Kwalificatiescript Spoedsamenvatting 2.2.0: verschil tussen versies
(→Scenario - Actuele contactmomenten van patiënt) |
(→Scenario - Beschikbaarstellen actuele episodes van patiënt) |
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(32 tussenliggende versies door 2 gebruikers niet weergegeven) | |||
Regel 1: | Regel 1: | ||
− | |||
= Inhoudelijke gegevens = | = Inhoudelijke gegevens = | ||
Regel 100: | Regel 99: | ||
− | ==Scenario - | + | ==Scenario - Beschikbaarstellen actuele contactmomenten van patiënt== |
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
Regel 134: | Regel 133: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Episode | |colspan="4"|Episode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|A20gesloten |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
− | + | <section begin=contactmomenttweedeconsultA20 /> | |
− | <section begin= | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactmoment | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactmoment | ||
Regel 147: | Regel 145: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Identificatienummer | |colspan="5"|Identificatienummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Contact11 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|ContactType | |colspan="5"|ContactType | ||
− | |style="background-color: white;"|Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | + | |style="background-color: white;"| Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Contact met | |colspan="6"|Contact met | ||
Regel 162: | Regel 160: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|BeginDatumTijd | |colspan="5"|BeginDatumTijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T-60D{11:10} |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|EindDatumTijd | |colspan="5"|EindDatumTijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T-60D{11:30} |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|RedenContact | |colspan="6"|RedenContact | ||
Regel 172: | Regel 170: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Episode | |colspan="4"|Episode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|A20 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
− | <section end= | + | <section end=contactmomenttweedeconsultA20/> |
− | |||
+ | <section begin=contactmoment02 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactmoment | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactmoment | ||
Regel 185: | Regel 183: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Identificatienummer | |colspan="5"|Identificatienummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Contact02 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|ContactType | |colspan="5"|ContactType | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |||
|colspan="6"|Contact met | |colspan="6"|Contact met | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 200: | Regel 197: | ||
|style="background-color: white;"| 10000002 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | |style="background-color: white;"| 10000002 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |||
|colspan="5"|BeginDatumTijd | |colspan="5"|BeginDatumTijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T-100D{13:30} |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|EindDatumTijd | |colspan="5"|EindDatumTijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T-100D{13:50} |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|RedenContact | |colspan="6"|RedenContact | ||
Regel 212: | Regel 208: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Episode | |colspan="4"|Episode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|D02 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
+ | <section end=contactmoment02 /> | ||
<section begin=contactmoment03 /> | <section begin=contactmoment03 /> | ||
Regel 229: | Regel 226: | ||
|style="background-color: white;"|Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | |style="background-color: white;"|Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |||
|colspan="6"|Contact met | |colspan="6"|Contact met | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 239: | Regel 235: | ||
|style="background-color: white;"| 10000002 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | |style="background-color: white;"| 10000002 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |||
|colspan="5"|BeginDatumTijd | |colspan="5"|BeginDatumTijd | ||
|style="background-color: white;"|T-9D{08:30} | |style="background-color: white;"|T-9D{08:30} | ||
Regel 270: | Regel 265: | ||
|style="background-color: white;"|Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | |style="background-color: white;"|Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |||
|colspan="6"|Contact met | |colspan="6"|Contact met | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 280: | Regel 274: | ||
|style="background-color: white;"| 10000002 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | |style="background-color: white;"| 10000002 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |||
|colspan="5"|BeginDatumTijd | |colspan="5"|BeginDatumTijd | ||
|style="background-color: white;"|T-6D{09:00} | |style="background-color: white;"|T-6D{09:00} | ||
Regel 297: | Regel 290: | ||
<section end=contactmoment04 /> | <section end=contactmoment04 /> | ||
− | |||
+ | <section begin=contactmoment05 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactmoment |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
Regel 306: | Regel 299: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Identificatienummer | |colspan="5"|Identificatienummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Contact05 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|ContactType |
− | |style="background-color: white;"| | + | |style="background-color: white;"|telefonisch contact (Code = 05 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Contact met |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |rowspan="2"| | ||
+ | |colspan="6"|Zorgverlener | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="1"| | ||
+ | |colspan="3"|Zorgverleneridentificatienummer | ||
+ | |style="background-color: white;"| 10000002 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|BeginDatumTijd |
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T-50D{14:30} |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="5"|EindDatumTijd |
+ | |style="background-color: white;"|T-50D{14:50} | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|RedenContact | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan="18"| | + | |rowspan="3"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Episode | ||
+ | |style="background-color: white;"|N88 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |} | ||
+ | <section end=contactmoment05 /> | ||
+ | |||
+ | ==Scenario - Beschikbaarstellen actuele contactverslagen van patiënt== | ||
+ | <section begin=contactverslag01/> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactverslag | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="5" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Identificatienummer | ||
+ | |style="background-color: white;"|Contactverslag01 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verwijzing Contact | ||
+ | |style="background-color: white;"|Contact01 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verwijzing Episode | ||
+ | |style="background-color: white;"|A20Gesloten | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|DatumTijd | ||
+ | |style="background-color: white;"|T-600D | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Journaalregel | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="18"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Type | |colspan="4"|Type | ||
Regel 341: | Regel 373: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Identificatienummer | |colspan="3"|Identificatienummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|ProbleemA20gesloten |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 351: | Regel 383: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|ProbleemEindDatum | |colspan="3"|ProbleemEindDatum | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T-61D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | <section end=contactverslag01/> | ||
− | + | <section begin=contactverslagtweedeA20/> | |
− | + | {| class="wikitable" width="85%" | |
− | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactverslag | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactverslag | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
Regel 363: | Regel 395: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Identificatienummer | |colspan="5"|Identificatienummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Contactverslag11 |
− | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
|colspan="5"|Verwijzing Contact | |colspan="5"|Verwijzing Contact | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Contact11 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verwijzing Episode | |colspan="5"|Verwijzing Episode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|A20 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|DatumTijd | |colspan="5"|DatumTijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T-60D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Journaalregel | |colspan="6"|Journaalregel | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="18"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Type | |colspan="4"|Type | ||
Regel 382: | Regel 414: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|S | |colspan="4"|S | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Herevaluatie niet reanimeerwens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|O | |colspan="4"|O | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Compos mentis |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|E | |colspan="4"|E | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Continueer behandelgrens, niet reanimeren |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Probleem | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="5"| |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Identificatienummer | |colspan="3"|Identificatienummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|ProbleemA20 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|ProbleemNaam | |colspan="3"|ProbleemNaam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"| Gesprek levenseinde/behandelwensen (Code = A20 uit Codesysteem 2.16.840.1.113883.2.4.4.31.1 De Nederlandse editie van International Classification of Primary Care ICPC-1-NL) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|ProbleemBeginDatum | |colspan="3"|ProbleemBeginDatum | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T-60D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|ProbleemEindDatum | |colspan="3"|ProbleemEindDatum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
− | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
− | + | <section end=contactverslagtweedeA20/> | |
− | |||
− | |||
+ | <section begin=contactverslag03/> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactverslag | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactverslag | ||
Regel 419: | Regel 449: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Identificatienummer | |colspan="5"|Identificatienummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Contactverslag02 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verwijzing Contact | |colspan="5"|Verwijzing Contact | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Contact02 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verwijzing Episode | |colspan="5"|Verwijzing Episode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|D02 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|DatumTijd | |colspan="5"|DatumTijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T-100D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Journaalregel | |colspan="6"|Journaalregel | ||
Regel 438: | Regel 468: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|S | |colspan="4"|S | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|In eerste instantie na warm eten enige uren pijn in bovenbuik. Niet misselijk, opboeren soms, opgeblazen gevoel |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|O | |colspan="4"|O | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Maagstreek gevoelig. Overig gb. |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|E | |colspan="4"|E | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Maag/duodenum problemen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 452: | Regel 482: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Identificatienummer | |colspan="3"|Identificatienummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|ProbleemD02 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|ProbleemNaam | |colspan="3"|ProbleemNaam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Maagpijn (Code = D02 uit Codesysteem 2.16.840.1.113883.2.4.4.31.1 De Nederlandse editie van International Classification of Primary Care ICPC-1-NL) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|ProbleemBeginDatum | |colspan="3"|ProbleemBeginDatum | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T-100D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|ProbleemEindDatum | |colspan="3"|ProbleemEindDatum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|T-90D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
+ | <section end=contactverslag03/> | ||
− | + | <section begin=contactverslag05 /> | |
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactverslag | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactverslag | ||
Regel 494: | Regel 525: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|S | |colspan="4"|S | ||
− | |style="background-color: white;"|Gaat beter, nog wel af en toe benauwd/ | + | |style="background-color: white;"|Gaat beter, nog wel af en toe benauwd/hoesten. Geen koorts, weinig slijm en geen PoB. |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|O | |colspan="4"|O | ||
Regel 523: | Regel 554: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
+ | <section end=contactverslag05 /> | ||
− | + | <section begin=contactverslag06 /> | |
− | + | {| class="wikitable" width="85%" | |
− | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactverslag | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactverslag | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
Regel 533: | Regel 564: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Identificatienummer | |colspan="5"|Identificatienummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Contactverslag04 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verwijzing Contact | |colspan="5"|Verwijzing Contact | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Contact04 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verwijzing Episode | |colspan="5"|Verwijzing Episode | ||
Regel 581: | Regel 612: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
+ | <section end=contactverslag06 /> | ||
− | = | + | <section begin=contactverslagepilepsie/> |
− | |||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactverslag |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Identificatienummer |
+ | |style="background-color: white;"|Contactverslag05 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verwijzing Contact | ||
+ | |style="background-color: white;"|Contact05 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verwijzing Episode | ||
|style="background-color: white;"|N88 | |style="background-color: white;"|N88 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|DatumTijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T-50D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Journaalregel |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="14"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Type |
− | |style="background-color: | + | |style="background-color: #E3E3E3;"|Tekst |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|S |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Belt voor herhaalrecept |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|O |
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|E |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Bekend met epilepsie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Probleem |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |rowspan="7"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="3"|Identificatienummer | ||
+ | |style="background-color: white;"|ProbleemN88 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|ProbleemNaam | ||
+ | |style="background-color: white;"|Epilepsie (Code = N88 uit Codesysteem 2.16.840.1.113883.2.4.4.31.1 De Nederlandse editie van International Classification of Primary Care ICPC-1-NL) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|ProbleemBeginDatum |
− | |style="background-color: white;"| T- | + | |style="background-color: white;"|T-1010D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|ProbleemEindDatum |
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |||
− | |||
|} | |} | ||
+ | <section end=contactverslagepilepsie/> | ||
− | + | ==Scenario - Beschikbaarstellen actuele episodes van patiënt== | |
+ | <section begin=episode01 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Episode | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Episode | ||
Regel 649: | Regel 680: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Identificatie | |colspan="5"|Identificatie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|N88 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Episodetitel | |colspan="5"|Episodetitel | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Epilepsie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Status | |colspan="5"|Status | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Open (code = ‘active’ in codeSystem 2.16.840.1.113883.5.14 ‘ActStatus’) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Startdatum | |colspan="5"|Startdatum | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"| T-1010D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Einddatum | |colspan="5"|Einddatum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verwijzing Probleem | |colspan="5"|Verwijzing Probleem | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|ProbleemN88 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Attentiewaarden | |colspan="5"|Attentiewaarden | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"| Ja |
|} | |} | ||
+ | <section end=episode01 /> | ||
− | + | <section begin=episode02 /> | |
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Episode | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Episode | ||
Regel 678: | Regel 710: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Identificatie | |colspan="5"|Identificatie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|A20Gesloten |
− | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
|colspan="5"|Episodetitel | |colspan="5"|Episodetitel | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Wilsverklaring: niet reanimeren |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Status | |colspan="5"|Status | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Gesloten (code = ‘completed’ in codeSystem 2.16.840.1.113883.5.14 ‘ActStatus’) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Startdatum | |colspan="5"|Startdatum | ||
− | |style="background-color: white;"| T- | + | |style="background-color: white;"| T-600D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Einddatum | |colspan="5"|Einddatum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"| T-61D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verwijzing Probleem | |colspan="5"|Verwijzing Probleem | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|ProbleemA20Gesloten |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Attentiewaarden | |colspan="5"|Attentiewaarden | ||
|style="background-color: white;"| Ja | |style="background-color: white;"| Ja | ||
|} | |} | ||
+ | <section end=episode02 /> | ||
− | = | + | <section begin=episodeOpen /> |
− | |||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Episode |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
Regel 708: | Regel 740: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Identificatie | |colspan="5"|Identificatie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|A20 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Episodetitel |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Recentelijk besproken met patient: Niet reanimeren. |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Open (code = ‘active’ in codeSystem 2.16.840.1.113883.5.14 ‘ActStatus’) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Startdatum |
