iaz:Vdraft2.4.0 Testscript Ambulanceoverdracht SEH Sturen Complexe Casus: verschil tussen versies
(→T1: aankomst bij de patient) |
|||
| (11 tussenliggende versies door dezelfde gebruiker niet weergegeven) | |||
| Regel 8: | Regel 8: | ||
{{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}} | ||
| + | =Inleiding= | ||
| + | Dit scenario bestaat uit drie opeenvolgende berichten die de ambulance stuurt naar de SEH: een bij aankomst bij | ||
| + | de patient (T1), een gedurende de rit (T2) en een vlak voor aankomst bij de SEH (T3). Deze berichten zijn | ||
| + | cumulatief, dus het bericht op T2 bevat alles van bericht T1, plus wat er sindsdien bijgevoegd is, en bericht 3 | ||
| + | alles van T2, plus wat er sindsdien bijgevoegd is. | ||
| + | Tenzij vermeld moeten alle velden vanaf het eerste bericht voorkomen; bij de metingen staat het tijdstip | ||
| + | expliciet aangegeven. Alleen de bijlagen worden slechts 1x verstuurd, omdat die in dit geval zelf cumulatief zijn | ||
| + | (zelfde setId met oplopend versienummer), en de oudere versies dus obsoleet zijn. | ||
| + | |||
| + | ==T1: aankomst bij de patient== | ||
| + | |||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | T1 | ||
| + | |} | ||
<section begin="patient" /> | <section begin="patient" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| Regel 16: | Regel 30: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Persoonidentificatie | |colspan="5"|Persoonidentificatie | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|999910553 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Naamgegevens | |colspan="6"|Naamgegevens | ||
| Regel 25: | Regel 39: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Initialen | |colspan="3"|Initialen | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|W. |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Achternaam | |colspan="6"|Achternaam | ||
| Regel 32: | Regel 46: | ||
|-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;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Voorvoegsels | |colspan="3"|Voorvoegsels | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-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;"|XXX_Witsiers |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Geslacht | |colspan="5"|Geslacht | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|M |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Geboortegegevens | |colspan="6"|Geboortegegevens | ||
| Regel 51: | Regel 65: | ||
|-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;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Adresgegevens | |colspan="6"|Adresgegevens | ||
| Regel 58: | Regel 72: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Straat | |colspan="4"|Straat | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|Hertog Aalbrechtweg |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Huisnummer | |colspan="4"|Huisnummer | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|8 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Huisnummerletter | |colspan="4"|Huisnummerletter | ||
| Regel 70: | Regel 84: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Postcode | |colspan="4"|Postcode | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|1823 DB |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Woonplaats | |colspan="4"|Woonplaats | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|Alkmaar |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Land | |colspan="4"|Land | ||
| Regel 79: | Regel 93: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Locatiebeschrijving | |colspan="4"|Locatiebeschrijving | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Overige Contactgegevens | |colspan="6"|Overige Contactgegevens | ||
| Regel 90: | Regel 104: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Telefoonnummer | |colspan="3"|Telefoonnummer | ||
| − | |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 telefoonnummer | |colspan="3"|Soort telefoonnummer | ||
| Regel 110: | Regel 124: | ||
|-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 | ||
| Regel 122: | Regel 136: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| Ziektekostenverzekering? | |colspan="5"| Ziektekostenverzekering? | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Verzekeringsgegevens | |colspan="6"|Verzekeringsgegevens | ||
| Regel 133: | Regel 147: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Naam | |colspan="3"|Naam | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Identificatienummer | |colspan="3"|Identificatienummer | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Polis | |colspan="5"|Polis | ||
| Regel 143: | Regel 157: | ||
|-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;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Vaste huisarts | |colspan="6"|Vaste huisarts | ||
| Regel 150: | Regel 164: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| ZorgverlenerIdentificatienummer | |colspan="4"| ZorgverlenerIdentificatienummer | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Rolcode | |colspan="4"| Rolcode | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
| Regel 160: | Regel 174: | ||
|-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;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Vaste huisartsenpraktijk | |colspan="6"|Vaste huisartsenpraktijk | ||
| Regel 167: | Regel 181: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Identificatie | |colspan="4"| Identificatie | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Naam | |colspan="4"| Naam | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| Adresgegevens | |colspan="5"| Adresgegevens | ||
| Regel 195: | Regel 209: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| Woonplaats | |colspan="3"| Woonplaats | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| Land | |colspan="3"| Land | ||
| Regel 212: | Regel 226: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| Telefoonnummer | |colspan="2"| Telefoonnummer | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Faxnummers | |colspan="4"| Faxnummers | ||
| Regel 239: | Regel 253: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Achternaam | |colspan="4"| Achternaam | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Telefoonnummer | |colspan="4"| Telefoonnummer | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Relatie tot patiënt | |colspan="4"| Relatie tot patiënt | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 258: | Regel 272: | ||
|-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;"| | + | |style="background-color: white;"| |
|-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;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Documentnummer | |colspan="5"|Documentnummer | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-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;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 280: | Regel 294: | ||
|-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;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 293: | Regel 307: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Datum/tijd melding | |colspan="5"|Datum/tijd melding | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| T1-15min |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Geplande brengtijd | |colspan="5"|Geplande brengtijd | ||
| Regel 302: | Regel 316: | ||
|-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;"| | + | |style="background-color: white;"| |
|-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;"| | + | |style="background-color: white;"| |
|-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;"| | + | |style="background-color: white;"| |
|-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;"| A2 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 324: | Regel 338: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Initialen | |colspan="5"|Initialen | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Achternaam | |colspan="5"|Achternaam | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Telefoonnummer | |colspan="5"|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"|Identificatie | |colspan="5"|Identificatie | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Type zorgaanvrager | |colspan="5"|Type zorgaanvrager | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 349: | Regel 363: | ||
|-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 (RAV identificatie) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Ritnummer | |colspan="5"|Ritnummer | ||
| − | |style="background-color: white;"| 25-2020- | + | |style="background-color: white;"| 25-2020-13-1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Ambulancenummer | |colspan="5"|Ambulancenummer | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| 25190 |
|-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;"| | + | |style="background-color: white;"| |
|-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;"| | + | |style="background-color: white;"| 596 |
|-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;"| | + | |style="background-color: white;"| 530 |
|-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;"| | + | |style="background-color: white;"| T1-10 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;"| | + | |style="background-color: white;"| T1-10 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;"| | + | |style="background-color: white;"| T1 |
|-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;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verwachte aankomsttijd bestemming | |colspan="5"|Verwachte aankomsttijd bestemming | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-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;"| | + | |style="background-color: white;"| |
|-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;"| | + | |style="background-color: white;"| |
|-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;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 401: | Regel 415: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Straat | |colspan="5"|Straat | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Huisnummer | |colspan="5"|Huisnummer | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Huisletter | |colspan="5"|Huisletter | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Huisnummertoevoeging | |colspan="5"|Huisnummertoevoeging | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Postcode | |colspan="5"|Postcode | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Locatiebeschrijving | |colspan="5"|Locatiebeschrijving | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Woonplaats | |colspan="5"|Woonplaats | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Land | |colspan="5"|Land | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-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;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Reden geen vervoer | |colspan="5"|Reden geen vervoer | ||
| Regel 434: | Regel 448: | ||
|-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;"| |
|-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;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Trialgegevens | |colspan="5"|Trialgegevens | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-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;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Gewondennummer | |colspan="5"|Gewondennummer | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Triageklasse | |colspan="5"|Triageklasse | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 457: | Regel 471: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Hulpverlenersnaam | |colspan="4"|Hulpverlenersnaam | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-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;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Telefoonnummer | |colspan="4"|Telefoonnummer | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|E-mailadres | |colspan="4"|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 478: | Regel 492: | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="5"|Bestemmingsstatus | + | |colspan="5"|Bestemmingsstatus in bericht op T1 |
| − | |style="background-color: white;"| | + | |style="background-color: white;"|Actief |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Bestemmingscode | |colspan="5"|Bestemmingscode | ||
| Regel 488: | Regel 502: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Straat | |colspan="5"|Straat | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Huisnummer | |colspan="5"|Huisnummer | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Huisletter | |colspan="5"|Huisletter | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Huisnummertoevoeging | |colspan="5"|Huisnummertoevoeging | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Postcode | |colspan="5"|Postcode | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Locatiebeschrijving | |colspan="5"|Locatiebeschrijving | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Woonplaats | |colspan="5"|Woonplaats | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Land | |colspan="5"|Land | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Bijzonderheden algemeen | |colspan="5"|Bijzonderheden algemeen | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verwacht specialisme | |colspan="5"|Verwacht specialisme | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Feedback | |colspan="6"|Feedback | ||
| Regel 522: | Regel 536: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Feedback gewenst | |colspan="4"|Feedback gewenst | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Feedback adres | |colspan="4"|Feedback adres | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Feedback methode | |colspan="4"|Feedback methode | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 542: | Regel 556: | ||
|colspan="5"|Mechanisme type | |colspan="5"|Mechanisme type | ||
|style="background-color: white;"| 35468003 bekneld geraakt tussen voorwerpen (gebeurtenis) | |style="background-color: white;"| 35468003 bekneld geraakt tussen voorwerpen (gebeurtenis) | ||
| − | |||
|-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;"| | + | |style="background-color: white;"| 71783008 auto (fysiek object) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Patiënt was bestuurder? | |colspan="5"|Patiënt was bestuurder? | ||
| Regel 551: | Regel 564: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Vervoermiddel contra | |colspan="5"|Vervoermiddel contra | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| 71783008 auto (fysiek object) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="5"|Beschermingsmiddelen patiënt | + | |colspan="5"|Beschermingsmiddelen patiënt (3x) |
| − | |style="background-color: white;"| 60054005 | + | |style="background-color: white;"| 285695004 helm (fysiek object) <br/> |
| + | 60054005 autogordel (fysiek object)<br/> | ||
| + | 102384007 airbag van motorvoertuig (fysiek object) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 591: | Regel 606: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Bloedsuiker waarde | |colspan="4"|Bloedsuiker waarde | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| 6 mmol/L |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|BloedsuikerDatumTijd | |colspan="4"|BloedsuikerDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| T1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Hartritme | |colspan="6"|Hartritme | ||
| Regel 601: | Regel 616: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Hartritme observatie | |colspan="4"|Hartritme observatie | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|HartritmeDatumTijd | |colspan="4"|HartritmeDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Toelichting hartritme/ECG | |colspan="4"|Toelichting hartritme/ECG | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|O2Saturatie | |colspan="6"|O2Saturatie | ||
| Regel 614: | Regel 629: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|SpO2waarde | |colspan="4"|SpO2waarde | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|99% |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|O2SaturatieDatumTijd | |colspan="4"|O2SaturatieDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|T1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Capnometrie | |colspan="6"|Capnometrie | ||
| Regel 624: | Regel 639: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|CO2Waarde | |colspan="4"|CO2Waarde | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|60 mm[Hg] <br/>8,0 kPa |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|CO2CapnometrieDatumTijd | |colspan="4"|CO2CapnometrieDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|T1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Hartfrequentie | |colspan="6"|Hartfrequentie | ||
| Regel 634: | Regel 649: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|HartfrequentieWaarde | |colspan="4"|HartfrequentieWaarde | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|120/min |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|HartfrequentieDatumTijd | |colspan="4"|HartfrequentieDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|T1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Bloeddruk | |colspan="6"|Bloeddruk | ||
