iaz:Vdraft2.4.0 Testscript Ambulanceoverdracht SEH Sturen Complexe Casus: verschil tussen versies
(→T1: aankomst bij de patient) |
|||
| (4 tussenliggende versies door dezelfde gebruiker niet weergegeven) | |||
| Regel 16: | Regel 16: | ||
expliciet aangegeven. Alleen de bijlagen worden slechts 1x verstuurd, omdat die in dit geval zelf cumulatief zijn | 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. | (zelfde setId met oplopend versienummer), en de oudere versies dus obsoleet zijn. | ||
| + | |||
| + | ==T1: aankomst bij de patient== | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| Regel 388: | Regel 390: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Datum/tijd vertrek patiënt | |colspan="5"|Datum/tijd vertrek patiënt | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verwachte aankomsttijd bestemming | |colspan="5"|Verwachte aankomsttijd bestemming | ||
| Regel 492: | Regel 494: | ||
|colspan="5"|Bestemmingsstatus in bericht op T1 | |colspan="5"|Bestemmingsstatus in bericht op T1 | ||
|style="background-color: white;"|Actief | |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 574: | Regel 570: | ||
60054005 autogordel (fysiek object)<br/> | 60054005 autogordel (fysiek object)<br/> | ||
102384007 airbag van motorvoertuig (fysiek object) | 102384007 airbag van motorvoertuig (fysiek object) | ||
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 615: | Regel 610: | ||
|colspan="4"|BloedsuikerDatumTijd | |colspan="4"|BloedsuikerDatumTijd | ||
|style="background-color: white;"| T1 | |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 659: | Regel 634: | ||
|style="background-color: white;"|T1 | |style="background-color: white;"|T1 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="6"| | + | |colspan="6"|Capnometrie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |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"| | + | |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"| | + | |colspan="6"|Hartfrequentie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"|HartfrequentieWaarde |
| − | |style="background-color: white;"| | + | |style="background-color: white;"|120/min |
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|HartfrequentieDatumTijd | ||
| + | |style="background-color: white;"|T1 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Bloeddruk | ||
|-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"|SystolischeBloeddruk |
| + | |style="background-color: white;"|90 mm[Hg] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"|DiastolischeBloeddruk |
| − | |style="background-color: white;"|60 mm[Hg] | + | |style="background-color: white;"|60 mm[Hg] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"|BloeddrukDatumTijd |
|style="background-color: white;"|T1 | |style="background-color: white;"|T1 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="6"| | + | |colspan="6"|Lichaamstemperatuur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |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"| | + | |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"| | + | |colspan="6"|Ademhaling |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |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"| | + | |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"| | + | |colspan="6"|GlasgowComaScale |
|-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"|GlasgowComaScaleDatumTijd |
| − | |||
| − | |||
| − | |||
|style="background-color: white;"|T1 | |style="background-color: white;"|T1 | ||
| − | |||
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |colspan="4"|GCS_Eyes |
| + | |style="background-color: white;"|4 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"|GCS_Motor |
| − | |style="background-color: white;"| | + | |style="background-color: white;"|6 |
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|GCS_Verbal | ||
| + | |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;;" | ||
| + | |colspan="4"|TotaalScore | ||
| + | |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;;" | ||
| − | |colspan="6"| | + | |colspan="6"|Revised Trauma Score |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |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"| | + | |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"| | + | |colspan="6"|Pediatric Trauma Score |
|-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"| | + | |colspan="4"|PediatricTraumaScoreWaarde |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"|PediatricTraumaScoreTijd |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Pijnschaal | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |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;"|T1 | |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;;" |
| + | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |} |
| − | |style="background-color: white;"| | + | <section end="Meetwaarden" /> |
| + | |||
| + | <section begin="Behandeling" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Behandeling | ||
| + | |-style="background-color: #1F497D;; 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;;" | |-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 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) |
|-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 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"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="2"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |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"| | ||
|-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"| 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"| | + | |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) |
|-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"| 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 |
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"| Beademing machine AMV |
| − | |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"| Beademing machine Freq. |
| − | |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 Peep |
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"| Hoeveelheid zuurstof |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |colspan=" | + | |colspan="6"|Circulatie (therapeutisch) |
