az:VDraft2.2.0 Kwalificatiescript Spoedsamenvatting addendum: verschil tussen versies
| Regel 91: | Regel 91: | ||
|} | |} | ||
<section end="bundel" /> | <section end="bundel" /> | ||
| + | |||
| + | ==Actuele contactmomenten van patiënt== | ||
| + | <section begin=contactmoment01/> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactmoment | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Identificatienummer | ||
| + | |style="background-color: white;"|Contact01 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Contact met | ||
| + | |style="background-color: white;"|* | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|ContactType | ||
| + | |style="background-color: white;"| Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|BeginDatumTijd | ||
| + | |style="background-color: white;"|08-06-2023{11:10} | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|EindDatumTijd | ||
| + | |style="background-color: white;"|08-06-2023{11:30} | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|RedenContact | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Episode | ||
| + | |style="background-color: white;"|EpisodeA20 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end=contactmoment01/> | ||
| + | |||
| + | <section begin=contactmoment11/> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactmoment | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Identificatienummer | ||
| + | |style="background-color: white;"|Contact11 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Contact met | ||
| + | |style="background-color: white;"| * | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|ContactType | ||
| + | |style="background-color: white;"| Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|BeginDatumTijd | ||
| + | |style="background-color: white;"|T-9D{11:10} | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|EindDatumTijd | ||
| + | |style="background-color: white;"|T-9D{11:30} | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|RedenContact | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Episode | ||
| + | |style="background-color: white;"|EpisodeA20 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end=contactmoment11/> | ||
| + | |||
| + | <section begin=contactmoment02 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactmoment | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Identificatienummer | ||
| + | |style="background-color: white;"|Contact02 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Contact met | ||
| + | |style="background-color: white;"| * | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|ContactType | ||
| + | |style="background-color: white;"|Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|BeginDatumTijd | ||
| + | |style="background-color: white;"|T-100D{13:30} | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|EindDatumTijd | ||
| + | |style="background-color: white;"|T-100D{13:50} | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|RedenContact | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Episode | ||
| + | |style="background-color: white;"|EpisodeD02 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end=contactmoment02 /> | ||
| + | |||
| + | <section begin=contactmoment03 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Contactmoment | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="7" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|Identificatienummer | ||
| + | |style="background-color: white;"|Contact03 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|ContactType | ||
| + | |style="background-color: white;"|Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|BeginDatumTijd | ||
| + | |style="background-color: white;"|T-9D{08:30} | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|EindDatumTijd | ||
| + | |style="background-color: white;"|T-9D{08:45} | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="8"|RedenContact | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Episode | ||
| + | |style="background-color: white;"|EpisodeR95 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="8"|ContactMet* | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="56"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|Zorgverlener | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="30"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|ZorgverlenerIdentificatienummer | ||
| + | |style="background-color: white;"| 000001111 (2.16.528.1.1007.3.1 UZI nummer natuurlijke personen; zorgverlener of medewerker met UZI pas) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Specialisme | ||
| + | |style="background-color: white;"| Huisarts (Code = '01.015' in codesysteem 2.16.840.1.113883.2.4.15.111 'RoleCodeNL - zorgverlenertype (personen)') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Naamgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="10"| | ||
| + | |colspan="4"|Voornamen | ||
| + | |style="background-color: white;"|Peter | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Initialen | ||
| + | |style="background-color: white;"|P. | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Roepnaam | ||
| + | |style="background-color: white;"|Peter | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Naamgebruik | ||
| + | |style="background-color: white;"|Eigen geslachtsnaam (Code = 'NL1' in codesysteem 2.16.840.1.113883.2.4.3.11.60.101.5.4 'NaamGebruik') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Geslachtsnaam | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Voorvoegsels | ||
| + | |style="background-color: white;"|van | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Achternaam | ||
| + | |style="background-color: white;"|Pulver | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|GeslachtsnaamPartner | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|VoorvoegselsPartner | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|AchternaamPartner | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Adresgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="10"| | ||
| + | |colspan="4"|Straat | ||
| + | |style="background-color: white;"|Valkendael | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Huisnummer | ||
| + | |style="background-color: white;"|45 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Huisnummerletter | ||
| + | |style="background-color: white;"| A | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Huisnummertoevoeging | ||
| + | |style="background-color: white;"| 2 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|AanduidingBijNummer | ||
| + | |style="background-color: white;"| Bij (Code = 'by' in codesysteem 2.16.840.1.113883.2.4.3.11.60.101.5.3 'AanduidingBijHuisnummer') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Postcode | ||
| + | |style="background-color: white;"|6245 HK | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Woonplaats | ||
| + | |style="background-color: white;"|Maastricht | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Land | ||
| + | |style="background-color: white;"|Nederland | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|AdditioneleInformatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|AdresSoort | ||
| + | |style="background-color: white;"|Werkadres (Code = 'WP' in codesysteem 2.16.840.1.113883.5.1119 'Address Use') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Contactgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |colspan="5"|Telefoonnummers | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Telefoonnummer | ||
| + | |style="background-color: white;"|0211234567 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TelecomType | ||
| + | |style="background-color: white;"|LL | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|NummerSoort | ||
| + | |style="background-color: white;"|Work Place (Code = 'WP' in codesysteem 2.16.840.1.113883.5.1119 'Address Use') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="8"|Zorgaanbieder | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="31"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"| ZorgaanbiederIdentificatienummer | ||