| Regel 644: | Regel 659: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|SystolischeBloeddruk | |colspan="4"|SystolischeBloeddruk | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|90 mm[Hg] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|DiastolischeBloeddruk | |colspan="4"|DiastolischeBloeddruk | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|60 mm[Hg] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|BloeddrukDatumTijd | |colspan="4"|BloeddrukDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|T1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Lichaamstemperatuur | |colspan="6"|Lichaamstemperatuur | ||
| Regel 657: | Regel 672: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|TemperatuurWaarde | |colspan="4"|TemperatuurWaarde | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|TemperatuurDatumTijd | |colspan="4"|TemperatuurDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Ademhaling | |colspan="6"|Ademhaling | ||
| Regel 667: | Regel 682: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Ademfrequentie | |colspan="4"|Ademfrequentie | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|4/min |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|AdemhalingDatumTijd | |colspan="4"|AdemhalingDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|T1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|GlasgowComaScale | |colspan="6"|GlasgowComaScale | ||
| Regel 677: | Regel 692: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|GlasgowComaScaleDatumTijd | |colspan="4"|GlasgowComaScaleDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|T1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|GCS_Eyes | |colspan="4"|GCS_Eyes | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|4 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|GCS_Motor | |colspan="4"|GCS_Motor | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|6 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|GCS_Verbal | |colspan="4"|GCS_Verbal | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|5 (uit 2.16.840.1.113883.2.4.3.11.60.40.4.2.3) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|TotaalScore | |colspan="4"|TotaalScore | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|15 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 697: | Regel 712: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|RevisedTraumaScoreWaarde | |colspan="4"|RevisedTraumaScoreWaarde | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|8 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|RevisedTraumaScoreTijd | |colspan="4"|RevisedTraumaScoreTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|T1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Pediatric Trauma Score | |colspan="6"|Pediatric Trauma Score | ||
| Regel 717: | Regel 732: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|PijnschaalWaarde | |colspan="4"|PijnschaalWaarde | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|3 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|PijnschaalTijd | |colspan="4"|PijnschaalTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|T1 |
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 744: | Regel 760: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Handelingen ademhaling en beademing | |colspan="4"|Handelingen ademhaling en beademing | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Bewustzijn en neurologische status (diagnostisch) | |colspan="6"|Bewustzijn en neurologische status (diagnostisch) | ||
| Regel 751: | Regel 767: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Handelingen bewustzijn en neurologische status | |colspan="4"|Handelingen bewustzijn en neurologische status | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Overige diagnostische handelingen | |colspan="6"|Overige diagnostische handelingen | ||
| Regel 758: | Regel 774: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Handelingen overige diagnostisch | |colspan="4"|Handelingen overige diagnostisch | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Luchtweg management (therapeutisch) | |colspan="6"|Luchtweg management (therapeutisch) | ||
| Regel 765: | Regel 781: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Handelingen luchtweg management | |colspan="4"| Handelingen luchtweg management | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Moeizame intubatie? | |colspan="4"| Moeizame intubatie? | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Oxygenatie en ventilatie (therapeutisch) | |colspan="6"|Oxygenatie en ventilatie (therapeutisch) | ||
| Regel 775: | Regel 791: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Handelingen oxygenatie en ventilatie | |colspan="4"| Handelingen oxygenatie en ventilatie | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
|-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 809: | Regel 803: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Beademing machine Peep | |colspan="4"| Beademing machine Peep | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Hoeveelheid zuurstof | |colspan="4"| Hoeveelheid zuurstof | ||
| Regel 819: | Regel 813: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Handelingen circulatie | |colspan="4"| Handelingen circulatie | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Pacemaker frequentie | |colspan="4"| Pacemaker frequentie | ||
| Regel 831: | Regel 825: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Cardioversies aantal | |colspan="4"| Cardioversies aantal | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Cardioversie maximale energie | |colspan="4"| Cardioversie maximale energie | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Defibrillaties aantal | |colspan="4"| Defibrillaties aantal | ||
| Regel 843: | Regel 837: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Return Of Spontaneous Circulation (ROSC) | |colspan="4"| Return Of Spontaneous Circulation (ROSC) | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| AED aangesloten voor aankomst | |colspan="4"| AED aangesloten voor aankomst | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| AED-schokken aantal | |colspan="4"| AED-schokken aantal | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="6"| | + | |colspan="6"|Traumatologie (therapeutisch) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| Handelingen | + | |colspan="4"| Handelingen traumatologie |
| − | |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"| Koelen tijdsduur |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Obstetrie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Handelingen obstetrie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Wijze van isolatie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |rowspan="2"| |
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"|Handelingen isolatie |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="6"|Medicatie |
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |rowspan="7"| |
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"| Medicatie toegediend? |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"| Medicatienaam |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"| Toegediende hoeveelheid medicatie |
| − | |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"| Tijd medicatietoediening |
| − | |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"| Medicatie toedieningsvorm |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="6"| | + | |colspan="4"| IV medicatiesnelheid |
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Infuus | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="5"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"| Infusen aantal |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"| Infuusvloeistofcode |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"| Infuusvloeistoftekst |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"| Infuushoeveelheid |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="5"|Extra informatie behandeling |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |} |
| + | <section end="Behandeling" /> | ||
| + | |||
| + | <section begin="Patiëntligging" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Patiëntligging | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Type patiëntligging | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |} |
| − | |style="background-color: white;"| | + | <section end="Patiëntligging" /> |
| + | |||
| + | <section begin="Primary Survey" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Primary Survey | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Airway | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |rowspan="3"| |
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"|Airway vrij? |
| − | |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"| | + | |colspan="4"|Stridor |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |||
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="6"| | + | |colspan="6"|Breathing |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"|Breathing sufficient? |
| − | |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"| | + | |colspan="4"|Breathing observaties |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
| − | |||
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |colspan="5"|Circulation |
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"|Circulation sufficient? |
| − | |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"|Capillaire refill > 2 seconde? |
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"|Huid observatie |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-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;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"|Duur buiten bewustzijn |
| − | |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"|Pupil |
| − | |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"|FAST symptomen aanwezig |
| − | |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"|Mogelijk trombolyse/trombectomie |
| − | |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"|Intoxicatie |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | + | |colspan="5"|Toelichting Primary Survey | |
| − | + | |style="background-color: white;"| | |
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |colspan="5"| | ||
| − | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| − | <section end=" | + | <section end="Primary Survey" /> |
| − | <section begin=" | + | <section begin="Secondary Survey" /> |
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Secondary Survey |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="6"|Anamnese |
| − | |style="background-color: | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Ample | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |rowspan="4"| |
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |colspan="3"|Code |
| + | |style="background-color: white;"| | ||
|-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;"| |
|-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;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Toelichting anamnese | ||
| + | |style="background-color: white;"| | ||
|-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"| | + | |colspan="4"| Verdenking infectieziekten? |
| − | |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"| Toelichting infectierisico |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="6"|Hoofd en gelaat |
|-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"| | + | |colspan="4"| Hoofd en gelaat observaties |
| − | |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"| Bloedverlies |
| − | |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"| Liquorverlies |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="4"| Pijnlocatie |
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |colspan="4"| Wond |
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="6"|Nek, hals, CWK |
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-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"| | + | |colspan="4"| Nek, hals, CWK observaties |
| − | |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"| Wond |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Thorax | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |rowspan="6"| |
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"|Thorax observaties |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | + | |colspan="4"|Pijn bij compressie | |
| − | + | |style="background-color: white;"| | |
| − | |colspan=" | ||
| − | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |colspan="4"|Locatie subcutaan emfyseem |
| − | + | |style="background-color: white;"| | |
| − | |||
| − | |||
| − | |||
| − | |||
| − | | | ||
| − | |||
| − | |||
| − | |||
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |colspan="4"|Locatie zwelling / oedeem (2x) |
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="4"|Wond |
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |colspan="6"|Rug |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |rowspan="3"| |
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="4"| Rug observaties |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="4"| Wond |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Abdomen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |rowspan="6"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |colspan="4"| Abdomen observaties |
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="4"| Locatie druk- / loslaatpijn |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="4"| Locatie zwelling / oedeem |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="4"| Locatie pulserende zwelling |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="4"| Wond |
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |colspan="6"|Bekken |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |rowspan="3"| |
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="4"| Bekken observaties |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="4"| Wond |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="6"|Extremiteiten Armen |
|-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=" | + | |colspan="5"|Extremiteit |
| − | |||
|-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="3"| | + | |colspan="3"|Lateraliteit |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="3"|Observaties |
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |colspan="3"|Wond |
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="6"|Extremiteiten Armen |
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |rowspan="6"| |
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="5"|Extremiteit |
| − | |||
|-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"|Lateraliteit |
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |colspan="3"|Observaties |
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |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"| | ||
|-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=" | + | |colspan="5"|Extremiteit |
| − | |||
|-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"|Lateraliteit |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="3"|Observaties (2x) |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="3"|Wond |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Uitscheiding | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |rowspan="4"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |colspan="4"|Uitscheiding observaties |
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"|Braken |
| − | |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"|Incontinent |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
| − | |||
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |colspan="6"|Verloskunde/Gynaecologie |
|-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="4"| | + | |colspan="4"|Verloskunde/Gynaecologie observaties |
| − | |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"|Vruchtwaterverlies |
| − | |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"|Weeën |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |} |
| − | |style="background-color: white;"| | + | <section end="Secondary Survey" /> |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |
| − | |colspan=" | + | <section begin="Consultgever op afstand" /> |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | {| class="wikitable" width="85%" |
| − | | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Consultgever op afstand |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |-style="background-color: #1F497D;; color: white; text-align:left;" |
| − | |colspan=" | + | |colspan="5" width="25%"| Gegevenselement |
| − | |style="background-color: white;"| | + | || Waarde |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |colspan=" | + | |colspan="5"|Initialen |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |colspan=" | + | |colspan="5"|Achternaam |
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Telefoonnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Identificatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Type consultgever | ||
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |colspan="5"|Toelichting/Afspraken met consultgever |
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |} |
| − | |style="background-color: white;"| | + | <section end="Consultgever op afstand" /> |
| + | |||