| − | |style="background-color: | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |rowspan="12"| |
| − | |colspan="4"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |style="background-color: white;"| | + | |colspan="4"| Handelingen circulatie |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |style="background-color: white;"| |
| − | |colspan="4"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |style="background-color: white;"| | + | |colspan="4"| Pacemaker frequentie |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |style="background-color: white;"| |
| − | |colspan="4"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |style="background-color: white;"| | + | |colspan="4"| Pacemaker stroomsterkte |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |style="background-color: white;"| |
| − | | | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | + | |colspan="4"| Pacemaker modus | |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |style="background-color: white;"| |
| − | | | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |colspan="4"| Cardioversies aantal |
| − | |colspan="4"| | + | |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"| | + | |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=" | + | |style="background-color: white;"| |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | | | + | |colspan="4"| Defibrillatie energie |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |style="background-color: white;"| |
| − | |colspan="4"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |style="background-color: white;"| | + | |colspan="4"| Return Of Spontaneous Circulation (ROSC) |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |style="background-color: white;"| |
| − | |colspan="4"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| − | |style="background-color: white;"|T2 | + | |colspan="4"| AED aangesloten voor aankomst |
| − | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |style="background-color: white;"| |
| − | |colspan="6"|Revised Trauma Score | + | |-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: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Patiëntligging | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Type patiëntligging | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="Patiëntligging" /> | ||
| + | |||
| + | <section begin="Primary Survey" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Primary Survey | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Airway | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Airway vrij? | ||
| + | |style="background-color: white;"| Ja | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |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: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Secondary Survey | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Anamnese | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |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: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Consultgever op afstand | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Initialen | ||
| + | |style="background-color: white;"| | ||
| + | |-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: #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;;" | ||
| + | |colspan="5"|Afspraken met patiënt | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <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;;" | ||
| + | |} | ||
| + | <section end="Bijlagen" /> | ||
| + | |||
| + | <section begin="Toestemmingsgegevens" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Toestemmingsgegevens | ||
| + | |-style="background-color: #1F497D;; 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: #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;;" | ||
| + | |} | ||
| + | <section end="Toelichtingsgegevens" /> | ||
| + | |||
| + | ==T2: gedurende de rit== | ||
| + | |||
| + | {| 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;;" | ||
| + | |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: #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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
| Regel 883: | Regel 3.304: | ||
|-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;"| |
|-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;"| |
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
|-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 910: | Regel 3.321: | ||
<section begin="Behandeling" /> | <section begin="Behandeling" /> | ||
{| 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" | Behandeling |
| − | |-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 1.075: | Regel 3.486: | ||
<section begin="Patiëntligging" /> | <section begin="Patiëntligging" /> | ||
{| 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" | Patiëntligging |
| − | |-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 1.088: | Regel 3.499: | ||
<section begin="Primary Survey" /> | <section begin="Primary Survey" /> | ||
{| 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" | Primary Survey |
| − | |-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 1.159: | Regel 3.570: | ||
<section begin="Secondary Survey" /> | <section begin="Secondary Survey" /> | ||
{| 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" | Secondary Survey |
| − | |-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 1.364: | Regel 3.775: | ||
<section begin="Consultgever op afstand" /> | <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 | ||
| Regel 1.392: | 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 | ||
| Regel 1.407: | Regel 3.818: | ||
<section begin="Bijlagen" /> | <section begin="Bijlagen" /> | ||
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{| 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 1.473: | 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 1.496: | 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 | ||
Huidige versie van 7 apr 2025 om 11:17
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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 | |||||