| + | |style="background-color: white;"|00001111 (2.16.528.1.1007.3.3 UZI register abonneenummer (URA); zorgaanbieder die UZI passen aanvraagt) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|OrganisatieNaam | ||
| + | |style="background-color: white;"|Gezondheidscentrum Aesculaap | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|OrganisatieType | ||
| + | |style="background-color: white;"|Z3 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"| Contactgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |colspan="5"| Telefoonnummers | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Telefoonnummer | ||
| + | |style="background-color: white;"|0211234567 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TelecomType | ||
| + | |style="background-color: white;"|LL | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|NummerSoort | ||
| + | |style="background-color: white;"|Work Place (Code = 'WP' in codesysteem 2.16.840.1.113883.5.1119 'Address Use') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"| Emailadressen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Emailadres | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|EmailSoort | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"| Adresgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="10"| | ||
| + | |colspan="4"|Straat | ||
| + | |style="background-color: white;"|Valkendael | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Huisnummer | ||
| + | |style="background-color: white;"|45 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Huisnummerletter | ||
| + | |style="background-color: white;"| A | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Huisnummertoevoeging | ||
| + | |style="background-color: white;"| 2 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|AanduidingBijNummer | ||
| + | |style="background-color: white;"|Bij (Code = 'by' in codesysteem 2.16.840.1.113883.2.4.3.11.60.101.5.3 'AanduidingBijHuisnummer') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Postcode | ||
| + | |style="background-color: white;"|6245 HK | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Woonplaats | ||
| + | |style="background-color: white;"|Maastricht | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Land | ||
| + | |style="background-color: white;"|Nederland | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|AdditioneleInformatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|AdresSoort | ||
| + | |style="background-color: white;"|Werkadres (Code = 'WP' in codesysteem 2.16.840.1.113883.5.1119 'Address Use') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end=contactmoment03 /> | ||
| + | |||
| + | <section begin=contactmoment04 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactmoment | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Identificatienummer | ||
| + | |style="background-color: white;"|Contact04 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Contact met | ||
| + | |style="background-color: white;"| * | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|ContactType | ||
| + | |style="background-color: white;"|Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|BeginDatumTijd | ||
| + | |style="background-color: white;"|T-6D{09:00} | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|EindDatumTijd | ||
| + | |style="background-color: white;"|T-6D{09:15} | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|RedenContact | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Episode | ||
| + | |style="background-color: white;"|EpisodeR95 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end=contactmoment04 /> | ||
| + | |||
| + | <section begin=contactmoment05 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactmoment | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Identificatienummer | ||
| + | |style="background-color: white;"|Contact05 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Contact met | ||
| + | |style="background-color: white;"| * | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|ContactType | ||
| + | |style="background-color: white;"|telefonisch contact (Code = 05 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|BeginDatumTijd | ||
| + | |style="background-color: white;"|T-150D{14:30} | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|EindDatumTijd | ||
| + | |style="background-color: white;"|T-150D{14:50} | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|RedenContact | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Episode | ||
| + | |style="background-color: white;"|EpisodeN88 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end=contactmoment05 /> | ||
| + | |||
| + | ==Actuele contactverslagen van patiënt== | ||
| + | <section begin=contactverslag01/> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactverslag | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Identificatienummer | ||
| + | |style="background-color: white;"|Contactverslag01 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|DatumTijd | ||
| + | |style="background-color: white;"|08-06-2023 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Journaalregel | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="13"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Type | ||
| + | |style="background-color: #E3E3E3;"|Tekst | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|S | ||
| + | |style="background-color: white;"|Weloverwogen besluit voor een niet reanimeerwens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|O | ||
| + | |style="background-color: white;"|Compos mentis | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|E | ||
| + | |style="background-color: white;"|Gesprek levenseinde, niet reanimeren | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|Identificatienummer | ||
| + | |style="background-color: white;"|ProbleemA20 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|ProbleemNaam | ||
| + | |style="background-color: white;"| Gesprek levenseinde/behandelwensen (Code = A20 uit Codesysteem 2.16.840.1.113883.2.4.4.31.1 De Nederlandse editie van International Classification of Primary Care ICPC-1-NL) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|ProbleemBeginDatum | ||
| + | |style="background-color: white;"|08-06-2023 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|ProbleemEindDatum | ||
| + | |style="background-color: white;"|T-1D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|P | ||
| + | |style="background-color: white;"|Wilsverklaring ondertekend | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing Contact | ||
| + | |style="background-color: white;"|Contact01 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing Episode | ||
| + | |style="background-color: white;"|EpisodeA20 | ||
| + | |} | ||
| + | <section end=contactverslag01/> | ||
| + | |||
| + | <section begin=contactverslagtweedeA20/> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactverslag | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Identificatienummer | ||
| + | |style="background-color: white;"|Contactverslag11 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|DatumTijd | ||
| + | |style="background-color: white;"|T-9D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Journaalregel | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Type | ||
| + | |style="background-color: #E3E3E3;"|Tekst | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|S | ||
| + | |style="background-color: white;"|Herevaluatie niet reanimeerwens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|O | ||
| + | |style="background-color: white;"|Compos mentis | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|E | ||
| + | |style="background-color: white;"|Continueer behandelgrens, niet reanimeren | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing Contact | ||
