iaz:Vdraft2.4.0 Testscript Ambulanceoverdracht SEH Sturen: verschil tussen versies
(22 tussenliggende versies door 2 gebruikers niet weergegeven) | |||
Regel 1: | Regel 1: | ||
− | [[ | + | [[az:Werkpagina|< Terug naar werkpagina]] |
<!-- TITEL en INHOUDSOPGAVE die alleen Niveau 1 en 2 kopjes toont --> | <!-- TITEL en INHOUDSOPGAVE die alleen Niveau 1 en 2 kopjes toont --> | ||
__NUMBEREDHEADINGS__ | __NUMBEREDHEADINGS__ | ||
Regel 7: | Regel 7: | ||
{{IssueBox|Please note that this is draft material which is still in development}} | {{IssueBox|Please note that this is draft material which is still in development}} | ||
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<section begin="patient" /> | <section begin="patient" /> | ||
Regel 27: | Regel 15: | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Persoonidentificatie | + | |colspan="5"| Persoonidentificatie |
− | |style="background-color: white;"|999910589 | + | |style="background-color: white;"| 999910589 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Naamgegevens | + | |colspan="6"| Naamgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="8"| | |rowspan="8"| | ||
Regel 36: | Regel 24: | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Initialen | + | |colspan="3"| Initialen |
− | |style="background-color: white;"|J.H.M. | + | |style="background-color: white;"| J.H.M. |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Achternaam | + | |colspan="6"| Achternaam |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Soort naam | + | |colspan="3"| Soort naam |
|style="background-color: white;"| Geboortenaam partner | |style="background-color: white;"| Geboortenaam partner | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Voorvoegsels | + | |colspan="3"| Voorvoegsels |
− | |style="background-color: white;"|van | + | |style="background-color: white;"| van |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Achternaam | + | |colspan="3"| Achternaam |
− | |style="background-color: white;"|XXX_Baatenburg | + | |style="background-color: white;"| XXX_Baatenburg |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Geslacht | + | |colspan="5"| Geslacht |
− | |style="background-color: white;"|Vrouw | + | |style="background-color: white;"| Vrouw |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Geboortegegevens | + | |colspan="6"| Geboortegegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Geboortedatum | + | |colspan="4"| Geboortedatum |
− | |style="background-color: white;"|06-08-1954 | + | |style="background-color: white;"| 06-08-1954 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Geschatte leeftijd | + | |colspan="5"| Geschatte leeftijd |
− | |style="background-color: white;"|45 | + | |style="background-color: white;"| 45 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Adresgegevens | + | |colspan="6"| Adresgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="10"| | |rowspan="10"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Straat | + | |colspan="4"| Straat |
− | |style="background-color: white;"|Knolweg | + | |style="background-color: white;"| Knolweg |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Huisnummer | + | |colspan="4"| Huisnummer |
− | |style="background-color: white;"|1003 | + | |style="background-color: white;"| 1003 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Huisnummerletter | + | |colspan="4"| Huisnummerletter |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Huisnummertoevoeging | + | |colspan="4"| Huisnummertoevoeging |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Postcode | + | |colspan="4"| Postcode |
− | |style="background-color: white;"|9999ZA | + | |style="background-color: white;"| 9999ZA |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Woonplaats | + | |colspan="4"| Woonplaats |
− | |style="background-color: white;"|Stitswerd | + | |style="background-color: white;"| Stitswerd |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Land | + | |colspan="4"| Land |
− | |style="background-color: white;"|Nederland | + | |style="background-color: white;"| Nederland |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Locatiebeschrijving | + | |colspan="4"| Locatiebeschrijving |
− | |style="background-color: white;"|naast de derde brug rechts | + | |style="background-color: white;"| naast de derde brug rechts |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Overige Contactgegevens | + | |colspan="6"| Overige Contactgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="15"| | |rowspan="15"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Telefoonnummers | + | |colspan="5"| Telefoonnummers |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Telefoonnummer | + | |colspan="3"| Telefoonnummer |
− | |style="background-color: white;"|611234567 | + | |style="background-color: white;"| 611234567 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Soort telefoonnummer | + | |colspan="3"| Soort telefoonnummer |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Werktelefoon | + | |colspan="5"| Werktelefoon |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|werknummer | + | |colspan="3"| werknummer |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Soort nummer | + | |colspan="3"| Soort nummer |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|EmailAdressen | + | |colspan="6"| EmailAdressen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Emailadres | + | |colspan="3"| Emailadres |
− | |style="background-color: white;"|giesput@myweb.nl | + | |style="background-color: white;"| giesput@myweb.nl |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Soort e-mailadres | + | |colspan="3"| Soort e-mailadres |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Emailadres | + | |colspan="3"| Emailadres |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Soort e-mailadres | + | |colspan="3"| Soort e-mailadres |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| Ziektekostenverzekering? | |colspan="5"| Ziektekostenverzekering? | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"| Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Verzekeringsgegevens | + | |colspan="6"| Verzekeringsgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="8"| | |rowspan="8"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Verzekeraar | + | |colspan="5"| Verzekeraar |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Naam | + | |colspan="3"| Naam |
− | |style="background-color: white;"|IZA | + | |style="background-color: white;"| IZA |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Identificatienummer | + | |colspan="3"| Identificatienummer |
− | |style="background-color: white;"|3334 | + | |style="background-color: white;"| 3334 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Polis | + | |colspan="5"| Polis |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| Polisnummer/Verzekerdenummer | |colspan="3"| Polisnummer/Verzekerdenummer | ||
− | |style="background-color: white;"|992298765 | + | |style="background-color: white;"| 992298765 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Vaste huisarts | + | |colspan="6"| Vaste huisarts |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="6"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| ZorgverlenerIdentificatienummer | |colspan="4"| ZorgverlenerIdentificatienummer | ||
+ | |style="background-color: white;"| UZI: 000014444 <br/> AGB: 01022418 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Rolcode | ||
+ | |style="background-color: white;"| 01.015 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"| Naam |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Achternaam | + | |colspan="3"| Achternaam |
− | |style="background-color: white;"| | + | |style="background-color: white;"| Pulver |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Vaste huisartsenpraktijk | + | |colspan="6"| Vaste huisartsenpraktijk |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="27"| | |rowspan="27"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"| Identificatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 12345678 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"| Naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"| Gezondheidscentrum Aesculaap |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"| Adresgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="9"| | |rowspan="9"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"| Soort adres |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"| Straatnaam |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"| Huisnummer |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"| Huisnummertoevoeging |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"| Postcode |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"| Gemeente |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"| Woonplaats |
− | |style="background-color: white;"| | + | |style="background-color: white;"| Zaandam |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"| Land |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"| Overige contactgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="13"| | |rowspan="13"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"| Telefoonnummers |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"| Soort telefoonnummer |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"| Telefoonnummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 06-11234567 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"| Faxnummers |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"| Soort faxnummer |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"| Faxnummer |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"| E-mailadressen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"| Soort e-mailadres |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"| E-mailadres |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 246: | Regel 238: | ||
|rowspan="5"| | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"| Achternaam |
− | |style="background-color: white;"| | + | |style="background-color: white;"| Putten |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"| Telefoonnummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 611234567 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"| Relatie tot patiënt |
− | |style="background-color: white;"| | + | |style="background-color: white;"|FAMMEMB |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
Regel 265: | Regel 257: | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|WID-controle uitgevoerd | + | |colspan="5"| WID-controle uitgevoerd |
