iaz:Vdraft2.4.0 Testscript Ambulanceoverdracht SEH Sturen Complexe Casus: verschil tussen versies

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(→‎T1: aankomst bij de patient)
 
(10 tussenliggende versies door dezelfde gebruiker niet weergegeven)
Regel 17: Regel 17:
 
(zelfde setId met oplopend versienummer), en de oudere versies dus obsoleet zijn.
 
(zelfde setId met oplopend versienummer), en de oudere versies dus obsoleet zijn.
  
 +
==T1: aankomst bij de patient==
 +
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | T1
 +
|}
 
<section begin="patient" />
 
<section begin="patient" />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
Regel 385: Regel 390:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Datum/tijd vertrek patiënt
 
|colspan="5"|Datum/tijd vertrek patiënt
−
|style="background-color: white;"| T1+2 min (alleen in bericht 2 en 3)
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Verwachte  aankomsttijd bestemming
 
|colspan="5"|Verwachte  aankomsttijd bestemming
Regel 487: Regel 492:
 
|| Waarde
 
|| Waarde
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="5"|Bestemmingsstatus
+
|colspan="5"|Bestemmingsstatus in bericht op T1
−
|style="background-color: white;"|Overgedragen
+
|style="background-color: white;"|Actief
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Bestemmingscode
 
|colspan="5"|Bestemmingscode
Regel 497: Regel 502:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Straat
 
|colspan="5"|Straat
−
|style="background-color: white;"|1e Jacob van Campenstr
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Huisnummer
 
|colspan="5"|Huisnummer
−
|style="background-color: white;"|15
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Huisletter
 
|colspan="5"|Huisletter
−
|style="background-color: white;"|B
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"  
 
|colspan="5"|Huisnummertoevoeging
 
|colspan="5"|Huisnummertoevoeging
−
|style="background-color: white;"|II
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Postcode
 
|colspan="5"|Postcode
−
|style="background-color: white;"|1012 NX
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Locatiebeschrijving
 
|colspan="5"|Locatiebeschrijving
−
|style="background-color: white;"|naast de derde brug rechts
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Woonplaats
 
|colspan="5"|Woonplaats
−
|style="background-color: white;"|Hoogmade
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Land
 
|colspan="5"|Land
−
|style="background-color: white;"|Nederland
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Bijzonderheden algemeen
 
|colspan="5"|Bijzonderheden algemeen
−
|style="background-color: white;"|Verbouwing van de zij-ingang
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Verwacht specialisme
 
|colspan="5"|Verwacht specialisme
−
|style="background-color: white;"|Chirurg (01.014)
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="6"|Feedback
 
|colspan="6"|Feedback
Regel 531: Regel 536:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="4"|Feedback gewenst
 
|colspan="4"|Feedback gewenst
−
|style="background-color: white;"| Ja
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="4"|Feedback adres
 
|colspan="4"|Feedback adres
−
|style="background-color: white;"| Test adres
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="4"|Feedback methode
 
|colspan="4"|Feedback methode
−
|style="background-color: white;"| Zorgmail
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|}
 
|}
Regel 551: Regel 556:
 
|colspan="5"|Mechanisme type
 
|colspan="5"|Mechanisme type
 
|style="background-color: white;"| 35468003  bekneld geraakt tussen voorwerpen (gebeurtenis)
 
|style="background-color: white;"| 35468003  bekneld geraakt tussen voorwerpen (gebeurtenis)
−
418019003 accidentele gebeurtenis (gebeurtenis)
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Vervoermiddel patiënt
 
|colspan="5"|Vervoermiddel patiënt
−
|style="background-color: white;"| 22674006  bus (fysiek object)
+
|style="background-color: white;"| 71783008 auto (fysiek object)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Patiënt was bestuurder?
 
|colspan="5"|Patiënt was bestuurder?
Regel 560: Regel 564:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Vervoermiddel contra
 
|colspan="5"|Vervoermiddel contra
−
|style="background-color: white;"| 22674006  bus (fysiek object)
+
|style="background-color: white;"| 71783008 auto (fysiek object)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"  
−
|colspan="5"|Beschermingsmiddelen patiënt  
+
|colspan="5"|Beschermingsmiddelen patiënt (3x)
−
|style="background-color: white;"| 60054005 autogordel (fysiek object)
+
|style="background-color: white;"| 285695004 helm (fysiek object) <br/>
 +
60054005 autogordel (fysiek object)<br/>
 +
102384007 airbag van motorvoertuig (fysiek object)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|}
 
|}
Regel 600: Regel 606:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Bloedsuiker waarde
 
|colspan="4"|Bloedsuiker waarde
−
|style="background-color: white;"| 7.1 mmol/L
+
|style="background-color: white;"| 6 mmol/L
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|BloedsuikerDatumTijd
 
|colspan="4"|BloedsuikerDatumTijd
−
|style="background-color: white;"| T-10 minuten
+
|style="background-color: white;"| T1
 
|-style="vertical-align:top; background-color: #E3E3E3;;"  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"  
 
|colspan="6"|Hartritme
 
|colspan="6"|Hartritme
Regel 610: Regel 616:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Hartritme observatie
 
|colspan="4"|Hartritme observatie
−
|style="background-color: white;"| 397829000  asystolie (aandoening)
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|HartritmeDatumTijd
 
|colspan="4"|HartritmeDatumTijd
−
|style="background-color: white;"| T-10 minuten
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Toelichting hartritme/ECG
 
|colspan="4"|Toelichting hartritme/ECG
−
|style="background-color: white;"| Niet normaal
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="6"|O2Saturatie
 
|colspan="6"|O2Saturatie
Regel 623: Regel 629:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|SpO2waarde
 
|colspan="4"|SpO2waarde
−
|style="background-color: white;"|98%
+
|style="background-color: white;"|99%
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|O2SaturatieDatumTijd
 
|colspan="4"|O2SaturatieDatumTijd
−
|style="background-color: white;"|T-10 minuten
+
|style="background-color: white;"|T1
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="6"|Capnometrie
 
|colspan="6"|Capnometrie
Regel 633: Regel 639:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|CO2Waarde
 
|colspan="4"|CO2Waarde
−
|style="background-color: white;"|42 mm[Hg] <br/>5,6 kPa
+
|style="background-color: white;"|60 mm[Hg] <br/>8,0 kPa
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|CO2CapnometrieDatumTijd
 
|colspan="4"|CO2CapnometrieDatumTijd
−
|style="background-color: white;"|T-10 minuten
+
|style="background-color: white;"|T1
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="6"|Hartfrequentie
 
|colspan="6"|Hartfrequentie
Regel 643: Regel 649:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|HartfrequentieWaarde
 
|colspan="4"|HartfrequentieWaarde
−
|style="background-color: white;"|76/min
+
|style="background-color: white;"|120/min
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|HartfrequentieDatumTijd
 
|colspan="4"|HartfrequentieDatumTijd
−
|style="background-color: white;"|T-10 minuten
+
|style="background-color: white;"|T1
 
|-style="vertical-align:top; background-color: #E3E3E3;;"  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"  
 
|colspan="6"|Bloeddruk
 
|colspan="6"|Bloeddruk
Regel 653: Regel 659:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|SystolischeBloeddruk
 
|colspan="4"|SystolischeBloeddruk
−
|style="background-color: white;"|155 mm[Hg]
+
|style="background-color: white;"|90 mm[Hg]
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|DiastolischeBloeddruk
 
|colspan="4"|DiastolischeBloeddruk
−
|style="background-color: white;"|70 mm[Hg]
+
|style="background-color: white;"|60 mm[Hg]
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|BloeddrukDatumTijd
 
|colspan="4"|BloeddrukDatumTijd
−
|style="background-color: white;"|T-10 minuten
+
|style="background-color: white;"|T1
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="6"|Lichaamstemperatuur
 
|colspan="6"|Lichaamstemperatuur
Regel 666: Regel 672:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|TemperatuurWaarde
 
|colspan="4"|TemperatuurWaarde
−
|style="background-color: white;"|37,3 °C (graden Celcius)
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|TemperatuurDatumTijd
 
|colspan="4"|TemperatuurDatumTijd
−
|style="background-color: white;"|T-10 minuten
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="6"|Ademhaling
 
|colspan="6"|Ademhaling
Regel 676: Regel 682:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Ademfrequentie
 
|colspan="4"|Ademfrequentie
−
|style="background-color: white;"|15/min
+
|style="background-color: white;"|4/min
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|AdemhalingDatumTijd
 
|colspan="4"|AdemhalingDatumTijd
−
|style="background-color: white;"|T-10 minuten
+
|style="background-color: white;"|T1
 
|-style="vertical-align:top; background-color: #E3E3E3;;"  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"  
 
|colspan="6"|GlasgowComaScale
 
|colspan="6"|GlasgowComaScale
Regel 686: Regel 692:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|GlasgowComaScaleDatumTijd
 
|colspan="4"|GlasgowComaScaleDatumTijd
−
|style="background-color: white;"|T-10 minuten
+
|style="background-color: white;"|T1
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|GCS_Eyes
 
|colspan="4"|GCS_Eyes
−
|style="background-color: white;"|E3
+
|style="background-color: white;"|4
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|GCS_Motor
 
|colspan="4"|GCS_Motor
−
|style="background-color: white;"|M4
+
|style="background-color: white;"|6
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="4"|GCS_Verbal
 
|colspan="4"|GCS_Verbal
−
|style="background-color: white;"|V3 (uit 2.16.840.1.113883.2.4.3.11.60.40.4.2.3)
+
|style="background-color: white;"|5 (uit 2.16.840.1.113883.2.4.3.11.60.40.4.2.3)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="4"|TotaalScore
 
|colspan="4"|TotaalScore
−
|style="background-color: white;"|10
+
|style="background-color: white;"|15
 
|-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 706: Regel 712:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|RevisedTraumaScoreWaarde
 
|colspan="4"|RevisedTraumaScoreWaarde
−
|style="background-color: white;"|11
+
|style="background-color: white;"|8
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|RevisedTraumaScoreTijd
 
|colspan="4"|RevisedTraumaScoreTijd
−
|style="background-color: white;"|T-10 minuten
+
|style="background-color: white;"|T1
 
|-style="vertical-align:top; background-color: #E3E3E3;;"  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"  
 
|colspan="6"|Pediatric Trauma Score
 
|colspan="6"|Pediatric Trauma Score
Regel 726: Regel 732:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|PijnschaalWaarde
 
|colspan="4"|PijnschaalWaarde
−
|style="background-color: white;"|5
+
|style="background-color: white;"|3
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|PijnschaalTijd
 
|colspan="4"|PijnschaalTijd
−
|style="background-color: white;"|T-10 minuten
+
|style="background-color: white;"|T1
 +
|-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;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
Regel 753: Regel 760:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Handelingen ademhaling en beademing  
 
|colspan="4"|Handelingen ademhaling en beademing  
−
|style="background-color: white;"| 408867002  meten van ademhalingsfrequentie (verrichting)
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="6"|Bewustzijn en neurologische status (diagnostisch)   
 
|colspan="6"|Bewustzijn en neurologische status (diagnostisch)   
Regel 760: Regel 767:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Handelingen bewustzijn en neurologische status  
 
|colspan="4"|Handelingen bewustzijn en neurologische status  
−
|style="background-color: white;"|291000146106  pupilreactie-onderzoek (verrichting)
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="6"|Overige diagnostische handelingen  
 
|colspan="6"|Overige diagnostische handelingen  
Regel 767: Regel 774:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Handelingen overige diagnostisch
 
|colspan="4"|Handelingen overige diagnostisch
−
|style="background-color: white;"|5880005  lichamelijk onderzoek (verrichting)
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="6"|Luchtweg management (therapeutisch)  
 
|colspan="6"|Luchtweg management (therapeutisch)  
Regel 774: Regel 781:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"| Handelingen luchtweg management  
 
|colspan="4"| Handelingen luchtweg management  
−
|style="background-color: white;"| 112798008 intubatie van trachea (verrichting)
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"| Moeizame intubatie?
 
|colspan="4"| Moeizame intubatie?
−
|style="background-color: white;"| Ja
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="6"|Oxygenatie en ventilatie (therapeutisch)  
 
|colspan="6"|Oxygenatie en ventilatie (therapeutisch)  
Regel 784: Regel 791:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"| Handelingen oxygenatie en ventilatie   
 
|colspan="4"| Handelingen oxygenatie en ventilatie   
−
|style="background-color: white;"| 40617009 kunstmatige beademing (verrichting)
+
|style="background-color: white;"|  
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="4"| Beademing machine Fi O2
 
−
|style="background-color: white;"| 0.50
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="4"| Beademing machine AMV
 
−
|style="background-color: white;"| 6 L/min
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="4"| Beademing machine Freq.
 