| + | |style="background-color: white;"|Contact11 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing Episode | ||
| + | |style="background-color: white;"|EpisodeA20 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end=contactverslagtweedeA20/> | ||
| + | |||
| + | <section begin=contactverslag02/> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactverslag | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Identificatienummer | ||
| + | |style="background-color: white;"|Contactverslag02 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|DatumTijd | ||
| + | |style="background-color: white;"|T-100D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Journaalregel | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="12"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Type | ||
| + | |style="background-color: #E3E3E3;"|Tekst | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|S | ||
| + | |style="background-color: white;"|In eerste instantie na warm eten enige uren pijn in bovenbuik. Niet misselijk, opboeren soms, opgeblazen gevoel | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|O | ||
| + | |style="background-color: white;"|Maagstreek gevoelig. Overig gb. | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|E | ||
| + | |style="background-color: white;"|Maag/duodenum problemen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|Identificatienummer | ||
| + | |style="background-color: white;"|ProbleemD02 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|ProbleemNaam | ||
| + | |style="background-color: white;"|Maagpijn (Code = D02 uit Codesysteem 2.16.840.1.113883.2.4.4.31.1 De Nederlandse editie van International Classification of Primary Care ICPC-1-NL) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|ProbleemBeginDatum | ||
| + | |style="background-color: white;"|T-100D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|ProbleemEindDatum | ||
| + | |style="background-color: white;"|T-90D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing Contact | ||
| + | |style="background-color: white;"|Contact02 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing Episode | ||
| + | |style="background-color: white;"|EpisodeD02 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end=contactverslag02/> | ||
| + | |||
| + | <section begin=contactverslag03 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactverslag | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Auteur * | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="12"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Zorgverlener | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|ZorgverlenerIdentificatienummer | ||
| + | |style="background-color: white;"| 000001111 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Specialisme | ||
| + | |style="background-color: white;"| Huisarts (Code = '01.015' in codesysteem 2.16.840.1.113883.2.4.15.111 'RoleCodeNL - zorgverlenertype (personen)') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Naamgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Voornamen | ||
| + | |style="background-color: white;"| Peter | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Initialen | ||
| + | |style="background-color: white;"| P. | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Geslachtsnaam | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Voorvoegsels | ||
| + | |style="background-color: white;"|van | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Achternaam | ||
| + | |style="background-color: white;"|Pulver | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Identificatienummer | ||
| + | |style="background-color: white;"|Contactverslag03 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|DatumTijd | ||
| + | |style="background-color: white;"|T-9D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Journaalregel | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="20"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Type | ||
| + | |style="background-color: #E3E3E3;"|Tekst | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|S | ||
| + | |style="background-color: white;"|Gaat beter, nog wel af en toe benauwd/hoesten. Geen koorts, weinig slijm en geen PoB. | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|Identificatienummer | ||
| + | |style="background-color: white;"|ProbleemR05 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|ProbleemNaam | ||
| + | |style="background-color: white;"|Hoesten (Code = R05 uit Codesysteem 2.16.840.1.113883.2.4.4.31.1 De Nederlandse editie van International Classification of Primary Care ICPC-1-NL) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|ProbleemBeginDatum | ||
| + | |style="background-color: white;"|T-9D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|ProbleemEindDatum | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|O | ||
| + | |style="background-color: white;"|Longen VAG geen crep, piep, wel wat rhonchi, Percussie gb | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|E | ||
| + | |style="background-color: white;"|COPD, beterend | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|Identificatienummer | ||
| + | |style="background-color: white;"|ProbleemR95 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|ProbleemNaam | ||
| + | |style="background-color: white;"|Emfyseem/COPD (Code = R95 uit Codesysteem 2.16.840.1.113883.2.4.4.31.1 De Nederlandse editie van International Classification of Primary Care ICPC-1-NL) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|ProbleemBeginDatum | ||
| + | |style="background-color: white;"|T-9D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|ProbleemEindDatum | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|P | ||
| + | |style="background-color: white;"|Controle afspreken POH voor ketenzorg en blaastest, continueren flixotide, zn ventolin | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing Contact | ||
| + | |style="background-color: white;"|Contact03 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing Episode | ||
| + | |style="background-color: white;"|EpisodeR95 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end=contactverslag03 /> | ||
| + | |||
| + | <section begin=contactverslag04 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactverslag | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Identificatienummer | ||
| + | |style="background-color: white;"|Contactverslag04 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|DatumTijd | ||
| + | |style="background-color: white;"|T-6D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Journaalregel | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Type | ||
| + | |style="background-color: #E3E3E3;"|Tekst | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|S | ||
| + | |style="background-color: white;"|Gaat slechter. Medicatie slaat niet aan aldus pat. Koorts -, Hoest +++, Slijm geel | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|O | ||
| + | |style="background-color: white;"|Longen VAG crep+, piep iets, rhonchi+. Percussie gb. | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|E | ||
| + | |style="background-color: white;"|COPD, exacerbatie. | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|P | ||
| + | |style="background-color: white;"|AB starten, ventolin 3-4 dgs. | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing Contact | ||
| + | |style="background-color: white;"|Contact04 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing Episode | ||
| + | |style="background-color: white;"|EpisodeR95 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end=contactverslag04 /> | ||
| + | |||
| + | <section begin=contactverslagepilepsie/> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Contactverslag | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Identificatienummer | ||
| + | |style="background-color: white;"|Contactverslag05 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|DatumTijd | ||