|style="background-color: white;"| Ja | |style="background-color: white;"| Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|WID controle datum | + | |colspan="5"| WID controle datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"| T |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Documentnummer | + | |colspan="5"| Documentnummer |
|style="background-color: white;"| NS07778999 | |style="background-color: white;"| NS07778999 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Document type | + | |colspan="5"| Document type |
− | |style="background-color: white;"| Paspoort | + | |style="background-color: white;"| Paspoort |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
Regel 287: | Regel 279: | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Datum/tijd incident | + | |colspan="5"| Datum/tijd incident |
|style="background-color: white;"| T-20 min | |style="background-color: white;"| T-20 min | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 303: | Regel 295: | ||
|style="background-color: white;"| T-15min | |style="background-color: white;"| T-15min | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Geplande brengtijd | + | |colspan="5"| Geplande brengtijd |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Geplande haaltijd | + | |colspan="5"| Geplande haaltijd |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Wzd/Wvggz maatregel | + | |colspan="5"| Wzd/Wvggz maatregel |
|style="background-color: white;"| TVZcm (code = 004 in codesysteem 2.16.840.1.113883.2.4.3.11.60.55.5.57 'acutezorg-codesysteem-57') | |style="background-color: white;"| TVZcm (code = 004 in codesysteem 2.16.840.1.113883.2.4.3.11.60.55.5.57 'acutezorg-codesysteem-57') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Datum/tijd aanvang TVZ | + | |colspan="5"| Datum/tijd aanvang TVZ |
− | |style="background-color: white;"| T | + | |style="background-color: white;"| T-10min |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Medische kladblok meldkamer | + | |colspan="5"| Medische kladblok meldkamer |
|style="background-color: white;"| Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur ridiculus mus. Donec quam felis, ultricies nec, pellentesque eu, pretium quis, sem. Nulla consequat massa quis enim. Donec pede justo, fringilla vel, aliquet nec, vulputate | |style="background-color: white;"| Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur ridiculus mus. Donec quam felis, ultricies nec, pellentesque eu, pretium quis, sem. Nulla consequat massa quis enim. Donec pede justo, fringilla vel, aliquet nec, vulputate | ||
|-style="vertical-align:top; background-color: #E3E3E3;; | |-style="vertical-align:top; background-color: #E3E3E3;; | ||
− | |colspan="5"|Meldkamerurgentie | + | |colspan="5"| Meldkamerurgentie |
− | |style="background-color: white;"| | + | |style="background-color: white;"| B1 Hoog complexe zorg bij planbare ambulancezorg |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
<section end="Meldingsgegevens" /> | <section end="Meldingsgegevens" /> | ||
+ | |||
+ | <section begin="Zorgaanvrager" /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Zorgaanvrager | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="5" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"| Initialen | ||
+ | |style="background-color: white;"| J.H.M. | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"| Achternaam | ||
+ | |style="background-color: white;"| Putten | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"| Telefoonnummer | ||
+ | |style="background-color: white;"| 61234567 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"| Identificatie | ||
+ | |style="background-color: white;"| UZI: 000014444 <br/> AGB: 01022418 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"| Type zorgaanvrager | ||
+ | |style="background-color: white;"| Huisarts (004) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |} | ||
+ | <section end="Zorgaanvrager" /> | ||
<section begin="Ritgegevens" /> | <section begin="Ritgegevens" /> | ||
Regel 331: | Regel 348: | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Ambulancevoorziening | + | |colspan="5"| Ambulancevoorziening |
|style="background-color: white;"| 25 | |style="background-color: white;"| 25 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Ritnummer | + | |colspan="5"| Ritnummer |
− | |style="background-color: white;"| 25- | + | |style="background-color: white;"| 25-2020-10-1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Ambulancenummer | + | |colspan="5"| Ambulancenummer |
|style="background-color: white;"| 25124 | |style="background-color: white;"| 25124 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Telefoon ambulance | + | |colspan="5"| Telefoon ambulance |
|style="background-color: white;"| 0612345678 | |style="background-color: white;"| 0612345678 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Ambulanceverpleegkundige identificatie | + | |colspan="5"| Ambulanceverpleegkundige identificatie |
|style="background-color: white;"| 123456789 | |style="background-color: white;"| 123456789 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Ambulancechauffeur identificatie | + | |colspan="5"| Ambulancechauffeur identificatie |
|style="background-color: white;"| 987654321 | |style="background-color: white;"| 987654321 | ||
|-style="vertical-align:top; background-color: #E3E3E3;; | |-style="vertical-align:top; background-color: #E3E3E3;; | ||
− | |colspan="5"|Datum/tijd ritopdracht | + | |colspan="5"| Datum/tijd ritopdracht |
|style="background-color: white;"| T-10 min | |style="background-color: white;"| T-10 min | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Datum/tijd uitruk/vertrek | + | |colspan="5"| Datum/tijd uitruk/vertrek |
|style="background-color: white;"| T-10 min | |style="background-color: white;"| T-10 min | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Datum/tijd aankomst patiënt | + | |colspan="5"| Datum/tijd aankomst patiënt |
|style="background-color: white;"| T-5 min | |style="background-color: white;"| T-5 min | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Datum/tijd vertrek patiënt | + | |colspan="5"| Datum/tijd vertrek patiënt |
− | |style="background-color: white;"| T | + | |style="background-color: white;"| T |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Verwachte aankomsttijd bestemming | + | |colspan="5"| Verwachte aankomsttijd bestemming |
|style="background-color: white;"| T+10 min** | |style="background-color: white;"| T+10 min** | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Datum/tijd aankomst bestemming | + | |colspan="5"| Datum/tijd aankomst bestemming |
|style="background-color: white;"| T+10 min | |style="background-color: white;"| T+10 min | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Datum/tijd vrijmelding | + | |colspan="5"| Datum/tijd vrijmelding |
|style="background-color: white;"| T+15 min | |style="background-color: white;"| T+15 min | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Soort vervoer | + | |colspan="5"| Soort vervoer |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 001 opnamerit |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
Regel 383: | Regel 400: | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Straat | + | |colspan="5"| Straat |
− | |style="background-color: white;"|1e Jacob van Campenstr | + | |style="background-color: white;"| 1e Jacob van Campenstr |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Huisnummer | + | |colspan="5"| Huisnummer |
− | |style="background-color: white;"|15 | + | |style="background-color: white;"| 15 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Huisletter | + | |colspan="5"| Huisletter |
− | |style="background-color: white;"|B | + | |style="background-color: white;"| B |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Huisnummertoevoeging | + | |colspan="5"| Huisnummertoevoeging |
− | |style="background-color: white;"|II | + | |style="background-color: white;"| II |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Postcode | + | |colspan="5"| Postcode |
− | |style="background-color: white;"|1012 NX | + | |style="background-color: white;"| 1012 NX |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Locatiebeschrijving | + | |colspan="5"| Locatiebeschrijving |
− | |style="background-color: white;"|naast de derde brug rechts | + | |style="background-color: white;"| naast de derde brug rechts |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Woonplaats | + | |colspan="5"| Woonplaats |
− | |style="background-color: white;"|Hoogmade | + | |style="background-color: white;"| Hoogmade |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Land | + | |colspan="5"| Land |
− | |style="background-color: white;"|Nederland | + | |style="background-color: white;"| Nederland |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Patiënt vervoerd? | + | |colspan="5"| Patiënt vervoerd? |
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"| Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Reden geen vervoer | + | |colspan="5"| Reden geen vervoer |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Tijdstip overlijden patiënt | + | |colspan="5"| Tijdstip overlijden patiënt |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Advies behandeling tijdens vervoer aanwezig? | + | |colspan="5"| Advies behandeling tijdens vervoer aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"| nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Niet reanimeren verklaring aanwezig? | + | |colspan="5"| Niet reanimeren verklaring aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"| nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Trialgegevens | + | |colspan="5"| Trialgegevens |
− | |style="background-color: white;"|Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur ridiculus mus. Donec quam felis, ultricies nec, pellentesque eu, pretium quis, sem. Nulla consequat massa quis enim. Donec pede justo, fringilla vel, aliquet nec, vulputate | + | |style="background-color: white;"| Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur ridiculus mus. Donec quam felis, ultricies nec, pellentesque eu, pretium quis, sem. Nulla consequat massa quis enim. Donec pede justo, fringilla vel, aliquet nec, vulputate |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Ambulance-urgentie | + | |colspan="5"| Ambulance-urgentie |
− | |style="background-color: white;"|A1 spoedrit | + | |style="background-color: white;"| A1 spoedrit |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Gewondennummer | + | |colspan="5"| Gewondennummer |