+ | |style="background-color: white;"| T-60D | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="5"|Einddatum | |
− | + | |style="background-color: white;"| | |
− | |colspan=" | ||
− | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verwijzing Probleem |
− | |style="background-color: white;"| | + | |style="background-color: white;"|ProbleemA20 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Attentiewaarden |
− | |style="background-color: white;"| | + | |style="background-color: white;"| Ja |
+ | |} | ||
+ | <section end=episodeOpen /> | ||
+ | |||
+ | <section begin=episode03 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Episode | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="5" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Identificatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|D02 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Episodetitel | ||
+ | |style="background-color: white;"|Maagpijn | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Status | ||
+ | |style="background-color: white;"|Gesloten (code = ‘completed’ in codeSystem 2.16.840.1.113883.5.14 ‘ActStatus’) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Startdatum | ||
+ | |style="background-color: white;"|T-100D | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Einddatum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T-90D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verwijzing Probleem |
− | |style="background-color: white;"| | + | |style="background-color: white;"|ProbleemD02 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Attentiewaarden |
− | |style="background-color: white;"| | + | |style="background-color: white;"| Nee |
|} | |} | ||
+ | <section end=episode03 /> | ||
− | + | <section begin=episode04 /> | |
− | |||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Episode |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
Regel 752: | Regel 800: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Identificatie | |colspan="5"|Identificatie | ||
− | |style="background-color: white;"|Lab02 | + | |style="background-color: white;"|R95 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Episodetitel | ||
+ | |style="background-color: white;"|COPD | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Status | ||
+ | |style="background-color: white;"|Open (code = ‘active’ in codeSystem 2.16.840.1.113883.5.14 ‘ActStatus’) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Startdatum | ||
+ | |style="background-color: white;"| T-9D | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Einddatum | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verwijzing Probleem | ||
+ | |style="background-color: white;"|ProbleemR95 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Attentiewaarden | ||
+ | |style="background-color: white;"| Ja | ||
+ | |} | ||
+ | <section end=episode04 /> | ||
+ | |||
+ | ==Scenario - Beschikbaarstellen actuele labbepalingen van patiënt== | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | LaboratoriumUitslag | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="5" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Identificatie | ||
+ | |style="background-color: white;"|Lab01 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verwijzing contact | ||
+ | |style="background-color: white;"|Contact01 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verwijzing episode | ||
+ | |style="background-color: white;"|R95 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|LaboratoriumTest | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Identificatienummer | ||
+ | |style="background-color: white;"|LabTest01 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|TestCode | ||
+ | |style="background-color: white;"|Huidsets hondepitheel (code = '2626' in codeSystem 'NHG Diagnostische bepalingen') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|TestDatumTijd | ||
+ | |style="background-color: white;"|T-600D | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|TestUitslag | ||
+ | |style="background-color: white;"|Twijfelachtig (code 312) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|ReferentieBovengrens | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|ReferentieOndergrens | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|UitslagInterpretatie | ||
+ | |style="background-color: white;"| | ||
+ | |} | ||
+ | |||
+ | <section begin=lab02 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | LaboratoriumUitslag | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="5" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Identificatie | ||
+ | |style="background-color: white;"|Lab02 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verwijzing contact | ||
+ | |style="background-color: white;"|Contact03 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verwijzing episode | ||
+ | |style="background-color: white;"|R95 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|LaboratoriumTest | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Identificatienummer | ||
+ | |style="background-color: white;"|LabTest02 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|TestCode | ||
+ | |style="background-color: white;"|MultiRAST (phadiaTop) (code = '852' in codeSystem 'NHG Diagnostische bepalingen') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|TestDatumTijd | ||
+ | |style="background-color: white;"|T-9D | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|TestUitslag | ||
+ | |style="background-color: white;"| ‘’Positief’’ (Vrije tekst) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|ReferentieBovengrens | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|ReferentieOndergrens | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|UitslagInterpretatie | ||
+ | |style="background-color: white;"| | ||
+ | |} | ||
+ | <section end=lab02 /> | ||
+ | |||
+ | <section begin=lab03 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | LaboratoriumUitslag | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="5" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Identificatie | ||
+ | |style="background-color: white;"|Lab03 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verwijzing contact | |colspan="5"|Verwijzing contact | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Contact04 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verwijzing episode | |colspan="5"|Verwijzing episode | ||
Regel 765: | Regel 931: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Identificatienummer | |colspan="4"|Identificatienummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|LabTest03 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|TestCode | |colspan="4"|TestCode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|as. Dermatophagoidus pteronyssinus d1 (code = '906' in codeSystem 'NHG Diagnostische bepalingen') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|TestDatumTijd | |colspan="4"|TestDatumTijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T-6D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|TestUitslag | |colspan="4"|TestUitslag | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Positief (vrije tekst) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 786: | Regel 952: | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|} | |} | ||
+ | <section end=lab03 /> | ||
− | + | <section begin=lab04 /> | |
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | LaboratoriumUitslag | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | LaboratoriumUitslag | ||
Regel 795: | Regel 962: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Identificatie | |colspan="5"|Identificatie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Lab04 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verwijzing contact | |colspan="5"|Verwijzing contact | ||
Regel 808: | Regel 975: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Identificatienummer | |colspan="4"|Identificatienummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|LabTest04 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|TestCode | |colspan="4"|TestCode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Glucose nuchter, veneus (code = '372' in codeSystem 'NHG Diagnostische bepalingen') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|TestDatumTijd | |colspan="4"|TestDatumTijd | ||
Regel 817: | Regel 984: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|TestUitslag | |colspan="4"|TestUitslag | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|4,5 mmol/l |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|ReferentieBovengrens | |colspan="4"|ReferentieBovengrens | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|6,1 mmol/l |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|ReferentieOndergrens | |colspan="4"|ReferentieOndergrens | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|4,0 mmol/l |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|UitslagInterpretatie | |colspan="4"|UitslagInterpretatie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Normal (code=N codesysteem 2.16.840.1.113883.5.83) |
|} | |} | ||
+ | <section end=lab04 /> | ||
− | + | ==Scenario - Beschikbaarstellen actuele algemene bepalingen van patiënt== | |
− | + | <section begin=AlgBep01 /> | |
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verwijzing contact | |colspan="5"|Verwijzing contact | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Contact01 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verwijzing episode | |colspan="5"|Verwijzing episode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|MeetUitslag | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="9"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |||
− | |||
|colspan="4"|Identificatienummer | |colspan="4"|Identificatienummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|AlgBep01 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|MetingNaam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Systolische bloeddruk (1744) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|UitslagWaarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|184 mmHg |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|UitslagDatumTijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T-600D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|ReferentieOndergrens | ||
+ | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|ReferentieBovengrens | + | |colspan="4"|ReferentieBovengrens |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 140 mmHG |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|UitslagInterpretatie | |colspan="4"|UitslagInterpretatie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|High (code= H codesysteem 2.16.840.1.113883.5.83) |
|} | |} | ||
+ | <section end=AlgBep01 /> | ||
− | + | <section begin=AlgBep02 /> | |
− | = | ||
− | |||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | ||
Regel 887: | Regel 1.050: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verwijzing episode | |colspan="5"|Verwijzing episode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|MeetUitslag | |colspan="6"|MeetUitslag | ||
Regel 894: | Regel 1.057: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Identificatienummer | |colspan="4"|Identificatienummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|AlgBep02 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|MetingNaam | |colspan="4"|MetingNaam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Diastolische bloeddruk (1740) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|UitslagWaarde | |colspan="4"|UitslagWaarde | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|94 mmHg |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|UitslagDatumTijd | |colspan="4"|UitslagDatumTijd | ||
Regel 906: | Regel 1.069: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|ReferentieOndergrens | |colspan="4"|ReferentieOndergrens | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|89 mmHg |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|ReferentieBovengrens | |colspan="4"|ReferentieBovengrens | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|UitslagInterpretatie | |colspan="4"|UitslagInterpretatie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Normal (code=N codesysteem 2.16.840.1.113883.5.83) |
|} | |} | ||
+ | <section end=AlgBep02 /> | ||
− | + | <section begin=AlgBep04 /> | |
− | |||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | ||
Regel 924: | Regel 1.087: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verwijzing contact | |colspan="5"|Verwijzing contact | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Contact03 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verwijzing episode | |colspan="5"|Verwijzing episode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|R95 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|MeetUitslag | |colspan="6"|MeetUitslag | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan="9"| | + | |rowspan="9"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Identificatienummer | |colspan="4"|Identificatienummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|AlgBep04 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|MetingNaam | |colspan="4"|MetingNaam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|FEV1/FVC ratio pré-BD (1675) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|UitslagWaarde | |colspan="4"|UitslagWaarde | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|66% |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|UitslagDatumTijd | |colspan="4"|UitslagDatumTijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T-9D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|ReferentieOndergrens | |colspan="4"|ReferentieOndergrens | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"| 70 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|ReferentieBovengrens | |colspan="4"|ReferentieBovengrens | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|UitslagInterpretatie | |colspan="4"|UitslagInterpretatie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Low (code=L codesysteem 2.16.840.1.113883.5.83) |
|} | |} | ||
+ | <section end=AlgBep04 /> | ||
− | + | <section begin=AlgBep05 /> | |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | ||
Regel 1.030: | Regel 1.157: | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|} | |} | ||
+ | <section end=AlgBep05 /> | ||
− | + | <section begin=AlgBep06 /> | |
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | ||
Regel 1.069: | Regel 1.197: | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|} | |} | ||
+ | <section end=AlgBep06 /> | ||
− | + | <section begin=AlgBep07 /> | |
− | |||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | ||
Regel 1.109: | Regel 1.237: | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|} | |} | ||
+ | <section end=AlgBep07 /> | ||
− | + | <section begin=AlgBep08 /> | |
− | |||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | ||
Regel 1.149: | Regel 1.277: | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|} | |} | ||
+ | <section end=AlgBep08 /> | ||
− | + | <section begin=AlgBep09 /> | |
− | |||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | ||
Regel 1.189: | Regel 1.317: | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|} | |} | ||
− | + | <section end=AlgBep09 /> | |
==Scenario - Beschikbaarstellen actuele medicatieafspraken van patiënt== | ==Scenario - Beschikbaarstellen actuele medicatieafspraken van patiënt== | ||
− | + | <section begin=MedAfs01 /> | |
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Medicatieafspraken | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Medicatieafspraken | ||
Regel 1.266: | Regel 1.394: | ||
|style="background-color: white;"|2 maal per dag 1 stuks | |style="background-color: white;"|2 maal per dag 1 stuks | ||
|} | |} | ||
+ | <section end=MedAfs01 /> | ||
+ | <section begin=MedAfs02 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Medicatieafspraken | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Medicatieafspraken | ||
Regel 1.340: | Regel 1.470: | ||
|style="background-color: white;"|1 maal per dag 1 stuks | |style="background-color: white;"|1 maal per dag 1 stuks | ||
|} | |} | ||
+ | <section end=MedAfs02 /> | ||
+ | <section begin=MedAfs03 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Medicatieafspraken | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Medicatieafspraken | ||
Regel 1.414: | Regel 1.546: | ||
|style="background-color: white;"| 2 maal daags 1 inhalatie | |style="background-color: white;"| 2 maal daags 1 inhalatie | ||
|} | |} | ||
+ | <section end=MedAfs03 /> | ||
+ | <section begin=MedAfs04 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Medicatieafspraken | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Medicatieafspraken | ||
Regel 1.487: | Regel 1.621: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Omschrijving | |colspan="4"|Omschrijving | ||
− | |style="background-color: white;"|2 maal daags | + | |style="background-color: white;"|2 maal daags 15 ml |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Toedieningsweg | |colspan="4"|Toedieningsweg | ||
Regel 1.493: | Regel 1.627: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Doseerinstructie | |colspan="4"|Doseerinstructie | ||
− | |style="background-color: white;"|2 maal daags | + | |style="background-color: white;"|2 maal daags 15 ml |
|} | |} | ||
+ | <section end=MedAfs04 /> | ||
+ | <section begin=MedAfs05 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Medicatieafspraken | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Medicatieafspraken | ||
Regel 1.572: | Regel 1.708: | ||
|style="background-color: white;"|14 dagen | |style="background-color: white;"|14 dagen | ||
|} | |} | ||
− | + | <section end=MedAfs05 /> | |
==Scenario - Beschikbaarstellen actuele alerts van patiënt== | ==Scenario - Beschikbaarstellen actuele alerts van patiënt== | ||
− | + | <section begin=alert01 /> | |
− | |||
− | |||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Alert | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Alert | ||
Regel 1.600: | Regel 1.734: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
+ | <section end=alert01 /> | ||
+ | <section begin=alert02 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Alert | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Alert | ||
Regel 1.623: | Regel 1.759: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
+ | <section end=alert02 /> | ||
+ | <section begin=alert03 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Alert | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Alert | ||
Regel 1.646: | Regel 1.784: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
− | + | <section end=alert03 /> | |
==Scenario - Beschikbaarstellen actuele allergie/intoleranties van patiënt== | ==Scenario - Beschikbaarstellen actuele allergie/intoleranties van patiënt== | ||
+ | <section begin=allergie01 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AllergieIntolerantie | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AllergieIntolerantie | ||
Regel 1.689: | Regel 1.828: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|SpecifiekeStof | |colspan="4"|SpecifiekeStof | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"| Amoxicilline |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Ernst | |colspan="4"|Ernst | ||
Regel 1.700: | Regel 1.839: | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|} | |} | ||
+ | <section end=allergie01 /> |
Huidige versie van 22 dec 2024 om 13:28
Inhoud
- 1 Inhoudelijke gegevens
- 1.1 Scenario - Beschikbaarstellen actuele contactmomenten van patiënt
- 1.2 Scenario - Beschikbaarstellen actuele contactverslagen van patiënt
- 1.3 Scenario - Beschikbaarstellen actuele episodes van patiënt
- 1.4 Scenario - Beschikbaarstellen actuele labbepalingen van patiënt
- 1.5 Scenario - Beschikbaarstellen actuele algemene bepalingen van patiënt
- 1.6 Scenario - Beschikbaarstellen actuele medicatieafspraken van patiënt
- 1.7 Scenario - Beschikbaarstellen actuele alerts van patiënt
- 1.8 Scenario - Beschikbaarstellen actuele allergie/intoleranties van patiënt
Inhoudelijke gegevens
De bundel geeft algemene gegevens over de auteur, dossierhouder en het onderwerp. De bundel is bij iedere bouwsteen hetzelfde. Minimaal worden onderstaande gegevens verwacht. De identificaties zijn in de praktijk vrij te kiezen.
