uitvoerder | ||||||||||
| Zorgverlener | Ja | |||||||||
| Patientprobleem | ||||||||||
| Probleem t-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') | |||||||||
| Toelichting | vastgesteld met DOS score | |||||||||
| Verpleegkundige interventie | ||||||||||
| Interventie | bevorderen van vochtinname (code = '113148007' in codeSystem 'SNOMED Clinical Terms') | |||||||||
| Indicatie | ||||||||||
| Probleem | Zie Probleem: t-1-1-patientprobleem-04 | |||||||||
| Uitvoerder | ||||||||||
| Verzorger | ||||||||||
| Contactpersoon | ||||||||||
| Naamgegevens | ||||||||||
| Voornamen | Gerda | |||||||||
| Naamgebruik | Geslachtsnaam partner (code = 'NL2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||||||||
| Geslachtsnaam partner | ||||||||||
| Achternaam partner | XXX_Altenborg | |||||||||
| Contactgegevens | ||||||||||
| Telefoonnummers | ||||||||||
| Telefoonnummer | +31662626262 | |||||||||
| Relatie | Echtgenoot (code = 'HUSB' in codeSystem 'HL7 RoleCode') | |||||||||
1.1.5 Verpleegkundige context specificatie gezondheidstoestand
| Verpleegkundige context specificatie gezondheidstoestand | |||||||
| Gegevenselement | Waarde | ||||||
| Voedingvocht | |||||||
| Sonde systeem | |||||||
| Sonde | |||||||
| Medisch hulpmiddel | |||||||
| Product | |||||||
| Product type | Neus-maagsonde (code = '17102003' in codeSystem 'SNOMED CT') | ||||||
| Product omschrijving | neus- maagsonde | ||||||
| Toelichting | wegens misselijkheid door chemotherapie | ||||||
| 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 | Perifeer intraveneus infuus | ||||||
| Toelichting | voor medicatie | ||||||
| Uitscheiding | |||||||
| Stoma | |||||||
| Stoma type | eindstandige ileostoma (code = '311412005' in codeSystem 'SNOMED CT') | ||||||
| Toelichting | na subtotale darmresectie wegens coloncarcinoom | ||||||
| Stoma | |||||||
| Stoma type | urostoma (code = '281601009' in codeSystem 'SNOMED CT') | ||||||
1.2 Test Aanmelding 1.2
1.2.1 Administratieve gegevens
| Administratieve gegevens | ||||||
| Gegevenselement | Waarde | |||||
| Datum overplaatsing | T + 1 dag | |||||
| Persoonsgegevens | ||||||
| Patient | ||||||
| Naamgegevens | ||||||
| Initialen | M | |||||
| Geslachtsnaam | ||||||
| Voorvoegsels | van de | |||||
| Achternaam | XXX_Quigleys | |||||
| Adresgegevens | ||||||
| Straat | Knolweg | |||||
| Huisnummer | 1000 | |||||
| Postcode | 9999ZA | |||||
| Woonplaats | Stitswerd | |||||
| Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||||
| Identificatienummer | 999900912 (in identificerend systeem: BSN) | |||||
| Geboortedatum | 5 nov 1963 | |||||
| Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |||||
| Betaler | ||||||
| Verzekeraar | ||||||
| Verzekering | ||||||
| Eind datum tijd | T + 250 dagen | |||||
| Verzekeringssoort | Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1') | |||||
| Verzekerde nummer | 12345678 | |||||
| Sturende organisatie | ||||||
| Zorgaanbieder | ||||||
| Zorgaanbieder identificatienummer | 75616161 (in identificerend systeem: AGB-Z) | |||||
| Organisatie naam | HomeCare | |||||
| Organisatie type | Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060') | |||||
| Ontvangende organisatie | ||||||
| Zorgaanbieder | ||||||
| Afdeling specialisme | Medisch specialisten, obstetrie en gynaecologie (code = '0307' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
| Organisatie type | Algemeen ziekenhuis (code = 'V6' 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 | zwangerschapsgeïnduceerde hypertensie (code = '48194001' in codeSystem 'SNOMED CT') | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
1.2.3 Verpleegkundige context zorgplan
| Verpleegkundige context zorgplan | ||||||
| Gegevenselement | Waarde | |||||
| Actuele patientproblemen | ||||||
| Patientprobleem | ||||||
| Probleem t-1-2-probleem-01 | ||||||
| Probleem naam | pijn (bevinding) (code = '22253000' in codeSystem 'Referentieset Nationale kernset patientproblemen') | |||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
| Toelichting | bij lopen | |||||
| Verpleegkundige interventie | ||||||
| Interventie | afleiden (code = '414039005' in codeSystem 'SNOMED Clinical Terms') | |||||
| Indicatie | ||||||
| Probleem | Zie Probleem: t-1-2-probleem-01 | |||||
1.3 Test Aanmelding 1.3
1.3.1 Administratieve gegevens
| Administratieve gegevens | ||||||
| Gegevenselement | Waarde | |||||
| Datum overplaatsing | T + 1 dag | |||||
| Persoonsgegevens | ||||||
| Patient | ||||||
| Naamgegevens | ||||||
| Initialen | J | |||||
| Geslachtsnaam | ||||||
| Achternaam | XXX_Verhulst | |||||
| Adresgegevens | ||||||
| Straat | Knolweg | |||||
| Huisnummer | 1001 | |||||
| Postcode | 9999XX | |||||
| Woonplaats | Stitswerd | |||||
| Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||||
| Identificatienummer | 999900092 (in identificerend systeem: BSN) | |||||
| Geboortedatum | 18 sep 1963 | |||||
| Geslacht | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |||||
| 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') | |||||
1.3.2 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') | |||
1.3.3 Verpleegkundige context zorgplan
| Verpleegkundige context zorgplan | |||||
| Gegevenselement | Waarde | ||||
| Actuele patientproblemen | |||||
| Patientprobleem | |||||
| Probleem t-1.3-patientprobleem-01 | |||||
| Probleem naam | probleem met zichzelf wassen en afdrogen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen') | ||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||||
| Verpleegkundige interventie | |||||
| Interventie | ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED Clinical Terms') | ||||
1.4 Test Aanmelding 1.4
1.4.1 Administratieve gegevens
| Administratieve gegevens | ||||||
| Gegevenselement | Waarde | |||||
| Datum overplaatsing | T + 1 dag | |||||
| Persoonsgegevens | ||||||
| Patient | ||||||
| Naamgegevens | ||||||
| Initialen | N | |||||
| Geslachtsnaam | ||||||
| Voorvoegsels | van | |||||
| Achternaam | XXX_Grieken | |||||
| Adresgegevens | ||||||
| Straat | Knolweg | |||||
| Huisnummer | 1002 | |||||
| Postcode | 9999XX | |||||
| Woonplaats | Stitswerd | |||||
| Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||||
| Identificatienummer | 999900109 (in identificerend systeem: BSN) | |||||
| Geboortedatum | 18 sep 1963 | |||||
| Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |||||
| 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') | |||||
1.4.2 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') | |||
1.4.3 Verpleegkundige context zorgplan
| Verpleegkundige context zorgplan | |||||
| Gegevenselement | Waarde | ||||
| Actuele patientproblemen | |||||
| Patientprobleem | |||||
| Probleem | |||||
| 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') | ||||