| + | <section begin="Afspraken met patiënt" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Afspraken met patiënt | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Huisarts ingelicht | ||
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="5"|Afspraken met patiënt |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |} |
| − | |style="background-color: white;"| | + | <section end="Afspraken met patiënt" /> |
| + | |||
| + | <section begin="Bijlagen T1" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Bijlagen | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Type Bijlage | ||
| + | |style="background-color: white;"|006 intern rapport/overdracht | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Bijlage id | ||
| + | |style="background-color: white;"| 9068 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Versie | ||
| + | |style="background-color: white;"| 1 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Bijlageset id | ||
| + | |style="background-color: white;"| 12 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |} |
| − | |style="background-color: white;"| | + | <section end="Bijlagen" /> |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |
| − | |colspan="4"| | + | <section begin="Toestemmingsgegevens" /> |
| − | |style="background-color: white;"| | + | {| class="wikitable" width="85%" |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Toestemmingsgegevens |
| − | |colspan="6"| | + | |-style="background-color: #1F497D;; color: white; text-align:left;" |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |colspan="5" width="25%"| Gegevenselement |
| − | | | + | || Waarde |
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Wetenschappelijk onderzoek | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Beschrijving | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Informed consent | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Toestemming informeren verwanten | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Toestemmingsgegevens" /> | ||
| + | |||
| + | <section begin="Toelichtingsgegevens" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Toelichtingsgegevens | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Toelichting algemeen | ||
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |} |
| − | |style="background-color: white;"| | + | <section end="Toelichtingsgegevens" /> |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |
| − | |colspan=" | + | ==T2: gedurende de rit== |
| − | |style="background-color: white;"| | + | |
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | T2 | ||
| + | |} | ||
| + | <section begin="patient" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Patient | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Persoonidentificatie | ||
| + | |style="background-color: white;"|999910553 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Naamgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="8"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |rowspan="2"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |colspan="3"|Initialen |
| + | |style="background-color: white;"|W. | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |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;;" | ||
| + | |colspan="3"|Soort naam | ||
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="3"| | + | |colspan="3"|Voorvoegsels |
| − | |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"|Achternaam |
| − | |style="background-color: white;"| | + | |style="background-color: white;"|XXX_Witsiers |
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Geslacht | ||
| + | |style="background-color: white;"|M | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Geboortegegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |rowspan="2"| |
| − | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| + | |colspan="4"|Geboortedatum | ||
| + | |style="background-color: white;"|06-08-1954 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Geschatte leeftijd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Adresgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |rowspan="10"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |colspan="4"|Straat |
| + | |style="background-color: white;"|Hertog Aalbrechtweg | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="4"|Huisnummer |
| + | |style="background-color: white;"|8 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |colspan="4"|Huisnummerletter |
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |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=" | + | |colspan="4"|Postcode |
| − | |style="background-color: white;"| | + | |style="background-color: white;"|1823 DB |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="4"|Woonplaats |
| − | |style="background-color: white;"| | + | |style="background-color: white;"|Alkmaar |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="4"|Land |
| + | |style="background-color: white;"|Nederland | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |colspan="4"|Locatiebeschrijving |
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="6"|Overige Contactgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="15"| |
| − | + | |-style="vertical-align:top; background-color: #E3E3E3;;" | |
| − | + | |colspan="5"|Telefoonnummers | |
| − | + | |-style="vertical-align:top; background-color: #E3E3E3;;" | |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |rowspan="3"| |
| − | |colspan="3"|Observaties (2x) | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |style="background-color: white;"| | + | |colspan="3"|Telefoonnummer |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |style="background-color: white;"| |
| − | |colspan="3"|Wond | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |style="background-color: white;"| | + | |colspan="3"|Soort telefoonnummer |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |style="background-color: white;"| |
| − | |colspan="6"|Uitscheiding | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |colspan="5"|Werktelefoon |
| − | |rowspan="4"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |rowspan="3"| |
| − | |colspan="4"|Uitscheiding observaties | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |style="background-color: white;"| | + | |colspan="3"|werknummer |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |style="background-color: white;"| |
| − | |colspan="4"|Braken | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |style="background-color: white;"| | + | |colspan="3"|Soort nummer |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |style="background-color: white;"| |
| − | |colspan="4"|Incontinent | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |style="background-color: white;"| | + | |colspan="6"|EmailAdressen |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |colspan="6"|Verloskunde/Gynaecologie | + | |rowspan="5"| |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |rowspan="4"| | + | |colspan="3"|Emailadres |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |style="background-color: white;"| |
| − | |colspan="4"|Verloskunde/Gynaecologie observaties | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |style="background-color: white;"| | + | |colspan="3"|Soort e-mailadres |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |style="background-color: white;"| |
| − | |colspan="4"|Vruchtwaterverlies | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |style="background-color: white;"| | + | |colspan="3"|Emailadres |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |style="background-color: white;"| |
| − | |colspan="4"|Weeën | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |style="background-color: white;"| | + | |colspan="3"|Soort e-mailadres |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |style="background-color: white;"| |
| − | |} | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | <section end="Secondary Survey" /> | + | |colspan="5"| Ziektekostenverzekering? |
| − | + | |style="background-color: white;"| | |
| − | <section begin="Consultgever op afstand" /> | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| + | |colspan="6"|Verzekeringsgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verzekeraar | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Naam | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Identificatienummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Polis | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Polisnummer/Verzekerdenummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Vaste huisarts | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| ZorgverlenerIdentificatienummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Rolcode | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Naam | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Achternaam | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Vaste huisartsenpraktijk | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="27"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Identificatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Naam | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"| Adresgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="9"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Soort adres | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Straatnaam | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Huisnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Huisnummertoevoeging | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Postcode | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Gemeente | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Woonplaats | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Land | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"| Overige contactgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="13"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Telefoonnummers | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"| Soort telefoonnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"| Telefoonnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Faxnummers | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"| Soort faxnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"| Faxnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| E-mailadressen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"| Soort e-mailadres | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"| E-mailadres | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Contactpersoon patiënt | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Achternaam | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Telefoonnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Relatie tot patiënt | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="patient" /> | ||
| + | |||
| + | <section begin="WID-controle" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | WID-controle | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|WID-controle uitgevoerd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|WID controle datum | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Documentnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Document type | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="WID-controle" /> | ||
| + | |||
| + | <section begin="Incidentgegevens" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Incidentgegevens | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd incident | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Incidentgegevens" /> | ||
| + | |||
| + | <section begin="Meldingsgegevens" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Meldingsgegevens | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd melding | ||
| + | |style="background-color: white;"| T1-15min | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Geplande brengtijd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Geplande haaltijd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Wzd/Wvggz maatregel | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd aanvang TVZ | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Medische kladblok meldkamer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;; | ||
| + | |colspan="5"|Meldkamerurgentie | ||
| + | |style="background-color: white;"| A2 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Meldingsgegevens" /> | ||
| + | |||
| + | <section begin="Zorgaanvrager" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Zorgaanvrager | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Initialen | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Achternaam | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Telefoonnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Identificatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Type zorgaanvrager | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Zorgaanvrager" /> | ||
| + | |||
| + | <section begin="Ritgegevens" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Ritgegevens | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Ambulancevoorziening | ||
| + | |style="background-color: white;"| 25 (RAV identificatie) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Ritnummer | ||
| + | |style="background-color: white;"| 25-2020-13-1 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Ambulancenummer | ||
| + | |style="background-color: white;"| 25190 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Telefoon ambulance | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Ambulanceverpleegkundige identificatie | ||
| + | |style="background-color: white;"| 596 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Ambulancechauffeur identificatie | ||
| + | |style="background-color: white;"| 530 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;; | ||
| + | |colspan="5"|Datum/tijd ritopdracht | ||
| + | |style="background-color: white;"| T1-10 min | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd uitruk/vertrek | ||
| + | |style="background-color: white;"| T1-10 min | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd aankomst patiënt | ||
| + | |style="background-color: white;"| T1 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd vertrek patiënt | ||
| + | |style="background-color: white;"| T1+2 min | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwachte aankomsttijd bestemming | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd aankomst bestemming | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd vrijmelding | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Soort vervoer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Ritgegevens" /> | ||
| + | |||
| + | <section begin="Haalgegevens" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Haalgegevens | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Straat | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Huisnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Huisletter | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Huisnummertoevoeging | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Postcode | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Locatiebeschrijving | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Woonplaats | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Land | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Patiënt vervoerd? | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Reden geen vervoer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Tijdstip overlijden patiënt | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Advies behandeling tijdens vervoer aanwezig? | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Niet reanimeren verklaring aanwezig? | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Trialgegevens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Ambulance-urgentie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Gewondennummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Triageklasse | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Hulpverleners ter plaatse | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="9"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Hulpverlenersnaam | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Type hulpverlener | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Telefoonnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|E-mailadres | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Haalgegevens" /> | ||
| + | |||
| + | <section begin="Bestemmingsgegevens" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Bestemmingsgegevens | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Bestemmingsstatus in bericht op T2 | ||
| + | |style="background-color: white;"|Actief | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Bestemmingscode | ||
| + | |style="background-color: white;"|AGB: 06010860 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Locatie of afdeling | ||