Bundel | ||||||
Gegevenselement | Waarde | |||||
Onderwerp | ||||||
Patient | ||||||
Naamgegevens | ||||||
Voornamen | Jan Willem | |||||
Initialen | J.W. | |||||
Roepnaam | Jantje | |||||
Geslachtsnaam | ||||||
Voorvoegsels | ||||||
Achternaam | XXX_Kuiperij | |||||
GeslachtsnaamPartner | ||||||
VoorvoegselsPartner | van | |||||
AchternaamPartner | Pieten | |||||
Adresgegevens | ||||||
Straat | Knolweg | |||||
Huisnummer | 1001 | |||||
Huisnummerletter | A | |||||
Huisnummertoevoeging | 2 | |||||
AanduidingBijNummer | ||||||
Postcode | 9999XX | |||||
Woonplaats | STITSWERD | |||||
Land | Nederland | |||||
AdditioneleInformatie | ||||||
AdresSoort | Primair huisadres (Code = 'HP' in codesysteem 2.16.840.1.113883.5.1119 'Address Use') | |||||
Identificatienummer | 999911090 | |||||
Geboortedatum | 19640725 | |||||
Geslacht | vrouw (Code = F in codesysteem 2.16.840.1.113883.5.1 'Administrative Gender') | |||||
MeerlingIndicator | Nee |
Scenario - Beschikbaarstellen actuele contactmomenten van patiënt
Contactmoment | ||||||
Gegevenselement | Waarde | |||||
Identificatienummer | Contact01 | |||||
ContactType | Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | |||||
Contact met | ||||||
Zorgverlener | ||||||
Zorgverleneridentificatienummer | 10000002 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | |||||
BeginDatumTijd | T-600D{11:10} | |||||
EindDatumTijd | T-600D{11:30} | |||||
RedenContact | ||||||
Episode | A20gesloten |
Contactmoment | ||||||
Gegevenselement | Waarde | |||||
Identificatienummer | Contact11 | |||||
ContactType | Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | |||||
Contact met | ||||||
Zorgverlener | ||||||
Zorgverleneridentificatienummer | 10000002 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | |||||
BeginDatumTijd | T-60D{11:10} | |||||
EindDatumTijd | T-60D{11:30} | |||||
RedenContact | ||||||
Episode | A20 |
Contactmoment | ||||||
Gegevenselement | Waarde | |||||
Identificatienummer | Contact02 | |||||
ContactType | Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | |||||
Contact met | ||||||
Zorgverlener | ||||||
Zorgverleneridentificatienummer | 10000002 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | |||||
BeginDatumTijd | T-100D{13:30} | |||||
EindDatumTijd | T-100D{13:50} | |||||
RedenContact | ||||||
Episode | D02 |
Contactmoment | ||||||
Gegevenselement | Waarde | |||||
Identificatienummer | Contact03 | |||||
ContactType | Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | |||||
Contact met | ||||||
Zorgverlener | ||||||
Zorgverleneridentificatienummer | 10000002 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | |||||
BeginDatumTijd | T-9D{08:30} | |||||
EindDatumTijd | T-9D{08:45} | |||||
RedenContact | ||||||
Episode | R95 |
Contactmoment | ||||||
Gegevenselement | Waarde | |||||
Identificatienummer | Contact04 | |||||
ContactType | Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | |||||
Contact met | ||||||
Zorgverlener | ||||||
Zorgverleneridentificatienummer | 10000002 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | |||||
BeginDatumTijd | T-6D{09:00} | |||||
EindDatumTijd | T-6D{09:15} | |||||
RedenContact | ||||||
Episode | R95 |
Contactmoment | ||||||
Gegevenselement | Waarde | |||||
Identificatienummer | Contact05 | |||||
ContactType | telefonisch contact (Code = 05 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | |||||
Contact met | ||||||
Zorgverlener | ||||||
Zorgverleneridentificatienummer | 10000002 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | |||||
BeginDatumTijd | T-50D{14:30} | |||||
EindDatumTijd | T-50D{14:50} | |||||
RedenContact | ||||||
Episode | N88 |
Scenario - Beschikbaarstellen actuele contactverslagen van patiënt
Contactverslag | |||||
Gegevenselement | Waarde | ||||
Identificatienummer | Contactverslag01 | ||||
Verwijzing Contact | Contact01 | ||||
Verwijzing Episode | A20Gesloten | ||||
DatumTijd | T-600D | ||||
Journaalregel | |||||
Type | Tekst | ||||
S | Weloverwogen besluit voor een niet reanimeerwens | ||||
O | Compos mentis | ||||
E | Gesprek levenseinde, niet reanimeren | ||||
P | Wilsverklaring ondertekend | ||||
Probleem | |||||
Identificatienummer | ProbleemA20gesloten | ||||
ProbleemNaam | Gesprek levenseinde/behandelwensen (Code = A20 uit Codesysteem 2.16.840.1.113883.2.4.4.31.1 De Nederlandse editie van International Classification of Primary Care ICPC-1-NL) | ||||
ProbleemBeginDatum | T-600D | ||||
ProbleemEindDatum | T-61D |
Contactverslag | |||||
Gegevenselement | Waarde | ||||
Identificatienummer | Contactverslag11 | ||||
Verwijzing Contact | Contact11 | ||||
Verwijzing Episode | A20 | ||||
DatumTijd | T-60D | ||||
Journaalregel | |||||
Type | Tekst | ||||
S | Herevaluatie niet reanimeerwens | ||||
O | Compos mentis | ||||
E | Continueer behandelgrens, niet reanimeren | ||||
Probleem | |||||
Identificatienummer | ProbleemA20 | ||||
ProbleemNaam | Gesprek levenseinde/behandelwensen (Code = A20 uit Codesysteem 2.16.840.1.113883.2.4.4.31.1 De Nederlandse editie van International Classification of Primary Care ICPC-1-NL) | ||||
ProbleemBeginDatum | T-60D | ||||
ProbleemEindDatum |
Contactverslag | |||||
Gegevenselement | Waarde | ||||
Identificatienummer | Contactverslag02 | ||||
Verwijzing Contact | Contact02 | ||||
Verwijzing Episode | D02 | ||||
DatumTijd | T-100D | ||||
Journaalregel | |||||
Type | Tekst | ||||
S | In eerste instantie na warm eten enige uren pijn in bovenbuik. Niet misselijk, opboeren soms, opgeblazen gevoel | ||||
O | Maagstreek gevoelig. Overig gb. | ||||
E | Maag/duodenum problemen | ||||
Probleem | |||||
Identificatienummer | ProbleemD02 | ||||
ProbleemNaam | Maagpijn (Code = D02 uit Codesysteem 2.16.840.1.113883.2.4.4.31.1 De Nederlandse editie van International Classification of Primary Care ICPC-1-NL) | ||||
ProbleemBeginDatum | T-100D | ||||
ProbleemEindDatum | T-90D |
Contactverslag | |||||