−
|style="background-color: white;"| 10 /min
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="4"| Beademing machine Peep
 
−
|style="background-color: white;"|3 cm[H2O]
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="4"| Hoeveelheid zuurstof
 
−
|style="background-color: white;"|3 L/min
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="6"|Oxygenatie en ventilatie (therapeutisch)
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|rowspan="7"|
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="4"| Handelingen oxygenatie en ventilatie 
 
−
|style="background-color: white;"| 11140008 handmatige beademing (verrichting)
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"| Beademing machine Fi O2  
 
|colspan="4"| Beademing machine Fi O2  
Regel 818: Regel 803:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"| Beademing machine Peep
 
|colspan="4"| Beademing machine Peep
−
|style="background-color: white;"|
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"| Hoeveelheid zuurstof
 
|colspan="4"| Hoeveelheid zuurstof
Regel 828: Regel 813:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"| Handelingen circulatie  
 
|colspan="4"| Handelingen circulatie  
−
|style="background-color: white;"|250980009 cardioversie (verrichting)
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"| Pacemaker frequentie
 
|colspan="4"| Pacemaker frequentie
Regel 840: Regel 825:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"| Cardioversies aantal
 
|colspan="4"| Cardioversies aantal
−
|style="background-color: white;"| 2
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"| Cardioversie maximale energie
 
|colspan="4"| Cardioversie maximale energie
−
|style="background-color: white;"| 600 Joule
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"| Defibrillaties aantal  
 
|colspan="4"| Defibrillaties aantal  
Regel 852: Regel 837:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"| Return Of Spontaneous Circulation (ROSC)
 
|colspan="4"| Return Of Spontaneous Circulation (ROSC)
−
|style="background-color: white;"|Nee
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"| AED aangesloten voor aankomst
 
|colspan="4"| AED aangesloten voor aankomst
−
|style="background-color: white;"|Ja
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"| AED-schokken aantal
 
|colspan="4"| AED-schokken aantal
−
|style="background-color: white;"|5
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Circulatie (therapeutisch)
+
|colspan="6"|Traumatologie (therapeutisch)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="12"|
+
|rowspan="3"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Handelingen circulatie
+
|colspan="4"| Handelingen traumatologie
−
|style="background-color: white;"|233181000 transthoracale cardiale pacing (verrichting)
+
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Koelen tijdsduur
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Obstetrie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Pacemaker frequentie
+
|colspan="4"|Handelingen obstetrie
−
|style="background-color: white;"|60 /min
+
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Wijze van isolatie
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Pacemaker stroomsterkte
+
|rowspan="2"|
−
|style="background-color: white;"|5 mA
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Pacemaker modus
+
|colspan="4"|Handelingen isolatie
−
|style="background-color: white;"|001 fixed rate
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Cardioversies aantal
+
|colspan="6"|Medicatie
−
|style="background-color: white;"| 
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Cardioversie maximale energie
+
|rowspan="7"|
−
|style="background-color: white;"|  
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Defibrillaties aantal
+
|colspan="4"| Medicatie toegediend?
 
|style="background-color: white;"|
 
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Defibrillatie energie
+
|colspan="4"| Medicatienaam
 
|style="background-color: white;"|
 
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Return Of Spontaneous Circulation (ROSC)
+
|colspan="4"| Toegediende hoeveelheid medicatie
−
|style="background-color: white;"|Nee
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| AED aangesloten voor aankomst
+
|colspan="4"| Tijd medicatietoediening
−
|style="background-color: white;"|Ja
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| AED-schokken aantal
+
|colspan="4"| Medicatie toedieningsvorm
−
|style="background-color: white;"|5
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Circulatie (therapeutisch)
+
|colspan="4"| IV medicatiesnelheid
 +
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="12"|
+
|colspan="6"|Infuus
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Handelingen circulatie
+
|rowspan="5"|
−
|style="background-color: white;"|308842001 defibrillatie met gelijkstroom (verrichting)
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Pacemaker frequentie
+
|colspan="4"| Infusen aantal
 
|style="background-color: white;"|
 
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Pacemaker stroomsterkte
+
|colspan="4"| Infuusvloeistofcode
 
|style="background-color: white;"|
 
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Pacemaker modus
+
|colspan="4"| Infuusvloeistoftekst
 
|style="background-color: white;"|
 
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Cardioversies aantal
+
|colspan="4"| Infuushoeveelheid
−
|style="background-color: white;"|  
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Cardioversie maximale energie
+
|colspan="5"|Extra informatie behandeling
 
|style="background-color: white;"|  
 
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Defibrillaties aantal
+
|}
−
|style="background-color: white;"| 3
+
<section end="Behandeling" />
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
 
−
|colspan="4"| Defibrillatie energie
+
<section begin="Patiëntligging" />
−
|style="background-color: white;"| 200 Joule
+
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Patiëntligging
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Type patiëntligging
 +
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Return Of Spontaneous Circulation (ROSC)
+
|}
−
|style="background-color: white;"|Nee
+
<section end="Patiëntligging" />
 +
 
 +
<section begin="Primary Survey" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Primary Survey
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Airway
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Airway vrij?
 +
|style="background-color: white;"| Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| AED aangesloten voor aankomst
+
|colspan="4"|Stridor
−
|style="background-color: white;"|Ja
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| AED-schokken aantal
 
−
|style="background-color: white;"|5
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Traumatologie (therapeutisch)
+
|colspan="6"|Breathing
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="3"|
 
|rowspan="3"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Handelingen traumatologie
+
|colspan="4"|Breathing sufficient?
−
|style="background-color: white;"|105382002  koelen van patiënt (verrichting)
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Koelen tijdsduur
+
|colspan="4"|Breathing observaties
−
|style="background-color: white;"|10 minuten
+
|style="background-color: white;"|
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Obstetrie
+
|colspan="5"|Circulation
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="2"|
+
|rowspan="4"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Handelingen obstetrie
+
|colspan="4"|Circulation sufficient?
−
|style="background-color: white;"|238248005  afklemmen van navelstreng (verrichting)
+
|style="background-color: white;"| Ja
−
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 
−
|colspan="6"|Wijze van isolatie
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="2"|
+
|colspan="4"|Capillaire refill > 2 seconde?
 +
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Handelingen isolatie
+
|colspan="4"|Huid observatie
−
|style="background-color: white;"|170499009  contactisolatie (verrichting)
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Medicatie
+
|colspan="6"|Disability
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="7"|
 
|rowspan="7"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Medicatie toegediend?
+
|colspan="4"|AVPU
−
|style="background-color: white;"|Ja
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Medicatienaam
+
|colspan="4"|Duur buiten bewustzijn
−
|style="background-color: white;"|13.1 Acetylsalicylzuur
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Toegediende hoeveelheid medicatie
+
|colspan="4"|Pupil
−
|style="background-color: white;"|2 stuk
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Tijd medicatietoediening
+
|colspan="4"|FAST symptomen aanwezig
−
|style="background-color: white;"|T-10 minuten
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Medicatie toedieningsvorm
+
|colspan="4"|Mogelijk trombolyse/trombectomie
−
|style="background-color: white;"| 386359008  oraal toedienen van medicatie (verrichting)
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| IV medicatiesnelheid
+
|colspan="4"|Intoxicatie
−
|style="background-color: white;"| 100 ml/uur
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Infuus
+
|colspan="5"|Toelichting Primary Survey
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|style="background-color: white;"|  
−
|rowspan="5"|
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="4"| Infusen aantal
 
−
|style="background-color: white;"|1
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="4"| Infuusvloeistofcode
 
−
|style="background-color: white;"|137774 (GPK)
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="4"| Infuusvloeistoftekst
 
−
|style="background-color: white;"|IMMUNOGLOBULINE NORMAAL INF
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="4"| Infuushoeveelheid
 
−
|style="background-color: white;"|200 ml
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="5"|Extra informatie behandeling
 
−
|style="background-color: white;"| Normale behandeling
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|}
 
|}
−
<section end="Behandeling" />
+
<section end="Primary Survey" />
  
−
<section begin="Patiëntligging" />
+
<section begin="Secondary Survey" />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
−
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Patiëntligging
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Secondary Survey
 
|-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"|Type patiëntligging
+
|colspan="6"|Anamnese
−
|style="background-color: white;"| 001 buik
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|}
+
|rowspan="7"|
−
<section end="Patiëntligging" />
 
−
 
 
−
<section begin="Primary Survey" />
 
−
{| class="wikitable" width="85%"
 
−
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Primary Survey
 
−
|-style="background-color: #1F497D;; color: white; text-align:left;"
 
−
|colspan="5" width="25%"| Gegevenselement
 
−
|| Waarde
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 
−
|colspan="6"|Airway
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="3"|
+
|colspan="5"|Ample
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Airway vrij?
+
|rowspan="4"|
−
|style="background-color: white;"| nee
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Stridor
+
|colspan="3"|Code
−
|style="background-color: white;"| 58596002 inspiratoire stridor (bevinding)
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Titel
 +
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Breathing
+
|colspan="3"|Omschrijving
 +
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="3"|
+
|colspan="4"|Toelichting anamnese
 +
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Breathing sufficient?
+
|colspan="6"|Infectierisico
−
|style="background-color: white;"|nee
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Breathing observaties
+
|rowspan="3"|
−
|style="background-color: white;"|271623001 asymmetrische thoraxbeweging (bevinding)
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="5"|Circulation
+
|colspan="4"| Verdenking infectieziekten?
 +
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="4"|
+
|colspan="4"| Toelichting infectierisico
 +
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Circulation sufficient?
+
|colspan="6"|Hoofd en gelaat
−
|style="background-color: white;"| nee
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Capillaire refill > 2 seconde?
+
|rowspan="6"|
−
|style="background-color: white;"| Ja
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Huid observatie
+
|colspan="4"| Hoofd en gelaat observaties
−
|style="background-color: white;"|248245006  klam zweet (bevinding)
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Disability
+
|colspan="4"| Bloedverlies
 +
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="7"|
+
|colspan="4"| Liquorverlies
 +
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|AVPU
+
|colspan="4"| Pijnlocatie
−
|style="background-color: white;"|248234008 alert (bevinding)
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Duur buiten bewustzijn
+
|colspan="4"| Wond
−
|style="background-color: white;"| 5 min
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Pupil
+
|colspan="6"|Nek, hals, CWK
−
|style="background-color: white;"|301941003 Normal pupil size (finding)
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|FAST symptomen aanwezig
+
|rowspan="3"|
−
|style="background-color: white;"| Ja
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Mogelijk trombolyse/trombectomie
+
|colspan="4"| Nek, hals, CWK observaties
−
|style="background-color: white;"|Ja
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Intoxicatie
+
|colspan="4"| Wond
−
|style="background-color: white;"|67426006 intoxicatie door alcohol (aandoening)
+
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Thorax
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
 
+
|rowspan="6"|
−
 
 
−
|colspan="5"|Toelichting Primary Survey
 
−
|style="background-color: white;"| Nee
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|}
+
|colspan="4"|Thorax observaties
−
<section end="Primary Survey" />
+
|style="background-color: white;"|
−
 
 
−
<section begin="Secondary Survey" />
 
−
{| class="wikitable" width="85%"
 
−
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Secondary Survey
 
−
|-style="background-color: #1F497D;; color: white; text-align:left;"
 