| + | |style="background-color: white;"|LSDV-code: 2.16.840.1.113883.2.4.6.1.6010860.000 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Straat | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Huisnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Huisletter | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Huisnummertoevoeging | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Postcode | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Locatiebeschrijving | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Woonplaats | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Land | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Bijzonderheden algemeen | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwacht specialisme | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Feedback | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="9"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Feedback gewenst | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Feedback adres | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Feedback methode | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Bestemmingsgegevens" /> | ||
| + | |||
| + | <section begin="Mechanisme" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Mechanisme | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Mechanisme type | ||
| + | |style="background-color: white;"| 35468003 bekneld geraakt tussen voorwerpen (gebeurtenis) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Vervoermiddel patiënt | ||
| + | |style="background-color: white;"| 71783008 auto (fysiek object) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Patiënt was bestuurder? | ||
| + | |style="background-color: white;"| ja | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Vervoermiddel contra | ||
| + | |style="background-color: white;"| 71783008 auto (fysiek object) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Beschermingsmiddelen patiënt (3x) | ||
| + | |style="background-color: white;"| 285695004 helm (fysiek object) <br/> | ||
| + | 60054005 autogordel (fysiek object)<br/> | ||
| + | 102384007 airbag van motorvoertuig (fysiek object) | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Mechanisme" /> | ||
| + | |||
| + | <section begin="Toestandsbeelden/Werkdiagnose" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" |Toestandsbeelden/Werkdiagnose | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Toestandsbeeld | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Toestandsbeeld code | ||
| + | |style="background-color: white;"| 125593007 letsel van aangezicht (aandoening) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Toelichting Toestandsbeeld | ||
| + | |style="background-color: white;"| Moeilijk observeren door weersomstandigheden | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Toestandsbeelden/Werkdiagnose" /> | ||
| + | |||
| + | <section begin="Meetwaarden" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Meetwaarden | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Bloedsuiker | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Bloedsuiker waarde | ||
| + | |style="background-color: white;"| 5 mmol/L | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|BloedsuikerDatumTijd | ||
| + | |style="background-color: white;"| T2 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Hartritme | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Hartritme observatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|HartritmeDatumTijd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Toelichting hartritme/ECG | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|O2Saturatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|SpO2waarde | ||
| + | |style="background-color: white;"|78% | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|O2SaturatieDatumTijd | ||
| + | |style="background-color: white;"|T2 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Capnometrie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|CO2Waarde | ||
| + | |style="background-color: white;"|40 mm[Hg] <br/>5,3 kPa | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|CO2CapnometrieDatumTijd | ||
| + | |style="background-color: white;"|T2 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Hartfrequentie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|HartfrequentieWaarde | ||
| + | |style="background-color: white;"|110/min | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|HartfrequentieDatumTijd | ||
| + | |style="background-color: white;"|T2 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Bloeddruk | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|SystolischeBloeddruk | ||
| + | |style="background-color: white;"|100 mm[Hg] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|DiastolischeBloeddruk | ||
| + | |style="background-color: white;"|80 mm[Hg] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|BloeddrukDatumTijd | ||
| + | |style="background-color: white;"|T2 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Lichaamstemperatuur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TemperatuurWaarde | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TemperatuurDatumTijd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Ademhaling | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Ademfrequentie | ||
| + | |style="background-color: white;"|4/min | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|AdemhalingDatumTijd | ||
| + | |style="background-color: white;"|T2 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|GlasgowComaScale | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|GlasgowComaScaleDatumTijd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|GCS_Eyes | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|GCS_Motor | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|GCS_Verbal | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TotaalScore | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Revised Trauma Score | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|RevisedTraumaScoreWaarde | ||
| + | |style="background-color: white;"|8 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|RevisedTraumaScoreTijd | ||
| + | |style="background-color: white;"|T2 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Pediatric Trauma Score | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|PediatricTraumaScoreWaarde | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|PediatricTraumaScoreTijd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Pijnschaal | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|PijnschaalWaarde | ||
| + | |style="background-color: white;"|3 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|PijnschaalTijd | ||
| + | |style="background-color: white;"|T2 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|APGAR-1 | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|APGAR-5 | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Meetwaarden" /> | ||
| + | |||
| + | <section begin="Behandeling" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Behandeling | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Ademhaling en beademing (diagnostisch) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Handelingen ademhaling en beademing | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Bewustzijn en neurologische status (diagnostisch) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Handelingen bewustzijn en neurologische status | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Overige diagnostische handelingen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Handelingen overige diagnostisch | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Luchtweg management (therapeutisch) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Handelingen luchtweg management | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Moeizame intubatie? | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Oxygenatie en ventilatie (therapeutisch) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Handelingen oxygenatie en ventilatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Beademing machine Fi O2 | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Beademing machine AMV | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Beademing machine Freq. | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Beademing machine Peep | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Hoeveelheid zuurstof | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Circulatie (therapeutisch) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="12"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Handelingen circulatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Pacemaker frequentie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Pacemaker stroomsterkte | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Pacemaker modus | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Cardioversies aantal | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Cardioversie maximale energie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Defibrillaties aantal | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Defibrillatie energie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Return Of Spontaneous Circulation (ROSC) | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| AED aangesloten voor aankomst | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| AED-schokken aantal | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Traumatologie (therapeutisch) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Handelingen traumatologie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Koelen tijdsduur | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Obstetrie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Handelingen obstetrie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Wijze van isolatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Handelingen isolatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Medicatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Medicatie toegediend? | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Medicatienaam | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Toegediende hoeveelheid medicatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Tijd medicatietoediening | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Medicatie toedieningsvorm | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| IV medicatiesnelheid | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Infuus | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Infusen aantal | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Infuusvloeistofcode | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Infuusvloeistoftekst | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Infuushoeveelheid | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Extra informatie behandeling | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Behandeling" /> | ||
| + | |||
| + | <section begin="Patiëntligging" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Patiëntligging | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Type patiëntligging | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Patiëntligging" /> | ||
| + | |||
| + | <section begin="Primary Survey" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Primary Survey | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Airway | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Airway vrij? | ||
| + | |style="background-color: white;"| Ja | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Stridor | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Breathing | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Breathing sufficient? | ||
| + | |style="background-color: white;"|Ja | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Breathing observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Circulation | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Circulation sufficient? | ||
| + | |style="background-color: white;"| Ja | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Capillaire refill > 2 seconde? | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Huid observatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Disability | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|AVPU | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Duur buiten bewustzijn | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Pupil | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|FAST symptomen aanwezig | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Mogelijk trombolyse/trombectomie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Intoxicatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |||
| + | |||
| + | |colspan="5"|Toelichting Primary Survey | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Primary Survey" /> | ||
| + | |||
| + | <section begin="Secondary Survey" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Secondary Survey | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Anamnese | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Ample | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Code | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Titel | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Omschrijving | ||
| + | |style="background-color: white;"| | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Toelichting anamnese | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Infectierisico | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Verdenking infectieziekten? | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Toelichting infectierisico | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Hoofd en gelaat | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Hoofd en gelaat observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Bloedverlies | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Liquorverlies | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Pijnlocatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Wond | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Nek, hals, CWK | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Nek, hals, CWK observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Wond | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Thorax | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Thorax observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Pijn bij compressie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Locatie subcutaan emfyseem | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Locatie zwelling / oedeem (2x) | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Wond | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Rug | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Rug observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Wond | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Abdomen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Abdomen observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Locatie druk- / loslaatpijn | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Locatie zwelling / oedeem | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Locatie pulserende zwelling | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Wond | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Bekken | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Bekken observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Wond | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Extremiteiten Armen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Extremiteit | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Lateraliteit | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Wond | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Extremiteiten Armen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Extremiteit | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Lateraliteit | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Wond | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Extremiteiten Benen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Extremiteit | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Lateraliteit | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Observaties (2x) | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Wond | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Uitscheiding | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Uitscheiding observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Braken | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Incontinent | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Verloskunde/Gynaecologie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Verloskunde/Gynaecologie observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Vruchtwaterverlies | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Weeën | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Secondary Survey" /> | ||
| + | |||
| + | <section begin="Consultgever op afstand" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Consultgever op afstand | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Initialen | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Achternaam | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Telefoonnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Identificatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Type consultgever | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Toelichting/Afspraken met consultgever | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Consultgever op afstand" /> | ||
| + | |||