Gegevenselement | Waarde | ||||
Identificatienummer | Contactverslag03 | ||||
Verwijzing Contact | Contact03 | ||||
Verwijzing Episode | R95 | ||||
DatumTijd | T-9D | ||||
Journaalregel | |||||
Type | Tekst | ||||
S | Gaat beter, nog wel af en toe benauwd/hoesten. Geen koorts, weinig slijm en geen PoB. | ||||
O | Longen VAG geen crep, piep, wel wat rhonchi, Percussi gb | ||||
E | COPD, beterend | ||||
P | Controle afspreken POH voor ketenzorg en blaastest, continueren flixotide, zn ventolin | ||||
Probleem | |||||
Identificatienummer | ProbleemR95 | ||||
ProbleemNaam | Emfyseem/COPD (Code = R95 uit Codesysteem 2.16.840.1.113883.2.4.4.31.1 De Nederlandse editie van International Classification of Primary Care ICPC-1-NL) | ||||
ProbleemBeginDatum | T-9D | ||||
ProbleemEindDatum |
Contactverslag | |||||
Gegevenselement | Waarde | ||||
Identificatienummer | Contactverslag04 | ||||
Verwijzing Contact | Contact04 | ||||
Verwijzing Episode | R95 | ||||
DatumTijd | T-6D | ||||
Journaalregel | |||||
Type | Tekst | ||||
S | Gaat slechter. Medicatie slaat niet aan aldus pat. Koorts -, Hoest +++, Slijm geel | ||||
O | Longen VAG crep+, piep iets, rhonchi+. Percussie gb. | ||||
E | COPD, exacerbatie. | ||||
P | AB starten, ventolin 3-4 dgs. | ||||
Probleem | |||||
Identificatienummer | ProbleemR95 | ||||
ProbleemNaam | Emfyseem/COPD (Code = R95 uit Codesysteem 2.16.840.1.113883.2.4.4.31.1 De Nederlandse editie van International Classification of Primary Care ICPC-1-NL) | ||||
ProbleemBeginDatum | T-9D | ||||
ProbleemEindDatum |
Contactverslag | |||||
Gegevenselement | Waarde | ||||
Identificatienummer | Contactverslag05 | ||||
Verwijzing Contact | Contact05 | ||||
Verwijzing Episode | N88 | ||||
DatumTijd | T-50D | ||||
Journaalregel | |||||
Type | Tekst | ||||
S | Belt voor herhaalrecept | ||||
O | |||||
E | Bekend met epilepsie | ||||
Probleem | |||||
Identificatienummer | ProbleemN88 | ||||
ProbleemNaam | Epilepsie (Code = N88 uit Codesysteem 2.16.840.1.113883.2.4.4.31.1 De Nederlandse editie van International Classification of Primary Care ICPC-1-NL) | ||||
ProbleemBeginDatum | T-1010D | ||||
ProbleemEindDatum |
Scenario - Beschikbaarstellen actuele episodes van patiënt
Episode | |||||
Gegevenselement | Waarde | ||||
Identificatie | N88 | ||||
Episodetitel | Epilepsie | ||||
Status | Open (code = ‘active’ in codeSystem 2.16.840.1.113883.5.14 ‘ActStatus’) | ||||
Startdatum | T-1010D | ||||
Einddatum | |||||
Verwijzing Probleem | ProbleemN88 | ||||
Attentiewaarden | Ja |
Episode | |||||
Gegevenselement | Waarde | ||||
Identificatie | A20Gesloten | ||||
Episodetitel | Wilsverklaring: niet reanimeren | ||||
Status | Gesloten (code = ‘completed’ in codeSystem 2.16.840.1.113883.5.14 ‘ActStatus’) | ||||
Startdatum | T-600D | ||||
Einddatum | T-61D | ||||
Verwijzing Probleem | ProbleemA20Gesloten | ||||
Attentiewaarden | Ja |
Episode | |||||
Gegevenselement | Waarde | ||||
Identificatie | A20 | ||||
Episodetitel | Recentelijk besproken met patient: Niet reanimeren. | ||||
Status | Open (code = ‘active’ in codeSystem 2.16.840.1.113883.5.14 ‘ActStatus’) | ||||
Startdatum | T-60D | ||||
Einddatum | |||||
Verwijzing Probleem | ProbleemA20 | ||||
Attentiewaarden | Ja |
Episode | |||||
Gegevenselement | Waarde | ||||
Identificatie | D02 | ||||
Episodetitel | Maagpijn | ||||
Status | Gesloten (code = ‘completed’ in codeSystem 2.16.840.1.113883.5.14 ‘ActStatus’) | ||||
Startdatum | T-100D | ||||
Einddatum | T-90D | ||||
Verwijzing Probleem | ProbleemD02 | ||||
Attentiewaarden | Nee |
Episode | |||||
Gegevenselement | Waarde | ||||
Identificatie | R95 | ||||
Episodetitel | COPD | ||||
Status | Open (code = ‘active’ in codeSystem 2.16.840.1.113883.5.14 ‘ActStatus’) | ||||
Startdatum | T-9D | ||||
Einddatum | |||||
Verwijzing Probleem | ProbleemR95 | ||||
Attentiewaarden | Ja |
Scenario - Beschikbaarstellen actuele labbepalingen van patiënt
LaboratoriumUitslag | |||||
Gegevenselement | Waarde | ||||
Identificatie | Lab01 | ||||
Verwijzing contact | Contact01 | ||||
Verwijzing episode | R95 | ||||
LaboratoriumTest | |||||
Identificatienummer | LabTest01 | ||||
TestCode | Huidsets hondepitheel (code = '2626' in codeSystem 'NHG Diagnostische bepalingen') | ||||
TestDatumTijd | T-600D | ||||
TestUitslag | Twijfelachtig (code 312) | ||||
ReferentieBovengrens | |||||
ReferentieOndergrens | |||||
UitslagInterpretatie |
LaboratoriumUitslag | |||||
Gegevenselement | Waarde | ||||
Identificatie | Lab02 | ||||
Verwijzing contact | Contact03 | ||||
Verwijzing episode | R95 | ||||
LaboratoriumTest | |||||
Identificatienummer | LabTest02 | ||||
TestCode | MultiRAST (phadiaTop) (code = '852' in codeSystem 'NHG Diagnostische bepalingen') | ||||
TestDatumTijd | T-9D | ||||
TestUitslag | ‘’Positief’’ (Vrije tekst) | ||||
ReferentieBovengrens | |||||
ReferentieOndergrens | |||||
UitslagInterpretatie |
LaboratoriumUitslag | |||||
Gegevenselement | Waarde | ||||
Identificatie | Lab03 | ||||
Verwijzing contact | Contact04 | ||||
Verwijzing episode | R95 | ||||
LaboratoriumTest | |||||
Identificatienummer | LabTest03 | ||||
TestCode | as. Dermatophagoidus pteronyssinus d1 (code = '906' in codeSystem 'NHG Diagnostische bepalingen') | ||||
TestDatumTijd | T-6D | ||||
TestUitslag | Positief (vrije tekst) | ||||
ReferentieBovengrens | |||||
ReferentieOndergrens | |||||
UitslagInterpretatie |
LaboratoriumUitslag | |||||
Gegevenselement | Waarde | ||||
Identificatie | Lab04 | ||||
Verwijzing contact | Contact04 | ||||
Verwijzing episode | R95 | ||||
LaboratoriumTest | |||||
Identificatienummer | LabTest04 | ||||
TestCode | Glucose nuchter, veneus (code = '372' in codeSystem 'NHG Diagnostische bepalingen') | ||||
TestDatumTijd | T-6D | ||||
TestUitslag | 4,5 mmol/l | ||||
ReferentieBovengrens | 6,1 mmol/l | ||||
ReferentieOndergrens | 4,0 mmol/l | ||||
UitslagInterpretatie | Normal (code=N codesysteem 2.16.840.1.113883.5.83) |