−
|colspan="5" width="25%"| Gegevenselement
 
−
|| Waarde
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 
−
|colspan="6"|Anamnese
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="27"|
+
|colspan="4"|Pijn bij compressie
 +
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="5"|Ample
+
|colspan="4"|Locatie subcutaan emfyseem
 +
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="4"|
+
|colspan="4"|Locatie zwelling / oedeem (2x)
 +
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Code
+
|colspan="4"|Wond
−
|style="background-color: white;"|473011001
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Titel
+
|colspan="6"|Rug
−
|style="background-color: white;"|Allergie
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Omschrijving
+
|rowspan="3"|
−
|style="background-color: white;"| Pinda's
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="5"|Ample
+
|colspan="4"| Rug observaties
 +
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="4"|
+
|colspan="4"| Wond
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Abdomen
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Code
+
|rowspan="6"|
−
|style="background-color: white;"|394829006
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Titel
+
|colspan="4"| Abdomen observaties
−
|style="background-color: white;"|Medicatie
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Omschrijving
+
|colspan="4"| Locatie druk- / loslaatpijn
−
|style="background-color: white;"|Geen medicatie
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="5"|Ample
+
|colspan="4"| Locatie zwelling / oedeem
 +
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="4"|
+
|colspan="4"| Locatie pulserende zwelling
 +
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Code
+
|colspan="4"| Wond
−
|style="background-color: white;"|417662000
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Titel
+
|colspan="6"|Bekken
−
|style="background-color: white;"|Past
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Omschrijving
+
|rowspan="3"|
−
|style="background-color: white;"|Nooit eerder opgenomen geweest
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="5"|Ample
+
|colspan="4"| Bekken observaties
 +
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="4"|
+
|colspan="4"| Wond
 +
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Code
+
|colspan="6"|Extremiteiten Armen
−
|style="background-color: white;"|405795006
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Titel
+
|rowspan="6"|
−
|style="background-color: white;"|Tijd eerste optreden symptomen
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Omschrijving
+
|colspan="5"|Extremiteit
−
|style="background-color: white;"|1 uur geleden
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="5"|Ample
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="4"|
 
|rowspan="4"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Code
+
|colspan="3"|Lateraliteit
−
|style="background-color: white;"|272379006
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Titel
+
|colspan="3"|Observaties
−
|style="background-color: white;"|Events
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Omschrijving
+
|colspan="3"|Wond
−
|style="background-color: white;"|Geen bijzonderheden
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Toelichting anamnese
+
|colspan="6"|Extremiteiten Armen
−
|style="background-color: white;"| Lastig vanwege weersomstandigheden
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Infectierisico
+
|rowspan="6"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="3"|
+
|colspan="5"|Extremiteit
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Verdenking infectieziekten?
+
|rowspan="4"|
−
|style="background-color: white;"|Ja
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Toelichting infectierisico
+
|colspan="3"|Lateraliteit
−
|style="background-color: white;"| Afgelopen maanden in een ziekenhuis in India geweest
+
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Wond
 +
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Hoofd en gelaat
+
|colspan="6"|Extremiteiten Benen
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="6"|
 
|rowspan="6"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Hoofd en gelaat observaties
+
|colspan="5"|Extremiteit
−
|style="background-color: white;"| 135874008  beet in eigen tong (aandoening)
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Bloedverlies
+
|rowspan="4"|
−
|style="background-color: white;"| 22490002  bloeding uit mond (aandoening)
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Liquorverlies
+
|colspan="3"|Lateraliteit
−
|style="background-color: white;"|85638002  nasale liquorroe (aandoening)
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Pijnlocatie
+
|colspan="3"|Observaties (2x)
−
|style="background-color: white;"|Kaaklijn<br/>Achterhoofd   
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Wond
+
|colspan="3"|Wond
−
|style="background-color: white;"|425322008  steekwond (aandoening) <br/> 399963005  abrasie (aandoening)
+
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Uitscheiding
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Nek, hals, CWK
+
|rowspan="4"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="3"|
+
|colspan="4"|Uitscheiding observaties
 +
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Nek, hals, CWK observaties
+
|colspan="4"|Braken
−
|style="background-color: white;"|279029001  pijn in cervicale wervelkolom (bevinding)
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Wond
+
|colspan="4"|Incontinent
−
|style="background-color: white;"|425322008 steekwond (aandoening)
+
|style="background-color: white;"|
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="6"|Thorax
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="6"|
+
|colspan="6"|Verloskunde/Gynaecologie
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Thorax observaties
+
|rowspan="4"|
−
|style="background-color: white;"|249672002 asymmetrische thorax (bevinding)
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Pijn bij compressie
+
|colspan="4"|Verloskunde/Gynaecologie observaties
−
|style="background-color: white;"|32391000146100  pijn van sternum bij compressie tijdens lichamelijk onderzoek (bevinding)
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Locatie subcutaan emfyseem
+
|colspan="4"|Vruchtwaterverlies
−
|style="background-color: white;"|32441000146104 drukpijn en/of loslaatpijn rechtsonder in abdomen bij lichamelijk onderzoek (bevinding)
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Locatie zwelling / oedeem (2x)
+
|colspan="4"|Weeën
−
|style="background-color: white;"|32431000146107 drukpijn en/of loslaatpijn rechtsboven in abdomen bij lichamelijk onderzoek (bevinding) <br/>
+
|style="background-color: white;"|  
−
32411000146100 drukpijn en/of loslaatpijn linksboven in abdomen bij lichamelijk onderzoek (bevinding)
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Wond
+
|}
−
|style="background-color: white;"|125666000  brandwond (aandoening)
+
<section end="Secondary Survey" />
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
 
−
|colspan="6"|Rug
+
<section begin="Consultgever op afstand" />
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
{| class="wikitable" width="85%"
−
|rowspan="3"|
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Consultgever op afstand
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|-style="background-color: #1F497D;; color: white; text-align:left;"  
−
|colspan="4"| Rug observaties
+
|colspan="5" width="25%"| Gegevenselement
−
|style="background-color: white;"|385494008 hematoom (aandoening)
+
|| Waarde
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Wond
+
|colspan="5"|Initialen
−
|style="background-color: white;"|399963005 abrasie (aandoening)
+
|style="background-color: white;"|  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Achternaam
 +
|style="background-color: white;"|  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Telefoonnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Identificatie
 +
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"  
−
|colspan="6"|Abdomen
+
|colspan="5"|Type consultgever
 +
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="6"|
+
|colspan="5"|Toelichting/Afspraken met consultgever
 +
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Abdomen observaties
+
|}
−
|style="background-color: white;"|297968009 bloeding van huid (bevinding)
+
<section end="Consultgever op afstand" />
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
 
−
|colspan="4"| Locatie druk- / loslaatpijn
+
<section begin="Afspraken met patiënt" />
−
|style="background-color: white;"| 32431000146107 drukpijn en/of loslaatpijn rechtsboven in abdomen bij lichamelijk onderzoek (bevinding)
+
{| class="wikitable" width="85%"
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Afspraken met patiënt
−
|colspan="4"| Locatie zwelling / oedeem
+
|-style="background-color: #1F497D;; color: white; text-align:left;"  
−
|style="background-color: white;"| 32411000146100 drukpijn en/of loslaatpijn linksboven in abdomen bij lichamelijk onderzoek (bevinding)
+
|colspan="5" width="25%"| Gegevenselement
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|| Waarde
−
|colspan="4"| Locatie pulserende zwelling
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|style="background-color: white;"| 32411000146100 drukpijn en/of loslaatpijn linksboven in abdomen bij lichamelijk onderzoek (bevinding)
+
|colspan="5"|Huisarts ingelicht
 +
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"| Wond
+
|colspan="5"|Afspraken met patiënt
−
|style="background-color: white;"|127315004  luchtaanzuigende thoraxverwonding (aandoening)
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Bekken
+
|}
 +
<section end="Afspraken met patiënt" />
 +
 
 +
<section begin="Bijlagen T1" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Bijlagen
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Type Bijlage
 +
|style="background-color: white;"|006 intern rapport/overdracht
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Bijlage id
 +
|style="background-color: white;"| 9068
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Versie
 +
|style="background-color: white;"| 1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Bijlageset id
 +
|style="background-color: white;"| 12
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="3"|
+
|}
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
<section end="Bijlagen" />
−
|colspan="4"| Bekken observaties
+
 
−
|style="background-color: white;"|67374007 instabiliteit van gewricht (bevinding)
+
<section begin="Toestemmingsgegevens" />
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
{| class="wikitable" width="85%"
−
|colspan="4"| Wond
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Toestemmingsgegevens
−
|style="background-color: white;"|262572000 letsel door afgevuurd projectiel (aandoening)
+
|-style="background-color: #1F497D;; color: white; text-align:left;"  
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|colspan="5" width="25%"| Gegevenselement
−
|colspan="6"|Extremiteiten Armen
+
|| Waarde
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="6"|
+
|colspan="6"|Wetenschappelijk onderzoek
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|-style="vertical-align:top; background-color: #E3E3E3;;" 
−
|colspan="5"|Extremiteit
+
|rowspan="3"|
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="4"|
+
|colspan="4"|Beschrijving
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|style="background-color: white;"|
−
|colspan="3"|Lateraliteit
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|style="background-color: white;"|7771000 links
+
|colspan="4"|Informed consent
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|style="background-color: white;"|
−
|colspan="3"|Observaties
+
|-style="vertical-align:top; background-color: #E3E3E3;;"  
−
|style="background-color: white;"|416462003 verwonding (aandoening)
+
|colspan="5"|Toestemming informeren verwanten
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Toestemmingsgegevens" />
 +
 
 +
<section begin="Toelichtingsgegevens" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Toelichtingsgegevens
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Toelichting algemeen
 +
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Wond
+
|}
−
|style="background-color: white;"|399963005 abrasie (aandoening)
+
<section end="Toelichtingsgegevens" />
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
 
−
|colspan="6"|Extremiteiten Armen
+
==T2: gedurende de rit==
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
 
−
|rowspan="6"|
+
{| class="wikitable" width="85%"
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | T2
−
|colspan="5"|Extremiteit
+
|}
 +
<section begin="patient" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Patient
 +
|-style="background-color: #8F00FF;; 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;;"
−
|rowspan="4"|
+
|colspan="5"|Persoonidentificatie
 +
|style="background-color: white;"|999910553
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Naamgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Lateraliteit
+
|rowspan="2"|
−
|style="background-color: white;"|24028007 right
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Observaties
+
|colspan="3"|Initialen
−
|style="background-color: white;"|22253000 pijn (bevinding)
+
|style="background-color: white;"|W.
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Wond
+
|colspan="6"|Achternaam
−
|style="background-color: white;"|
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="6"|Extremiteiten Benen
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|rowspan="6"|
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="5"|Extremiteit
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="4"|
 
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="3"|Soort naam
 +
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Lateraliteit
+
|colspan="3"|Voorvoegsels
−
|style="background-color: white;"|24028007 rechts
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="3"|Observaties (2x)
 
−
|style="background-color: white;"|22253000  pijn (bevinding) <br/> 248477007 zwelling of oedeem (bevinding)
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="3"|Wond
 
 
|style="background-color: white;"|
 
|style="background-color: white;"|
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="6"|Uitscheiding
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="4"|
+
|colspan="3"|Achternaam
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|style="background-color: white;"|XXX_Witsiers
−
|colspan="4"|Uitscheiding observaties
+
|-style="vertical-align:top; background-color: #E3E3E3;;" 
−
|style="background-color: white;"|422400008  braken (aandoening) <br/> 48340000 incontinentie (bevinding)
+
|colspan="5"|Geslacht
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|style="background-color: white;"|M
−
|colspan="4"|Braken
+
|-style="vertical-align:top; background-color: #E3E3E3;;" 
−
|style="background-color: white;"|8765009 hematemese (aandoening)
+
|colspan="6"|Geboortegegevens
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Incontinent
+
|rowspan="2"|
−
|style="background-color: white;"|72042002 incontinentie voor feces (bevinding)
+
|-style="vertical-align:top; background-color: #E3E3E3;;" 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|colspan="4"|Geboortedatum
−
|colspan="6"|Verloskunde/Gynaecologie
+
|style="background-color: white;"|06-08-1954
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|-style="vertical-align:top; background-color: #E3E3E3;;" 
−
|rowspan="4"|
+
|colspan="5"|Geschatte leeftijd
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|style="background-color: white;"|
−
|colspan="4"|Verloskunde/Gynaecologie observaties
+
|-style="vertical-align:top; background-color: #E3E3E3;;" 
−
|style="background-color: white;"|47821001  postpartumbloeding (aandoening) <br/> 371380006 lekken van vruchtwater (aandoening)
+
|colspan="6"|Adresgegevens
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Vruchtwaterverlies
+
|rowspan="10"|
−
|style="background-color: white;"|168090003 helder vruchtwater (bevinding)
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|colspan="4"|Straat
−
|colspan="4"|Weeën
+
|style="background-color: white;"|Hertog Aalbrechtweg
−
|style="background-color: white;"| 2 minuten
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|colspan="4"|Huisnummer
−
|}
+
|style="background-color: white;"|8
−
<section end="Secondary Survey" />
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
 