| + | |style="background-color: white;"|T-150D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Journaalregel | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="11"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Type | ||
| + | |style="background-color: #E3E3E3;"|Tekst | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|S | ||
| + | |style="background-color: white;"|Belt voor herhaalrecept | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|E | ||
| + | |style="background-color: white;"|Bekend met epilepsie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|Identificatienummer | ||
| + | |style="background-color: white;"|ProbleemN88 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|ProbleemNaam | ||
| + | |style="background-color: white;"|Epilepsie (Code = N88 uit Codesysteem 2.16.840.1.113883.2.4.4.31.1 De Nederlandse editie van International Classification of Primary Care ICPC-1-NL) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|ProbleemBeginDatum | ||
| + | |style="background-color: white;"|T-1010D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|ProbleemEindDatum | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing Contact | ||
| + | |style="background-color: white;"|Contact05 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing Episode | ||
| + | |style="background-color: white;"|EpisodeN88 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end=contactverslagepilepsie/> | ||
| + | |||
| + | ==Beschikbaarstellen actuele episodes van patiënt== | ||
| + | <section begin=episode01 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Episode | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Identificatie | ||
| + | |style="background-color: white;"|EpisodeN88 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Episodetitel = ICPC-omschrijving | ||
| + | |style="background-color: white;"|Epilepsie (alle vormen) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Status | ||
| + | |style="background-color: white;"|Open (code = ‘active’ in codeSystem 2.16.840.1.113883.5.14 ‘ActStatus’) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Startdatum | ||
| + | |style="background-color: white;"| T-1010D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Einddatum | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing Probleem | ||
| + | |style="background-color: white;"|ProbleemN88 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Attentiewaarde | ||
| + | |style="background-color: white;"| Ja | ||
| + | |} | ||
| + | <section end=episode01 /> | ||
| + | |||
| + | <section begin=episode02 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Episode | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Identificatie | ||
| + | |style="background-color: white;"|EpisodeA20 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|ICPC omschrijving | ||
| + | |style="background-color: white;"|Gesprek levenseinde/behandelwensen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Episodetitel (eigen omschrijving) | ||
| + | |style="background-color: white;"|08-06-2023 besluit met patient. Wilsverklaring: niet reanimeren. PZP:Z wel, IC wel, B wel, BP wel, AB wel | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Status | ||
| + | |style="background-color: white;"|Gesloten (code = ‘completed’ in codeSystem 2.16.840.1.113883.5.14 ‘ActStatus’) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Startdatum | ||
| + | |style="background-color: white;"| 08-06-2023 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Einddatum | ||
| + | |style="background-color: white;"| T-1D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing Probleem | ||
| + | |style="background-color: white;"|ProbleemA20 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Attentiewaarde | ||
| + | |style="background-color: white;"| Ja | ||
| + | |} | ||
| + | <section end=episode02 /> | ||
| + | |||
| + | <section begin=episode03 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Episode | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Identificatie | ||
| + | |style="background-color: white;"|EpisodeD02 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Episodetitel = ICPC-omschrijving | ||
| + | |style="background-color: white;"|Maagpijn | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Status | ||
| + | |style="background-color: white;"|Gesloten (code = ‘completed’ in codeSystem 2.16.840.1.113883.5.14 ‘ActStatus’) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Startdatum | ||
| + | |style="background-color: white;"|T-100D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Einddatum | ||
| + | |style="background-color: white;"|T-90D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing Probleem | ||
| + | |style="background-color: white;"|ProbleemD02 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Attentiewaarde | ||
| + | |style="background-color: white;"| Nee | ||
| + | |} | ||
| + | <section end=episode03 /> | ||
| + | |||
| + | <section begin=episode04 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Episode | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Auteur * | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="12"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Zorgverlener | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|ZorgverlenerIdentificatienummer | ||
| + | |style="background-color: white;"| 000001111 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Specialisme | ||
| + | |style="background-color: white;"| Huisarts (Code = '01.015' in codesysteem 2.16.840.1.113883.2.4.15.111 'RoleCodeNL - zorgverlenertype (personen)') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Naamgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Voornamen | ||
| + | |style="background-color: white;"|Peter | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Initialen | ||
| + | |style="background-color: white;"| P. | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Geslachtsnaam | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Voorvoegsels | ||
| + | |style="background-color: white;"|van | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Achternaam | ||
| + | |style="background-color: white;"|Pulver | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Identificatie | ||
| + | |style="background-color: white;"|EpisodeR95 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|ICPC omschrijving | ||
| + | |style="background-color: white;"|Emfyseem/COPD | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Episodetitel (eigen omschrijving) | ||
| + | |style="background-color: white;"|COPD | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Status | ||
| + | |style="background-color: white;"|Open (code = ‘active’ in codeSystem 2.16.840.1.113883.5.14 ‘ActStatus’) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Startdatum | ||
| + | |style="background-color: white;"| T-9D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Einddatum | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing Probleem | ||
| + | |style="background-color: white;"|ProbleemR95 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Attentiewaarde | ||
| + | |style="background-color: white;"| Nee | ||
| + | |} | ||
| + | <section end=episode04 /> | ||
| + | |||
| + | ==Beschikbaarstellen actuele labbepalingen van patiënt== | ||
| + | <section begin=lab01 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | LaboratoriumUitslag | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|LaboratoriumTest | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Identificatienummer | ||
| + | |style="background-color: white;"|LabTest01 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TestCode | ||
| + | |style="background-color: white;"|Huidsets hondepitheel (code = '2626' in codeSystem 'NHG Diagnostische bepalingen') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TestDatumTijd | ||
| + | |style="background-color: white;"|T-9D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TestUitslag | ||