| + | <section begin="Afspraken met patiënt" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Afspraken met patiënt | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Huisarts ingelicht | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Afspraken met patiënt | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Afspraken met patiënt" /> | ||
| + | |||
| + | <section begin="Bijlagen" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Bijlagen T2 | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Type Bijlage | ||
| + | |style="background-color: white;"|006 intern rapport/overdracht | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Bijlage id | ||
| + | |style="background-color: white;"| 9068 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Versie | ||
| + | |style="background-color: white;"| 3 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Bijlageset id | ||
| + | |style="background-color: white;"| 12 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Bijlagen" /> | ||
| + | |||
| + | <section begin="Toestemmingsgegevens" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Toestemmingsgegevens | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Wetenschappelijk onderzoek | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Beschrijving | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Informed consent | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Toestemming informeren verwanten | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Toestemmingsgegevens" /> | ||
| + | |||
| + | <section begin="Toelichtingsgegevens" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Toelichtingsgegevens | ||
| + | |-style="background-color: #8F00FF;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Toelichting algemeen | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Toelichtingsgegevens" /> | ||
| + | |||
| + | ==T3: vlak voor aankomst bij de SEH== | ||
| + | |||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | T3 | ||
| + | |} | ||
| + | <section begin="patient" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | Patient | ||
| + | |-style="background-color: #ED2939;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Persoonidentificatie | ||
| + | |style="background-color: white;"|999910553 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Naamgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Initialen | ||
| + | |style="background-color: white;"|W. | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Achternaam | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Soort naam | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Voorvoegsels | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Achternaam | ||
| + | |style="background-color: white;"|XXX_Witsiers | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Geslacht | ||
| + | |style="background-color: white;"|M | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Geboortegegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Geboortedatum | ||
| + | |style="background-color: white;"|06-08-1954 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Geschatte leeftijd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Adresgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="10"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Straat | ||
| + | |style="background-color: white;"|Hertog Aalbrechtweg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Huisnummer | ||
| + | |style="background-color: white;"|8 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Huisnummerletter | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Huisnummertoevoeging | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Postcode | ||
| + | |style="background-color: white;"|1823 DB | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Woonplaats | ||
| + | |style="background-color: white;"|Alkmaar | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Land | ||
| + | |style="background-color: white;"|Nederland | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Locatiebeschrijving | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Overige Contactgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="15"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Telefoonnummers | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Telefoonnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Soort telefoonnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Werktelefoon | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|werknummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Soort nummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|EmailAdressen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Emailadres | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Soort e-mailadres | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Emailadres | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Soort e-mailadres | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"| Ziektekostenverzekering? | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Verzekeringsgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verzekeraar | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Naam | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Identificatienummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Polis | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Polisnummer/Verzekerdenummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Vaste huisarts | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| ZorgverlenerIdentificatienummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Rolcode | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Naam | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Achternaam | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Vaste huisartsenpraktijk | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="27"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Identificatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Naam | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"| Adresgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="9"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Soort adres | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Straatnaam | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Huisnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Huisnummertoevoeging | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Postcode | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Gemeente | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Woonplaats | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Land | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"| Overige contactgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="13"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Telefoonnummers | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"| Soort telefoonnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"| Telefoonnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Faxnummers | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"| Soort faxnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"| Faxnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| E-mailadressen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"| Soort e-mailadres | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"| E-mailadres | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Contactpersoon patiënt | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Achternaam | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Telefoonnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Relatie tot patiënt | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="patient" /> | ||
| + | |||
| + | <section begin="WID-controle" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | WID-controle | ||
| + | |-style="background-color: #ED2939;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|WID-controle uitgevoerd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|WID controle datum | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Documentnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Document type | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="WID-controle" /> | ||
| + | |||
| + | <section begin="Incidentgegevens" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | Incidentgegevens | ||
| + | |-style="background-color: #ED2939;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd incident | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Incidentgegevens" /> | ||
| + | |||
| + | <section begin="Meldingsgegevens" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | Meldingsgegevens | ||
| + | |-style="background-color: #ED2939;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd melding | ||
| + | |style="background-color: white;"| T1-15min | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Geplande brengtijd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Geplande haaltijd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Wzd/Wvggz maatregel | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd aanvang TVZ | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Medische kladblok meldkamer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;; | ||
| + | |colspan="5"|Meldkamerurgentie | ||
| + | |style="background-color: white;"| A2 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Meldingsgegevens" /> | ||
| + | |||
| + | <section begin="Zorgaanvrager" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | Zorgaanvrager | ||
| + | |-style="background-color: #ED2939;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Initialen | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Achternaam | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Telefoonnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Identificatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Type zorgaanvrager | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Zorgaanvrager" /> | ||
| + | |||
| + | <section begin="Ritgegevens" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | Ritgegevens | ||
| + | |-style="background-color: #ED2939;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Ambulancevoorziening | ||
| + | |style="background-color: white;"| 25 (RAV identificatie) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Ritnummer | ||
| + | |style="background-color: white;"| 25-2020-13-1 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Ambulancenummer | ||
| + | |style="background-color: white;"| 25190 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Telefoon ambulance | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Ambulanceverpleegkundige identificatie | ||
| + | |style="background-color: white;"| 596 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Ambulancechauffeur identificatie | ||
| + | |style="background-color: white;"| 530 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;; | ||
| + | |colspan="5"|Datum/tijd ritopdracht | ||
| + | |style="background-color: white;"| T1-10 min | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd uitruk/vertrek | ||
| + | |style="background-color: white;"| T1-10 min | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd aankomst patiënt | ||
| + | |style="background-color: white;"| T1 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd vertrek patiënt | ||
| + | |style="background-color: white;"| T1+2 min | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwachte aankomsttijd bestemming | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd aankomst bestemming | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd vrijmelding | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Soort vervoer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Ritgegevens" /> | ||
| + | |||
| + | <section begin="Haalgegevens" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | Haalgegevens | ||
| + | |-style="background-color: #ED2939;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Straat | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Huisnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Huisletter | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Huisnummertoevoeging | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Postcode | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Locatiebeschrijving | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Woonplaats | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Land | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Patiënt vervoerd? | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Reden geen vervoer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Tijdstip overlijden patiënt | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Advies behandeling tijdens vervoer aanwezig? | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Niet reanimeren verklaring aanwezig? | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Trialgegevens | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Ambulance-urgentie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Gewondennummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Triageklasse | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Hulpverleners ter plaatse | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="9"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Hulpverlenersnaam | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Type hulpverlener | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Telefoonnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|E-mailadres | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Haalgegevens" /> | ||
| + | |||
| + | <section begin="Bestemmingsgegevens" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | Bestemmingsgegevens | ||
| + | |-style="background-color: #ED2939;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Bestemmingsstatus in bericht op T3 | ||
| + | |style="background-color: white;"|Overgedragen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Bestemmingscode | ||
| + | |style="background-color: white;"|AGB: 06010860 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Locatie of afdeling | ||
| + | |style="background-color: white;"|LSDV-code: 2.16.840.1.113883.2.4.6.1.6010860.000 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Straat | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Huisnummer | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Huisletter | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Huisnummertoevoeging | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Postcode | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Locatiebeschrijving | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Woonplaats | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Land | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Bijzonderheden algemeen | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verwacht specialisme | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Feedback | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="9"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Feedback gewenst | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Feedback adres | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Feedback methode | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Bestemmingsgegevens" /> | ||
| + | |||
| + | <section begin="Mechanisme" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | Mechanisme | ||
| + | |-style="background-color: #ED2939;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Mechanisme type | ||
| + | |style="background-color: white;"| 35468003 bekneld geraakt tussen voorwerpen (gebeurtenis) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Vervoermiddel patiënt | ||
| + | |style="background-color: white;"| 71783008 auto (fysiek object) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Patiënt was bestuurder? | ||
| + | |style="background-color: white;"| ja | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Vervoermiddel contra | ||
| + | |style="background-color: white;"| 71783008 auto (fysiek object) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Beschermingsmiddelen patiënt (3x) | ||
| + | |style="background-color: white;"| 285695004 helm (fysiek object) <br/> | ||
| + | 60054005 autogordel (fysiek object)<br/> | ||
| + | 102384007 airbag van motorvoertuig (fysiek object) | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Mechanisme" /> | ||
| + | |||
| + | <section begin="Toestandsbeelden/Werkdiagnose" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" |Toestandsbeelden/Werkdiagnose | ||
| + | |-style="background-color: #ED2939;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Toestandsbeeld | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Toestandsbeeld code | ||
| + | |style="background-color: white;"| 125593007 letsel van aangezicht (aandoening) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Toelichting Toestandsbeeld | ||
| + | |style="background-color: white;"| Moeilijk observeren door weersomstandigheden | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Toestandsbeelden/Werkdiagnose" /> | ||
| + | |||
| + | <section begin="Meetwaarden" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | Meetwaarden | ||
| + | |-style="background-color: #ED2939;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Bloedsuiker | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Bloedsuiker waarde | ||