+
|colspan="4"|Huisnummerletter
−
<section begin="Consultgever op afstand" />
+
|style="background-color: white;"|
−
{| class="wikitable" width="85%"
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Consultgever op afstand
+
|colspan="4"|Huisnummertoevoeging
−
|-style="background-color: #1F497D;; color: white; text-align:left;"  
+
|style="background-color: white;"|
−
|colspan="5" width="25%"| Gegevenselement
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|| Waarde
+
|colspan="4"|Postcode
−
|-style="vertical-align:top; background-color: #E3E3E3;;"   
+
|style="background-color: white;"|1823 DB
−
|colspan="5"|Initialen
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|style="background-color: white;"| J.H.M.
+
|colspan="4"|Woonplaats
−
|-style="vertical-align:top; background-color: #E3E3E3;;"   
+
|style="background-color: white;"|Alkmaar
−
|colspan="5"|Achternaam
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|style="background-color: white;"| Putten
+
|colspan="4"|Land
−
|-style="vertical-align:top; background-color: #E3E3E3;;"   
+
|style="background-color: white;"|Nederland
−
|colspan="5"|Telefoonnummer
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|style="background-color: white;"| 0611234567
+
|colspan="4"|Locatiebeschrijving
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Overige Contactgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="15"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Telefoonnummers
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Telefoonnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Soort telefoonnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Werktelefoon
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|werknummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Soort nummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|EmailAdressen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Emailadres
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Soort e-mailadres
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Emailadres
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Soort e-mailadres
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"| Ziektekostenverzekering?
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Verzekeringsgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verzekeraar
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Naam
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Identificatienummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Polis
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"| Polisnummer/Verzekerdenummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Vaste huisarts
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| ZorgverlenerIdentificatienummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Rolcode
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Naam
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Achternaam
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Vaste huisartsenpraktijk
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="27"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|  Identificatie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|  Naam
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|  Adresgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|  Soort adres
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|  Straatnaam
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|  Huisnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|  Huisnummertoevoeging
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|  Postcode
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|  Gemeente
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|  Woonplaats
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|  Land
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|  Overige contactgegevens 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="13"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|  Telefoonnummers
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|  Soort telefoonnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|  Telefoonnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|  Faxnummers
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|  Soort faxnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|  Faxnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|  E-mailadressen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|  Soort e-mailadres 
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|  E-mailadres
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Contactpersoon patiënt
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|  Achternaam 
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|  Telefoonnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|  Relatie tot patiënt
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="patient" />
 +
 
 +
<section begin="WID-controle" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;"  colspan="6" | WID-controle
 +
|-style="background-color: #8F00FF;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|WID-controle uitgevoerd
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|WID controle datum
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Documentnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Document type
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="WID-controle" />
 +
 
 +
<section begin="Incidentgegevens" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Incidentgegevens
 +
|-style="background-color: #8F00FF;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Datum/tijd incident
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Incidentgegevens" />
 +
 
 +
<section begin="Meldingsgegevens" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Meldingsgegevens
 +
|-style="background-color: #8F00FF;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Datum/tijd melding
 +
|style="background-color: white;"| T1-15min
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Geplande brengtijd
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Geplande haaltijd
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Wzd/Wvggz maatregel
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Datum/tijd aanvang TVZ
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Medische kladblok meldkamer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="5"|Meldkamerurgentie
 +
|style="background-color: white;"| A2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Meldingsgegevens" />
 +
 
 +
<section begin="Zorgaanvrager" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Zorgaanvrager
 +
|-style="background-color: #8F00FF;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Initialen
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Achternaam
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Telefoonnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Identificatie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Type zorgaanvrager
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Zorgaanvrager" />
 +
 
 +
<section begin="Ritgegevens" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Ritgegevens
 +
|-style="background-color: #8F00FF;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Ambulancevoorziening
 +
|style="background-color: white;"| 25 (RAV identificatie)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Ritnummer
 +
|style="background-color: white;"| 25-2020-13-1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Ambulancenummer
 +
|style="background-color: white;"| 25190
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Telefoon ambulance
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ambulanceverpleegkundige identificatie
 +
|style="background-color: white;"| 596
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ambulancechauffeur identificatie
 +
|style="background-color: white;"| 530
 +
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="5"|Datum/tijd ritopdracht
 +
|style="background-color: white;"| T1-10 min
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Datum/tijd uitruk/vertrek
 +
|style="background-color: white;"| T1-10 min
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Datum/tijd aankomst patiënt
 +
|style="background-color: white;"| T1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Datum/tijd vertrek patiënt
 +
|style="background-color: white;"| T1+2 min
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Verwachte  aankomsttijd bestemming
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Datum/tijd aankomst bestemming
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Datum/tijd vrijmelding
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Soort vervoer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Ritgegevens" />
 +
 
 +
<section begin="Haalgegevens" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Haalgegevens
 +
|-style="background-color: #8F00FF;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Straat
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Huisnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Huisletter
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Huisnummertoevoeging
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Postcode
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Locatiebeschrijving
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Woonplaats
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Land
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Patiënt vervoerd?
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Reden geen vervoer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Tijdstip overlijden patiënt
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Advies behandeling tijdens vervoer aanwezig?
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Niet reanimeren verklaring aanwezig?
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Trialgegevens
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Ambulance-urgentie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Gewondennummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Triageklasse
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Hulpverleners ter plaatse
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Hulpverlenersnaam
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Type hulpverlener
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Telefoonnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|E-mailadres
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|}
 +
<section end="Haalgegevens" />
 +
 
 +
<section begin="Bestemmingsgegevens" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Bestemmingsgegevens
 +
|-style="background-color: #8F00FF;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Bestemmingsstatus in bericht op T2
 +
|style="background-color: white;"|Actief
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Bestemmingscode
 +
|style="background-color: white;"|AGB: 06010860
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Locatie of afdeling
 +
|style="background-color: white;"|LSDV-code: 2.16.840.1.113883.2.4.6.1.6010860.000
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Straat
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Huisnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Huisletter
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Huisnummertoevoeging
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Postcode
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Locatiebeschrijving
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Woonplaats
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Land
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Bijzonderheden algemeen
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verwacht specialisme
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Feedback
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Feedback gewenst
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Feedback adres
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Feedback methode
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|}
 +
<section end="Bestemmingsgegevens" />
 +
 
 +
<section begin="Mechanisme" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Mechanisme
 +
|-style="background-color: #8F00FF;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Mechanisme type
 +
|style="background-color: white;"| 35468003  bekneld geraakt tussen voorwerpen (gebeurtenis)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Vervoermiddel patiënt
 +
|style="background-color: white;"| 71783008 auto (fysiek object)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Patiënt was bestuurder?
 +
|style="background-color: white;"| ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Vervoermiddel contra
 +
|style="background-color: white;"| 71783008 auto (fysiek object)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Beschermingsmiddelen patiënt (3x)
 +
|style="background-color: white;"| 285695004 helm (fysiek object) <br/>
 +
60054005 autogordel (fysiek object)<br/>
 +
102384007 airbag van motorvoertuig (fysiek object)
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Mechanisme" />
 +
 
 +
<section begin="Toestandsbeelden/Werkdiagnose" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;"  colspan="6" |Toestandsbeelden/Werkdiagnose
 +
|-style="background-color: #8F00FF;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Toestandsbeeld
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Toestandsbeeld code
 +
|style="background-color: white;"| 125593007 letsel van aangezicht (aandoening)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Toelichting Toestandsbeeld
 +
|style="background-color: white;"| Moeilijk observeren door weersomstandigheden
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|}
 +
<section end="Toestandsbeelden/Werkdiagnose" />
 +
 
 +
<section begin="Meetwaarden" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Meetwaarden
 +
|-style="background-color: #8F00FF;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Bloedsuiker
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Bloedsuiker waarde
 +
|style="background-color: white;"| 5 mmol/L
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|BloedsuikerDatumTijd
 +
|style="background-color: white;"| T2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Hartritme
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Hartritme observatie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|HartritmeDatumTijd
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Toelichting hartritme/ECG
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|O2Saturatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|SpO2waarde
 +
|style="background-color: white;"|78%
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|O2SaturatieDatumTijd
 +
|style="background-color: white;"|T2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Capnometrie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|CO2Waarde
 +
|style="background-color: white;"|40 mm[Hg] <br/>5,3 kPa
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|CO2CapnometrieDatumTijd
 +
|style="background-color: white;"|T2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Hartfrequentie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|HartfrequentieWaarde
 +
|style="background-color: white;"|110/min
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|HartfrequentieDatumTijd
 +
|style="background-color: white;"|T2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Bloeddruk
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|SystolischeBloeddruk
 +
|style="background-color: white;"|100 mm[Hg]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|DiastolischeBloeddruk
 +
|style="background-color: white;"|80 mm[Hg]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|BloeddrukDatumTijd
 +
|style="background-color: white;"|T2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Lichaamstemperatuur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|TemperatuurWaarde
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|TemperatuurDatumTijd
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Ademhaling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ademfrequentie
 +
|style="background-color: white;"|4/min
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|AdemhalingDatumTijd
 +
|style="background-color: white;"|T2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|GlasgowComaScale
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|GlasgowComaScaleDatumTijd
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|GCS_Eyes
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|GCS_Motor
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|GCS_Verbal
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|TotaalScore
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Revised Trauma Score
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|RevisedTraumaScoreWaarde
 +
|style="background-color: white;"|8
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|RevisedTraumaScoreTijd
 +
|style="background-color: white;"|T2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Pediatric Trauma Score
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|PediatricTraumaScoreWaarde
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|PediatricTraumaScoreTijd
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Pijnschaal
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|PijnschaalWaarde
 +
|style="background-color: white;"|3
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|PijnschaalTijd
 +
|style="background-color: white;"|T2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|APGAR-1
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|APGAR-5
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Meetwaarden" />
 +
 
 +
<section begin="Behandeling" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Behandeling
 +
|-style="background-color: #8F00FF;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Ademhaling en beademing (diagnostisch)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Handelingen ademhaling en beademing
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Bewustzijn en neurologische status (diagnostisch) 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Handelingen bewustzijn en neurologische status
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Overige diagnostische handelingen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Handelingen overige diagnostisch
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Luchtweg management (therapeutisch)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Handelingen luchtweg management
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Moeizame intubatie?
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Oxygenatie en ventilatie (therapeutisch)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Handelingen oxygenatie en ventilatie 
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Beademing machine Fi O2
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Beademing machine AMV
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Beademing machine Freq.
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Beademing machine Peep
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Hoeveelheid zuurstof
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Circulatie (therapeutisch)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="12"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Handelingen circulatie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Pacemaker frequentie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Pacemaker stroomsterkte
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Pacemaker modus
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Cardioversies aantal
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Cardioversie maximale energie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Defibrillaties aantal
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Defibrillatie energie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Return Of Spontaneous Circulation (ROSC)
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| AED aangesloten voor aankomst
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| AED-schokken aantal
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Traumatologie (therapeutisch)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Handelingen traumatologie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Koelen tijdsduur
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Obstetrie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Handelingen obstetrie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Wijze van isolatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Handelingen isolatie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Medicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Medicatie toegediend?
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Medicatienaam
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Toegediende hoeveelheid medicatie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Tijd medicatietoediening
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Medicatie toedieningsvorm
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| IV medicatiesnelheid
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Infuus
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Infusen aantal
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Infuusvloeistofcode
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Infuusvloeistoftekst
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Infuushoeveelheid
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Extra informatie behandeling
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Behandeling" />
 +
 
 +
<section begin="Patiëntligging" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Patiëntligging
 +
|-style="background-color: #8F00FF;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Type patiëntligging
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Patiëntligging" />
 +
 
 +
<section begin="Primary Survey" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Primary Survey
 +
|-style="background-color: #8F00FF;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Airway
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Airway vrij?
 +
|style="background-color: white;"| Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Stridor
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Breathing
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Breathing sufficient?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Breathing observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Circulation
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Circulation sufficient?
 +
|style="background-color: white;"| Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Capillaire refill > 2 seconde?
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Huid observatie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Disability
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|AVPU
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Duur buiten bewustzijn
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Pupil
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|FAST symptomen aanwezig
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Mogelijk trombolyse/trombectomie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Intoxicatie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
 
 +
 
 +
|colspan="5"|Toelichting Primary Survey
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Primary Survey" />
 +
 
 +
<section begin="Secondary Survey" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Secondary Survey
 +
|-style="background-color: #8F00FF;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Anamnese
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ample
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Code
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Titel
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Omschrijving
 +
|style="background-color: white;"|
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Toelichting anamnese
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Infectierisico
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Verdenking infectieziekten?
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Toelichting infectierisico
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Hoofd en gelaat
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Hoofd en gelaat observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Bloedverlies
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Liquorverlies
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Pijnlocatie
 +
|style="background-color: white;"|   
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Wond
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Nek, hals, CWK
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Nek, hals, CWK observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Wond
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Thorax
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Thorax observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Pijn bij compressie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Locatie subcutaan emfyseem
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Locatie zwelling / oedeem (2x)
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Wond
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Rug
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Rug observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Wond
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Abdomen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Abdomen observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Locatie druk- / loslaatpijn
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Locatie zwelling / oedeem
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Locatie pulserende zwelling
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Wond
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Bekken
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Bekken observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Wond
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Extremiteiten Armen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Extremiteit
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Lateraliteit
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Wond
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Extremiteiten Armen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Extremiteit
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Lateraliteit
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Wond
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Extremiteiten Benen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Extremiteit
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Lateraliteit
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Observaties (2x)
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Wond
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Uitscheiding
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Uitscheiding observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Braken
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Incontinent
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Verloskunde/Gynaecologie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Verloskunde/Gynaecologie observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Vruchtwaterverlies
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Weeën
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Secondary Survey" />
 +
 