− | |style="background-color: white;"|12345678 | + | |style="background-color: white;"| 12345678 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Triageklasse | + | |colspan="5"| Triageklasse |
− | |style="background-color: white;"|T2 | + | |style="background-color: white;"| T2 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="6"| Hulpverleners ter plaatse | |
− | |colspan="6"|Hulpverleners ter plaatse | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="9"| | |rowspan="9"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Hulpverlenersnaam | + | |colspan="4"| Hulpverlenersnaam |
|style="background-color: white;"| Jansen | |style="background-color: white;"| Jansen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Type hulpverlener | + | |colspan="4"| Type hulpverlener |
− | |style="background-color: white;"| Ambulance ( | + | |style="background-color: white;"| Ambulance (001) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Telefoonnummer | + | |colspan="4"| Telefoonnummer |
|style="background-color: white;"| 611234567 | |style="background-color: white;"| 611234567 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| E-mailadres | ||
+ | |style="background-color: white;"| hulpverlener@myweb.nl | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
Regel 458: | Regel 477: | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Bestemmingsstatus | + | |colspan="5"| Bestemmingsstatus |
− | |style="background-color: white;"|Overgedragen | + | |style="background-color: white;"| Overgedragen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Bestemmingscode | + | |colspan="5"| Bestemmingscode |
− | |style="background-color: white;"|AGB: 06010860 | + | |style="background-color: white;"| AGB: 06010860 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Locatie of afdeling | + | |colspan="5"| Locatie of afdeling |
− | |style="background-color: white;"|LSDV-code: 2.16.840.1.113883.2.4.6.1.6010860.000 | + | |style="background-color: white;"| LSDV-code: 2.16.840.1.113883.2.4.6.1.6010860.000 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Straat | + | |colspan="5"| Straat |
− | |style="background-color: white;"|1e Jacob van Campenstr | + | |style="background-color: white;"| 1e Jacob van Campenstr |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Huisnummer | + | |colspan="5"| Huisnummer |
− | |style="background-color: white;"|15 | + | |style="background-color: white;"| 15 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Huisletter | + | |colspan="5"| Huisletter |
− | |style="background-color: white;"|B | + | |style="background-color: white;"| B |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Huisnummertoevoeging | + | |colspan="5"| Huisnummertoevoeging |
− | |style="background-color: white;"|II | + | |style="background-color: white;"| II |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Postcode | + | |colspan="5"| Postcode |
− | |style="background-color: white;"|1012 NX | + | |style="background-color: white;"| 1012 NX |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Locatiebeschrijving | + | |colspan="5"| Locatiebeschrijving |
− | |style="background-color: white;"|naast de derde brug rechts | + | |style="background-color: white;"| naast de derde brug rechts |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Woonplaats | + | |colspan="5"| Woonplaats |
− | |style="background-color: white;"|Hoogmade | + | |style="background-color: white;"| Hoogmade |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Land | + | |colspan="5"| Land |
− | |style="background-color: white;"|Nederland | + | |style="background-color: white;"| Nederland |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Bijzonderheden algemeen | + | |colspan="5"| Bijzonderheden algemeen |
− | |style="background-color: white;"|Verbouwing van de zij-ingang | + | |style="background-color: white;"| Verbouwing van de zij-ingang |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Verwacht specialisme | + | |colspan="5"| Verwacht specialisme |
− | |style="background-color: white;"|Chirurg ( | + | |style="background-color: white;"| Chirurg (01.014) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Feedback | + | |colspan="6"| Feedback |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="9"| | |rowspan="9"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Feedback | + | |colspan="4"| Feedback gewenst |
|style="background-color: white;"| Ja | |style="background-color: white;"| Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Feedback adres | + | |colspan="4"| Feedback adres |
− | |style="background-color: white;"| | + | |style="background-color: white;"| Test adres |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Feedback methode | ||
+ | |style="background-color: white;"| Zorgmail | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
Regel 517: | Regel 539: | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Mechanisme type | + | |colspan="5"| Mechanisme type |
|style="background-color: white;"| 35468003 bekneld geraakt tussen voorwerpen (gebeurtenis) | |style="background-color: white;"| 35468003 bekneld geraakt tussen voorwerpen (gebeurtenis) | ||
− | 418019003 | + | 418019003 accidentele gebeurtenis (gebeurtenis) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Vervoermiddel patiënt | + | |colspan="5"| Vervoermiddel patiënt |
|style="background-color: white;"| 22674006 bus (fysiek object) | |style="background-color: white;"| 22674006 bus (fysiek object) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Patiënt was bestuurder? | + | |colspan="5"| Patiënt was bestuurder? |
|style="background-color: white;"| ja | |style="background-color: white;"| ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Vervoermiddel contra | + | |colspan="5"| Vervoermiddel contra |
|style="background-color: white;"| 22674006 bus (fysiek object) | |style="background-color: white;"| 22674006 bus (fysiek object) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Beschermingsmiddelen patiënt | + | |colspan="5"| Beschermingsmiddelen patiënt |
|style="background-color: white;"| 60054005 autogordel (fysiek object) | |style="background-color: white;"| 60054005 autogordel (fysiek object) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 543: | Regel 565: | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Toestandsbeeld | + | |colspan="6"| Toestandsbeeld |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="6"| | |rowspan="6"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Toestandsbeeld code | + | |colspan="4"| Toestandsbeeld code |
− | |style="background-color: white;"| 125593007 | + | |style="background-color: white;"| 125593007 letsel van aangezicht (aandoening) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Toestandsbeeld | + | |colspan="4"| Toelichting Toestandsbeeld |
− | |style="background-color: white;"| | + | |style="background-color: white;"| Moeilijk observeren door weersomstandigheden |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |||
− | |||
− | |||
|} | |} | ||
<section end="Toestandsbeelden/Werkdiagnose" /> | <section end="Toestandsbeelden/Werkdiagnose" /> | ||
Regel 569: | Regel 585: | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Bloedsuiker | + | |colspan="6"| Bloedsuiker |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Bloedsuiker waarde | + | |colspan="4"| Bloedsuiker waarde |
|style="background-color: white;"| 7.1 mmol/L | |style="background-color: white;"| 7.1 mmol/L | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|BloedsuikerDatumTijd | + | |colspan="4"| BloedsuikerDatumTijd |
|style="background-color: white;"| T-10 minuten | |style="background-color: white;"| T-10 minuten | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Hartritme | + | |colspan="6"| Hartritme |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Hartritme observatie | + | |colspan="4"| Hartritme observatie |
|style="background-color: white;"| 397829000 asystolie (aandoening) | |style="background-color: white;"| 397829000 asystolie (aandoening) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|HartritmeDatumTijd | + | |colspan="4"| HartritmeDatumTijd |
|style="background-color: white;"| T-10 minuten | |style="background-color: white;"| T-10 minuten | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Toelichting hartritme/ECG | + | |colspan="4"| Toelichting hartritme/ECG |
|style="background-color: white;"| Niet normaal | |style="background-color: white;"| Niet normaal | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|O2Saturatie | + | |colspan="6"| O2Saturatie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|SpO2waarde | + | |colspan="4"| SpO2waarde |
− | |style="background-color: white;"|98% | + | |style="background-color: white;"| 98% |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|O2SaturatieDatumTijd | + | |colspan="4"| O2SaturatieDatumTijd |
− | |style="background-color: white;"|T-10 minuten | + | |style="background-color: white;"| T-10 minuten |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Capnometrie | + | |colspan="6"| Capnometrie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|CO2Waarde | + | |colspan="4"| CO2Waarde |
− | |style="background-color: white;"|42 mm[Hg] | + | |style="background-color: white;"| 42 mm[Hg] <br/>5,6 kPa |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|CO2CapnometrieDatumTijd | + | |colspan="4"| CO2CapnometrieDatumTijd |
− | |style="background-color: white;"|T-10 minuten | + | |style="background-color: white;"| T-10 minuten |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Hartfrequentie | + | |colspan="6"| Hartfrequentie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|HartfrequentieWaarde | + | |colspan="4"| HartfrequentieWaarde |
− | |style="background-color: white;"|76/min | + | |style="background-color: white;"| 76/min |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|HartfrequentieDatumTijd | + | |colspan="4"| HartfrequentieDatumTijd |
− | |style="background-color: white;"|T-10 minuten | + | |style="background-color: white;"| T-10 minuten |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Bloeddruk | + | |colspan="6"| Bloeddruk |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|SystolischeBloeddruk | + | |colspan="4"| SystolischeBloeddruk |
− | |style="background-color: white;"|155 mm[Hg] | + | |style="background-color: white;"| 155 mm[Hg] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|DiastolischeBloeddruk | + | |colspan="4"| DiastolischeBloeddruk |