| + | |style="background-color: white;"| 6 mmol/L | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|BloedsuikerDatumTijd | ||
| + | |style="background-color: white;"| T3 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Hartritme | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Hartritme observatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|HartritmeDatumTijd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Toelichting hartritme/ECG | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|O2Saturatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|SpO2waarde | ||
| + | |style="background-color: white;"|98% | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|O2SaturatieDatumTijd | ||
| + | |style="background-color: white;"|T3 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Capnometrie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|CO2Waarde | ||
| + | |style="background-color: white;"|35 mm[Hg] <br/>4,7 kPa | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|CO2CapnometrieDatumTijd | ||
| + | |style="background-color: white;"|T3 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Hartfrequentie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|HartfrequentieWaarde | ||
| + | |style="background-color: white;"|90/min | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|HartfrequentieDatumTijd | ||
| + | |style="background-color: white;"|T3 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Bloeddruk | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|SystolischeBloeddruk | ||
| + | |style="background-color: white;"|60 mm[Hg] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|DiastolischeBloeddruk | ||
| + | |style="background-color: white;"|50 mm[Hg] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|BloeddrukDatumTijd | ||
| + | |style="background-color: white;"|T3 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Lichaamstemperatuur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TemperatuurWaarde | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TemperatuurDatumTijd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Ademhaling | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Ademfrequentie | ||
| + | |style="background-color: white;"|4/min | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|AdemhalingDatumTijd | ||
| + | |style="background-color: white;"|T3 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|GlasgowComaScale | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|GlasgowComaScaleDatumTijd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|GCS_Eyes | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|GCS_Motor | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|GCS_Verbal | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|TotaalScore | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Revised Trauma Score | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|RevisedTraumaScoreWaarde | ||
| + | |style="background-color: white;"|8 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|RevisedTraumaScoreTijd | ||
| + | |style="background-color: white;"|T3 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Pediatric Trauma Score | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|PediatricTraumaScoreWaarde | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|PediatricTraumaScoreTijd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Pijnschaal | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|PijnschaalWaarde | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|PijnschaalTijd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|APGAR-1 | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|APGAR-5 | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Meetwaarden" /> | ||
| + | |||
| + | <section begin="Behandeling" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | Behandeling | ||
| + | |-style="background-color: #ED2939;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Ademhaling en beademing (diagnostisch) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Handelingen ademhaling en beademing | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Bewustzijn en neurologische status (diagnostisch) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Handelingen bewustzijn en neurologische status | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Overige diagnostische handelingen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Handelingen overige diagnostisch | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Luchtweg management (therapeutisch) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Handelingen luchtweg management | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Moeizame intubatie? | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Oxygenatie en ventilatie (therapeutisch) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Handelingen oxygenatie en ventilatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Beademing machine Fi O2 | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Beademing machine AMV | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Beademing machine Freq. | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Beademing machine Peep | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Hoeveelheid zuurstof | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Circulatie (therapeutisch) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="12"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Handelingen circulatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Pacemaker frequentie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Pacemaker stroomsterkte | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Pacemaker modus | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Cardioversies aantal | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Cardioversie maximale energie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Defibrillaties aantal | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Defibrillatie energie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Return Of Spontaneous Circulation (ROSC) | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| AED aangesloten voor aankomst | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| AED-schokken aantal | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Traumatologie (therapeutisch) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Handelingen traumatologie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Koelen tijdsduur | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Obstetrie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Handelingen obstetrie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Wijze van isolatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Handelingen isolatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Medicatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Medicatie toegediend? | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Medicatienaam | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Toegediende hoeveelheid medicatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Tijd medicatietoediening | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Medicatie toedieningsvorm | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| IV medicatiesnelheid | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Infuus | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Infusen aantal | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Infuusvloeistofcode | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Infuusvloeistoftekst | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Infuushoeveelheid | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Extra informatie behandeling | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Behandeling" /> | ||
| + | |||
| + | <section begin="Patiëntligging" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | Patiëntligging | ||
| + | |-style="background-color: #ED2939;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Type patiëntligging | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Patiëntligging" /> | ||
| + | |||
| + | <section begin="Primary Survey" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | Primary Survey | ||
| + | |-style="background-color: #ED2939;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Airway | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Airway vrij? | ||
| + | |style="background-color: white;"| Ja | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Stridor | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Breathing | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Breathing sufficient? | ||
| + | |style="background-color: white;"|Ja | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Breathing observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Circulation | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Circulation sufficient? | ||
| + | |style="background-color: white;"| Ja | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Capillaire refill > 2 seconde? | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Huid observatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Disability | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|AVPU | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Duur buiten bewustzijn | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Pupil | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|FAST symptomen aanwezig | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Mogelijk trombolyse/trombectomie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Intoxicatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |||
| + | |||
| + | |colspan="5"|Toelichting Primary Survey | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Primary Survey" /> | ||
| + | |||
| + | <section begin="Secondary Survey" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | Secondary Survey | ||
| + | |-style="background-color: #ED2939;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Anamnese | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Ample | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Code | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Titel | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Omschrijving | ||
| + | |style="background-color: white;"| | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Toelichting anamnese | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Infectierisico | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Verdenking infectieziekten? | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Toelichting infectierisico | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Hoofd en gelaat | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Hoofd en gelaat observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Bloedverlies | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Liquorverlies | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Pijnlocatie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Wond | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Nek, hals, CWK | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Nek, hals, CWK observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Wond | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Thorax | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Thorax observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Pijn bij compressie | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Locatie subcutaan emfyseem | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Locatie zwelling / oedeem (2x) | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Wond | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Rug | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Rug observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Wond | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Abdomen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Abdomen observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Locatie druk- / loslaatpijn | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Locatie zwelling / oedeem | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Locatie pulserende zwelling | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Wond | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Bekken | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Bekken observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Wond | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Extremiteiten Armen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Extremiteit | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Lateraliteit | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Wond | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Extremiteiten Armen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Extremiteit | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Lateraliteit | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Wond | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Extremiteiten Benen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Extremiteit | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Lateraliteit | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Observaties (2x) | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Wond | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Uitscheiding | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Uitscheiding observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Braken | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Incontinent | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Verloskunde/Gynaecologie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Verloskunde/Gynaecologie observaties | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Vruchtwaterverlies | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Weeën | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Secondary Survey" /> | ||
| + | |||
| + | <section begin="Consultgever op afstand" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | Consultgever op afstand |
| − | |-style="background-color: # | + | |-style="background-color: #ED2939;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Initialen | |colspan="5"|Initialen | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Achternaam | |colspan="5"|Achternaam | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Telefoonnummer | |colspan="5"|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"|Identificatie | |colspan="5"|Identificatie | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Type consultgever | |colspan="5"|Type consultgever | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Toelichting/Afspraken met consultgever | |colspan="5"|Toelichting/Afspraken met consultgever | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 1.364: | Regel 3.803: | ||
<section begin="Afspraken met patiënt" /> | <section begin="Afspraken met patiënt" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | Afspraken met patiënt |
| − | |-style="background-color: # | + | |-style="background-color: #ED2939;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Huisarts ingelicht | |colspan="5"|Huisarts ingelicht | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Afspraken met patiënt | |colspan="5"|Afspraken met patiënt | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 1.380: | Regel 3.819: | ||
<section begin="Bijlagen" /> | <section begin="Bijlagen" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | Bijlagen T3 |
| − | |-style="background-color: # | + | |-style="background-color: #ED2939;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
| Regel 1.392: | Regel 3.831: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Versie | |colspan="5"|Versie | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| 6 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Bijlageset id | |colspan="5"|Bijlageset id | ||
| Regel 1.402: | Regel 3.841: | ||
<section begin="Toestemmingsgegevens" /> | <section begin="Toestemmingsgegevens" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | Toestemmingsgegevens |
| − | |-style="background-color: # | + | |-style="background-color: #ED2939;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
| Regel 1.412: | Regel 3.851: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Beschrijving | |colspan="4"|Beschrijving | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Informed consent | |colspan="4"|Informed consent | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Toestemming informeren verwanten | |colspan="5"|Toestemming informeren verwanten | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 1.425: | Regel 3.864: | ||
<section begin="Toelichtingsgegevens" /> | <section begin="Toelichtingsgegevens" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | Toelichtingsgegevens |
| − | |-style="background-color: # | + | |-style="background-color: #ED2939;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Toelichting algemeen | |colspan="5"|Toelichting algemeen | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
<section end="Toelichtingsgegevens" /> | <section end="Toelichtingsgegevens" /> | ||
Huidige versie van 7 apr 2025 om 11:17
|