 +
<section begin="Consultgever op afstand" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Consultgever op afstand
 +
|-style="background-color: #8F00FF;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Initialen
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Achternaam
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Telefoonnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Identificatie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Type consultgever
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Toelichting/Afspraken met consultgever
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Consultgever op afstand" />
 +
 
 +
<section begin="Afspraken met patiënt" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Afspraken met patiënt
 +
|-style="background-color: #8F00FF;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Huisarts ingelicht
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Afspraken met patiënt
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Afspraken met patiënt" />
 +
 
 +
<section begin="Bijlagen" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Bijlagen T2
 +
|-style="background-color: #8F00FF;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Type Bijlage
 +
|style="background-color: white;"|006 intern rapport/overdracht
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Bijlage id
 +
|style="background-color: white;"| 9068
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Versie
 +
|style="background-color: white;"| 3
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Bijlageset id
 +
|style="background-color: white;"| 12
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Bijlagen" />
 +
 
 +
<section begin="Toestemmingsgegevens" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Toestemmingsgegevens
 +
|-style="background-color: #8F00FF;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Wetenschappelijk onderzoek
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Beschrijving
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Informed consent
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Toestemming informeren verwanten
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|}
 +
<section end="Toestemmingsgegevens" />
 +
 
 +
<section begin="Toelichtingsgegevens" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Toelichtingsgegevens
 +
|-style="background-color: #8F00FF;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Toelichting algemeen
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Toelichtingsgegevens" />
 +
 
 +
==T3: vlak voor aankomst bij de SEH==
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | T3
 +
|}
 +
<section begin="patient" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Patient
 +
|-style="background-color: #ED2939;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Persoonidentificatie
 +
|style="background-color: white;"|999910553
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Naamgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Initialen
 +
|style="background-color: white;"|W.
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Achternaam
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="3"|Soort naam
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Voorvoegsels
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Achternaam
 +
|style="background-color: white;"|XXX_Witsiers
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Geslacht
 +
|style="background-color: white;"|M
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Geboortegegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Geboortedatum
 +
|style="background-color: white;"|06-08-1954
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Geschatte leeftijd
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Adresgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="10"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Straat
 +
|style="background-color: white;"|Hertog Aalbrechtweg
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Huisnummer
 +
|style="background-color: white;"|8
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Huisnummerletter
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Huisnummertoevoeging
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Postcode
 +
|style="background-color: white;"|1823 DB
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Woonplaats
 +
|style="background-color: white;"|Alkmaar
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Land
 +
|style="background-color: white;"|Nederland
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Locatiebeschrijving
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Overige Contactgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="15"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Telefoonnummers
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Telefoonnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Soort telefoonnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Werktelefoon
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|werknummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Soort nummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|EmailAdressen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Emailadres
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Soort e-mailadres
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Emailadres
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Soort e-mailadres
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"| Ziektekostenverzekering?
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Verzekeringsgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verzekeraar
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Naam
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Identificatienummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Polis
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"| Polisnummer/Verzekerdenummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Vaste huisarts
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| ZorgverlenerIdentificatienummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Rolcode
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Naam
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Achternaam
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Vaste huisartsenpraktijk
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="27"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|  Identificatie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|  Naam
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|  Adresgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|  Soort adres
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|  Straatnaam
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|  Huisnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|  Huisnummertoevoeging
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|  Postcode
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|  Gemeente
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|  Woonplaats
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|  Land
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|  Overige contactgegevens 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="13"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|  Telefoonnummers
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|  Soort telefoonnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|  Telefoonnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|  Faxnummers
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|  Soort faxnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|  Faxnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|  E-mailadressen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|  Soort e-mailadres 
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|  E-mailadres
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Contactpersoon patiënt
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|  Achternaam 
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|  Telefoonnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|  Relatie tot patiënt
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="patient" />
 +
 
 +
<section begin="WID-controle" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | WID-controle
 +
|-style="background-color: #ED2939;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|WID-controle uitgevoerd
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|WID controle datum
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Documentnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Document type
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="WID-controle" />
 +
 
 +
<section begin="Incidentgegevens" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Incidentgegevens
 +
|-style="background-color: #ED2939;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Datum/tijd incident
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Incidentgegevens" />
 +
 
 +
<section begin="Meldingsgegevens" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Meldingsgegevens
 +
|-style="background-color: #ED2939;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Datum/tijd melding
 +
|style="background-color: white;"| T1-15min
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Geplande brengtijd
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Geplande haaltijd
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Wzd/Wvggz maatregel
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Datum/tijd aanvang TVZ
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Medische kladblok meldkamer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="5"|Meldkamerurgentie
 +
|style="background-color: white;"| A2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Meldingsgegevens" />
 +
 
 +
<section begin="Zorgaanvrager" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Zorgaanvrager
 +
|-style="background-color: #ED2939;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Initialen
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Achternaam
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Telefoonnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Identificatie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Type zorgaanvrager
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Zorgaanvrager" />
 +
 
 +
<section begin="Ritgegevens" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Ritgegevens
 +
|-style="background-color: #ED2939;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Ambulancevoorziening
 +
|style="background-color: white;"| 25 (RAV identificatie)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Ritnummer
 +
|style="background-color: white;"| 25-2020-13-1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Ambulancenummer
 +
|style="background-color: white;"| 25190
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Telefoon ambulance
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ambulanceverpleegkundige identificatie
 +
|style="background-color: white;"| 596
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ambulancechauffeur identificatie
 +
|style="background-color: white;"| 530
 +
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="5"|Datum/tijd ritopdracht
 +
|style="background-color: white;"| T1-10 min
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Datum/tijd uitruk/vertrek
 +
|style="background-color: white;"| T1-10 min
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Datum/tijd aankomst patiënt
 +
|style="background-color: white;"| T1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Datum/tijd vertrek patiënt
 +
|style="background-color: white;"| T1+2 min
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Verwachte  aankomsttijd bestemming
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Datum/tijd aankomst bestemming
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Datum/tijd vrijmelding
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Soort vervoer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Ritgegevens" />
 +
 
 +
<section begin="Haalgegevens" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Haalgegevens
 +
|-style="background-color: #ED2939;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Straat
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Huisnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Huisletter
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Huisnummertoevoeging
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Postcode
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Locatiebeschrijving
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Woonplaats
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Land
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Patiënt vervoerd?
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Reden geen vervoer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Tijdstip overlijden patiënt
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Advies behandeling tijdens vervoer aanwezig?
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Niet reanimeren verklaring aanwezig?
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Trialgegevens
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Ambulance-urgentie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Gewondennummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Triageklasse
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Hulpverleners ter plaatse
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Hulpverlenersnaam
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Type hulpverlener
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Telefoonnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|E-mailadres
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|}
 +
<section end="Haalgegevens" />
 +
 
 +
<section begin="Bestemmingsgegevens" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Bestemmingsgegevens
 +
|-style="background-color: #ED2939;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Bestemmingsstatus in bericht op T3
 +
|style="background-color: white;"|Overgedragen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Bestemmingscode
 +
|style="background-color: white;"|AGB: 06010860
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Locatie of afdeling
 +
|style="background-color: white;"|LSDV-code: 2.16.840.1.113883.2.4.6.1.6010860.000
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Straat
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Huisnummer
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Huisletter
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Huisnummertoevoeging
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Postcode
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Locatiebeschrijving
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Woonplaats
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Land
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Bijzonderheden algemeen
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verwacht specialisme
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Feedback
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Feedback gewenst
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Feedback adres
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Feedback methode
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|}
 +
<section end="Bestemmingsgegevens" />
 +
 
 +
<section begin="Mechanisme" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Mechanisme
 +
|-style="background-color: #ED2939;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Mechanisme type
 +
|style="background-color: white;"| 35468003  bekneld geraakt tussen voorwerpen (gebeurtenis)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Vervoermiddel patiënt
 +
|style="background-color: white;"| 71783008 auto (fysiek object)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Patiënt was bestuurder?
 +
|style="background-color: white;"| ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Vervoermiddel contra
 +
|style="background-color: white;"| 71783008 auto (fysiek object)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Beschermingsmiddelen patiënt (3x)
 +
|style="background-color: white;"| 285695004 helm (fysiek object) <br/>
 +
60054005 autogordel (fysiek object)<br/>
 +
102384007 airbag van motorvoertuig (fysiek object)
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Mechanisme" />
 +
 
 +
<section begin="Toestandsbeelden/Werkdiagnose" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" |Toestandsbeelden/Werkdiagnose
 +
|-style="background-color: #ED2939;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Toestandsbeeld
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Toestandsbeeld code
 +
|style="background-color: white;"| 125593007 letsel van aangezicht (aandoening)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Toelichting Toestandsbeeld
 +
|style="background-color: white;"| Moeilijk observeren door weersomstandigheden
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|}
 +
<section end="Toestandsbeelden/Werkdiagnose" />
 +
 
 +
<section begin="Meetwaarden" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Meetwaarden
 +
|-style="background-color: #ED2939;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Bloedsuiker
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Bloedsuiker waarde
 +
|style="background-color: white;"| 6 mmol/L
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|BloedsuikerDatumTijd
 +
|style="background-color: white;"| T3
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Hartritme
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Hartritme observatie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|HartritmeDatumTijd
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Toelichting hartritme/ECG
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|O2Saturatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|SpO2waarde
 +
|style="background-color: white;"|98%
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|O2SaturatieDatumTijd
 +
|style="background-color: white;"|T3
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Capnometrie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|CO2Waarde
 +
|style="background-color: white;"|35 mm[Hg] <br/>4,7 kPa
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|CO2CapnometrieDatumTijd
 +
|style="background-color: white;"|T3
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Hartfrequentie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|HartfrequentieWaarde
 +
|style="background-color: white;"|90/min
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|HartfrequentieDatumTijd
 +
|style="background-color: white;"|T3
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Bloeddruk
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|SystolischeBloeddruk
 +
|style="background-color: white;"|60 mm[Hg]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|DiastolischeBloeddruk
 +
|style="background-color: white;"|50 mm[Hg]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|BloeddrukDatumTijd
 +
|style="background-color: white;"|T3
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Lichaamstemperatuur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|TemperatuurWaarde
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|TemperatuurDatumTijd
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Ademhaling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ademfrequentie
 +
|style="background-color: white;"|4/min
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|AdemhalingDatumTijd
 +
|style="background-color: white;"|T3
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|GlasgowComaScale
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|GlasgowComaScaleDatumTijd
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|GCS_Eyes
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|GCS_Motor
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|GCS_Verbal
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|TotaalScore
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Revised Trauma Score
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|RevisedTraumaScoreWaarde
 +
|style="background-color: white;"|8
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|RevisedTraumaScoreTijd
 +
|style="background-color: white;"|T3
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Pediatric Trauma Score
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|PediatricTraumaScoreWaarde
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|PediatricTraumaScoreTijd
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Pijnschaal
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|PijnschaalWaarde
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|PijnschaalTijd
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|APGAR-1
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|APGAR-5
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Meetwaarden" />
 +
 
 +
<section begin="Behandeling" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Behandeling
 +
|-style="background-color: #ED2939;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Ademhaling en beademing (diagnostisch)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Handelingen ademhaling en beademing
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Bewustzijn en neurologische status (diagnostisch) 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Handelingen bewustzijn en neurologische status
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Overige diagnostische handelingen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Handelingen overige diagnostisch
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Luchtweg management (therapeutisch)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Handelingen luchtweg management
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Moeizame intubatie?
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Oxygenatie en ventilatie (therapeutisch)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Handelingen oxygenatie en ventilatie 
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Beademing machine Fi O2
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Beademing machine AMV
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Beademing machine Freq.
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Beademing machine Peep
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Hoeveelheid zuurstof
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Circulatie (therapeutisch)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="12"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Handelingen circulatie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Pacemaker frequentie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Pacemaker stroomsterkte
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Pacemaker modus
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Cardioversies aantal
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Cardioversie maximale energie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Defibrillaties aantal
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Defibrillatie energie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Return Of Spontaneous Circulation (ROSC)
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| AED aangesloten voor aankomst
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| AED-schokken aantal
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Traumatologie (therapeutisch)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Handelingen traumatologie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Koelen tijdsduur
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Obstetrie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Handelingen obstetrie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Wijze van isolatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Handelingen isolatie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Medicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Medicatie toegediend?
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Medicatienaam
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Toegediende hoeveelheid medicatie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Tijd medicatietoediening
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Medicatie toedieningsvorm
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| IV medicatiesnelheid
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Infuus
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Infusen aantal
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Infuusvloeistofcode
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Infuusvloeistoftekst
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Infuushoeveelheid
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Extra informatie behandeling
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Behandeling" />
 +
 