| + | |style="background-color: white;"|Twijfelachtig (code 312) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieBovengrens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieOndergrens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagInterpretatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing contact | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing episode | ||
| + | |style="background-color: white;"| | ||
| + | |} | ||
| + | <section end=lab01 /> | ||
| + | |||
| + | <section begin=lab02 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | LaboratoriumUitslag | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|LaboratoriumTest | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Identificatienummer | ||
| + | |style="background-color: white;"|LabTest02 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TestCode | ||
| + | |style="background-color: white;"|MultiRAST (phadiaTop) (code = '852' in codeSystem 'NHG Diagnostische bepalingen') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TestDatumTijd | ||
| + | |style="background-color: white;"|T-9D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TestUitslag | ||
| + | |style="background-color: white;"| ‘’Positief’’ (Vrije tekst) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieBovengrens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieOndergrens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagInterpretatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing contact | ||
| + | |style="background-color: white;"|Contact03 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing episode | ||
| + | |style="background-color: white;"|EpisodeR95 | ||
| + | |} | ||
| + | <section end=lab02 /> | ||
| + | |||
| + | <section begin=lab03 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | LaboratoriumUitslag | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|LaboratoriumTest | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Identificatienummer | ||
| + | |style="background-color: white;"|LabTest03 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TestCode | ||
| + | |style="background-color: white;"|kweek MultiRes.Staf.Aur. (MRSA) keel (code = '2654' in codeSystem 'NHG Diagnostische bepalingen') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TestDatumTijd | ||
| + | |style="background-color: white;"|T-6D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TestUitslag | ||
| + | |style="background-color: white;"|Positief (vrije tekst) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieBovengrens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieOndergrens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagInterpretatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing contact | ||
| + | |style="background-color: white;"|Contact03 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing episode | ||
| + | |style="background-color: white;"|EpisodeR95 | ||
| + | |} | ||
| + | <section end=lab03 /> | ||
| + | |||
| + | <section begin=lab04 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | LaboratoriumUitslag | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|LaboratoriumTest | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Identificatienummer | ||
| + | |style="background-color: white;"|LabTest04 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TestCode | ||
| + | |style="background-color: white;"|Glucose nuchter, veneus (code = '372' in codeSystem 'NHG Diagnostische bepalingen') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TestDatumTijd | ||
| + | |style="background-color: white;"|T-6D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TestUitslag | ||
| + | |style="background-color: white;"|4,5 mmol/L | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieBovengrens | ||
| + | |style="background-color: white;"|6,1 mmol/L | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieOndergrens | ||
| + | |style="background-color: white;"|4,0 mmol/L | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagInterpretatie | ||
| + | |style="background-color: white;"|Normal (code=N codesysteem 2.16.840.1.113883.5.83) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing contact | ||
| + | |style="background-color: white;"|Contact04 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing episode | ||
| + | |style="background-color: white;"|EpisodeR95 | ||
| + | |} | ||
| + | <section end=lab04 /> | ||
| + | |||
| + | ==Beschikbaarstellen actuele algemene bepalingen van patiënt== | ||
| + | <section begin=AlgBep01 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|MeetUitslag | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Identificatienummer | ||
| + | |style="background-color: white;"|AlgBep01 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|MetingNaam | ||
| + | |style="background-color: white;"|Systolische bloeddruk (1744) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagWaarde | ||
| + | |style="background-color: white;"|184 mm[Hg] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagDatumTijd | ||
| + | |style="background-color: white;"|08-06-2023 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieOndergrens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieBovengrens | ||
| + | |style="background-color: white;"| 140 mm[Hg] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagInterpretatie | ||
| + | |style="background-color: white;"|High (code= H codesysteem 2.16.840.1.113883.5.83) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing contact | ||
| + | |style="background-color: white;"|Contact01 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing episode | ||
| + | |style="background-color: white;"| | ||
| + | |} | ||
| + | <section end=AlgBep01 /> | ||
| + | |||
| + | <section begin=AlgBep02 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|MeetUitslag | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Identificatienummer | ||
| + | |style="background-color: white;"|AlgBep02 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|MetingNaam | ||
| + | |style="background-color: white;"|Diastolische bloeddruk (1740) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagWaarde | ||
| + | |style="background-color: white;"|93 mm[Hg] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagDatumTijd | ||
| + | |style="background-color: white;"|08-06-2023 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieOndergrens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieBovengrens | ||
| + | |style="background-color: white;"| 89 mm[Hg] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagInterpretatie | ||
| + | |style="background-color: white;"|Normal (code=N codesysteem 2.16.840.1.113883.5.83) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing contact | ||
| + | |style="background-color: white;"|Contact01 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing episode | ||
| + | |style="background-color: white;"| | ||
| + | |} | ||
| + | <section end=AlgBep02 /> | ||
| + | |||
| + | <section begin=AlgBep04 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|MeetUitslag | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Identificatienummer | ||
| + | |style="background-color: white;"|AlgBep04 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|MetingNaam | ||
| + | |style="background-color: white;"|FEV1/FVC ratio pré-BD (1675) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagWaarde | ||
| + | |style="background-color: white;"|66% | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagDatumTijd | ||
| + | |style="background-color: white;"|T-9D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieOndergrens | ||
| + | |style="background-color: white;"|70% | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieBovengrens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagInterpretatie | ||
| + | |style="background-color: white;"|Low (code=L codesysteem 2.16.840.1.113883.5.83) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing contact | ||