Please note that this is draft material which is still in development |
1 Inleiding
Dit scenario bestaat uit drie opeenvolgende berichten die de ambulance stuurt naar de SEH: een bij aankomst bij de patient (T1), een gedurende de rit (T2) en een vlak voor aankomst bij de SEH (T3). Deze berichten zijn cumulatief, dus het bericht op T2 bevat alles van bericht T1, plus wat er sindsdien bijgevoegd is, en bericht 3 alles van T2, plus wat er sindsdien bijgevoegd is. Tenzij vermeld moeten alle velden vanaf het eerste bericht voorkomen; bij de metingen staat het tijdstip expliciet aangegeven. Alleen de bijlagen worden slechts 1x verstuurd, omdat die in dit geval zelf cumulatief zijn (zelfde setId met oplopend versienummer), en de oudere versies dus obsoleet zijn.
1.1 T1: aankomst bij de patient
| T1 |
| Patient | |||||
| Gegevenselement | Waarde | ||||
| Persoonidentificatie | 999910553 | ||||
| Naamgegevens | |||||
| Initialen | W. | ||||
| Achternaam | |||||
| Soort naam | |||||
| Voorvoegsels | |||||
| Achternaam | XXX_Witsiers | ||||
| Geslacht | M | ||||
| Geboortegegevens | |||||
| Geboortedatum | 06-08-1954 | ||||
| Geschatte leeftijd | |||||
| Adresgegevens | |||||
| Straat | Hertog Aalbrechtweg | ||||
| Huisnummer | 8 | ||||
| Huisnummerletter | |||||
| Huisnummertoevoeging | |||||
| Postcode | 1823 DB | ||||
| Woonplaats | Alkmaar | ||||
| Land | Nederland | ||||
| Locatiebeschrijving | |||||
| Overige Contactgegevens | |||||
| Telefoonnummers | |||||
| Telefoonnummer | |||||
| Soort telefoonnummer | |||||
| Werktelefoon | |||||
| werknummer | |||||
| Soort nummer | |||||
| EmailAdressen | |||||
| Emailadres | |||||
| Soort e-mailadres | |||||
| Emailadres | |||||
| Soort e-mailadres | |||||
| Ziektekostenverzekering? | |||||
| Verzekeringsgegevens | |||||
| Verzekeraar | |||||
| Naam | |||||
| Identificatienummer | |||||
| Polis | |||||
| Polisnummer/Verzekerdenummer | |||||
| Vaste huisarts | |||||
| ZorgverlenerIdentificatienummer | |||||
| Rolcode | |||||
| Naam | |||||
| Achternaam | |||||
| Vaste huisartsenpraktijk | |||||
| Identificatie | |||||
| Naam | |||||
| Adresgegevens | |||||
| Soort adres | |||||
| Straatnaam | |||||
| Huisnummer | |||||
| Huisnummertoevoeging | |||||
| Postcode | |||||
| Gemeente | |||||
| Woonplaats | |||||
| Land | |||||
| Overige contactgegevens | |||||
| Telefoonnummers | |||||
| Soort telefoonnummer | |||||
| Telefoonnummer | |||||
| Faxnummers | |||||
| Soort faxnummer | |||||
| Faxnummer | |||||
| E-mailadressen | |||||
| Soort e-mailadres | |||||
| E-mailadres | |||||
| Contactpersoon patiënt | |||||
| Achternaam | |||||
| Telefoonnummer | |||||
| Relatie tot patiënt | |||||
| WID-controle | |||||
| Gegevenselement | Waarde | ||||
| WID-controle uitgevoerd | |||||
| WID controle datum | |||||
| Documentnummer | |||||
| Document type | |||||
| Incidentgegevens | |||||
| Gegevenselement | Waarde | ||||
| Datum/tijd incident | |||||
| Meldingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Datum/tijd melding | T1-15min | ||||
| Geplande brengtijd | |||||
| Geplande haaltijd | |||||
| Wzd/Wvggz maatregel | |||||
| Datum/tijd aanvang TVZ | |||||
| Medische kladblok meldkamer | |||||
| Meldkamerurgentie | A2 | ||||
| Zorgaanvrager | |||||
| Gegevenselement | Waarde | ||||
| Initialen | |||||
| Achternaam | |||||
| Telefoonnummer | |||||
| Identificatie | |||||
| Type zorgaanvrager | |||||
| Ritgegevens | |||||
| Gegevenselement | Waarde | ||||
| Ambulancevoorziening | 25 (RAV identificatie) | ||||
| Ritnummer | 25-2020-13-1 | ||||
| Ambulancenummer | 25190 | ||||
| Telefoon ambulance | |||||
| Ambulanceverpleegkundige identificatie | 596 | ||||
| Ambulancechauffeur identificatie | 530 | ||||
| Datum/tijd ritopdracht | T1-10 min | ||||
| Datum/tijd uitruk/vertrek | T1-10 min | ||||
| Datum/tijd aankomst patiënt | T1 | ||||
| Datum/tijd vertrek patiënt | |||||
| Verwachte aankomsttijd bestemming | |||||
| Datum/tijd aankomst bestemming | |||||
| Datum/tijd vrijmelding | |||||
| Soort vervoer | |||||
| Haalgegevens | |||||
| Gegevenselement | Waarde | ||||
| Straat | |||||
| Huisnummer | |||||
| Huisletter | |||||
| Huisnummertoevoeging | |||||
| Postcode | |||||
| Locatiebeschrijving | |||||
| Woonplaats | |||||
| Land | |||||
| Patiënt vervoerd? | |||||
| Reden geen vervoer | |||||
| Tijdstip overlijden patiënt | |||||
| Advies behandeling tijdens vervoer aanwezig? | |||||
| Niet reanimeren verklaring aanwezig? | |||||
| Trialgegevens | |||||
| Ambulance-urgentie | |||||
| Gewondennummer | |||||
| Triageklasse | |||||
| Hulpverleners ter plaatse | |||||
| Hulpverlenersnaam | |||||
| Type hulpverlener | |||||
| Telefoonnummer | |||||
| E-mailadres | |||||
| Bestemmingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Bestemmingsstatus in bericht op T1 | Actief | ||||
| Bestemmingscode | AGB: 06010860 | ||||
| Locatie of afdeling | LSDV-code: 2.16.840.1.113883.2.4.6.1.6010860.000 | ||||
| Straat | |||||
| Huisnummer | |||||
| Huisletter | |||||
| Huisnummertoevoeging | |||||
| Postcode | |||||
| Locatiebeschrijving | |||||
| Woonplaats | |||||
| Land | |||||
| Bijzonderheden algemeen | |||||
| Verwacht specialisme | |||||
| Feedback | |||||
| Feedback gewenst | |||||
| Feedback adres | |||||
| Feedback methode | |||||
| Mechanisme | |||||
| Gegevenselement | Waarde | ||||
| Mechanisme type | 35468003 bekneld geraakt tussen voorwerpen (gebeurtenis) | ||||
| Vervoermiddel patiënt | 71783008 auto (fysiek object) | ||||
| Patiënt was bestuurder? | ja | ||||
| Vervoermiddel contra | 71783008 auto (fysiek object) | ||||
| Beschermingsmiddelen patiënt (3x) | 285695004 helm (fysiek object) 60054005 autogordel (fysiek object) | ||||
| Toestandsbeelden/Werkdiagnose | |||||
| Gegevenselement | Waarde | ||||
| Toestandsbeeld | |||||
| Toestandsbeeld code | 125593007 letsel van aangezicht (aandoening) | ||||
| Toelichting Toestandsbeeld | Moeilijk observeren door weersomstandigheden | ||||
| Meetwaarden | |||||
| Gegevenselement | Waarde | ||||
| Bloedsuiker | |||||
| Bloedsuiker waarde | 6 mmol/L | ||||
| BloedsuikerDatumTijd | T1 | ||||
| Hartritme | |||||
| Hartritme observatie | |||||
| HartritmeDatumTijd | |||||
| Toelichting hartritme/ECG | |||||
| O2Saturatie | |||||
| SpO2waarde | 99% | ||||
| O2SaturatieDatumTijd | T1 | ||||
| Capnometrie | |||||
| CO2Waarde | 60 mm[Hg] 8,0 kPa | ||||
| CO2CapnometrieDatumTijd | T1 | ||||
| Hartfrequentie | |||||
| HartfrequentieWaarde | 120/min | ||||
| HartfrequentieDatumTijd | T1 | ||||
| Bloeddruk | |||||
| SystolischeBloeddruk | 90 mm[Hg] | ||||
| DiastolischeBloeddruk | 60 mm[Hg] | ||||
| BloeddrukDatumTijd | T1 | ||||
| Lichaamstemperatuur | |||||
| TemperatuurWaarde | |||||
| TemperatuurDatumTijd | |||||
| Ademhaling | |||||
| Ademfrequentie | 4/min | ||||
| AdemhalingDatumTijd | T1 | ||||
| GlasgowComaScale | |||||
| GlasgowComaScaleDatumTijd | T1 | ||||
| GCS_Eyes | 4 | ||||
| GCS_Motor | 6 | ||||
| GCS_Verbal | 5 (uit 2.16.840.1.113883.2.4.3.11.60.40.4.2.3) | ||||
| TotaalScore | 15 | ||||
| Revised Trauma Score | |||||
| RevisedTraumaScoreWaarde | 8 | ||||
| RevisedTraumaScoreTijd | T1 | ||||
| Pediatric Trauma Score | |||||
| PediatricTraumaScoreWaarde | |||||
| PediatricTraumaScoreTijd | |||||
| Pijnschaal | |||||
| PijnschaalWaarde | 3 | ||||
| PijnschaalTijd | T1 | ||||
| APGAR-1 | |||||
| APGAR-5 | |||||
| Behandeling | |||||
| Gegevenselement | Waarde | ||||
| Ademhaling en beademing (diagnostisch) | |||||
| Handelingen ademhaling en beademing | |||||
| Bewustzijn en neurologische status (diagnostisch) | |||||
| Handelingen bewustzijn en neurologische status | |||||
| Overige diagnostische handelingen | |||||
| Handelingen overige diagnostisch | |||||
| Luchtweg management (therapeutisch) | |||||
| Handelingen luchtweg management | |||||
| Moeizame intubatie? | |||||
| Oxygenatie en ventilatie (therapeutisch) | |||||
| Handelingen oxygenatie en ventilatie | |||||
| Beademing machine Fi O2 | |||||
| Beademing machine AMV | |||||
| Beademing machine Freq. | |||||
| Beademing machine Peep | |||||
| Hoeveelheid zuurstof | |||||
| Circulatie (therapeutisch) | |||||
| Handelingen circulatie | |||||
| Pacemaker frequentie | |||||
| Pacemaker stroomsterkte | |||||
| Pacemaker modus | |||||
| Cardioversies aantal | |||||
| Cardioversie maximale energie | |||||
| Defibrillaties aantal | |||||
| Defibrillatie energie | |||||
| Return Of Spontaneous Circulation (ROSC) | |||||
| AED aangesloten voor aankomst | |||||
| AED-schokken aantal | |||||
| Traumatologie (therapeutisch) | |||||
| Handelingen traumatologie | |||||
| Koelen tijdsduur | |||||
| Obstetrie | |||||
| Handelingen obstetrie | |||||
| Wijze van isolatie | |||||
| Handelingen isolatie | |||||
| Medicatie | |||||
| Medicatie toegediend? | |||||
| Medicatienaam | |||||
| Toegediende hoeveelheid medicatie | |||||
| Tijd medicatietoediening | |||||
| Medicatie toedieningsvorm | |||||
| IV medicatiesnelheid | |||||
| Infuus | |||||
| Infusen aantal | |||||
| Infuusvloeistofcode | |||||
| Infuusvloeistoftekst | |||||
| Infuushoeveelheid | |||||
| Extra informatie behandeling | |||||
| Patiëntligging | |||||
| Gegevenselement | Waarde | ||||
| Type patiëntligging | |||||
| Primary Survey | |||||
| Gegevenselement | Waarde | ||||
| Airway | |||||
| Airway vrij? | Ja | ||||
| Stridor | |||||
| Breathing | |||||
| Breathing sufficient? | Ja | ||||
| Breathing observaties | |||||
| Circulation | |||||
| Circulation sufficient? | Ja | ||||
| Capillaire refill > 2 seconde? | |||||
| Huid observatie | |||||
| Disability | |||||
| AVPU | |||||
| Duur buiten bewustzijn | |||||
| Pupil | |||||
| FAST symptomen aanwezig | |||||
| Mogelijk trombolyse/trombectomie | |||||
| Intoxicatie | |||||
| Toelichting Primary Survey | |||||
| Secondary Survey | |||||
| Gegevenselement | Waarde | ||||
| Anamnese | |||||
| Ample | |||||
| Code | |||||
| Titel | |||||
| Omschrijving | |||||
| Toelichting anamnese | |||||
| Infectierisico | |||||
| Verdenking infectieziekten? | |||||
| Toelichting infectierisico | |||||
| Hoofd en gelaat | |||||
| Hoofd en gelaat observaties | |||||
| Bloedverlies | |||||
| Liquorverlies | |||||
| Pijnlocatie | |||||
| Wond | |||||
| Nek, hals, CWK | |||||
| Nek, hals, CWK observaties | |||||
| Wond | |||||
| Thorax | |||||
| Thorax observaties | |||||
| Pijn bij compressie | |||||
| Locatie subcutaan emfyseem | |||||
| Locatie zwelling / oedeem (2x) | |||||
| Wond | |||||
| Rug | |||||
| Rug observaties | |||||
| Wond | |||||
| Abdomen | |||||
| Abdomen observaties | |||||
| Locatie druk- / loslaatpijn | |||||
| Locatie zwelling / oedeem | |||||
| Locatie pulserende zwelling | |||||
| Wond | |||||
| Bekken | |||||
| Bekken observaties | |||||
| Wond | |||||
| Extremiteiten Armen | |||||
| Extremiteit | |||||
| Lateraliteit | |||||
| Observaties | |||||
| Wond | |||||
| Extremiteiten Armen | |||||
| Extremiteit | |||||
| Lateraliteit | |||||
| Observaties | |||||
| Wond | |||||
| Extremiteiten Benen | |||||
| Extremiteit | |||||
| Lateraliteit | |||||
| Observaties (2x) | |||||
| Wond | |||||
| Uitscheiding | |||||
| Uitscheiding observaties | |||||
| Braken | |||||
| Incontinent | |||||
| Verloskunde/Gynaecologie | |||||
| Verloskunde/Gynaecologie observaties | |||||
| Vruchtwaterverlies | |||||
| Weeën | |||||
| Consultgever op afstand | |||||
| Gegevenselement | Waarde | ||||
| Initialen | |||||
| Achternaam | |||||
| Telefoonnummer | |||||
| Identificatie | |||||
| Type consultgever | |||||
| Toelichting/Afspraken met consultgever | |||||
| Afspraken met patiënt | |||||
| Gegevenselement | Waarde | ||||
| Huisarts ingelicht | |||||
| Afspraken met patiënt | |||||
| Bijlagen | |||||
| Gegevenselement | Waarde | ||||
| Type Bijlage | 006 intern rapport/overdracht | ||||
| Bijlage id | 9068 | ||||
| Versie | 1 | ||||
| Bijlageset id | 12 | ||||
| Toestemmingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Wetenschappelijk onderzoek | |||||
| Beschrijving | |||||
| Informed consent | |||||
| Toestemming informeren verwanten | |||||
| Toelichtingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Toelichting algemeen | |||||
1.2 T2: gedurende de rit
| T2 |
| Patient | |||||
| Gegevenselement | Waarde | ||||
| Persoonidentificatie | 999910553 | ||||
| Naamgegevens | |||||
| Initialen | W. | ||||
| Achternaam | |||||
| Soort naam | |||||
| Voorvoegsels | |||||
| Achternaam | XXX_Witsiers | ||||
| Geslacht | M | ||||
| Geboortegegevens | |||||
| Geboortedatum | 06-08-1954 | ||||
| Geschatte leeftijd | |||||
| Adresgegevens | |||||
| Straat | Hertog Aalbrechtweg | ||||
| Huisnummer | 8 | ||||
| Huisnummerletter | |||||
| Huisnummertoevoeging | |||||
| Postcode | 1823 DB | ||||
| Woonplaats | Alkmaar | ||||
| Land | Nederland | ||||
| Locatiebeschrijving | |||||
| Overige Contactgegevens | |||||
| Telefoonnummers | |||||
| Telefoonnummer | |||||
| Soort telefoonnummer | |||||
| Werktelefoon | |||||
| werknummer | |||||
| Soort nummer | |||||
| EmailAdressen | |||||
| Emailadres | |||||
| Soort e-mailadres | |||||
| Emailadres | |||||
| Soort e-mailadres | |||||
| Ziektekostenverzekering? | |||||
| Verzekeringsgegevens | |||||
| Verzekeraar | |||||
| Naam | |||||
| Identificatienummer | |||||
| Polis | |||||
| Polisnummer/Verzekerdenummer | |||||
| Vaste huisarts | |||||
| ZorgverlenerIdentificatienummer | |||||
| Rolcode | |||||
| Naam | |||||
| Achternaam | |||||
| Vaste huisartsenpraktijk | |||||
| Identificatie | |||||
| Naam | |||||
| Adresgegevens | |||||
| Soort adres | |||||
| Straatnaam | |||||
| Huisnummer | |||||
| Huisnummertoevoeging | |||||
| Postcode | |||||
| Gemeente | |||||
| Woonplaats | |||||
| Land | |||||
| Overige contactgegevens | |||||
| Telefoonnummers | |||||
| Soort telefoonnummer | |||||
| Telefoonnummer | |||||
| Faxnummers | |||||
| Soort faxnummer | |||||
| Faxnummer | |||||
| E-mailadressen | |||||
| Soort e-mailadres | |||||
| E-mailadres | |||||
| Contactpersoon patiënt | |||||
| Achternaam | |||||
| Telefoonnummer | |||||
| Relatie tot patiënt | |||||
| WID-controle | |||||
| Gegevenselement | Waarde | ||||
| WID-controle uitgevoerd | |||||
| WID controle datum | |||||
| Documentnummer | |||||
| Document type | |||||
| Incidentgegevens | |||||
| Gegevenselement | Waarde | ||||
| Datum/tijd incident | |||||
| Meldingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Datum/tijd melding | T1-15min | ||||
| Geplande brengtijd | |||||
| Geplande haaltijd | |||||
| Wzd/Wvggz maatregel | |||||
| Datum/tijd aanvang TVZ | |||||
| Medische kladblok meldkamer | |||||
| Meldkamerurgentie | A2 | ||||
| Zorgaanvrager | |||||
| Gegevenselement | Waarde | ||||
| Initialen | |||||
| Achternaam | |||||
| Telefoonnummer | |||||
| Identificatie | |||||
| Type zorgaanvrager | |||||
| Ritgegevens | |||||
| Gegevenselement | Waarde | ||||
| Ambulancevoorziening | 25 (RAV identificatie) | ||||
| Ritnummer | 25-2020-13-1 | ||||
| Ambulancenummer | 25190 | ||||
| Telefoon ambulance | |||||
| Ambulanceverpleegkundige identificatie | 596 | ||||
| Ambulancechauffeur identificatie | 530 | ||||
| Datum/tijd ritopdracht | T1-10 min | ||||
| Datum/tijd uitruk/vertrek | T1-10 min | ||||
| Datum/tijd aankomst patiënt | T1 | ||||
| Datum/tijd vertrek patiënt | T1+2 min | ||||
| Verwachte aankomsttijd bestemming | |||||
| Datum/tijd aankomst bestemming | |||||
| Datum/tijd vrijmelding | |||||
| Soort vervoer | |||||
| Haalgegevens | |||||
| Gegevenselement | Waarde | ||||
| Straat | |||||
| Huisnummer | |||||
| Huisletter | |||||
| Huisnummertoevoeging | |||||
| Postcode | |||||
| Locatiebeschrijving | |||||
| Woonplaats | |||||
| Land | |||||
| Patiënt vervoerd? | |||||
| Reden geen vervoer | |||||
| Tijdstip overlijden patiënt | |||||
| Advies behandeling tijdens vervoer aanwezig? | |||||
| Niet reanimeren verklaring aanwezig? | |||||
| Trialgegevens | |||||
| Ambulance-urgentie | |||||
| Gewondennummer | |||||
| Triageklasse | |||||
| Hulpverleners ter plaatse | |||||
| Hulpverlenersnaam | |||||
| Type hulpverlener | |||||
| Telefoonnummer | |||||
| E-mailadres | |||||
| Bestemmingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Bestemmingsstatus in bericht op T2 | Actief | ||||
| Bestemmingscode | AGB: 06010860 | ||||
| Locatie of afdeling | LSDV-code: 2.16.840.1.113883.2.4.6.1.6010860.000 | ||||
| Straat | |||||
| Huisnummer | |||||
| Huisletter | |||||
| Huisnummertoevoeging | |||||
| Postcode | |||||
| Locatiebeschrijving | |||||
| Woonplaats | |||||
| Land | |||||
| Bijzonderheden algemeen | |||||
| Verwacht specialisme | |||||
| Feedback | |||||
| Feedback gewenst | |||||
| Feedback adres | |||||
| Feedback methode | |||||
| Mechanisme | |||||
| Gegevenselement | Waarde | ||||
| Mechanisme type | 35468003 bekneld geraakt tussen voorwerpen (gebeurtenis) | ||||
| Vervoermiddel patiënt | 71783008 auto (fysiek object) | ||||
| Patiënt was bestuurder? | ja | ||||
| Vervoermiddel contra | 71783008 auto (fysiek object) | ||||
| Beschermingsmiddelen patiënt (3x) | 285695004 helm (fysiek object) 60054005 autogordel (fysiek object) | ||||
| Toestandsbeelden/Werkdiagnose | |||||
| Gegevenselement | Waarde | ||||
| Toestandsbeeld | |||||
| Toestandsbeeld code | 125593007 letsel van aangezicht (aandoening) | ||||
| Toelichting Toestandsbeeld | Moeilijk observeren door weersomstandigheden | ||||
| Meetwaarden | |||||
| Gegevenselement | Waarde | ||||
| Bloedsuiker | |||||