 +
<section begin="Patiëntligging" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Patiëntligging
 +
|-style="background-color: #ED2939;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Type patiëntligging
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Patiëntligging" />
 +
 
 +
<section begin="Primary Survey" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Primary Survey
 +
|-style="background-color: #ED2939;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Airway
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Airway vrij?
 +
|style="background-color: white;"| Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Stridor
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Breathing
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Breathing sufficient?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Breathing observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Circulation
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Circulation sufficient?
 +
|style="background-color: white;"| Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Capillaire refill > 2 seconde?
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Huid observatie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Disability
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|AVPU
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Duur buiten bewustzijn
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Pupil
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|FAST symptomen aanwezig
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Mogelijk trombolyse/trombectomie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Intoxicatie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
 
 +
 
 +
|colspan="5"|Toelichting Primary Survey
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Primary Survey" />
 +
 
 +
<section begin="Secondary Survey" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Secondary Survey
 +
|-style="background-color: #ED2939;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Anamnese
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ample
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Code
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Titel
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Omschrijving
 +
|style="background-color: white;"|
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Toelichting anamnese
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Infectierisico
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Verdenking infectieziekten?
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Toelichting infectierisico
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Hoofd en gelaat
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Hoofd en gelaat observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Bloedverlies
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Liquorverlies
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Pijnlocatie
 +
|style="background-color: white;"|   
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Wond
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Nek, hals, CWK
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Nek, hals, CWK observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Wond
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Thorax
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Thorax observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Pijn bij compressie
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Locatie subcutaan emfyseem
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Locatie zwelling / oedeem (2x)
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Wond
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Rug
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Rug observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Wond
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Abdomen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Abdomen observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Locatie druk- / loslaatpijn
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Locatie zwelling / oedeem
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Locatie pulserende zwelling
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Wond
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Bekken
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Bekken observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"| Wond
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Extremiteiten Armen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Extremiteit
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Lateraliteit
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Wond
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Extremiteiten Armen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Extremiteit
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Lateraliteit
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Wond
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Extremiteiten Benen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Extremiteit
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Lateraliteit
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Observaties (2x)
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Wond
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Uitscheiding
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Uitscheiding observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Braken
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Incontinent
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Verloskunde/Gynaecologie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Verloskunde/Gynaecologie observaties
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Vruchtwaterverlies
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Weeën
 +
|style="background-color: white;"|  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|}
 +
<section end="Secondary Survey" />
 +
 
 +
<section begin="Consultgever op afstand" />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Consultgever op afstand
 +
|-style="background-color: #ED2939;; color: white; text-align:left;"  
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 +
|colspan="5"|Initialen
 +
|style="background-color: white;"|  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 +
|colspan="5"|Achternaam
 +
|style="background-color: white;"|  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 +
|colspan="5"|Telefoonnummer
 +
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Identificatie
 
|colspan="5"|Identificatie
−
|style="background-color: white;"| 000014444 (UZI)
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"  
 
|colspan="5"|Type consultgever
 
|colspan="5"|Type consultgever
−
|style="background-color: white;"| 001 huisarts
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Toelichting/Afspraken met consultgever
 
|colspan="5"|Toelichting/Afspraken met consultgever
−
|style="background-color: white;"| terugbellen
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|}
 
|}
Regel 1.373: Regel 3.803:
 
<section begin="Afspraken met patiënt" />
 
<section begin="Afspraken met patiënt" />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
−
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Afspraken met patiënt
+
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Afspraken met patiënt
−
|-style="background-color: #1F497D;; color: white; text-align:left;"  
+
|-style="background-color: #ED2939;; 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"|Huisarts ingelicht
 
|colspan="5"|Huisarts ingelicht
−
|style="background-color: white;"|Nee
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Afspraken met patiënt
 
|colspan="5"|Afspraken met patiënt
−
|style="background-color: white;"|Huisarts nog inlichten
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|}
 
|}
Regel 1.389: Regel 3.819:
 
<section begin="Bijlagen" />
 
<section begin="Bijlagen" />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
−
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Bijlagen
+
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Bijlagen T3
−
|-style="background-color: #1F497D;; color: white; text-align:left;"  
+
|-style="background-color: #ED2939;; color: white; text-align:left;"  
 
|colspan="5" width="25%"| Gegevenselement
 
|colspan="5" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
Regel 1.401: Regel 3.831:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Versie
 
|colspan="5"|Versie
−
|style="background-color: white;"| 1
+
|style="background-color: white;"| 6
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Bijlageset id
 
|colspan="5"|Bijlageset id
Regel 1.411: Regel 3.841:
 
<section begin="Toestemmingsgegevens" />
 
<section begin="Toestemmingsgegevens" />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
−
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Toestemmingsgegevens
+
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Toestemmingsgegevens
−
|-style="background-color: #1F497D;; color: white; text-align:left;"  
+
|-style="background-color: #ED2939;; color: white; text-align:left;"  
 
|colspan="5" width="25%"| Gegevenselement
 
|colspan="5" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
Regel 1.421: Regel 3.851:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="4"|Beschrijving
 
|colspan="4"|Beschrijving
−
|style="background-color: white;"| Observaties
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="4"|Informed consent
 
|colspan="4"|Informed consent
−
|style="background-color: white;"| Ja
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"  
 
|colspan="5"|Toestemming informeren verwanten
 
|colspan="5"|Toestemming informeren verwanten
−
|style="background-color: white;"|001 Patiënt geeft toestemming 
+
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|}
 
|}
Regel 1.434: Regel 3.864:
 
<section begin="Toelichtingsgegevens" />
 
<section begin="Toelichtingsgegevens" />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
−
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Toelichtingsgegevens
+
|style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Toelichtingsgegevens
−
|-style="background-color: #1F497D;; color: white; text-align:left;"  
+
|-style="background-color: #ED2939;; 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"|Toelichting algemeen
 
|colspan="5"|Toelichting algemeen
−
|style="background-color: white;"| Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur ridiculus mus. Donec quam felis, ultricies nec, pellentesque eu, pretium quis, sem. Nulla consequat massa quis enim. Donec pede justo, fringilla vel, aliquet nec, vulputate
+
|style="background-color: white;"|  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|}
 
|}
 
<section end="Toelichtingsgegevens" />
 
<section end="Toelichtingsgegevens" />

Huidige versie van 7 apr 2025 om 11:17

< Terug naar werkpagina


Issue icon.png

Please note that this is draft material which is still in development

1 Inleiding

Dit scenario bestaat uit drie opeenvolgende berichten die de ambulance stuurt naar de SEH: een bij aankomst bij de patient (T1), een gedurende de rit (T2) en een vlak voor aankomst bij de SEH (T3). Deze berichten zijn cumulatief, dus het bericht op T2 bevat alles van bericht T1, plus wat er sindsdien bijgevoegd is, en bericht 3 alles van T2, plus wat er sindsdien bijgevoegd is. Tenzij vermeld moeten alle velden vanaf het eerste bericht voorkomen; bij de metingen staat het tijdstip expliciet aangegeven. Alleen de bijlagen worden slechts 1x verstuurd, omdat die in dit geval zelf cumulatief zijn (zelfde setId met oplopend versienummer), en de oudere versies dus obsoleet zijn.

1.1 T1: aankomst bij de patient

T1
Patient
Gegevenselement Waarde
Persoonidentificatie 999910553
Naamgegevens
Initialen W.
Achternaam
Soort naam
Voorvoegsels
Achternaam XXX_Witsiers
Geslacht M
Geboortegegevens
Geboortedatum 06-08-1954
Geschatte leeftijd
Adresgegevens
Straat Hertog Aalbrechtweg
Huisnummer 8
Huisnummerletter
Huisnummertoevoeging
Postcode 1823 DB
Woonplaats Alkmaar
Land Nederland
Locatiebeschrijving
Overige Contactgegevens
Telefoonnummers
Telefoonnummer
Soort telefoonnummer
Werktelefoon
werknummer
Soort nummer
EmailAdressen
Emailadres
Soort e-mailadres
Emailadres
Soort e-mailadres
Ziektekostenverzekering?
Verzekeringsgegevens
Verzekeraar
Naam
Identificatienummer
Polis
Polisnummer/Verzekerdenummer
Vaste huisarts
ZorgverlenerIdentificatienummer
Rolcode
Naam
Achternaam
Vaste huisartsenpraktijk
Identificatie
Naam
Adresgegevens
Soort adres
Straatnaam
Huisnummer
Huisnummertoevoeging
Postcode
Gemeente
Woonplaats
Land
Overige contactgegevens
Telefoonnummers
Soort telefoonnummer
Telefoonnummer
Faxnummers
Soort faxnummer
Faxnummer
E-mailadressen
Soort e-mailadres
E-mailadres
Contactpersoon patiënt
Achternaam
Telefoonnummer
Relatie tot patiënt


WID-controle
Gegevenselement Waarde
WID-controle uitgevoerd
WID controle datum
Documentnummer
Document type


Incidentgegevens
Gegevenselement Waarde
Datum/tijd incident


Meldingsgegevens
Gegevenselement Waarde
Datum/tijd melding T1-15min
Geplande brengtijd
Geplande haaltijd
Wzd/Wvggz maatregel
Datum/tijd aanvang TVZ
Medische kladblok meldkamer
Meldkamerurgentie A2


Zorgaanvrager
Gegevenselement Waarde
Initialen
Achternaam
Telefoonnummer
Identificatie
Type zorgaanvrager


Ritgegevens
Gegevenselement Waarde
Ambulancevoorziening 25 (RAV identificatie)
Ritnummer 25-2020-13-1
Ambulancenummer 25190
Telefoon ambulance
Ambulanceverpleegkundige identificatie 596
Ambulancechauffeur identificatie 530
Datum/tijd ritopdracht T1-10 min
Datum/tijd uitruk/vertrek T1-10 min
Datum/tijd aankomst patiënt T1
Datum/tijd vertrek patiënt
Verwachte aankomsttijd bestemming
Datum/tijd aankomst bestemming
Datum/tijd vrijmelding
Soort vervoer


Haalgegevens
Gegevenselement Waarde
Straat
Huisnummer
Huisletter
Huisnummertoevoeging
Postcode
Locatiebeschrijving
Woonplaats
Land
Patiënt vervoerd?
Reden geen vervoer
Tijdstip overlijden patiënt
Advies behandeling tijdens vervoer aanwezig?
Niet reanimeren verklaring aanwezig?
Trialgegevens
Ambulance-urgentie
Gewondennummer
Triageklasse
Hulpverleners ter plaatse
Hulpverlenersnaam
Type hulpverlener
Telefoonnummer
E-mailadres


Bestemmingsgegevens
Gegevenselement Waarde
Bestemmingsstatus in bericht op T1 Actief
Bestemmingscode AGB: 06010860
Locatie of afdeling LSDV-code: 2.16.840.1.113883.2.4.6.1.6010860.000
Straat
Huisnummer
Huisletter
Huisnummertoevoeging
Postcode
Locatiebeschrijving
Woonplaats
Land
Bijzonderheden algemeen
Verwacht specialisme
Feedback
Feedback gewenst
Feedback adres
Feedback methode


Mechanisme
Gegevenselement Waarde
Mechanisme type 35468003 bekneld geraakt tussen voorwerpen (gebeurtenis)
Vervoermiddel patiënt 71783008 auto (fysiek object)
Patiënt was bestuurder? ja
Vervoermiddel contra 71783008 auto (fysiek object)
Beschermingsmiddelen patiënt (3x) 285695004 helm (fysiek object)

60054005 autogordel (fysiek object)
102384007 airbag van motorvoertuig (fysiek object)


Toestandsbeelden/Werkdiagnose
Gegevenselement Waarde
Toestandsbeeld
Toestandsbeeld code 125593007 letsel van aangezicht (aandoening)
Toelichting Toestandsbeeld Moeilijk observeren door weersomstandigheden