− | |style="background-color: white;"|70 mm[Hg] | + | |style="background-color: white;"| 70 mm[Hg] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|BloeddrukDatumTijd | + | |colspan="4"| BloeddrukDatumTijd |
− | |style="background-color: white;"|T-10 minuten | + | |style="background-color: white;"| T-10 minuten |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Lichaamstemperatuur | + | |colspan="6"| Lichaamstemperatuur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|TemperatuurWaarde | + | |colspan="4"| TemperatuurWaarde |
− | |style="background-color: white;"|37,3 | + | |style="background-color: white;"| 37,3 °C (graden Celcius) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|TemperatuurDatumTijd | + | |colspan="4"| TemperatuurDatumTijd |
− | |style="background-color: white;"|T-10 minuten | + | |style="background-color: white;"| T-10 minuten |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Ademhaling | + | |colspan="6"| Ademhaling |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Ademfrequentie | + | |colspan="4"| Ademfrequentie |
− | |style="background-color: white;"|15/min | + | |style="background-color: white;"| 15/min |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|AdemhalingDatumTijd | + | |colspan="4"| AdemhalingDatumTijd |
− | |style="background-color: white;"|T-10 minuten | + | |style="background-color: white;"| T-10 minuten |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|GlasgowComaScale | + | |colspan="6"| GlasgowComaScale |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="6"| | |rowspan="6"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|GlasgowComaScaleDatumTijd | + | |colspan="4"| GlasgowComaScaleDatumTijd |
− | |style="background-color: white;"|T-10 minuten | + | |style="background-color: white;"| T-10 minuten |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|GCS_Eyes | + | |colspan="4"| GCS_Eyes |
− | |style="background-color: white;"|E3 | + | |style="background-color: white;"| E3 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|GCS_Motor | + | |colspan="4"| GCS_Motor |
− | |style="background-color: white;"|M4 | + | |style="background-color: white;"| M4 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|GCS_Verbal | + | |colspan="4"| GCS_Verbal |
− | |style="background-color: white;"|V3 (uit 2.16.840.1.113883.2.4.3.11.60.40.4.2.3) | + | |style="background-color: white;"| V3 (uit 2.16.840.1.113883.2.4.3.11.60.40.4.2.3) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|TotaalScore | + | |colspan="4"| TotaalScore |
− | |style="background-color: white;"|10 | + | |style="background-color: white;"| 10 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="6"| Revised Trauma Score | |
− | |colspan="6"|Revised Trauma Score | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|RevisedTraumaScoreWaarde | + | |colspan="4"| RevisedTraumaScoreWaarde |
− | |style="background-color: white;"|11 | + | |style="background-color: white;"| 11 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|RevisedTraumaScoreTijd | + | |colspan="4"| RevisedTraumaScoreTijd |
− | |style="background-color: white;"|T-10 minuten | + | |style="background-color: white;"| T-10 minuten |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Pediatric Trauma Score | + | |colspan="6"| Pediatric Trauma Score |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|PediatricTraumaScoreWaarde | + | |colspan="4"| PediatricTraumaScoreWaarde |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|PediatricTraumaScoreTijd | + | |colspan="4"| PediatricTraumaScoreTijd |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Pijnschaal | + | |colspan="6"| Pijnschaal |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|PijnschaalWaarde | + | |colspan="4"| PijnschaalWaarde |
− | |style="background-color: white;"|5 | + | |style="background-color: white;"| 5 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|PijnschaalTijd | + | |colspan="4"| PijnschaalTijd |
− | |style="background-color: white;"|T-10 minuten | + | |style="background-color: white;"| T-10 minuten |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="5"| APGAR-1 | |
− | |colspan="5"|APGAR-1 | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|APGAR-5 | + | |colspan="5"| APGAR-5 |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 722: | Regel 736: | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Ademhaling en beademing (diagnostisch) | + | |colspan="6"| Ademhaling en beademing (diagnostisch) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Handelingen ademhaling en beademing | + | |colspan="4"| Handelingen ademhaling en beademing |
|style="background-color: white;"| 408867002 meten van ademhalingsfrequentie (verrichting) | |style="background-color: white;"| 408867002 meten van ademhalingsfrequentie (verrichting) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Bewustzijn en neurologische status (diagnostisch) | + | |colspan="6"| Bewustzijn en neurologische status (diagnostisch) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Handelingen bewustzijn en neurologische status | + | |colspan="4"| Handelingen bewustzijn en neurologische status |
− | |style="background-color: white;"|291000146106 pupilreactie-onderzoek (verrichting) | + | |style="background-color: white;"| 291000146106 pupilreactie-onderzoek (verrichting) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Overige diagnostische handelingen | + | |colspan="6"| Overige diagnostische handelingen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Handelingen overige diagnostisch | + | |colspan="4"| Handelingen overige diagnostisch |
|style="background-color: white;"|5880005 lichamelijk onderzoek (verrichting) | |style="background-color: white;"|5880005 lichamelijk onderzoek (verrichting) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Luchtweg management (therapeutisch) | + | |colspan="6"| Luchtweg management (therapeutisch) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
Regel 751: | Regel 765: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Moeizame intubatie? | |colspan="4"| Moeizame intubatie? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"| Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Oxygenatie en ventilatie (therapeutisch) | + | |colspan="6"| Oxygenatie en ventilatie (therapeutisch) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="7"| | |rowspan="7"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Handelingen oxygenatie en ventilatie | |colspan="4"| Handelingen oxygenatie en ventilatie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"| 40617009 kunstmatige beademing (verrichting) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Beademing machine Fi O2 | |colspan="4"| Beademing machine Fi O2 | ||
Regel 770: | Regel 784: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Beademing machine Peep | |colspan="4"| Beademing machine Peep | ||
− | |style="background-color: white;"|3cm[H2O] | + | |style="background-color: white;"| 3cm[H2O] |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Hoeveelheid zuurstof | ||
+ | |style="background-color: white;"| 3L/min | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"| Oxygenatie en ventilatie (therapeutisch) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Handelingen oxygenatie en ventilatie | ||
+ | |style="background-color: white;"| 11140008 handmatige beademing (verrichting) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Beademing machine Fi O2 | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Beademing machine AMV | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Beademing machine Freq. | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Beademing machine Peep | ||
+ | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Hoeveelheid zuurstof | |colspan="4"| Hoeveelheid zuurstof | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Circulatie (therapeutisch) | + | |colspan="6"| Circulatie (therapeutisch) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="12"| | |rowspan="12"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Handelingen circulatie | |colspan="4"| Handelingen circulatie | ||
− | |style="background-color: white;"|250980009 cardioversie (verrichting) | + | |style="background-color: white;"| 250980009 cardioversie (verrichting) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Pacemaker frequentie | |colspan="4"| Pacemaker frequentie | ||
Regel 804: | Regel 840: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Return Of Spontaneous Circulation (ROSC) | |colspan="4"| Return Of Spontaneous Circulation (ROSC) | ||
− | |style="background-color: white;"|Nee | + | |style="background-color: white;"| Nee |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| AED aangesloten voor aankomst | ||
+ | |style="background-color: white;"| Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| AED-schokken aantal | ||
+ | |style="background-color: white;"| 5 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"| Circulatie (therapeutisch) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Handelingen circulatie | ||
+ | |style="background-color: white;"| 233181000 transthoracale cardiale pacing (verrichting) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Pacemaker frequentie | ||
+ | |style="background-color: white;"| 60 /min | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Pacemaker stroomsterkte | ||
+ | |style="background-color: white;"| 5 mA | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Pacemaker modus | ||
+ | |style="background-color: white;"| 001 fixed rate | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Cardioversies aantal | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Cardioversie maximale energie | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Defibrillaties aantal | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Defibrillatie energie | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Return Of Spontaneous Circulation (ROSC) | ||
+ | |style="background-color: white;"| Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| AED aangesloten voor aankomst | ||
+ | |style="background-color: white;"| Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| AED-schokken aantal | ||
+ | |style="background-color: white;"| 5 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"| Circulatie (therapeutisch) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Handelingen circulatie | ||