| Bloedsuiker waarde | 5 mmol/L | ||||
| BloedsuikerDatumTijd | T2 | ||||
| Hartritme | |||||
| Hartritme observatie | |||||
| HartritmeDatumTijd | |||||
| Toelichting hartritme/ECG | |||||
| O2Saturatie | |||||
| SpO2waarde | 78% | ||||
| O2SaturatieDatumTijd | T2 | ||||
| Capnometrie | |||||
| CO2Waarde | 40 mm[Hg] 5,3 kPa | ||||
| CO2CapnometrieDatumTijd | T2 | ||||
| Hartfrequentie | |||||
| HartfrequentieWaarde | 110/min | ||||
| HartfrequentieDatumTijd | T2 | ||||
| Bloeddruk | |||||
| SystolischeBloeddruk | 100 mm[Hg] | ||||
| DiastolischeBloeddruk | 80 mm[Hg] | ||||
| BloeddrukDatumTijd | T2 | ||||
| Lichaamstemperatuur | |||||
| TemperatuurWaarde | |||||
| TemperatuurDatumTijd | |||||
| Ademhaling | |||||
| Ademfrequentie | 4/min | ||||
| AdemhalingDatumTijd | T2 | ||||
| GlasgowComaScale | |||||
| GlasgowComaScaleDatumTijd | |||||
| GCS_Eyes | |||||
| GCS_Motor | |||||
| GCS_Verbal | |||||
| TotaalScore | |||||
| Revised Trauma Score | |||||
| RevisedTraumaScoreWaarde | 8 | ||||
| RevisedTraumaScoreTijd | T2 | ||||
| Pediatric Trauma Score | |||||
| PediatricTraumaScoreWaarde | |||||
| PediatricTraumaScoreTijd | |||||
| Pijnschaal | |||||
| PijnschaalWaarde | 3 | ||||
| PijnschaalTijd | T2 | ||||
| APGAR-1 | |||||
| APGAR-5 | |||||
| Behandeling | |||||
| Gegevenselement | Waarde | ||||
| Ademhaling en beademing (diagnostisch) | |||||
| Handelingen ademhaling en beademing | |||||
| Bewustzijn en neurologische status (diagnostisch) | |||||
| Handelingen bewustzijn en neurologische status | |||||
| Overige diagnostische handelingen | |||||
| Handelingen overige diagnostisch | |||||
| Luchtweg management (therapeutisch) | |||||
| Handelingen luchtweg management | |||||
| Moeizame intubatie? | |||||
| Oxygenatie en ventilatie (therapeutisch) | |||||
| Handelingen oxygenatie en ventilatie | |||||
| Beademing machine Fi O2 | |||||
| Beademing machine AMV | |||||
| Beademing machine Freq. | |||||
| Beademing machine Peep | |||||
| Hoeveelheid zuurstof | |||||
| Circulatie (therapeutisch) | |||||
| Handelingen circulatie | |||||
| Pacemaker frequentie | |||||
| Pacemaker stroomsterkte | |||||
| Pacemaker modus | |||||
| Cardioversies aantal | |||||
| Cardioversie maximale energie | |||||
| Defibrillaties aantal | |||||
| Defibrillatie energie | |||||
| Return Of Spontaneous Circulation (ROSC) | |||||
| AED aangesloten voor aankomst | |||||
| AED-schokken aantal | |||||
| Traumatologie (therapeutisch) | |||||
| Handelingen traumatologie | |||||
| Koelen tijdsduur | |||||
| Obstetrie | |||||
| Handelingen obstetrie | |||||
| Wijze van isolatie | |||||
| Handelingen isolatie | |||||
| Medicatie | |||||
| Medicatie toegediend? | |||||
| Medicatienaam | |||||
| Toegediende hoeveelheid medicatie | |||||
| Tijd medicatietoediening | |||||
| Medicatie toedieningsvorm | |||||
| IV medicatiesnelheid | |||||
| Infuus | |||||
| Infusen aantal | |||||
| Infuusvloeistofcode | |||||
| Infuusvloeistoftekst | |||||
| Infuushoeveelheid | |||||
| Extra informatie behandeling | |||||
| Patiëntligging | |||||
| Gegevenselement | Waarde | ||||
| Type patiëntligging | |||||
| Primary Survey | |||||
| Gegevenselement | Waarde | ||||
| Airway | |||||
| Airway vrij? | Ja | ||||
| Stridor | |||||
| Breathing | |||||
| Breathing sufficient? | Ja | ||||
| Breathing observaties | |||||
| Circulation | |||||
| Circulation sufficient? | Ja | ||||
| Capillaire refill > 2 seconde? | |||||
| Huid observatie | |||||
| Disability | |||||
| AVPU | |||||
| Duur buiten bewustzijn | |||||
| Pupil | |||||
| FAST symptomen aanwezig | |||||
| Mogelijk trombolyse/trombectomie | |||||
| Intoxicatie | |||||
| Toelichting Primary Survey | |||||
| Secondary Survey | |||||
| Gegevenselement | Waarde | ||||
| Anamnese | |||||
| Ample | |||||
| Code | |||||
| Titel | |||||
| Omschrijving | |||||
| Toelichting anamnese | |||||
| Infectierisico | |||||
| Verdenking infectieziekten? | |||||
| Toelichting infectierisico | |||||
| Hoofd en gelaat | |||||
| Hoofd en gelaat observaties | |||||
| Bloedverlies | |||||
| Liquorverlies | |||||
| Pijnlocatie | |||||
| Wond | |||||
| Nek, hals, CWK | |||||
| Nek, hals, CWK observaties | |||||
| Wond | |||||
| Thorax | |||||
| Thorax observaties | |||||
| Pijn bij compressie | |||||
| Locatie subcutaan emfyseem | |||||
| Locatie zwelling / oedeem (2x) | |||||
| Wond | |||||
| Rug | |||||
| Rug observaties | |||||
| Wond | |||||
| Abdomen | |||||
| Abdomen observaties | |||||
| Locatie druk- / loslaatpijn | |||||
| Locatie zwelling / oedeem | |||||
| Locatie pulserende zwelling | |||||
| Wond | |||||
| Bekken | |||||
| Bekken observaties | |||||
| Wond | |||||
| Extremiteiten Armen | |||||
| Extremiteit | |||||
| Lateraliteit | |||||
| Observaties | |||||
| Wond | |||||
| Extremiteiten Armen | |||||
| Extremiteit | |||||
| Lateraliteit | |||||
| Observaties | |||||
| Wond | |||||
| Extremiteiten Benen | |||||
| Extremiteit | |||||
| Lateraliteit | |||||
| Observaties (2x) | |||||
| Wond | |||||
| Uitscheiding | |||||
| Uitscheiding observaties | |||||
| Braken | |||||
| Incontinent | |||||
| Verloskunde/Gynaecologie | |||||
| Verloskunde/Gynaecologie observaties | |||||
| Vruchtwaterverlies | |||||
| Weeën | |||||
| Consultgever op afstand | |||||
| Gegevenselement | Waarde | ||||
| Initialen | |||||
| Achternaam | |||||
| Telefoonnummer | |||||
| Identificatie | |||||
| Type consultgever | |||||
| Toelichting/Afspraken met consultgever | |||||
| Afspraken met patiënt | |||||
| Gegevenselement | Waarde | ||||
| Huisarts ingelicht | |||||
| Afspraken met patiënt | |||||
| Bijlagen T2 | |||||
| Gegevenselement | Waarde | ||||
| Type Bijlage | 006 intern rapport/overdracht | ||||
| Bijlage id | 9068 | ||||
| Versie | 3 | ||||
| Bijlageset id | 12 | ||||
| Toestemmingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Wetenschappelijk onderzoek | |||||
| Beschrijving | |||||
| Informed consent | |||||
| Toestemming informeren verwanten | |||||
| Toelichtingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Toelichting algemeen | |||||
1.3 T3: vlak voor aankomst bij de SEH
| T3 |
| Patient | |||||
| Gegevenselement | Waarde | ||||
| Persoonidentificatie | 999910553 | ||||
| Naamgegevens | |||||
| Initialen | W. | ||||
| Achternaam | |||||
| Soort naam | |||||
| Voorvoegsels | |||||
| Achternaam | XXX_Witsiers | ||||
| Geslacht | M | ||||
| Geboortegegevens | |||||
| Geboortedatum | 06-08-1954 | ||||
| Geschatte leeftijd | |||||
| Adresgegevens | |||||
| Straat | Hertog Aalbrechtweg | ||||
| Huisnummer | 8 | ||||
| Huisnummerletter | |||||
| Huisnummertoevoeging | |||||
| Postcode | 1823 DB | ||||
| Woonplaats | Alkmaar | ||||
| Land | Nederland | ||||
| Locatiebeschrijving | |||||
| Overige Contactgegevens | |||||
| Telefoonnummers | |||||
| Telefoonnummer | |||||
| Soort telefoonnummer | |||||
| Werktelefoon | |||||
| werknummer | |||||
| Soort nummer | |||||
| EmailAdressen | |||||
| Emailadres | |||||
| Soort e-mailadres | |||||
| Emailadres | |||||
| Soort e-mailadres | |||||
| Ziektekostenverzekering? | |||||
| Verzekeringsgegevens | |||||
| Verzekeraar | |||||
| Naam | |||||
| Identificatienummer | |||||
| Polis | |||||
| Polisnummer/Verzekerdenummer | |||||
| Vaste huisarts | |||||
| ZorgverlenerIdentificatienummer | |||||
| Rolcode | |||||
| Naam | |||||
| Achternaam | |||||
| Vaste huisartsenpraktijk | |||||
| Identificatie | |||||
| Naam | |||||
| Adresgegevens | |||||
| Soort adres | |||||
| Straatnaam | |||||
| Huisnummer | |||||
| Huisnummertoevoeging | |||||
| Postcode | |||||
| Gemeente | |||||
| Woonplaats | |||||
| Land | |||||
| Overige contactgegevens | |||||
| Telefoonnummers | |||||
| Soort telefoonnummer | |||||
| Telefoonnummer | |||||
| Faxnummers | |||||
| Soort faxnummer | |||||
| Faxnummer | |||||
| E-mailadressen | |||||
| Soort e-mailadres | |||||
| E-mailadres | |||||
| Contactpersoon patiënt | |||||
| Achternaam | |||||
| Telefoonnummer | |||||
| Relatie tot patiënt | |||||
| WID-controle | |||||
| Gegevenselement | Waarde | ||||
| WID-controle uitgevoerd | |||||
| WID controle datum | |||||
| Documentnummer | |||||
| Document type | |||||
| Incidentgegevens | |||||
| Gegevenselement | Waarde | ||||
| Datum/tijd incident | |||||
| Meldingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Datum/tijd melding | T1-15min | ||||
| Geplande brengtijd | |||||
| Geplande haaltijd | |||||
| Wzd/Wvggz maatregel | |||||
| Datum/tijd aanvang TVZ | |||||
| Medische kladblok meldkamer | |||||
| Meldkamerurgentie | A2 | ||||
| Zorgaanvrager | |||||
| Gegevenselement | Waarde | ||||
| Initialen | |||||
| Achternaam | |||||
| Telefoonnummer | |||||
| Identificatie | |||||
| Type zorgaanvrager | |||||
| Ritgegevens | |||||
| Gegevenselement | Waarde | ||||
| Ambulancevoorziening | 25 (RAV identificatie) | ||||
| Ritnummer | 25-2020-13-1 | ||||
| Ambulancenummer | 25190 | ||||
| Telefoon ambulance | |||||
| Ambulanceverpleegkundige identificatie | 596 | ||||
| Ambulancechauffeur identificatie | 530 | ||||
| Datum/tijd ritopdracht | T1-10 min | ||||
| Datum/tijd uitruk/vertrek | T1-10 min | ||||
| Datum/tijd aankomst patiënt | T1 | ||||
| Datum/tijd vertrek patiënt | T1+2 min | ||||
| Verwachte aankomsttijd bestemming | |||||
| Datum/tijd aankomst bestemming | |||||
| Datum/tijd vrijmelding | |||||
| Soort vervoer | |||||
| Haalgegevens | |||||
| Gegevenselement | Waarde | ||||
| Straat | |||||
| Huisnummer | |||||
| Huisletter | |||||
| Huisnummertoevoeging | |||||
| Postcode | |||||
| Locatiebeschrijving | |||||
| Woonplaats | |||||
| Land | |||||
| Patiënt vervoerd? | |||||
| Reden geen vervoer | |||||
| Tijdstip overlijden patiënt | |||||
| Advies behandeling tijdens vervoer aanwezig? | |||||
| Niet reanimeren verklaring aanwezig? | |||||
| Trialgegevens | |||||
| Ambulance-urgentie | |||||
| Gewondennummer | |||||
| Triageklasse | |||||
| Hulpverleners ter plaatse | |||||
| Hulpverlenersnaam | |||||
| Type hulpverlener | |||||
| Telefoonnummer | |||||
| E-mailadres | |||||
| Bestemmingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Bestemmingsstatus in bericht op T3 | Overgedragen | ||||
| Bestemmingscode | AGB: 06010860 | ||||
| Locatie of afdeling | LSDV-code: 2.16.840.1.113883.2.4.6.1.6010860.000 | ||||
| Straat | |||||
| Huisnummer | |||||
| Huisletter | |||||
| Huisnummertoevoeging | |||||
| Postcode | |||||
| Locatiebeschrijving | |||||
| Woonplaats | |||||
| Land | |||||
| Bijzonderheden algemeen | |||||
| Verwacht specialisme | |||||
| Feedback | |||||
| Feedback gewenst | |||||
| Feedback adres | |||||
| Feedback methode | |||||
| Mechanisme | |||||
| Gegevenselement | Waarde | ||||
| Mechanisme type | 35468003 bekneld geraakt tussen voorwerpen (gebeurtenis) | ||||
| Vervoermiddel patiënt | 71783008 auto (fysiek object) | ||||
| Patiënt was bestuurder? | ja | ||||
| Vervoermiddel contra | 71783008 auto (fysiek object) | ||||
| Beschermingsmiddelen patiënt (3x) | 285695004 helm (fysiek object) 60054005 autogordel (fysiek object) | ||||
| Toestandsbeelden/Werkdiagnose | |||||
| Gegevenselement | Waarde | ||||
| Toestandsbeeld | |||||
| Toestandsbeeld code | 125593007 letsel van aangezicht (aandoening) | ||||
| Toelichting Toestandsbeeld | Moeilijk observeren door weersomstandigheden | ||||
| Meetwaarden | |||||
| Gegevenselement | Waarde | ||||
| Bloedsuiker | |||||
| Bloedsuiker waarde | 6 mmol/L | ||||
| BloedsuikerDatumTijd | T3 | ||||
| Hartritme | |||||
| Hartritme observatie | |||||
| HartritmeDatumTijd | |||||
| Toelichting hartritme/ECG | |||||
| O2Saturatie | |||||
| SpO2waarde | 98% | ||||
| O2SaturatieDatumTijd | T3 | ||||
| Capnometrie | |||||
| CO2Waarde | 35 mm[Hg] 4,7 kPa | ||||
| CO2CapnometrieDatumTijd | T3 | ||||
| Hartfrequentie | |||||
| HartfrequentieWaarde | 90/min | ||||
| HartfrequentieDatumTijd | T3 | ||||
| Bloeddruk | |||||
| SystolischeBloeddruk | 60 mm[Hg] | ||||
| DiastolischeBloeddruk | 50 mm[Hg] | ||||
| BloeddrukDatumTijd | T3 | ||||
| Lichaamstemperatuur | |||||
| TemperatuurWaarde | |||||
| TemperatuurDatumTijd | |||||
| Ademhaling | |||||
| Ademfrequentie | 4/min | ||||
| AdemhalingDatumTijd | T3 | ||||
| GlasgowComaScale | |||||
| GlasgowComaScaleDatumTijd | |||||
| GCS_Eyes | |||||
| GCS_Motor | |||||
| GCS_Verbal | |||||
| TotaalScore | |||||
| Revised Trauma Score | |||||
| RevisedTraumaScoreWaarde | 8 | ||||
| RevisedTraumaScoreTijd | T3 | ||||
| Pediatric Trauma Score | |||||
| PediatricTraumaScoreWaarde | |||||
| PediatricTraumaScoreTijd | |||||
| Pijnschaal | |||||
| PijnschaalWaarde | |||||
| PijnschaalTijd | |||||
| APGAR-1 | |||||
| APGAR-5 | |||||
| Behandeling | |||||
| Gegevenselement | Waarde | ||||
| Ademhaling en beademing (diagnostisch) | |||||
| Handelingen ademhaling en beademing | |||||
| Bewustzijn en neurologische status (diagnostisch) | |||||
| Handelingen bewustzijn en neurologische status | |||||
| Overige diagnostische handelingen | |||||
| Handelingen overige diagnostisch | |||||
| Luchtweg management (therapeutisch) | |||||
| Handelingen luchtweg management | |||||
| Moeizame intubatie? | |||||
| Oxygenatie en ventilatie (therapeutisch) | |||||
| Handelingen oxygenatie en ventilatie | |||||
| Beademing machine Fi O2 | |||||
| Beademing machine AMV | |||||
| Beademing machine Freq. | |||||
| Beademing machine Peep | |||||
| Hoeveelheid zuurstof | |||||
| Circulatie (therapeutisch) | |||||
| Handelingen circulatie | |||||
| Pacemaker frequentie | |||||
| Pacemaker stroomsterkte | |||||
| Pacemaker modus | |||||
| Cardioversies aantal | |||||
| Cardioversie maximale energie | |||||
| Defibrillaties aantal | |||||
| Defibrillatie energie | |||||
| Return Of Spontaneous Circulation (ROSC) | |||||
| AED aangesloten voor aankomst | |||||
| AED-schokken aantal | |||||
| Traumatologie (therapeutisch) | |||||
| Handelingen traumatologie | |||||
| Koelen tijdsduur | |||||
| Obstetrie | |||||
| Handelingen obstetrie | |||||
| Wijze van isolatie | |||||
| Handelingen isolatie | |||||
| Medicatie | |||||
| Medicatie toegediend? | |||||
| Medicatienaam | |||||
| Toegediende hoeveelheid medicatie | |||||
| Tijd medicatietoediening | |||||
| Medicatie toedieningsvorm | |||||
| IV medicatiesnelheid | |||||
| Infuus | |||||
| Infusen aantal | |||||
| Infuusvloeistofcode | |||||
| Infuusvloeistoftekst | |||||
| Infuushoeveelheid | |||||
| Extra informatie behandeling | |||||
| Patiëntligging | |||||
| Gegevenselement | Waarde | ||||
| Type patiëntligging | |||||
| Primary Survey | |||||
| Gegevenselement | Waarde | ||||
| Airway | |||||
| Airway vrij? | Ja | ||||
| Stridor | |||||
| Breathing | |||||
| Breathing sufficient? | Ja | ||||
| Breathing observaties | |||||
| Circulation | |||||
| Circulation sufficient? | Ja | ||||
| Capillaire refill > 2 seconde? | |||||
| Huid observatie | |||||
| Disability | |||||
| AVPU | |||||
| Duur buiten bewustzijn | |||||
| Pupil | |||||
| FAST symptomen aanwezig | |||||
| Mogelijk trombolyse/trombectomie | |||||
| Intoxicatie | |||||
| Toelichting Primary Survey | |||||
| Secondary Survey | |||||
| Gegevenselement | Waarde | ||||
| Anamnese | |||||
| Ample | |||||
| Code | |||||
| Titel | |||||
| Omschrijving | |||||
| Toelichting anamnese | |||||
| Infectierisico | |||||
| Verdenking infectieziekten? | |||||
| Toelichting infectierisico | |||||
| Hoofd en gelaat | |||||
| Hoofd en gelaat observaties | |||||
| Bloedverlies | |||||
| Liquorverlies | |||||
| Pijnlocatie | |||||
| Wond | |||||
| Nek, hals, CWK | |||||
| Nek, hals, CWK observaties | |||||
| Wond | |||||
| Thorax | |||||
| Thorax observaties | |||||
| Pijn bij compressie | |||||
| Locatie subcutaan emfyseem | |||||
| Locatie zwelling / oedeem (2x) | |||||
| Wond | |||||
| Rug | |||||
| Rug observaties | |||||
| Wond | |||||
| Abdomen | |||||
| Abdomen observaties | |||||
| Locatie druk- / loslaatpijn | |||||
| Locatie zwelling / oedeem | |||||
| Locatie pulserende zwelling | |||||
| Wond | |||||
| Bekken | |||||
| Bekken observaties | |||||
| Wond | |||||
| Extremiteiten Armen | |||||
| Extremiteit | |||||
| Lateraliteit | |||||
| Observaties | |||||
| Wond | |||||
| Extremiteiten Armen | |||||
| Extremiteit | |||||
| Lateraliteit | |||||
| Observaties | |||||
| Wond | |||||
| Extremiteiten Benen | |||||
| Extremiteit | |||||
| Lateraliteit | |||||
| Observaties (2x) | |||||
| Wond | |||||
| Uitscheiding | |||||
| Uitscheiding observaties | |||||
| Braken | |||||
| Incontinent | |||||
| Verloskunde/Gynaecologie | |||||
| Verloskunde/Gynaecologie observaties | |||||
| Vruchtwaterverlies | |||||
| Weeën | |||||
| Consultgever op afstand | |||||
| Gegevenselement | Waarde | ||||
| Initialen | |||||
| Achternaam | |||||
| Telefoonnummer | |||||
| Identificatie | |||||
| Type consultgever | |||||
| Toelichting/Afspraken met consultgever | |||||
| Afspraken met patiënt | |||||
| Gegevenselement | Waarde | ||||
| Huisarts ingelicht | |||||
| Afspraken met patiënt | |||||
| Bijlagen T3 | |||||
| Gegevenselement | Waarde | ||||
| Type Bijlage | 006 intern rapport/overdracht | ||||
| Bijlage id | 9068 | ||||
| Versie | 6 | ||||
| Bijlageset id | 12 | ||||
| Toestemmingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Wetenschappelijk onderzoek | |||||
| Beschrijving | |||||
| Informed consent | |||||
| Toestemming informeren verwanten | |||||
| Toelichtingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Toelichting algemeen | |||||