| + | |style="background-color: white;"|Contact03 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing episode | ||
| + | |style="background-color: white;"|EpisodeR95 | ||
| + | |} | ||
| + | <section end=AlgBep04 /> | ||
| + | |||
| + | <section begin=AlgBep05 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|MeetUitslag | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Identificatienummer | ||
| + | |style="background-color: white;"|AlgBep05 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|MetingNaam | ||
| + | |style="background-color: white;"|Conclusie longfunctieonderzoek (1704) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagWaarde | ||
| + | |style="background-color: white;"|COPD (vrije tekst) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagDatumTijd | ||
| + | |style="background-color: white;"|T-9D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieOndergrens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieBovengrens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagInterpretatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing contact | ||
| + | |style="background-color: white;"|Contact03 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing episode | ||
| + | |style="background-color: white;"|EpisodeR95 | ||
| + | |} | ||
| + | <section end=AlgBep05 /> | ||
| + | |||
| + | <section begin=AlgBep06 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|MeetUitslag | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Identificatienummer | ||
| + | |style="background-color: white;"|AlgBep06 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|MetingNaam | ||
| + | |style="background-color: white;"|Roken (1739) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagWaarde | ||
| + | |style="background-color: white;"|Voorheen (4) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagDatumTijd | ||
| + | |style="background-color: white;"|T-9D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieOndergrens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieBovengrens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagInterpretatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing contact | ||
| + | |style="background-color: white;"|Contact03 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing episode | ||
| + | |style="background-color: white;"|EpisodeR95 | ||
| + | |} | ||
| + | <section end=AlgBep06 /> | ||
| + | |||
| + | <section begin=AlgBep07 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|MeetUitslag | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Identificatienummer | ||
| + | |style="background-color: white;"|AlgBep07 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|MetingNaam | ||
| + | |style="background-color: white;"|Aantal jaren gerookt (1991) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagWaarde | ||
| + | |style="background-color: white;"|10 jaar | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagDatumTijd | ||
| + | |style="background-color: white;"|T-9D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieOndergrens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieBovengrens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagInterpretatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing contact | ||
| + | |style="background-color: white;"|Contact03 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing episode | ||
| + | |style="background-color: white;"|EpisodeR95 | ||
| + | |} | ||
| + | <section end=AlgBep07 /> | ||
| + | |||
| + | <section begin=AlgBep08 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|MeetUitslag | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Identificatienummer | ||
| + | |style="background-color: white;"|AlgBep08 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|MetingNaam | ||
| + | |style="background-color: white;"|Temperatuur patiënt (in oor gemeten) (1913) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagWaarde | ||
| + | |style="background-color: white;"|37.5 Cel | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagDatumTijd | ||
| + | |style="background-color: white;"|T-6D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieOndergrens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieBovengrens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagInterpretatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing contact | ||
| + | |style="background-color: white;"|Contact04 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing episode | ||
| + | |style="background-color: white;"|EpisodeR95 | ||
| + | |} | ||
| + | <section end=AlgBep08 /> | ||
| + | |||
| + | <section begin=AlgBep09 /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | AlgemeneBepaling | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|MeetUitslag | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Identificatienummer | ||
| + | |style="background-color: white;"|AlgBep09 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|MetingNaam | ||
| + | |style="background-color: white;"|Stadium COPD (GOLD classificatie) (2209) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagWaarde | ||
| + | |style="background-color: white;"|1:mild COPD (255) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagDatumTijd | ||
| + | |style="background-color: white;"|T-6D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieOndergrens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|ReferentieBovengrens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|UitslagInterpretatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing contact | ||
| + | |style="background-color: white;"|Contact04 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwijzing episode | ||
| + | |style="background-color: white;"|EpisodeR95 | ||
| + | |} | ||
| + | <section end=AlgBep09 /> | ||
Versie van 24 sep 2025 om 11:53
| Bundel | ||||||
| Gegevenselement | Waarde | |||||
| Onderwerp | ||||||
| Patient | ||||||
| Naamgegevens | ||||||
| Voornamen | Antoin | |||||
| Initialen | A. | |||||
| Roepnaam | ||||||
| Geslachtsnaam | ||||||
| Voorvoegsels | ||||||
| Achternaam | XXX_Gieteling | |||||
| GeslachtsnaamPartner | ||||||
| VoorvoegselsPartner | ||||||
| AchternaamPartner | ||||||
| Adresgegevens | ||||||
| Straat | Knolweg | |||||
| Huisnummer | 1002 | |||||
| Huisnummerletter | ||||||
| Huisnummertoevoeging | ||||||
| AanduidingBijNummer | ||||||
| Postcode | 9999ZZ | |||||
| Woonplaats | STITSWERD | |||||
| Land | Nederland | |||||
| AdditioneleInformatie | ||||||
| AdresSoort | Primair huisadres (Code = 'HP' in codesysteem 2.16.840.1.113883.5.1119 'Address Use') | |||||
| Identificatienummer | 999910528 (BSN) | |||||
| Geboortedatum | 19540806 | |||||
| Geslacht | man (Code = M in codesysteem 2.16.840.1.113883.5.1 'Administrative Gender') | |||||
| MeerlingIndicator | Nee | |||||
Inhoud
Actuele contactmomenten van patiënt
| Contactmoment | |||||
| Gegevenselement | Waarde | ||||
| Identificatienummer | Contact01 | ||||
| Contact met | * | ||||
| ContactType | Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | ||||
| BeginDatumTijd | 08-06-2023{11:10} | ||||
| EindDatumTijd | 08-06-2023{11:30} | ||||
| RedenContact | |||||
| Episode | EpisodeA20 | ||||
| Contactmoment | |||||
| Gegevenselement | Waarde | ||||
| Identificatienummer | Contact11 | ||||
| Contact met | * | ||||
| ContactType | Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | ||||
| BeginDatumTijd | T-9D{11:10} | ||||
| EindDatumTijd | T-9D{11:30} | ||||
| RedenContact | |||||
| Episode | EpisodeA20 | ||||
| Contactmoment | |||||
| Gegevenselement | Waarde | ||||
| Identificatienummer | Contact02 | ||||
| Contact met | * | ||||
| ContactType | Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | ||||
| BeginDatumTijd | T-100D{13:30} | ||||
| EindDatumTijd | T-100D{13:50} | ||||
| RedenContact | |||||
| Episode | EpisodeD02 | ||||
| Contactmoment | |||||||
| Gegevenselement | Waarde | ||||||