+ | |style="background-color: white;"| 308842001 defibrillatie met gelijkstroom (verrichting) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Pacemaker frequentie | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Pacemaker stroomsterkte | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Pacemaker modus | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Cardioversies aantal | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Cardioversie maximale energie | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Defibrillaties aantal | ||
+ | |style="background-color: white;"| 3 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Defibrillatie energie | ||
+ | |style="background-color: white;"| 200 Joule | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Return Of Spontaneous Circulation (ROSC) | ||
+ | |style="background-color: white;"| Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| AED aangesloten voor aankomst | |colspan="4"| AED aangesloten voor aankomst | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"| Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| AED-schokken aantal | |colspan="4"| AED-schokken aantal | ||
|style="background-color: white;"|5 | |style="background-color: white;"|5 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Traumatologie (therapeutisch) | + | |colspan="6"| Traumatologie (therapeutisch) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Handelingen traumatologie | |colspan="4"| Handelingen traumatologie | ||
− | |style="background-color: white;"|105382002 koelen van patiënt (verrichting) | + | |style="background-color: white;"| 105382002 koelen van patiënt (verrichting) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Koelen tijdsduur | |colspan="4"| Koelen tijdsduur | ||
− | |style="background-color: white;"|10 minuten | + | |style="background-color: white;"| 10 minuten |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Obstetrie | + | |colspan="6"| Obstetrie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Handelingen obstetrie | + | |colspan="4"| Handelingen obstetrie |
− | |style="background-color: white;"|238248005 afklemmen van navelstreng (verrichting) | + | |style="background-color: white;"| 238248005 afklemmen van navelstreng (verrichting) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Wijze van isolatie | + | |colspan="6"| Wijze van isolatie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Handelingen isolatie | + | |colspan="4"| Handelingen isolatie |
− | |style="background-color: white;"|170499009 contactisolatie (verrichting) | + | |style="background-color: white;"| 170499009 contactisolatie (verrichting) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Medicatie | + | |colspan="6"| Medicatie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="7"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Medicatie toegediend? | |colspan="4"| Medicatie toegediend? | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"| Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Medicatienaam | |colspan="4"| Medicatienaam | ||
− | |style="background-color: white;"|13.1 Acetylsalicylzuur | + | |style="background-color: white;"| 13.1 Acetylsalicylzuur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Toegediende hoeveelheid medicatie | |colspan="4"| Toegediende hoeveelheid medicatie | ||
− | |style="background-color: white;"|2 stuk | + | |style="background-color: white;"| 2 stuk |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Tijd medicatietoediening | |colspan="4"| Tijd medicatietoediening | ||
− | |style="background-color: white;"|T-10 minuten | + | |style="background-color: white;"| T-10 minuten |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Medicatie toedieningsvorm | |colspan="4"| Medicatie toedieningsvorm | ||
|style="background-color: white;"| 386359008 oraal toedienen van medicatie (verrichting) | |style="background-color: white;"| 386359008 oraal toedienen van medicatie (verrichting) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Extra informatie behandeling | + | |colspan="4"| IV medicatiesnelheid |
+ | |style="background-color: white;"| 100 ml/uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"| Infuus | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Infusen aantal | ||
+ | |style="background-color: white;"| 1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Infuusvloeistofcode | ||
+ | |style="background-color: white;"| 137774 (GPK) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Infuusvloeistoftekst | ||
+ | |style="background-color: white;"| IMMUNOGLOBULINE NORMAAL INF | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Infuushoeveelheid | ||
+ | |style="background-color: white;"| 200 ml | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"| Extra informatie behandeling | ||
|style="background-color: white;"| Normale behandeling | |style="background-color: white;"| Normale behandeling | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 868: | Regel 997: | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Type patiëntligging | + | |colspan="5"| Type patiëntligging |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 001 buik |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
Regel 881: | Regel 1.010: | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Airway | + | |colspan="6"| Airway |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"| Airway vrij? |
+ | |style="background-color: white;"| nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"| Stridor |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 58596002 inspiratoire stridor (bevinding) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"| Breathing |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"| Breathing sufficient? |
− | |style="background-color: white;"| | + | |style="background-color: white;"| nee |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Breathing observaties | ||
+ | |style="background-color: white;"| 271623001 asymmetrische thoraxbeweging (bevinding) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"| Circulation | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Circulation sufficient? | ||
+ | |style="background-color: white;"| nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Capillaire refill > 2 seconde? | ||
+ | |style="background-color: white;"| Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"| Huid observatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 248245006 klam zweet (bevinding) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"| Disability |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="7"| | |rowspan="7"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"| AVPU |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 248234008 alert (bevinding) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"| Duur buiten bewustzijn |
+ | |style="background-color: white;"| 5 min | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"| Pupil |
+ | |style="background-color: white;"| 301941003 Normal pupil size (finding) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"| FAST symptomen aanwezig |
− | |style="background-color: white;"| | + | |style="background-color: white;"| Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"| Mogelijk trombolyse/trombectomie |
− | |style="background-color: white;"| | + | |style="background-color: white;"| Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"| Intoxicatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 67426006 intoxicatie door alcohol (aandoening) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |
+ | |||
+ | |colspan="5"|Toelichting Primary Survey | ||
+ | |style="background-color: white;"| Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |} |
+ | <section end="Primary Survey" /> | ||
+ | |||
+ | <section begin="Secondary Survey" /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Secondary Survey | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="5" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"| Anamnese | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="27"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"| Ample |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="4"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"| Code |
+ | |style="background-color: white;"| 473011001 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"| Titel |
+ | |style="background-color: white;"| Allergie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"| Omschrijving |
− | |style="background-color: white;"| | + | |style="background-color: white;"| Pinda's |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"| Ample |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="4"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"| Code |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 394829006 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"| Titel |
− | |style="background-color: white;"| | + | |style="background-color: white;"| Medicatie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"| Omschrijving | ||
+ | |style="background-color: white;"| Geen medicatie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"| Ample |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"| Code |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 417662000 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"| Titel | ||
+ | |style="background-color: white;"| Past | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"| Omschrijving | ||
+ | |style="background-color: white;"| Nooit eerder opgenomen geweest | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"| Ample |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="4"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"| Code |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 405795006 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"| Titel |
− | + | |style="background-color: white;"| Tijd eerste optreden symptomen | |
− | |||
− | |||
− | |||
− | |||
− | | | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"| Omschrijving |
+ | |style="background-color: white;"| 1 uur geleden | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"| Ample |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Code | + | |colspan="3"| Code |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 272379006 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Titel | + | |colspan="3"| Titel |
− | |style="background-color: white;"| | + | |style="background-color: white;"| Events |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Omschrijving | + | |colspan="3"| Omschrijving |
− | |style="background-color: white;"| | + | |style="background-color: white;"| Geen bijzonderheden |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Toelichting anamnese | + | |colspan="4"| Toelichting anamnese |