Scenario - Beschikbaarstellen actuele algemene bepalingen van patiënt
AlgemeneBepaling | |||||
Gegevenselement | Waarde | ||||
Verwijzing contact | Contact01 | ||||
Verwijzing episode | |||||
MeetUitslag | |||||
Identificatienummer | AlgBep01 | ||||
MetingNaam | Systolische bloeddruk (1744) | ||||
UitslagWaarde | 184 mmHg | ||||
UitslagDatumTijd | T-600D | ||||
ReferentieOndergrens | |||||
ReferentieBovengrens | 140 mmHG | ||||
UitslagInterpretatie | High (code= H codesysteem 2.16.840.1.113883.5.83) |
AlgemeneBepaling | |||||
Gegevenselement | Waarde | ||||
Verwijzing contact | Contact01 | ||||
Verwijzing episode | |||||
MeetUitslag | |||||
Identificatienummer | AlgBep02 | ||||
MetingNaam | Diastolische bloeddruk (1740) | ||||
UitslagWaarde | 94 mmHg | ||||
UitslagDatumTijd | T-600D | ||||
ReferentieOndergrens | 89 mmHg | ||||
ReferentieBovengrens | |||||
UitslagInterpretatie | Normal (code=N codesysteem 2.16.840.1.113883.5.83) |
AlgemeneBepaling | |||||
Gegevenselement | Waarde | ||||
Verwijzing contact | Contact03 | ||||
Verwijzing episode | R95 | ||||
MeetUitslag | |||||
Identificatienummer | AlgBep04 | ||||
MetingNaam | FEV1/FVC ratio pré-BD (1675) | ||||
UitslagWaarde | 66% | ||||
UitslagDatumTijd | T-9D | ||||
ReferentieOndergrens | 70 | ||||
ReferentieBovengrens | |||||
UitslagInterpretatie | Low (code=L codesysteem 2.16.840.1.113883.5.83) |
AlgemeneBepaling | |||||
Gegevenselement | Waarde | ||||
Verwijzing contact | Contact03 | ||||
Verwijzing episode | R95 | ||||
MeetUitslag | |||||
Identificatienummer | AlgBep05 | ||||
MetingNaam | Conclusie longfunctieonderzoek (1704) | ||||
UitslagWaarde | COPD (vrije tekst) | ||||
UitslagDatumTijd | T-9D | ||||
ReferentieOndergrens | |||||
ReferentieBovengrens | |||||
UitslagInterpretatie |
AlgemeneBepaling | |||||
Gegevenselement | Waarde | ||||
Verwijzing contact | Contact03 | ||||
Verwijzing episode | R95 | ||||
MeetUitslag | |||||
Identificatienummer | AlgBep06 | ||||
MetingNaam | Roken (1739) | ||||
UitslagWaarde | Voorheen (4) | ||||
UitslagDatumTijd | T-9D | ||||
ReferentieOndergrens | |||||
ReferentieBovengrens | |||||
UitslagInterpretatie |
AlgemeneBepaling | |||||
Gegevenselement | Waarde | ||||
Verwijzing contact | Contact03 | ||||
Verwijzing episode | R95 | ||||
MeetUitslag | |||||
Identificatienummer | AlgBep07 | ||||
MetingNaam | Aantal jaren gerookt | ||||
UitslagWaarde | 10 jaar | ||||
UitslagDatumTijd | T-9D | ||||
ReferentieOndergrens | |||||
ReferentieBovengrens | |||||
UitslagInterpretatie |
AlgemeneBepaling | |||||
Gegevenselement | Waarde | ||||
Verwijzing contact | Contact04 | ||||
Verwijzing episode | R95 | ||||
MeetUitslag | |||||
Identificatienummer | AlgBep08 | ||||
MetingNaam | Temperatuur patiënt (in oor gemeten) | ||||
UitslagWaarde | 37.5 oC | ||||
UitslagDatumTijd | T-6D | ||||
ReferentieOndergrens | |||||
ReferentieBovengrens | |||||
UitslagInterpretatie |
AlgemeneBepaling | |||||
Gegevenselement | Waarde | ||||
Verwijzing contact | Contact04 | ||||
Verwijzing episode | R95 | ||||
MeetUitslag | |||||
Identificatienummer | AlgBep09 | ||||
MetingNaam | Stadium COPD (GOLD classificatie)(2209) | ||||
UitslagWaarde | 1:mild COPD (255) | ||||
UitslagDatumTijd | T-6D | ||||
ReferentieOndergrens | |||||
ReferentieBovengrens | |||||
UitslagInterpretatie |
Scenario - Beschikbaarstellen actuele medicatieafspraken van patiënt
Medicatieafspraken | |||||
Gegevenselement | Waarde | ||||
Identificatie | Med01 | ||||
Afspraakdatum | T-600 dagen | ||||
Gebruiksperiode | |||||
Ingangsdatum | T-600 dagen | ||||
Einddatum | T - 570 dagen | ||||
Voorschrijver | |||||
Zorgverlener | |||||
Zorgverlener identificatienummer | 10000002 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | ||||
Naamgegevens | Meindert Aanmoedigend | ||||
Specialisme | Arts (Code = '01.000' in codesysteem 2.16.840.1.113883.2.4.15.111 'RoleCodeNL - zorgverlenertype (personen)') | ||||
Zorgaanbieder | |||||
Zorgaanbieder identificatienummer | 20000001 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | ||||
Organisatie naam | Huisartsenpraktijk van Noord | ||||
Adresgegevens | Werkadres: Medicijnweg 9990, 3032 ZZ Rotterdam | ||||
Geneesmiddel - primaire code | SOTALOL 40MG TABLET (code = '84239' in codeSystem 'G-Standaard PRK' | ||||
Geneesmiddel - generiekere code | SOTALOL 40MG TABLET (code = '127868' in codeSystem 'G-Standaard GPK') | ||||
Gebruiksinstructie | |||||
Omschrijving | Vanaf vandaag, + 29 dagen, 2 maal per dag 1 stuks, Oraal | ||||
Toedieningsweg | Oraal (code = '9' in codeSystem 'G-Standaard Toedieningswegen') | ||||
Doseerinstructie | 2 maal per dag 1 stuks |
Medicatieafspraken | |||||
Gegevenselement | Waarde | ||||
Identificatie | Med02 | ||||
Afspraakdatum | T-100 dagen | ||||
Gebruiksperiode | |||||
Ingangsdatum | T-100 dagen | ||||
Einddatum | T - 85 dagen | ||||
Voorschrijver | |||||
Zorgverlener | |||||
Zorgverlener identificatienummer | 10000002 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | ||||
Naamgegevens | Meindert Aanmoedigend | ||||
Specialisme | Arts (Code = '01.000' in codesysteem 2.16.840.1.113883.2.4.15.111 'RoleCodeNL - zorgverlenertype (personen)') | ||||
Zorgaanbieder | |||||
Zorgaanbieder identificatienummer | 20000001 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | ||||
Organisatie naam | Huisartsenpraktijk van Noord | ||||
Adresgegevens | Werkadres: Medicijnweg 9990, 3032 ZZ Rotterdam | ||||
Geneesmiddel - primaire code | PANTOPRAZOL 40 MG TABLET MSR (code = '43044' in codeSystem 'G-Standaard PRK') | ||||
Geneesmiddel - generiekere code | PANTOPRAZOL 40 MG TABLET MSR (code = '96938' in codeSystem 'G-Standaard GPK') | ||||
Gebruiksinstructie | |||||
Omschrijving | Vanaf vandaag, + 15 dagen, 1 maal per dag 1 stuks (1D1T), oraal | ||||
Toedieningsweg | Oraal (code = '9' in codeSystem 'G-Standaard Toedieningswegen') | ||||
Doseerinstructie | 1 maal per dag 1 stuks |
Medicatieafspraken | |||||