Meetwaarden
Gegevenselement Waarde
Bloedsuiker
Bloedsuiker waarde 6 mmol/L
BloedsuikerDatumTijd T1
Hartritme
Hartritme observatie
HartritmeDatumTijd
Toelichting hartritme/ECG
O2Saturatie
SpO2waarde 99%
O2SaturatieDatumTijd T1
Capnometrie
CO2Waarde 60 mm[Hg]
8,0 kPa
CO2CapnometrieDatumTijd T1
Hartfrequentie
HartfrequentieWaarde 120/min
HartfrequentieDatumTijd T1
Bloeddruk
SystolischeBloeddruk 90 mm[Hg]
DiastolischeBloeddruk 60 mm[Hg]
BloeddrukDatumTijd T1
Lichaamstemperatuur
TemperatuurWaarde
TemperatuurDatumTijd
Ademhaling
Ademfrequentie 4/min
AdemhalingDatumTijd T1
GlasgowComaScale
GlasgowComaScaleDatumTijd T1
GCS_Eyes 4
GCS_Motor 6
GCS_Verbal 5 (uit 2.16.840.1.113883.2.4.3.11.60.40.4.2.3)
TotaalScore 15
Revised Trauma Score
RevisedTraumaScoreWaarde 8
RevisedTraumaScoreTijd T1
Pediatric Trauma Score
PediatricTraumaScoreWaarde
PediatricTraumaScoreTijd
Pijnschaal
PijnschaalWaarde 3
PijnschaalTijd T1
APGAR-1
APGAR-5


Behandeling
Gegevenselement Waarde
Ademhaling en beademing (diagnostisch)
Handelingen ademhaling en beademing
Bewustzijn en neurologische status (diagnostisch)
Handelingen bewustzijn en neurologische status
Overige diagnostische handelingen
Handelingen overige diagnostisch
Luchtweg management (therapeutisch)
Handelingen luchtweg management
Moeizame intubatie?
Oxygenatie en ventilatie (therapeutisch)
Handelingen oxygenatie en ventilatie
Beademing machine Fi O2
Beademing machine AMV
Beademing machine Freq.
Beademing machine Peep
Hoeveelheid zuurstof
Circulatie (therapeutisch)
Handelingen circulatie
Pacemaker frequentie
Pacemaker stroomsterkte
Pacemaker modus
Cardioversies aantal
Cardioversie maximale energie
Defibrillaties aantal
Defibrillatie energie
Return Of Spontaneous Circulation (ROSC)
AED aangesloten voor aankomst
AED-schokken aantal
Traumatologie (therapeutisch)
Handelingen traumatologie
Koelen tijdsduur
Obstetrie
Handelingen obstetrie
Wijze van isolatie
Handelingen isolatie
Medicatie
Medicatie toegediend?
Medicatienaam
Toegediende hoeveelheid medicatie
Tijd medicatietoediening
Medicatie toedieningsvorm
IV medicatiesnelheid
Infuus
Infusen aantal
Infuusvloeistofcode
Infuusvloeistoftekst
Infuushoeveelheid
Extra informatie behandeling


Patiëntligging
Gegevenselement Waarde
Type patiëntligging


Primary Survey
Gegevenselement Waarde
Airway
Airway vrij? Ja
Stridor
Breathing
Breathing sufficient? Ja
Breathing observaties
Circulation
Circulation sufficient? Ja
Capillaire refill > 2 seconde?
Huid observatie
Disability
AVPU
Duur buiten bewustzijn
Pupil
FAST symptomen aanwezig
Mogelijk trombolyse/trombectomie
Intoxicatie
Toelichting Primary Survey


Secondary Survey
Gegevenselement Waarde
Anamnese
Ample
Code
Titel
Omschrijving
Toelichting anamnese
Infectierisico
Verdenking infectieziekten?
Toelichting infectierisico
Hoofd en gelaat
Hoofd en gelaat observaties
Bloedverlies
Liquorverlies
Pijnlocatie
Wond
Nek, hals, CWK
Nek, hals, CWK observaties
Wond
Thorax
Thorax observaties
Pijn bij compressie
Locatie subcutaan emfyseem
Locatie zwelling / oedeem (2x)
Wond
Rug
Rug observaties
Wond
Abdomen
Abdomen observaties
Locatie druk- / loslaatpijn
Locatie zwelling / oedeem
Locatie pulserende zwelling
Wond
Bekken
Bekken observaties
Wond
Extremiteiten Armen
Extremiteit
Lateraliteit
Observaties
Wond
Extremiteiten Armen
Extremiteit
Lateraliteit
Observaties
Wond
Extremiteiten Benen
Extremiteit
Lateraliteit
Observaties (2x)
Wond
Uitscheiding
Uitscheiding observaties
Braken
Incontinent
Verloskunde/Gynaecologie
Verloskunde/Gynaecologie observaties
Vruchtwaterverlies
Weeën


Consultgever op afstand
Gegevenselement Waarde
Initialen
Achternaam
Telefoonnummer
Identificatie
Type consultgever
Toelichting/Afspraken met consultgever


Afspraken met patiënt
Gegevenselement Waarde
Huisarts ingelicht
Afspraken met patiënt


Bijlagen
Gegevenselement Waarde
Type Bijlage 006 intern rapport/overdracht
Bijlage id 9068
Versie 1
Bijlageset id 12


Toestemmingsgegevens
Gegevenselement Waarde
Wetenschappelijk onderzoek
Beschrijving
Informed consent
Toestemming informeren verwanten


Toelichtingsgegevens
Gegevenselement Waarde
Toelichting algemeen


1.2 T2: gedurende de rit

T2
Patient
Gegevenselement Waarde
Persoonidentificatie 999910553
Naamgegevens
Initialen W.
Achternaam
Soort naam
Voorvoegsels
Achternaam XXX_Witsiers
Geslacht M
Geboortegegevens
Geboortedatum 06-08-1954
Geschatte leeftijd
Adresgegevens
Straat Hertog Aalbrechtweg
Huisnummer 8
Huisnummerletter
Huisnummertoevoeging
Postcode 1823 DB
Woonplaats Alkmaar
Land Nederland
Locatiebeschrijving
Overige Contactgegevens
Telefoonnummers
Telefoonnummer
Soort telefoonnummer
Werktelefoon
werknummer
Soort nummer
EmailAdressen
Emailadres
Soort e-mailadres
Emailadres
Soort e-mailadres
Ziektekostenverzekering?
Verzekeringsgegevens
Verzekeraar
Naam
Identificatienummer
Polis
Polisnummer/Verzekerdenummer
Vaste huisarts
ZorgverlenerIdentificatienummer
Rolcode
Naam
Achternaam
Vaste huisartsenpraktijk
Identificatie
Naam
Adresgegevens
Soort adres
Straatnaam
Huisnummer
Huisnummertoevoeging
Postcode
Gemeente
Woonplaats
Land
Overige contactgegevens
Telefoonnummers
Soort telefoonnummer
Telefoonnummer
Faxnummers
Soort faxnummer
Faxnummer
E-mailadressen
Soort e-mailadres
E-mailadres
Contactpersoon patiënt
Achternaam
Telefoonnummer
Relatie tot patiënt


WID-controle
Gegevenselement Waarde
WID-controle uitgevoerd
WID controle datum
Documentnummer
Document type


Incidentgegevens
Gegevenselement Waarde
Datum/tijd incident


Meldingsgegevens
Gegevenselement Waarde
Datum/tijd melding T1-15min
Geplande brengtijd
Geplande haaltijd
Wzd/Wvggz maatregel
Datum/tijd aanvang TVZ
Medische kladblok meldkamer
Meldkamerurgentie A2


Zorgaanvrager
Gegevenselement Waarde
Initialen
Achternaam
Telefoonnummer
Identificatie
Type zorgaanvrager


Ritgegevens
Gegevenselement Waarde
Ambulancevoorziening 25 (RAV identificatie)
Ritnummer 25-2020-13-1
Ambulancenummer 25190
Telefoon ambulance
Ambulanceverpleegkundige identificatie 596
Ambulancechauffeur identificatie 530
Datum/tijd ritopdracht T1-10 min
Datum/tijd uitruk/vertrek T1-10 min
Datum/tijd aankomst patiënt T1
Datum/tijd vertrek patiënt T1+2 min
Verwachte aankomsttijd bestemming
Datum/tijd aankomst bestemming
Datum/tijd vrijmelding
Soort vervoer


Haalgegevens
Gegevenselement Waarde
Straat
Huisnummer
Huisletter
Huisnummertoevoeging
Postcode
Locatiebeschrijving
Woonplaats
Land
Patiënt vervoerd?
Reden geen vervoer
Tijdstip overlijden patiënt
Advies behandeling tijdens vervoer aanwezig?
Niet reanimeren verklaring aanwezig?
Trialgegevens
Ambulance-urgentie
Gewondennummer
Triageklasse
Hulpverleners ter plaatse
Hulpverlenersnaam
Type hulpverlener
Telefoonnummer
E-mailadres


Bestemmingsgegevens
Gegevenselement Waarde
Bestemmingsstatus in bericht op T2 Actief
Bestemmingscode AGB: 06010860
Locatie of afdeling LSDV-code: 2.16.840.1.113883.2.4.6.1.6010860.000
Straat
Huisnummer
Huisletter
Huisnummertoevoeging
Postcode
Locatiebeschrijving
Woonplaats
Land
Bijzonderheden algemeen
Verwacht specialisme
Feedback
Feedback gewenst
Feedback adres
Feedback methode


Mechanisme
Gegevenselement Waarde
Mechanisme type 35468003 bekneld geraakt tussen voorwerpen (gebeurtenis)
Vervoermiddel patiënt 71783008 auto (fysiek object)
Patiënt was bestuurder? ja
Vervoermiddel contra 71783008 auto (fysiek object)
Beschermingsmiddelen patiënt (3x) 285695004 helm (fysiek object)

60054005 autogordel (fysiek object)
102384007 airbag van motorvoertuig (fysiek object)


Toestandsbeelden/Werkdiagnose
Gegevenselement Waarde
Toestandsbeeld
Toestandsbeeld code 125593007 letsel van aangezicht (aandoening)
Toelichting Toestandsbeeld Moeilijk observeren door weersomstandigheden


Meetwaarden
Gegevenselement Waarde
Bloedsuiker
Bloedsuiker waarde 5 mmol/L
BloedsuikerDatumTijd T2
Hartritme
Hartritme observatie
HartritmeDatumTijd
Toelichting hartritme/ECG
O2Saturatie
SpO2waarde 78%
O2SaturatieDatumTijd T2
Capnometrie
CO2Waarde 40 mm[Hg]
5,3 kPa
CO2CapnometrieDatumTijd T2
Hartfrequentie
HartfrequentieWaarde 110/min
HartfrequentieDatumTijd T2
Bloeddruk
SystolischeBloeddruk 100 mm[Hg]
DiastolischeBloeddruk 80 mm[Hg]
BloeddrukDatumTijd T2
Lichaamstemperatuur
TemperatuurWaarde
TemperatuurDatumTijd
Ademhaling
Ademfrequentie 4/min
AdemhalingDatumTijd T2
GlasgowComaScale
GlasgowComaScaleDatumTijd
GCS_Eyes
GCS_Motor
GCS_Verbal
TotaalScore
Revised Trauma Score
RevisedTraumaScoreWaarde 8
RevisedTraumaScoreTijd T2
Pediatric Trauma Score
PediatricTraumaScoreWaarde
PediatricTraumaScoreTijd
Pijnschaal
PijnschaalWaarde 3
PijnschaalTijd T2
APGAR-1
APGAR-5


Behandeling
Gegevenselement Waarde
Ademhaling en beademing (diagnostisch)
Handelingen ademhaling en beademing
Bewustzijn en neurologische status (diagnostisch)
Handelingen bewustzijn en neurologische status
Overige diagnostische handelingen
Handelingen overige diagnostisch
Luchtweg management (therapeutisch)
Handelingen luchtweg management
Moeizame intubatie?
Oxygenatie en ventilatie (therapeutisch)
Handelingen oxygenatie en ventilatie
Beademing machine Fi O2
Beademing machine AMV
Beademing machine Freq.
Beademing machine Peep
Hoeveelheid zuurstof
Circulatie (therapeutisch)
Handelingen circulatie
Pacemaker frequentie
Pacemaker stroomsterkte
Pacemaker modus
Cardioversies aantal
Cardioversie maximale energie
Defibrillaties aantal
Defibrillatie energie
Return Of Spontaneous Circulation (ROSC)
AED aangesloten voor aankomst
AED-schokken aantal
Traumatologie (therapeutisch)
Handelingen traumatologie
Koelen tijdsduur
Obstetrie
Handelingen obstetrie
Wijze van isolatie
Handelingen isolatie
Medicatie
Medicatie toegediend?
Medicatienaam
Toegediende hoeveelheid medicatie
Tijd medicatietoediening
Medicatie toedieningsvorm
IV medicatiesnelheid
Infuus
Infusen aantal
Infuusvloeistofcode
Infuusvloeistoftekst
Infuushoeveelheid
Extra informatie behandeling