|style="background-color: white;"| Lastig vanwege weersomstandigheden | |style="background-color: white;"| Lastig vanwege weersomstandigheden | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"| Infectierisico |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| Verdenking | + | |colspan="4"| Verdenking infectieziekten? |
− | |style="background-color: white;"| | + | |style="background-color: white;"| Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| Toelichting | + | |colspan="4"| Toelichting infectierisico |
|style="background-color: white;"| Afgelopen maanden in een ziekenhuis in India geweest | |style="background-color: white;"| Afgelopen maanden in een ziekenhuis in India geweest | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Hoofd en gelaat | + | |colspan="6"| Hoofd en gelaat |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="6"| | |rowspan="6"| | ||
Regel 1.018: | Regel 1.173: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Liquorverlies | |colspan="4"| Liquorverlies | ||
− | |style="background-color: white;"|85638002 nasale liquorroe (aandoening) | + | |style="background-color: white;"| 85638002 nasale liquorroe (aandoening) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Pijnlocatie | |colspan="4"| Pijnlocatie | ||
− | |style="background-color: white;"|Kaaklijn | + | |style="background-color: white;"| Kaaklijn<br/>Achterhoofd |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Wond | |colspan="4"| Wond | ||
− | |style="background-color: white;"|425322008 steekwond (aandoening) | + | |style="background-color: white;"| 425322008 steekwond (aandoening) <br/> 399963005 abrasie (aandoening) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Nek, hals, CWK | + | |colspan="6"| Nek, hals, CWK |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Nek, hals, CWK observaties | |colspan="4"| Nek, hals, CWK observaties | ||
− | |style="background-color: white;"|279029001 pijn in cervicale wervelkolom (bevinding) | + | |style="background-color: white;"| 279029001 pijn in cervicale wervelkolom (bevinding) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Wond | |colspan="4"| Wond | ||
− | |style="background-color: white;"|425322008 steekwond (aandoening) | + | |style="background-color: white;"| 425322008 steekwond (aandoening) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Thorax | + | |colspan="6"| Thorax |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"| Thorax observaties |
+ | |style="background-color: white;"| 249672002 asymmetrische thorax (bevinding) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Pijn bij compressie | ||
+ | |style="background-color: white;"| 32391000146100 pijn van sternum bij compressie tijdens lichamelijk onderzoek (bevinding) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"| Locatie subcutaan emfyseem |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 32441000146104 drukpijn en/of loslaatpijn rechtsonder in abdomen bij lichamelijk onderzoek (bevinding) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"| Locatie zwelling / oedeem (2x) |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 32431000146107 drukpijn en/of loslaatpijn rechtsboven in abdomen bij lichamelijk onderzoek (bevinding) <br/> |
+ | 32411000146100 drukpijn en/of loslaatpijn linksboven in abdomen bij lichamelijk onderzoek (bevinding) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Wond | + | |colspan="4"| Wond |
− | |style="background-color: white;"|125666000 brandwond (aandoening) | + | |style="background-color: white;"| 125666000 brandwond (aandoening) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Rug | + | |colspan="6"| Rug |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Rug observaties | |colspan="4"| Rug observaties | ||
− | |style="background-color: white;"|385494008 hematoom (aandoening) | + | |style="background-color: white;"| 385494008 hematoom (aandoening) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Wond | |colspan="4"| Wond | ||
− | |style="background-color: white;"|399963005 abrasie (aandoening) | + | |style="background-color: white;"| 399963005 abrasie (aandoening) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Abdomen | + | |colspan="6"| Abdomen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="6"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Abdomen observaties | |colspan="4"| Abdomen observaties | ||
− | |style="background-color: white;"|297968009 bloeding van huid (bevinding) | + | |style="background-color: white;"| 297968009 bloeding van huid (bevinding) |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"| Locatie druk- / loslaatpijn | ||
+ | |style="background-color: white;"| 32431000146107 drukpijn en/of loslaatpijn rechtsboven in abdomen bij lichamelijk onderzoek (bevinding) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| Locatie | + | |colspan="4"| Locatie zwelling / oedeem |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 32411000146100 drukpijn en/of loslaatpijn linksboven in abdomen bij lichamelijk onderzoek (bevinding) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| Locatie | + | |colspan="4"| Locatie pulserende zwelling |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 32411000146100 drukpijn en/of loslaatpijn linksboven in abdomen bij lichamelijk onderzoek (bevinding) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Wond | |colspan="4"| Wond | ||
− | |style="background-color: white;"|127315004 luchtaanzuigende thoraxverwonding (aandoening) | + | |style="background-color: white;"| 127315004 luchtaanzuigende thoraxverwonding (aandoening) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Bekken | + | |colspan="6"| Bekken |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Bekken observaties | |colspan="4"| Bekken observaties | ||
− | |style="background-color: white;"|67374007 instabiliteit van gewricht (bevinding) | + | |style="background-color: white;"| 67374007 instabiliteit van gewricht (bevinding) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Wond | |colspan="4"| Wond | ||
− | |style="background-color: white;"|262572000 letsel door afgevuurd projectiel (aandoening) | + | |style="background-color: white;"| 262572000 letsel door afgevuurd projectiel (aandoening) |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"| Extremiteiten Armen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"| Extremiteit | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"| Lateraliteit | ||
+ | |style="background-color: white;"| 7771000 links | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Extremiteiten Armen | + | |colspan="3"| Observaties |
+ | |style="background-color: white;"| 416462003 verwonding (aandoening) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"| Wond | ||
+ | |style="background-color: white;"| 399963005 abrasie (aandoening) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"| Extremiteiten Armen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="6"| | |rowspan="6"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Extremiteit | + | |colspan="5"| Extremiteit |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Lateraliteit | + | |colspan="3"| Lateraliteit |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 24028007 right |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Observaties | + | |colspan="3"| Observaties |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 22253000 pijn (bevinding) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Wond | + | |colspan="3"| Wond |
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Extremiteiten Benen | + | |colspan="6"| Extremiteiten Benen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="6"| | |rowspan="6"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Extremiteit | + | |colspan="5"| Extremiteit |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Lateraliteit | + | |colspan="3"| Lateraliteit |
− | |style="background-color: white;"|24028007 rechts | + | |style="background-color: white;"| 24028007 rechts |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Observaties | + | |colspan="3"| Observaties (2x) |
− | |style="background-color: white;"|22253000 pijn (bevinding) | + | |style="background-color: white;"| 22253000 pijn (bevinding) <br/> 248477007 zwelling of oedeem (bevinding) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"|Wond | + | |colspan="3"| Wond |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Uitscheiding | + | |colspan="6"| Uitscheiding |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Uitscheiding observaties | + | |colspan="4"| Uitscheiding observaties |
− | |style="background-color: white;"|422400008 braken (aandoening) | + | |style="background-color: white;"| 422400008 braken (aandoening) <br/> 48340000 incontinentie (bevinding) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Braken | + | |colspan="4"| Braken |
− | |style="background-color: white;"|8765009 hematemese (aandoening) | + | |style="background-color: white;"| 8765009 hematemese (aandoening) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Incontinent | + | |colspan="4"| Incontinent |
− | |style="background-color: white;"|72042002 incontinentie voor feces (bevinding) | + | |style="background-color: white;"| 72042002 incontinentie voor feces (bevinding) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Verloskunde/Gynaecologie | + | |colspan="6"| Verloskunde/Gynaecologie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Verloskunde/Gynaecologie observaties | + | |colspan="4"| Verloskunde/Gynaecologie observaties |
− | |style="background-color: white;"|47821001 postpartumbloeding (aandoening) | + | |style="background-color: white;"| 47821001 postpartumbloeding (aandoening) <br/> 371380006 lekken van vruchtwater (aandoening) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Vruchtwaterverlies | + | |colspan="4"| Vruchtwaterverlies |
− | |style="background-color: white;"|168090003 helder vruchtwater (bevinding) | + | |style="background-color: white;"| 168090003 helder vruchtwater (bevinding) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Weeën | + | |colspan="4"| Weeën |
|style="background-color: white;"| 2 minuten | |style="background-color: white;"| 2 minuten | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 1.155: | Regel 1.337: | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Initialen | + | |colspan="5"| Initialen |
|style="background-color: white;"| J.H.M. | |style="background-color: white;"| J.H.M. | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Achternaam | + | |colspan="5"| Achternaam |