Gegevenselement | Waarde | ||||
Identificatie | Med03 | ||||
Afspraakdatum | T-9 dagen | ||||
Gebruiksperiode | |||||
Ingangsdatum | T-9 dagen | ||||
Einddatum | T + 21 dagen | ||||
Voorschrijver | |||||
Zorgverlener | |||||
Zorgverlener identificatienummer | 10000002 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | ||||
Naamgegevens | Meindert Aanmoedigend | ||||
Specialisme | Arts (Code = '01.000' in codesysteem 2.16.840.1.113883.2.4.15.111 'RoleCodeNL - zorgverlenertype (personen)') | ||||
Zorgaanbieder | |||||
Zorgaanbieder identificatienummer | 20000001 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | ||||
Organisatie naam | Huisartsenpraktijk van Noord | ||||
Adresgegevens | Werkadres: Medicijnweg 9990, 3032 ZZ Rotterdam | ||||
Geneesmiddel - primaire code | FLUTICASON INHALATIEPOEDER 250UG/DO (code = '45632’ in codeSystem 'G-Standaard PRK') | ||||
Geneesmiddel - generiekere code | FLUTICASON INHALATIEPOEDER 250UG/DO (code = '92495' in codeSystem 'G-Standaard GPK') | ||||
Gebruiksinstructie | |||||
Omschrijving | Vanaf vandaag, + 29 dagen, 2 maal daags 1 inhalatie (2D1I), inhalatie | ||||
Toedieningsweg | Inhalatie (code = '62' in codeSystem 'G-Standaard Toedieningswegen') | ||||
Doseerinstructie | 2 maal daags 1 inhalatie |
Medicatieafspraken | |||||
Gegevenselement | Waarde | ||||
Identificatie | Med04 | ||||
Afspraakdatum | T-50 dagen | ||||
Gebruiksperiode | |||||
Ingangsdatum | T-50 dagen | ||||
Einddatum | |||||
Voorschrijver | |||||
Zorgverlener | |||||
Zorgverlener identificatienummer | 10000002 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | ||||
Naamgegevens | Meindert Aanmoedigend | ||||
Specialisme | Arts (Code = '01.000' in codesysteem 2.16.840.1.113883.2.4.15.111 'RoleCodeNL - zorgverlenertype (personen)') | ||||
Zorgaanbieder | |||||
Zorgaanbieder identificatienummer | 20000001 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | ||||
Organisatie naam | Huisartsenpraktijk van Noord | ||||
Adresgegevens | Werkadres: Medicijnweg 9990, 3032 ZZ Rotterdam | ||||
Geneesmiddel - primaire code | VALPROINEZUUR DRANK 40MG/ML (code = '43966’ in codeSystem 'G-Standaard PRK') | ||||
Geneesmiddel - generiekere code | VALPROINEZUUR DRANK 40MG/ML (code = '97888' in codeSystem 'G-Standaard GPK') | ||||
Reden van voorschrijven | |||||
Probleemnaam | N88 - Epilepsie (alle vormen) | ||||
Gebruiksinstructie | |||||
Omschrijving | 2 maal daags 15 ml | ||||
Toedieningsweg | Oraal (code = '9' in codeSystem 'G-Standaard Toedieningswegen') | ||||
Doseerinstructie | 2 maal daags 15 ml |
Medicatieafspraken | |||||
Gegevenselement | Waarde | ||||
Identificatie | Med05 | ||||
Afspraakdatum | T-6 dagen | ||||
Gebruiksperiode | |||||
Ingangsdatum | T-6 dagen | ||||
Einddatum | |||||
Voorschrijver | |||||
Zorgverlener | |||||
Zorgverlener identificatienummer | 10000002 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | ||||
Naamgegevens | Meindert Aanmoedigend | ||||
Specialisme | Arts (Code = '01.000' in codesysteem 2.16.840.1.113883.2.4.15.111 'RoleCodeNL - zorgverlenertype (personen)') | ||||
Zorgaanbieder | |||||
Zorgaanbieder identificatienummer | 20000001 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | ||||
Organisatie naam | Huisartsenpraktijk van Noord | ||||
Adresgegevens | Werkadres: Medicijnweg 9990, 3032 ZZ Rotterdam | ||||
Geneesmiddel - primaire code | CIPROFLOXACINE TABLET 500MG (code = '138932’ in codeSystem 'G-Standaard PRK') | ||||
Geneesmiddel - generiekere code | CIPROFLOXACINE TABLET 500MG (code = '167479' in codeSystem 'G-Standaard GPK') | ||||
Gebruiksinstructie | |||||
Omschrijving | Vanaf vandaag, 2 maal daags 1 stuks, oraal, gedurende 2 weken. | ||||
Toedieningsweg | Oraal (code = '9' in codeSystem 'G-Standaard Toedieningswegen') | ||||
Doseerinstructie | 2 maal daags 1 stuks | ||||
Doseerduur | 14 dagen |
Scenario - Beschikbaarstellen actuele alerts van patiënt
Alert | |||||
Gegevenselement | Waarde | ||||
Identificatie | Alert01 | ||||
AlertNaam | COPD (code = 1348 in codesysteem 2.16.840.1.113883.2.4.4.1.902.40 ‘G-standaard Thesaurus 40 contra-indicatiearaard) | ||||
BeginDatumTijd | T-9 dagen | ||||
EindDatumTijd | |||||
Verwijzing episode | R95 |
Alert | |||||
Gegevenselement | Waarde | ||||
Identificatie | Alert02 | ||||
AlertNaam | Drager van multiresistente Stenotrophomonas maltophilia (code= 97981000146105 in codesysteem 2.16.840.1.113883.6.96 SNOMED CT in waardelijst ‘AlertNaamCodelijst’) | ||||
BeginDatumTijd | T-100D | ||||
EindDatumTijd | T-90 | ||||
Verwijzing episode | D02 |
Alert | |||||
Gegevenselement | Waarde | ||||
Identificatie | Alert03 | ||||
AlertNaam | Epilepsie (code = 42 in codesysteem 2.16.840.1.113883.2.4.4.1.902.40 ‘G-standaard Thesaurus 40 contra-indicatiearaard) | ||||
BeginDatumTijd | T-1010 dagen | ||||
EindDatumTijd | |||||
Verwijzing episode | N88 |
Scenario - Beschikbaarstellen actuele allergie/intoleranties van patiënt
AllergieIntolerantie | |||||
Gegevenselement | Waarde | ||||
Identificatienummer | Allergie01 | ||||
Informatiebron Patient | |||||
Auteur ZorgverlenerIdentificatienummer | 10000002 (2.16.840.1.113883.2.4.6.1 Vektis AGB-z zorgverlener tabel) | ||||
VeroorzakendeStof | Amoxicilline | ||||
AllergieCategorie | Neiging tot ongewenste reactie op medicatie en/of drug (Code = 419511003 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
BeginDatumTijd | 20200827 | ||||
MateVanKritiekZijn | Low (code = 62482003 codesysteem 2.16.840.1.113883.2.4.3.11.60.66.11.117 'Criticality') | ||||
Toelichting | Via neuroloog | ||||
Reactie | |||||
Symptoom | dyspneu (code = 267036007 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
SpecifiekeStof | Amoxicilline | ||||
Ernst | Matig (code = 6736007 codesysteem 2.16.840.1.113883.6.96 ‘SNOMED Clinical Terms’) | ||||
WijzeVanBlootstelling | Oral route (Code = 26643006 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
ReactieTijdstip |