Patiëntligging
Gegevenselement Waarde
Type patiëntligging


Primary Survey
Gegevenselement Waarde
Airway
Airway vrij? Ja
Stridor
Breathing
Breathing sufficient? Ja
Breathing observaties
Circulation
Circulation sufficient? Ja
Capillaire refill > 2 seconde?
Huid observatie
Disability
AVPU
Duur buiten bewustzijn
Pupil
FAST symptomen aanwezig
Mogelijk trombolyse/trombectomie
Intoxicatie
Toelichting Primary Survey


Secondary Survey
Gegevenselement Waarde
Anamnese
Ample
Code
Titel
Omschrijving
Toelichting anamnese
Infectierisico
Verdenking infectieziekten?
Toelichting infectierisico
Hoofd en gelaat
Hoofd en gelaat observaties
Bloedverlies
Liquorverlies
Pijnlocatie
Wond
Nek, hals, CWK
Nek, hals, CWK observaties
Wond
Thorax
Thorax observaties
Pijn bij compressie
Locatie subcutaan emfyseem
Locatie zwelling / oedeem (2x)
Wond
Rug
Rug observaties
Wond
Abdomen
Abdomen observaties
Locatie druk- / loslaatpijn
Locatie zwelling / oedeem
Locatie pulserende zwelling
Wond
Bekken
Bekken observaties
Wond
Extremiteiten Armen
Extremiteit
Lateraliteit
Observaties
Wond
Extremiteiten Armen
Extremiteit
Lateraliteit
Observaties
Wond
Extremiteiten Benen
Extremiteit
Lateraliteit
Observaties (2x)
Wond
Uitscheiding
Uitscheiding observaties
Braken
Incontinent
Verloskunde/Gynaecologie
Verloskunde/Gynaecologie observaties
Vruchtwaterverlies
Weeën


Consultgever op afstand
Gegevenselement Waarde
Initialen
Achternaam
Telefoonnummer
Identificatie
Type consultgever
Toelichting/Afspraken met consultgever


Afspraken met patiënt
Gegevenselement Waarde
Huisarts ingelicht
Afspraken met patiënt


Bijlagen T2
Gegevenselement Waarde
Type Bijlage 006 intern rapport/overdracht
Bijlage id 9068
Versie 3
Bijlageset id 12


Toestemmingsgegevens
Gegevenselement Waarde
Wetenschappelijk onderzoek
Beschrijving
Informed consent
Toestemming informeren verwanten


Toelichtingsgegevens
Gegevenselement Waarde
Toelichting algemeen


1.3 T3: vlak voor aankomst bij de SEH

T3
Patient
Gegevenselement Waarde
Persoonidentificatie 999910553
Naamgegevens
Initialen W.
Achternaam
Soort naam
Voorvoegsels
Achternaam XXX_Witsiers
Geslacht M
Geboortegegevens
Geboortedatum 06-08-1954
Geschatte leeftijd
Adresgegevens
Straat Hertog Aalbrechtweg
Huisnummer 8
Huisnummerletter
Huisnummertoevoeging
Postcode 1823 DB
Woonplaats Alkmaar
Land Nederland
Locatiebeschrijving
Overige Contactgegevens
Telefoonnummers
Telefoonnummer
Soort telefoonnummer
Werktelefoon
werknummer
Soort nummer
EmailAdressen
Emailadres
Soort e-mailadres
Emailadres
Soort e-mailadres
Ziektekostenverzekering?
Verzekeringsgegevens
Verzekeraar
Naam
Identificatienummer
Polis
Polisnummer/Verzekerdenummer
Vaste huisarts
ZorgverlenerIdentificatienummer
Rolcode
Naam
Achternaam
Vaste huisartsenpraktijk
Identificatie
Naam
Adresgegevens
Soort adres
Straatnaam
Huisnummer
Huisnummertoevoeging
Postcode
Gemeente
Woonplaats
Land
Overige contactgegevens
Telefoonnummers
Soort telefoonnummer
Telefoonnummer
Faxnummers
Soort faxnummer
Faxnummer
E-mailadressen
Soort e-mailadres
E-mailadres
Contactpersoon patiënt
Achternaam
Telefoonnummer
Relatie tot patiënt


WID-controle
Gegevenselement Waarde
WID-controle uitgevoerd
WID controle datum
Documentnummer
Document type


Incidentgegevens
Gegevenselement Waarde
Datum/tijd incident


Meldingsgegevens
Gegevenselement Waarde
Datum/tijd melding T1-15min
Geplande brengtijd
Geplande haaltijd
Wzd/Wvggz maatregel
Datum/tijd aanvang TVZ
Medische kladblok meldkamer
Meldkamerurgentie A2


Zorgaanvrager
Gegevenselement Waarde
Initialen
Achternaam
Telefoonnummer
Identificatie
Type zorgaanvrager


Ritgegevens
Gegevenselement Waarde
Ambulancevoorziening 25 (RAV identificatie)
Ritnummer 25-2020-13-1
Ambulancenummer 25190
Telefoon ambulance
Ambulanceverpleegkundige identificatie 596
Ambulancechauffeur identificatie 530
Datum/tijd ritopdracht T1-10 min
Datum/tijd uitruk/vertrek T1-10 min
Datum/tijd aankomst patiënt T1
Datum/tijd vertrek patiënt T1+2 min
Verwachte aankomsttijd bestemming
Datum/tijd aankomst bestemming
Datum/tijd vrijmelding
Soort vervoer


Haalgegevens
Gegevenselement Waarde
Straat
Huisnummer
Huisletter
Huisnummertoevoeging
Postcode
Locatiebeschrijving
Woonplaats
Land
Patiënt vervoerd?
Reden geen vervoer
Tijdstip overlijden patiënt
Advies behandeling tijdens vervoer aanwezig?
Niet reanimeren verklaring aanwezig?
Trialgegevens
Ambulance-urgentie
Gewondennummer
Triageklasse
Hulpverleners ter plaatse
Hulpverlenersnaam
Type hulpverlener
Telefoonnummer
E-mailadres


Bestemmingsgegevens
Gegevenselement Waarde
Bestemmingsstatus in bericht op T3 Overgedragen
Bestemmingscode AGB: 06010860
Locatie of afdeling LSDV-code: 2.16.840.1.113883.2.4.6.1.6010860.000
Straat
Huisnummer
Huisletter
Huisnummertoevoeging
Postcode
Locatiebeschrijving
Woonplaats
Land
Bijzonderheden algemeen
Verwacht specialisme
Feedback
Feedback gewenst
Feedback adres
Feedback methode


Mechanisme
Gegevenselement Waarde
Mechanisme type 35468003 bekneld geraakt tussen voorwerpen (gebeurtenis)
Vervoermiddel patiënt 71783008 auto (fysiek object)
Patiënt was bestuurder? ja
Vervoermiddel contra 71783008 auto (fysiek object)
Beschermingsmiddelen patiënt (3x) 285695004 helm (fysiek object)

60054005 autogordel (fysiek object)
102384007 airbag van motorvoertuig (fysiek object)


Toestandsbeelden/Werkdiagnose
Gegevenselement Waarde
Toestandsbeeld
Toestandsbeeld code 125593007 letsel van aangezicht (aandoening)
Toelichting Toestandsbeeld Moeilijk observeren door weersomstandigheden


Meetwaarden
Gegevenselement Waarde
Bloedsuiker
Bloedsuiker waarde 6 mmol/L
BloedsuikerDatumTijd T3
Hartritme
Hartritme observatie
HartritmeDatumTijd
Toelichting hartritme/ECG
O2Saturatie
SpO2waarde 98%
O2SaturatieDatumTijd T3
Capnometrie
CO2Waarde 35 mm[Hg]
4,7 kPa
CO2CapnometrieDatumTijd T3
Hartfrequentie
HartfrequentieWaarde 90/min
HartfrequentieDatumTijd T3
Bloeddruk
SystolischeBloeddruk 60 mm[Hg]
DiastolischeBloeddruk 50 mm[Hg]
BloeddrukDatumTijd T3
Lichaamstemperatuur
TemperatuurWaarde
TemperatuurDatumTijd
Ademhaling
Ademfrequentie 4/min
AdemhalingDatumTijd T3
GlasgowComaScale
GlasgowComaScaleDatumTijd
GCS_Eyes
GCS_Motor
GCS_Verbal
TotaalScore
Revised Trauma Score
RevisedTraumaScoreWaarde 8
RevisedTraumaScoreTijd T3
Pediatric Trauma Score
PediatricTraumaScoreWaarde
PediatricTraumaScoreTijd
Pijnschaal
PijnschaalWaarde
PijnschaalTijd
APGAR-1
APGAR-5


Behandeling
Gegevenselement Waarde
Ademhaling en beademing (diagnostisch)
Handelingen ademhaling en beademing
Bewustzijn en neurologische status (diagnostisch)
Handelingen bewustzijn en neurologische status
Overige diagnostische handelingen
Handelingen overige diagnostisch
Luchtweg management (therapeutisch)
Handelingen luchtweg management
Moeizame intubatie?
Oxygenatie en ventilatie (therapeutisch)
Handelingen oxygenatie en ventilatie
Beademing machine Fi O2
Beademing machine AMV
Beademing machine Freq.
Beademing machine Peep
Hoeveelheid zuurstof
Circulatie (therapeutisch)
Handelingen circulatie
Pacemaker frequentie
Pacemaker stroomsterkte
Pacemaker modus
Cardioversies aantal
Cardioversie maximale energie
Defibrillaties aantal
Defibrillatie energie
Return Of Spontaneous Circulation (ROSC)
AED aangesloten voor aankomst
AED-schokken aantal
Traumatologie (therapeutisch)
Handelingen traumatologie
Koelen tijdsduur
Obstetrie
Handelingen obstetrie
Wijze van isolatie
Handelingen isolatie
Medicatie
Medicatie toegediend?
Medicatienaam
Toegediende hoeveelheid medicatie
Tijd medicatietoediening
Medicatie toedieningsvorm
IV medicatiesnelheid
Infuus
Infusen aantal
Infuusvloeistofcode
Infuusvloeistoftekst
Infuushoeveelheid
Extra informatie behandeling


Patiëntligging
Gegevenselement Waarde
Type patiëntligging


Primary Survey
Gegevenselement Waarde
Airway
Airway vrij? Ja
Stridor
Breathing
Breathing sufficient? Ja
Breathing observaties
Circulation
Circulation sufficient? Ja
Capillaire refill > 2 seconde?
Huid observatie
Disability
AVPU
Duur buiten bewustzijn
Pupil
FAST symptomen aanwezig
Mogelijk trombolyse/trombectomie
Intoxicatie
Toelichting Primary Survey


Secondary Survey
Gegevenselement Waarde
Anamnese
Ample
Code
Titel
Omschrijving
Toelichting anamnese
Infectierisico
Verdenking infectieziekten?
Toelichting infectierisico
Hoofd en gelaat
Hoofd en gelaat observaties
Bloedverlies
Liquorverlies
Pijnlocatie
Wond
Nek, hals, CWK
Nek, hals, CWK observaties
Wond
Thorax
Thorax observaties
Pijn bij compressie
Locatie subcutaan emfyseem
Locatie zwelling / oedeem (2x)
Wond
Rug
Rug observaties
Wond
Abdomen
Abdomen observaties
Locatie druk- / loslaatpijn
Locatie zwelling / oedeem
Locatie pulserende zwelling
Wond
Bekken
Bekken observaties
Wond
Extremiteiten Armen
Extremiteit
Lateraliteit
Observaties
Wond
Extremiteiten Armen
Extremiteit
Lateraliteit
Observaties
Wond
Extremiteiten Benen
Extremiteit
Lateraliteit
Observaties (2x)
Wond
Uitscheiding
Uitscheiding observaties
Braken
Incontinent
Verloskunde/Gynaecologie
Verloskunde/Gynaecologie observaties
Vruchtwaterverlies
Weeën


Consultgever op afstand
Gegevenselement Waarde
Initialen
Achternaam
Telefoonnummer
Identificatie
Type consultgever
Toelichting/Afspraken met consultgever


Afspraken met patiënt
Gegevenselement Waarde
Huisarts ingelicht
Afspraken met patiënt


Bijlagen T3
Gegevenselement Waarde
Type Bijlage 006 intern rapport/overdracht
Bijlage id 9068
Versie 6
Bijlageset id 12


Toestemmingsgegevens
Gegevenselement Waarde
Wetenschappelijk onderzoek
Beschrijving
Informed consent
Toestemming informeren verwanten


Toelichtingsgegevens
Gegevenselement Waarde
Toelichting algemeen
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