|style="background-color: white;"| Putten | |style="background-color: white;"| Putten | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Telefoonnummer | + | |colspan="5"| Telefoonnummer |
|style="background-color: white;"| 0611234567 | |style="background-color: white;"| 0611234567 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Identificatie | + | |colspan="5"| Identificatie |
|style="background-color: white;"| 000014444 (UZI) | |style="background-color: white;"| 000014444 (UZI) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Type consultgever | + | |colspan="5"| Type consultgever |
− | |style="background-color: white;"| | + | |style="background-color: white;"| 001 huisarts |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Toelichting/Afspraken met consultgever | + | |colspan="5"| Toelichting/Afspraken met consultgever |
− | |style="background-color: white;"| | + | |style="background-color: white;"| terugbellen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
Regel 1.183: | Regel 1.365: | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Huisarts ingelicht | + | |colspan="5"| Huisarts ingelicht |
− | |style="background-color: white;"|Nee | + | |style="background-color: white;"| Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Afspraken met patiënt | + | |colspan="5"| Afspraken met patiënt |
− | |style="background-color: white;"|Huisarts nog inlichten | + | |style="background-color: white;"| Huisarts nog inlichten |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
Regel 1.199: | Regel 1.381: | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Type Bijlage | + | |colspan="5"| Type Bijlage |
− | |style="background-color: white;"|intern rapport/overdracht | + | |style="background-color: white;"| 006 intern rapport/overdracht |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Bijlage id | + | |colspan="5"| Bijlage id |
|style="background-color: white;"| 9068 | |style="background-color: white;"| 9068 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Versie | + | |colspan="5"| Versie |
|style="background-color: white;"| 1 | |style="background-color: white;"| 1 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Bijlageset id | + | |colspan="5"| Bijlageset id |
|style="background-color: white;"| 12 | |style="background-color: white;"| 12 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 1.221: | Regel 1.403: | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|Wetenschappelijk onderzoek | + | |colspan="6"| Wetenschappelijk onderzoek |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Beschrijving | + | |colspan="4"| Beschrijving |
|style="background-color: white;"| Observaties | |style="background-color: white;"| Observaties | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Informed consent | + | |colspan="4"| Informed consent |
|style="background-color: white;"| Ja | |style="background-color: white;"| Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Toestemming informeren verwanten | + | |colspan="5"| Toestemming informeren verwanten |
− | |style="background-color: white;"|Patiënt geeft toestemming | + | |style="background-color: white;"| 001 Patiënt geeft toestemming |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
Regel 1.244: | Regel 1.426: | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Toelichting algemeen | + | |colspan="5"| Toelichting algemeen |
|style="background-color: white;"| Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur ridiculus mus. Donec quam felis, ultricies nec, pellentesque eu, pretium quis, sem. Nulla consequat massa quis enim. Donec pede justo, fringilla vel, aliquet nec, vulputate | |style="background-color: white;"| Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur ridiculus mus. Donec quam felis, ultricies nec, pellentesque eu, pretium quis, sem. Nulla consequat massa quis enim. Donec pede justo, fringilla vel, aliquet nec, vulputate | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
<section end="Toelichtingsgegevens" /> | <section end="Toelichtingsgegevens" /> |
Huidige versie van 14 mrt 2025 om 11:39
Please note that this is draft material which is still in development |
Patient | |||||
Gegevenselement | Waarde | ||||
Persoonidentificatie | 999910589 | ||||
Naamgegevens | |||||
Initialen | J.H.M. | ||||
Achternaam | |||||
Soort naam | Geboortenaam partner | ||||
Voorvoegsels | van | ||||
Achternaam | XXX_Baatenburg | ||||
Geslacht | Vrouw | ||||
Geboortegegevens | |||||
Geboortedatum | 06-08-1954 | ||||
Geschatte leeftijd | 45 | ||||
Adresgegevens | |||||
Straat | Knolweg | ||||
Huisnummer | 1003 | ||||
Huisnummerletter | |||||
Huisnummertoevoeging | |||||
Postcode | 9999ZA | ||||
Woonplaats | Stitswerd | ||||
Land | Nederland | ||||
Locatiebeschrijving | naast de derde brug rechts | ||||
Overige Contactgegevens | |||||
Telefoonnummers | |||||
Telefoonnummer | 611234567 | ||||
Soort telefoonnummer | |||||
Werktelefoon | |||||
werknummer | |||||
Soort nummer | |||||
EmailAdressen | |||||
Emailadres | giesput@myweb.nl | ||||
Soort e-mailadres | |||||
Emailadres | |||||
Soort e-mailadres | |||||
Ziektekostenverzekering? | Ja | ||||
Verzekeringsgegevens | |||||
Verzekeraar | |||||
Naam | IZA | ||||
Identificatienummer | 3334 | ||||
Polis | |||||
Polisnummer/Verzekerdenummer | 992298765 | ||||
Vaste huisarts | |||||
ZorgverlenerIdentificatienummer | UZI: 000014444 AGB: 01022418 | ||||
Rolcode | 01.015 | ||||
Naam | |||||
Achternaam | Pulver | ||||
Vaste huisartsenpraktijk | |||||
Identificatie | 12345678 | ||||
Naam | Gezondheidscentrum Aesculaap | ||||
Adresgegevens | |||||
Soort adres | |||||
Straatnaam | |||||
Huisnummer | |||||
Huisnummertoevoeging | |||||
Postcode | |||||
Gemeente | |||||
Woonplaats | Zaandam | ||||
Land | |||||
Overige contactgegevens | |||||
Telefoonnummers | |||||
Soort telefoonnummer | |||||
Telefoonnummer | 06-11234567 | ||||
Faxnummers | |||||
Soort faxnummer | |||||
Faxnummer | |||||
E-mailadressen | |||||
Soort e-mailadres | |||||
E-mailadres | |||||
Contactpersoon patiënt | |||||
Achternaam | Putten | ||||
Telefoonnummer | 611234567 | ||||
Relatie tot patiënt | FAMMEMB |
WID-controle | |||||
Gegevenselement | Waarde | ||||
WID-controle uitgevoerd | Ja | ||||
WID controle datum | T | ||||
Documentnummer | NS07778999 | ||||
Document type | Paspoort |
Incidentgegevens | |||||
Gegevenselement | Waarde | ||||
Datum/tijd incident | T-20 min |
Meldingsgegevens | |||||
Gegevenselement | Waarde | ||||
Datum/tijd melding | T-15min | ||||
Geplande brengtijd | |||||
Geplande haaltijd | |||||
Wzd/Wvggz maatregel | TVZcm (code = 004 in codesysteem 2.16.840.1.113883.2.4.3.11.60.55.5.57 'acutezorg-codesysteem-57') | ||||
Datum/tijd aanvang TVZ | T-10min | ||||
Medische kladblok meldkamer | Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur ridiculus mus. Donec quam felis, ultricies nec, pellentesque eu, pretium quis, sem. Nulla consequat massa quis enim. Donec pede justo, fringilla vel, aliquet nec, vulputate | ||||
Meldkamerurgentie | B1 Hoog complexe zorg bij planbare ambulancezorg |
Zorgaanvrager | |||||
Gegevenselement | Waarde | ||||
Initialen | J.H.M. | ||||
Achternaam | Putten | ||||
Telefoonnummer | 61234567 | ||||
Identificatie | UZI: 000014444 AGB: 01022418 | ||||
Type zorgaanvrager | Huisarts (004) |
Ritgegevens | |||||
Gegevenselement | Waarde | ||||
Ambulancevoorziening | 25 | ||||
Ritnummer | 25-2020-10-1 | ||||
Ambulancenummer | 25124 | ||||
Telefoon ambulance | 0612345678 | ||||
Ambulanceverpleegkundige identificatie | 123456789 | ||||
Ambulancechauffeur identificatie | 987654321 | ||||
Datum/tijd ritopdracht | T-10 min | ||||
Datum/tijd uitruk/vertrek | T-10 min | ||||
Datum/tijd aankomst patiënt | T-5 min | ||||
Datum/tijd vertrek patiënt | T | ||||
Verwachte aankomsttijd bestemming | T+10 min** | ||||
Datum/tijd aankomst bestemming | T+10 min | ||||
Datum/tijd vrijmelding | T+15 min | ||||
Soort vervoer | 001 opnamerit |
Haalgegevens | |||||
Gegevenselement | Waarde | ||||
Straat | 1e Jacob van Campenstr | ||||
Huisnummer | 15 | ||||
Huisletter | B | ||||
Huisnummertoevoeging | II | ||||
Postcode | 1012 NX | ||||
Locatiebeschrijving | naast de derde brug rechts | ||||
Woonplaats | Hoogmade | ||||
Land | Nederland | ||||
Patiënt vervoerd? | Ja | ||||
Reden geen vervoer | |||||
Tijdstip overlijden patiënt | |||||
Advies behandeling tijdens vervoer aanwezig? | nee | ||||
Niet reanimeren verklaring aanwezig? | nee | ||||
Trialgegevens | Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur ridiculus mus. Donec quam felis, ultricies nec, pellentesque eu, pretium quis, sem. Nulla consequat massa quis enim. Donec pede justo, fringilla vel, aliquet nec, vulputate | ||||
Ambulance-urgentie | A1 spoedrit | ||||
Gewondennummer | 12345678 | ||||
Triageklasse | T2 | ||||
Hulpverleners ter plaatse | |||||
Hulpverlenersnaam | Jansen | ||||
Type hulpverlener | Ambulance (001) | ||||
Telefoonnummer | 611234567 | ||||
E-mailadres | hulpverlener@myweb.nl |
Bestemmingsgegevens | |||||
Gegevenselement | Waarde | ||||
Bestemmingsstatus | Overgedragen | ||||
Bestemmingscode | AGB: 06010860 | ||||
Locatie of afdeling | LSDV-code: 2.16.840.1.113883.2.4.6.1.6010860.000 | ||||
Straat | 1e Jacob van Campenstr | ||||
Huisnummer | 15 | ||||
Huisletter | B | ||||
Huisnummertoevoeging | II | ||||
Postcode | 1012 NX | ||||
Locatiebeschrijving | naast de derde brug rechts | ||||
Woonplaats | Hoogmade | ||||
Land | Nederland | ||||
Bijzonderheden algemeen | Verbouwing van de zij-ingang | ||||
Verwacht specialisme | Chirurg (01.014) | ||||
Feedback | |||||
Feedback gewenst | Ja | ||||
Feedback adres | Test adres | ||||
Feedback methode | Zorgmail |
Mechanisme | |||||
Gegevenselement | Waarde | ||||
Mechanisme type | 35468003 bekneld geraakt tussen voorwerpen (gebeurtenis)
418019003 accidentele gebeurtenis (gebeurtenis) | ||||
Vervoermiddel patiënt | 22674006 bus (fysiek object) | ||||
Patiënt was bestuurder? | ja | ||||
Vervoermiddel contra | 22674006 bus (fysiek object) | ||||
Beschermingsmiddelen patiënt | 60054005 autogordel (fysiek object) |
Toestandsbeelden/Werkdiagnose | |||||
Gegevenselement | Waarde | ||||
Toestandsbeeld | |||||
Toestandsbeeld code | 125593007 letsel van aangezicht (aandoening) | ||||
Toelichting Toestandsbeeld | Moeilijk observeren door weersomstandigheden |
Meetwaarden | |||||
Gegevenselement | Waarde | ||||
Bloedsuiker | |||||
Bloedsuiker waarde | 7.1 mmol/L | ||||
BloedsuikerDatumTijd | T-10 minuten | ||||
Hartritme | |||||
Hartritme observatie | 397829000 asystolie (aandoening) | ||||
HartritmeDatumTijd | T-10 minuten | ||||
Toelichting hartritme/ECG | Niet normaal | ||||
O2Saturatie | |||||