| Identificatienummer | Contact03 | ||||||
| ContactType | Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | ||||||
| BeginDatumTijd | T-9D{08:30} | ||||||
| EindDatumTijd | T-9D{08:45} | ||||||
| RedenContact | |||||||
| Episode | EpisodeR95 | ||||||
| ContactMet* | |||||||
| Zorgverlener | |||||||
| ZorgverlenerIdentificatienummer | 000001111 (2.16.528.1.1007.3.1 UZI nummer natuurlijke personen; zorgverlener of medewerker met UZI pas) | ||||||
| Specialisme | Huisarts (Code = '01.015' in codesysteem 2.16.840.1.113883.2.4.15.111 'RoleCodeNL - zorgverlenertype (personen)') | ||||||
| Naamgegevens | |||||||
| Voornamen | Peter | ||||||
| Initialen | P. | ||||||
| Roepnaam | Peter | ||||||
| Naamgebruik | Eigen geslachtsnaam (Code = 'NL1' in codesysteem 2.16.840.1.113883.2.4.3.11.60.101.5.4 'NaamGebruik') | ||||||
| Geslachtsnaam | |||||||
| Voorvoegsels | van | ||||||
| Achternaam | Pulver | ||||||
| GeslachtsnaamPartner | |||||||
| VoorvoegselsPartner | |||||||
| AchternaamPartner | |||||||
| Adresgegevens | |||||||
| Straat | Valkendael | ||||||
| Huisnummer | 45 | ||||||
| Huisnummerletter | A | ||||||
| Huisnummertoevoeging | 2 | ||||||
| AanduidingBijNummer | Bij (Code = 'by' in codesysteem 2.16.840.1.113883.2.4.3.11.60.101.5.3 'AanduidingBijHuisnummer') | ||||||
| Postcode | 6245 HK | ||||||
| Woonplaats | Maastricht | ||||||
| Land | Nederland | ||||||
| AdditioneleInformatie | |||||||
| AdresSoort | Werkadres (Code = 'WP' in codesysteem 2.16.840.1.113883.5.1119 'Address Use') | ||||||
| Contactgegevens | |||||||
| Telefoonnummers | |||||||
| Telefoonnummer | 0211234567 | ||||||
| TelecomType | LL | ||||||
| NummerSoort | Work Place (Code = 'WP' in codesysteem 2.16.840.1.113883.5.1119 'Address Use') | ||||||
| Zorgaanbieder | |||||||
| ZorgaanbiederIdentificatienummer | 00001111 (2.16.528.1.1007.3.3 UZI register abonneenummer (URA); zorgaanbieder die UZI passen aanvraagt) | ||||||
| OrganisatieNaam | Gezondheidscentrum Aesculaap | ||||||
| OrganisatieType | Z3 | ||||||
| Contactgegevens | |||||||
| Telefoonnummers | |||||||
| Telefoonnummer | 0211234567 | ||||||
| TelecomType | LL | ||||||
| NummerSoort | Work Place (Code = 'WP' in codesysteem 2.16.840.1.113883.5.1119 'Address Use') | ||||||
| Emailadressen | |||||||
| Emailadres | |||||||
| EmailSoort | |||||||
| Adresgegevens | |||||||
| Straat | Valkendael | ||||||
| Huisnummer | 45 | ||||||
| Huisnummerletter | A | ||||||
| Huisnummertoevoeging | 2 | ||||||
| AanduidingBijNummer | Bij (Code = 'by' in codesysteem 2.16.840.1.113883.2.4.3.11.60.101.5.3 'AanduidingBijHuisnummer') | ||||||
| Postcode | 6245 HK | ||||||
| Woonplaats | Maastricht | ||||||
| Land | Nederland | ||||||
| AdditioneleInformatie | |||||||
| AdresSoort | Werkadres (Code = 'WP' in codesysteem 2.16.840.1.113883.5.1119 'Address Use') | ||||||
| Contactmoment | |||||
| Gegevenselement | Waarde | ||||
| Identificatienummer | Contact04 | ||||
| Contact met | * | ||||
| ContactType | Consult (Code = 03 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | ||||
| BeginDatumTijd | T-6D{09:00} | ||||
| EindDatumTijd | T-6D{09:15} | ||||
| RedenContact | |||||
| Episode | EpisodeR95 | ||||
| Contactmoment | |||||
| Gegevenselement | Waarde | ||||
| Identificatienummer | Contact05 | ||||
| Contact met | * | ||||
| ContactType | telefonisch contact (Code = 05 in codesysteem 2.16.840.1.113883.2.4.4.30.14 'NHG Contactwijze') | ||||
| BeginDatumTijd | T-150D{14:30} | ||||
| EindDatumTijd | T-150D{14:50} | ||||
| RedenContact | |||||
| Episode | EpisodeN88 | ||||
Actuele contactverslagen van patiënt
| Contactverslag | |||||
| Gegevenselement | Waarde | ||||
| Identificatienummer | Contactverslag01 | ||||
| DatumTijd | 08-06-2023 | ||||
| Journaalregel | |||||
| Type | Tekst | ||||
| S | Weloverwogen besluit voor een niet reanimeerwens | ||||
| O | Compos mentis | ||||
| E | Gesprek levenseinde, niet reanimeren | ||||
| Probleem | |||||
| Identificatienummer | ProbleemA20 | ||||
| ProbleemNaam | Gesprek levenseinde/behandelwensen (Code = A20 uit Codesysteem 2.16.840.1.113883.2.4.4.31.1 De Nederlandse editie van International Classification of Primary Care ICPC-1-NL) | ||||
| ProbleemBeginDatum | 08-06-2023 | ||||
| ProbleemEindDatum | T-1D | ||||
| P | Wilsverklaring ondertekend | ||||
| Verwijzing Contact | Contact01 | ||||
| Verwijzing Episode | EpisodeA20 | ||||
| Contactverslag | |||||
| Gegevenselement | Waarde | ||||
| Identificatienummer | Contactverslag11 | ||||
| DatumTijd | T-9D | ||||
| Journaalregel | |||||
| Type | Tekst | ||||
| S | Herevaluatie niet reanimeerwens | ||||
| O | Compos mentis | ||||
| E | Continueer behandelgrens, niet reanimeren | ||||
| Verwijzing Contact | Contact11 | ||||
| Verwijzing Episode | EpisodeA20 | ||||
| Contactverslag | |||||
| Gegevenselement | Waarde | ||||
| Identificatienummer | Contactverslag02 | ||||
| DatumTijd | T-100D | ||||
| Journaalregel | |||||
| Type | Tekst | ||||
| S | In eerste instantie na warm eten enige uren pijn in bovenbuik. Niet misselijk, opboeren soms, opgeblazen gevoel | ||||
| O | Maagstreek gevoelig. Overig gb. | ||||
| E | Maag/duodenum problemen | ||||
| Probleem | |||||
| Identificatienummer | ProbleemD02 | ||||
| ProbleemNaam | Maagpijn (Code = D02 uit Codesysteem 2.16.840.1.113883.2.4.4.31.1 De Nederlandse editie van International Classification of Primary Care ICPC-1-NL) | ||||
| ProbleemBeginDatum | T-100D | ||||
| ProbleemEindDatum | T-90D | ||||
| Verwijzing Contact | Contact02 | ||||
| Verwijzing Episode | EpisodeD02 | ||||
| Contactverslag | |||||
| Gegevenselement | Waarde | ||||
| Auteur * | |||||
| Zorgverlener | |||||
| ZorgverlenerIdentificatienummer | 000001111 | ||||
| Specialisme | Huisarts (Code = '01.015' in codesysteem 2.16.840.1.113883.2.4.15.111 'RoleCodeNL - zorgverlenertype (personen)') | ||||
| Naamgegevens | |||||
| Voornamen | Peter | ||||
| Initialen | P. | ||||
| Geslachtsnaam | |||||
| Voorvoegsels | van | ||||
| Achternaam | Pulver | ||||
| Identificatienummer | Contactverslag03 | ||||
| DatumTijd | T-9D | ||||
| Journaalregel | |||||
| Type | Tekst | ||||
| S | Gaat beter, nog wel af en toe benauwd/hoesten. Geen koorts, weinig slijm en geen PoB. | ||||
| Probleem | |||||
| Identificatienummer | ProbleemR05 | ||||
| ProbleemNaam | Hoesten (Code = R05 uit Codesysteem 2.16.840.1.113883.2.4.4.31.1 De Nederlandse editie van International Classification of Primary Care ICPC-1-NL) | ||||
| ProbleemBeginDatum | T-9D | ||||
| ProbleemEindDatum | |||||
| O | Longen VAG geen crep, piep, wel wat rhonchi, Percussie gb | ||||
| E | COPD, beterend | ||||
| Probleem | |||||
| Identificatienummer | ProbleemR95 | ||||
| ProbleemNaam | Emfyseem/COPD (Code = R95 uit Codesysteem 2.16.840.1.113883.2.4.4.31.1 De Nederlandse editie van International Classification of Primary Care ICPC-1-NL) | ||||
| ProbleemBeginDatum | T-9D | ||||
| ProbleemEindDatum | |||||
| P | Controle afspreken POH voor ketenzorg en blaastest, continueren flixotide, zn ventolin | ||||
| Verwijzing Contact | Contact03 | ||||
| Verwijzing Episode | EpisodeR95 | ||||
| Contactverslag | |||||
| Gegevenselement | Waarde | ||||
| Identificatienummer | Contactverslag04 | ||||
| DatumTijd | T-6D | ||||
| Journaalregel | |||||
| Type | Tekst | ||||
| S | Gaat slechter. Medicatie slaat niet aan aldus pat. Koorts -, Hoest +++, Slijm geel | ||||
| O | Longen VAG crep+, piep iets, rhonchi+. Percussie gb. | ||||
| E | COPD, exacerbatie. | ||||
| P | AB starten, ventolin 3-4 dgs. | ||||
| Verwijzing Contact | Contact04 | ||||
| Verwijzing Episode | EpisodeR95 | ||||
| Contactverslag | |||||
| Gegevenselement | Waarde | ||||
| Identificatienummer | Contactverslag05 | ||||
| DatumTijd | T-150D | ||||
| Journaalregel | |||||
| Type | Tekst | ||||
| S | Belt voor herhaalrecept | ||||
| E | Bekend met epilepsie | ||||
| Probleem | |||||
| Identificatienummer | ProbleemN88 | ||||