SpO2waarde | 98% | ||||
O2SaturatieDatumTijd | T-10 minuten | ||||
Capnometrie | |||||
CO2Waarde | 42 mm[Hg] 5,6 kPa | ||||
CO2CapnometrieDatumTijd | T-10 minuten | ||||
Hartfrequentie | |||||
HartfrequentieWaarde | 76/min | ||||
HartfrequentieDatumTijd | T-10 minuten | ||||
Bloeddruk | |||||
SystolischeBloeddruk | 155 mm[Hg] | ||||
DiastolischeBloeddruk | 70 mm[Hg] | ||||
BloeddrukDatumTijd | T-10 minuten | ||||
Lichaamstemperatuur | |||||
TemperatuurWaarde | 37,3 °C (graden Celcius) | ||||
TemperatuurDatumTijd | T-10 minuten | ||||
Ademhaling | |||||
Ademfrequentie | 15/min | ||||
AdemhalingDatumTijd | T-10 minuten | ||||
GlasgowComaScale | |||||
GlasgowComaScaleDatumTijd | T-10 minuten | ||||
GCS_Eyes | E3 | ||||
GCS_Motor | M4 | ||||
GCS_Verbal | V3 (uit 2.16.840.1.113883.2.4.3.11.60.40.4.2.3) | ||||
TotaalScore | 10 | ||||
Revised Trauma Score | |||||
RevisedTraumaScoreWaarde | 11 | ||||
RevisedTraumaScoreTijd | T-10 minuten | ||||
Pediatric Trauma Score | |||||
PediatricTraumaScoreWaarde | |||||
PediatricTraumaScoreTijd | |||||
Pijnschaal | |||||
PijnschaalWaarde | 5 | ||||
PijnschaalTijd | T-10 minuten | ||||
APGAR-1 | |||||
APGAR-5 |
Behandeling | |||||
Gegevenselement | Waarde | ||||
Ademhaling en beademing (diagnostisch) | |||||
Handelingen ademhaling en beademing | 408867002 meten van ademhalingsfrequentie (verrichting) | ||||
Bewustzijn en neurologische status (diagnostisch) | |||||
Handelingen bewustzijn en neurologische status | 291000146106 pupilreactie-onderzoek (verrichting) | ||||
Overige diagnostische handelingen | |||||
Handelingen overige diagnostisch | 5880005 lichamelijk onderzoek (verrichting) | ||||
Luchtweg management (therapeutisch) | |||||
Handelingen luchtweg management | 112798008 intubatie van trachea (verrichting) | ||||
Moeizame intubatie? | Ja | ||||
Oxygenatie en ventilatie (therapeutisch) | |||||
Handelingen oxygenatie en ventilatie | 40617009 kunstmatige beademing (verrichting) | ||||
Beademing machine Fi O2 | 0.50 | ||||
Beademing machine AMV | 6L/min | ||||
Beademing machine Freq. | 10/min | ||||
Beademing machine Peep | 3cm[H2O] | ||||
Hoeveelheid zuurstof | 3L/min | ||||
Oxygenatie en ventilatie (therapeutisch) | |||||
Handelingen oxygenatie en ventilatie | 11140008 handmatige beademing (verrichting) | ||||
Beademing machine Fi O2 | |||||
Beademing machine AMV | |||||
Beademing machine Freq. | |||||
Beademing machine Peep | |||||
Hoeveelheid zuurstof | |||||
Circulatie (therapeutisch) | |||||
Handelingen circulatie | 250980009 cardioversie (verrichting) | ||||
Pacemaker frequentie | |||||
Pacemaker stroomsterkte | |||||
Pacemaker modus | |||||
Cardioversies aantal | 2 | ||||
Cardioversie maximale energie | 600 Joule | ||||
Defibrillaties aantal | |||||
Defibrillatie energie | |||||
Return Of Spontaneous Circulation (ROSC) | Nee | ||||
AED aangesloten voor aankomst | Ja | ||||
AED-schokken aantal | 5 | ||||
Circulatie (therapeutisch) | |||||
Handelingen circulatie | 233181000 transthoracale cardiale pacing (verrichting) | ||||
Pacemaker frequentie | 60 /min | ||||
Pacemaker stroomsterkte | 5 mA | ||||
Pacemaker modus | 001 fixed rate | ||||
Cardioversies aantal | |||||
Cardioversie maximale energie | |||||
Defibrillaties aantal | |||||
Defibrillatie energie | |||||
Return Of Spontaneous Circulation (ROSC) | Nee | ||||
AED aangesloten voor aankomst | Ja | ||||
AED-schokken aantal | 5 | ||||
Circulatie (therapeutisch) | |||||
Handelingen circulatie | 308842001 defibrillatie met gelijkstroom (verrichting) | ||||
Pacemaker frequentie | |||||
Pacemaker stroomsterkte | |||||
Pacemaker modus | |||||
Cardioversies aantal | |||||
Cardioversie maximale energie | |||||
Defibrillaties aantal | 3 | ||||
Defibrillatie energie | 200 Joule | ||||
Return Of Spontaneous Circulation (ROSC) | Nee | ||||
AED aangesloten voor aankomst | Ja | ||||
AED-schokken aantal | 5 | ||||
Traumatologie (therapeutisch) | |||||
Handelingen traumatologie | 105382002 koelen van patiënt (verrichting) | ||||
Koelen tijdsduur | 10 minuten | ||||
Obstetrie | |||||
Handelingen obstetrie | 238248005 afklemmen van navelstreng (verrichting) | ||||
Wijze van isolatie | |||||
Handelingen isolatie | 170499009 contactisolatie (verrichting) | ||||
Medicatie | |||||
Medicatie toegediend? | Ja | ||||
Medicatienaam | 13.1 Acetylsalicylzuur | ||||
Toegediende hoeveelheid medicatie | 2 stuk | ||||
Tijd medicatietoediening | T-10 minuten | ||||
Medicatie toedieningsvorm | 386359008 oraal toedienen van medicatie (verrichting) | ||||
IV medicatiesnelheid | 100 ml/uur | ||||
Infuus | |||||
Infusen aantal | 1 | ||||
Infuusvloeistofcode | 137774 (GPK) | ||||
Infuusvloeistoftekst | IMMUNOGLOBULINE NORMAAL INF | ||||
Infuushoeveelheid | 200 ml | ||||
Extra informatie behandeling | Normale behandeling |
Patiëntligging | |||||
Gegevenselement | Waarde | ||||
Type patiëntligging | 001 buik |
Primary Survey | |||||
Gegevenselement | Waarde | ||||
Airway | |||||
Airway vrij? | nee | ||||
Stridor | 58596002 inspiratoire stridor (bevinding) | ||||
Breathing | |||||
Breathing sufficient? | nee | ||||
Breathing observaties | 271623001 asymmetrische thoraxbeweging (bevinding) | ||||
Circulation | |||||
Circulation sufficient? | nee | ||||
Capillaire refill > 2 seconde? | Ja | ||||
Huid observatie | 248245006 klam zweet (bevinding) | ||||
Disability | |||||
AVPU | 248234008 alert (bevinding) | ||||
Duur buiten bewustzijn | 5 min | ||||
Pupil | 301941003 Normal pupil size (finding) | ||||
FAST symptomen aanwezig | Ja | ||||
Mogelijk trombolyse/trombectomie | Ja | ||||
Intoxicatie | 67426006 intoxicatie door alcohol (aandoening) | ||||
Toelichting Primary Survey | Nee |
Secondary Survey | |||||
Gegevenselement | Waarde | ||||
Anamnese | |||||
Ample | |||||
Code | 473011001 | ||||
Titel | Allergie | ||||
Omschrijving | Pinda's | ||||
Ample | |||||
Code | 394829006 | ||||
Titel | Medicatie | ||||
Omschrijving | Geen medicatie | ||||
Ample | |||||
Code | 417662000 | ||||
Titel | Past | ||||
Omschrijving | Nooit eerder opgenomen geweest | ||||
Ample | |||||
Code | 405795006 | ||||
Titel | Tijd eerste optreden symptomen | ||||
Omschrijving | 1 uur geleden | ||||
Ample | |||||
Code | 272379006 | ||||
Titel | Events | ||||
Omschrijving | Geen bijzonderheden | ||||
Toelichting anamnese | Lastig vanwege weersomstandigheden | ||||
Infectierisico | |||||
Verdenking infectieziekten? | Ja | ||||
Toelichting infectierisico | Afgelopen maanden in een ziekenhuis in India geweest | ||||
Hoofd en gelaat | |||||
Hoofd en gelaat observaties | 135874008 beet in eigen tong (aandoening) | ||||
Bloedverlies | 22490002 bloeding uit mond (aandoening) | ||||
Liquorverlies | 85638002 nasale liquorroe (aandoening) | ||||
Pijnlocatie | Kaaklijn Achterhoofd | ||||
Wond | 425322008 steekwond (aandoening) 399963005 abrasie (aandoening) | ||||
Nek, hals, CWK | |||||
Nek, hals, CWK observaties | 279029001 pijn in cervicale wervelkolom (bevinding) | ||||
Wond | 425322008 steekwond (aandoening) | ||||
Thorax | |||||
Thorax observaties | 249672002 asymmetrische thorax (bevinding) | ||||
Pijn bij compressie | 32391000146100 pijn van sternum bij compressie tijdens lichamelijk onderzoek (bevinding) | ||||
Locatie subcutaan emfyseem | 32441000146104 drukpijn en/of loslaatpijn rechtsonder in abdomen bij lichamelijk onderzoek (bevinding) | ||||
Locatie zwelling / oedeem (2x) | 32431000146107 drukpijn en/of loslaatpijn rechtsboven in abdomen bij lichamelijk onderzoek (bevinding) 32411000146100 drukpijn en/of loslaatpijn linksboven in abdomen bij lichamelijk onderzoek (bevinding) | ||||
Wond | 125666000 brandwond (aandoening) | ||||
Rug | |||||
Rug observaties | 385494008 hematoom (aandoening) | ||||
Wond | 399963005 abrasie (aandoening) | ||||
Abdomen | |||||
Abdomen observaties | 297968009 bloeding van huid (bevinding) | ||||
Locatie druk- / loslaatpijn | 32431000146107 drukpijn en/of loslaatpijn rechtsboven in abdomen bij lichamelijk onderzoek (bevinding) | ||||
Locatie zwelling / oedeem | 32411000146100 drukpijn en/of loslaatpijn linksboven in abdomen bij lichamelijk onderzoek (bevinding) | ||||
Locatie pulserende zwelling | 32411000146100 drukpijn en/of loslaatpijn linksboven in abdomen bij lichamelijk onderzoek (bevinding) | ||||
Wond | 127315004 luchtaanzuigende thoraxverwonding (aandoening) | ||||
Bekken | |||||
Bekken observaties | 67374007 instabiliteit van gewricht (bevinding) | ||||
Wond | 262572000 letsel door afgevuurd projectiel (aandoening) | ||||
Extremiteiten Armen | |||||
Extremiteit | |||||
Lateraliteit | 7771000 links | ||||
Observaties | 416462003 verwonding (aandoening) | ||||
Wond | 399963005 abrasie (aandoening) | ||||
Extremiteiten Armen | |||||
Extremiteit | |||||
Lateraliteit | 24028007 right | ||||
Observaties | 22253000 pijn (bevinding) | ||||
Wond | |||||
Extremiteiten Benen | |||||
Extremiteit | |||||
Lateraliteit | 24028007 rechts | ||||
Observaties (2x) | 22253000 pijn (bevinding) 248477007 zwelling of oedeem (bevinding) | ||||
Wond | |||||
Uitscheiding | |||||
Uitscheiding observaties | 422400008 braken (aandoening) 48340000 incontinentie (bevinding) | ||||
Braken | 8765009 hematemese (aandoening) | ||||
Incontinent | 72042002 incontinentie voor feces (bevinding) | ||||
Verloskunde/Gynaecologie | |||||
Verloskunde/Gynaecologie observaties | 47821001 postpartumbloeding (aandoening) 371380006 lekken van vruchtwater (aandoening) | ||||
Vruchtwaterverlies | 168090003 helder vruchtwater (bevinding) | ||||
Weeën | 2 minuten |
Consultgever op afstand | |||||
Gegevenselement | Waarde | ||||
Initialen | J.H.M. | ||||
Achternaam | Putten | ||||
Telefoonnummer | 0611234567 | ||||
Identificatie | 000014444 (UZI) | ||||
Type consultgever | 001 huisarts | ||||
Toelichting/Afspraken met consultgever | terugbellen |
Afspraken met patiënt | |||||
Gegevenselement | Waarde | ||||
Huisarts ingelicht | Nee | ||||
Afspraken met patiënt | Huisarts nog inlichten |
Bijlagen | |||||
Gegevenselement | Waarde | ||||
Type Bijlage | 006 intern rapport/overdracht | ||||
Bijlage id | 9068 | ||||
Versie | 1 | ||||
Bijlageset id | 12 |
Toestemmingsgegevens | |||||
Gegevenselement | Waarde | ||||
Wetenschappelijk onderzoek | |||||
Beschrijving | Observaties | ||||
Informed consent | Ja | ||||
Toestemming informeren verwanten | 001 Patiënt geeft toestemming |
Toelichtingsgegevens | |||||
Gegevenselement | Waarde | ||||
Toelichting algemeen | Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur ridiculus mus. Donec quam felis, ultricies nec, pellentesque eu, pretium quis, sem. Nulla consequat massa quis enim. Donec pede justo, fringilla vel, aliquet nec, vulputate |