| ProbleemNaam | Epilepsie (Code = N88 uit Codesysteem 2.16.840.1.113883.2.4.4.31.1 De Nederlandse editie van International Classification of Primary Care ICPC-1-NL) | ||||
| ProbleemBeginDatum | T-1010D | ||||
| ProbleemEindDatum | |||||
| Verwijzing Contact | Contact05 | ||||
| Verwijzing Episode | EpisodeN88 | ||||
Beschikbaarstellen actuele episodes van patiënt
| Episode | |||||
| Gegevenselement | Waarde | ||||
| Identificatie | EpisodeN88 | ||||
| Episodetitel = ICPC-omschrijving | Epilepsie (alle vormen) | ||||
| Status | Open (code = ‘active’ in codeSystem 2.16.840.1.113883.5.14 ‘ActStatus’) | ||||
| Startdatum | T-1010D | ||||
| Einddatum | |||||
| Verwijzing Probleem | ProbleemN88 | ||||
| Attentiewaarde | Ja | ||||
| Episode | |||||
| Gegevenselement | Waarde | ||||
| Identificatie | EpisodeA20 | ||||
| ICPC omschrijving | Gesprek levenseinde/behandelwensen | ||||
| Episodetitel (eigen omschrijving) | 08-06-2023 besluit met patient. Wilsverklaring: niet reanimeren. PZP:Z wel, IC wel, B wel, BP wel, AB wel | ||||
| Status | Gesloten (code = ‘completed’ in codeSystem 2.16.840.1.113883.5.14 ‘ActStatus’) | ||||
| Startdatum | 08-06-2023 | ||||
| Einddatum | T-1D | ||||
| Verwijzing Probleem | ProbleemA20 | ||||
| Attentiewaarde | Ja | ||||
| Episode | |||||
| Gegevenselement | Waarde | ||||
| Identificatie | EpisodeD02 | ||||
| Episodetitel = ICPC-omschrijving | Maagpijn | ||||
| Status | Gesloten (code = ‘completed’ in codeSystem 2.16.840.1.113883.5.14 ‘ActStatus’) | ||||
| Startdatum | T-100D | ||||
| Einddatum | T-90D | ||||
| Verwijzing Probleem | ProbleemD02 | ||||
| Attentiewaarde | Nee | ||||
| Episode | |||||
| Gegevenselement | Waarde | ||||
| Auteur * | |||||
| Zorgverlener | |||||
| ZorgverlenerIdentificatienummer | 000001111 | ||||
| Specialisme | Huisarts (Code = '01.015' in codesysteem 2.16.840.1.113883.2.4.15.111 'RoleCodeNL - zorgverlenertype (personen)') | ||||
| Naamgegevens | |||||
| Voornamen | Peter | ||||
| Initialen | P. | ||||
| Geslachtsnaam | |||||
| Voorvoegsels | van | ||||
| Achternaam | Pulver | ||||
| Identificatie | EpisodeR95 | ||||
| ICPC omschrijving | Emfyseem/COPD | ||||
| Episodetitel (eigen omschrijving) | COPD | ||||
| Status | Open (code = ‘active’ in codeSystem 2.16.840.1.113883.5.14 ‘ActStatus’) | ||||
| Startdatum | T-9D | ||||
| Einddatum | |||||
| Verwijzing Probleem | ProbleemR95 | ||||
| Attentiewaarde | Nee | ||||
Beschikbaarstellen actuele labbepalingen van patiënt
| LaboratoriumUitslag | |||||
| Gegevenselement | Waarde | ||||
| LaboratoriumTest | |||||
| Identificatienummer | LabTest01 | ||||
| TestCode | Huidsets hondepitheel (code = '2626' in codeSystem 'NHG Diagnostische bepalingen') | ||||
| TestDatumTijd | T-9D | ||||
| TestUitslag | Twijfelachtig (code 312) | ||||
| ReferentieBovengrens | |||||
| ReferentieOndergrens | |||||
| UitslagInterpretatie | |||||
| Verwijzing contact | |||||
| Verwijzing episode | |||||
| LaboratoriumUitslag | |||||
| Gegevenselement | Waarde | ||||
| LaboratoriumTest | |||||
| Identificatienummer | LabTest02 | ||||
| TestCode | MultiRAST (phadiaTop) (code = '852' in codeSystem 'NHG Diagnostische bepalingen') | ||||
| TestDatumTijd | T-9D | ||||
| TestUitslag | ‘’Positief’’ (Vrije tekst) | ||||
| ReferentieBovengrens | |||||
| ReferentieOndergrens | |||||
| UitslagInterpretatie | |||||
| Verwijzing contact | Contact03 | ||||
| Verwijzing episode | EpisodeR95 | ||||
| LaboratoriumUitslag | |||||
| Gegevenselement | Waarde | ||||
| LaboratoriumTest | |||||
| Identificatienummer | LabTest03 | ||||
| TestCode | kweek MultiRes.Staf.Aur. (MRSA) keel (code = '2654' in codeSystem 'NHG Diagnostische bepalingen') | ||||
| TestDatumTijd | T-6D | ||||
| TestUitslag | Positief (vrije tekst) | ||||
| ReferentieBovengrens | |||||
| ReferentieOndergrens | |||||
| UitslagInterpretatie | |||||
| Verwijzing contact | Contact03 | ||||
| Verwijzing episode | EpisodeR95 | ||||
| LaboratoriumUitslag | |||||
| Gegevenselement | Waarde | ||||
| LaboratoriumTest | |||||
| Identificatienummer | LabTest04 | ||||
| TestCode | Glucose nuchter, veneus (code = '372' in codeSystem 'NHG Diagnostische bepalingen') | ||||
| TestDatumTijd | T-6D | ||||
| TestUitslag | 4,5 mmol/L | ||||
| ReferentieBovengrens | 6,1 mmol/L | ||||
| ReferentieOndergrens | 4,0 mmol/L | ||||
| UitslagInterpretatie | Normal (code=N codesysteem 2.16.840.1.113883.5.83) | ||||
| Verwijzing contact | Contact04 | ||||
| Verwijzing episode | EpisodeR95 | ||||
Beschikbaarstellen actuele algemene bepalingen van patiënt
| AlgemeneBepaling | |||||
| Gegevenselement | Waarde | ||||
| MeetUitslag | |||||
| Identificatienummer | AlgBep01 | ||||
| MetingNaam | Systolische bloeddruk (1744) | ||||
| UitslagWaarde | 184 mm[Hg] | ||||
| UitslagDatumTijd | 08-06-2023 | ||||
| ReferentieOndergrens | |||||
| ReferentieBovengrens | 140 mm[Hg] | ||||
| UitslagInterpretatie | High (code= H codesysteem 2.16.840.1.113883.5.83) | ||||
| Verwijzing contact | Contact01 | ||||
| Verwijzing episode | |||||
| AlgemeneBepaling | |||||
| Gegevenselement | Waarde | ||||
| MeetUitslag | |||||
| Identificatienummer | AlgBep02 | ||||
| MetingNaam | Diastolische bloeddruk (1740) | ||||
| UitslagWaarde | 93 mm[Hg] | ||||
| UitslagDatumTijd | 08-06-2023 | ||||
| ReferentieOndergrens | |||||
| ReferentieBovengrens | 89 mm[Hg] | ||||
| UitslagInterpretatie | Normal (code=N codesysteem 2.16.840.1.113883.5.83) | ||||
| Verwijzing contact | Contact01 | ||||
| Verwijzing episode | |||||
| AlgemeneBepaling | |||||
| Gegevenselement | Waarde | ||||
| MeetUitslag | |||||
| Identificatienummer | AlgBep04 | ||||
| MetingNaam | FEV1/FVC ratio pré-BD (1675) | ||||
| UitslagWaarde | 66% | ||||
| UitslagDatumTijd | T-9D | ||||
| ReferentieOndergrens | 70% | ||||
| ReferentieBovengrens | |||||
| UitslagInterpretatie | Low (code=L codesysteem 2.16.840.1.113883.5.83) | ||||
| Verwijzing contact | Contact03 | ||||
| Verwijzing episode | EpisodeR95 | ||||
| AlgemeneBepaling | |||||
| Gegevenselement | Waarde | ||||
| MeetUitslag | |||||
| Identificatienummer | AlgBep05 | ||||
| MetingNaam | Conclusie longfunctieonderzoek (1704) | ||||
| UitslagWaarde | COPD (vrije tekst) | ||||
| UitslagDatumTijd | T-9D | ||||
| ReferentieOndergrens | |||||
| ReferentieBovengrens | |||||
| UitslagInterpretatie | |||||
| Verwijzing contact | Contact03 | ||||
| Verwijzing episode | EpisodeR95 | ||||
| AlgemeneBepaling | |||||
| Gegevenselement | Waarde | ||||
| MeetUitslag | |||||
| Identificatienummer | AlgBep06 | ||||
| MetingNaam | Roken (1739) | ||||
| UitslagWaarde | Voorheen (4) | ||||
| UitslagDatumTijd | T-9D | ||||
| ReferentieOndergrens | |||||
| ReferentieBovengrens | |||||
| UitslagInterpretatie | |||||
| Verwijzing contact | Contact03 | ||||
| Verwijzing episode | EpisodeR95 | ||||
| AlgemeneBepaling | |||||
| Gegevenselement | Waarde | ||||
| MeetUitslag | |||||
| Identificatienummer | AlgBep07 | ||||
| MetingNaam | Aantal jaren gerookt (1991) | ||||
| UitslagWaarde | 10 jaar | ||||
| UitslagDatumTijd | T-9D | ||||
| ReferentieOndergrens | |||||
| ReferentieBovengrens | |||||
| UitslagInterpretatie | |||||
| Verwijzing contact | Contact03 | ||||
| Verwijzing episode | EpisodeR95 | ||||
| AlgemeneBepaling | |||||
| Gegevenselement | Waarde | ||||
| MeetUitslag | |||||
| Identificatienummer | AlgBep08 | ||||
| MetingNaam | Temperatuur patiënt (in oor gemeten) (1913) | ||||
| UitslagWaarde | 37.5 Cel | ||||
| UitslagDatumTijd | T-6D | ||||
| ReferentieOndergrens | |||||
| ReferentieBovengrens | |||||
| UitslagInterpretatie | |||||
| Verwijzing contact | Contact04 | ||||
| Verwijzing episode | EpisodeR95 | ||||
| AlgemeneBepaling | |||||
| Gegevenselement | Waarde | ||||
| MeetUitslag | |||||
| Identificatienummer | AlgBep09 | ||||
| MetingNaam | Stadium COPD (GOLD classificatie) (2209) | ||||
| UitslagWaarde | 1:mild COPD (255) | ||||
| UitslagDatumTijd | T-6D | ||||
| ReferentieOndergrens | |||||
| ReferentieBovengrens | |||||
| UitslagInterpretatie | |||||
| Verwijzing contact | Contact04 | ||||
| Verwijzing episode | EpisodeR95 | ||||