az:V2.5.0 Testscript Ambulanceoverdracht SEH complex addendum: verschil tussen versies
(→T1: annulering) |
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| (87 tussenliggende versies door dezelfde gebruiker niet weergegeven) | |||
| Regel 1: | Regel 1: | ||
| − | ==T1: | + | ==T1: fout BSN== |
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" | T1 |
|} | |} | ||
<section begin="patientT1" /> | <section begin="patientT1" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" | Patient |
| − | |-style="background-color: # | + | |-style="background-color: #FF9900;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Persoonidentificatie | |colspan="5"|Persoonidentificatie | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|999910322 [BSN] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Naamgegevens | |colspan="6"|Naamgegevens | ||
| Regel 21: | Regel 21: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Initialen | |colspan="3"|Initialen | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|H. |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Achternaam | |colspan="6"|Achternaam | ||
| Regel 34: | Regel 34: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Achternaam | |colspan="3"|Achternaam | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|XXX_Verschuur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Geslacht | |colspan="5"|Geslacht | ||
| − | |style="background-color: white;"|F | + | |style="background-color: white;"| vrouw (Code = F in codesysteem 2.16.840.1.113883.5.1 'Administrative Gender') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Geboortegegevens | |colspan="6"|Geboortegegevens | ||
| Regel 44: | Regel 44: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geboortedatum | |colspan="4"|Geboortedatum | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|19540725 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Geschatte leeftijd | |colspan="5"|Geschatte leeftijd | ||
| Regel 54: | Regel 54: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Straat | |colspan="4"|Straat | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|Knolweg |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Huisnummer | |colspan="4"|Huisnummer | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|1003 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"|Huisletter |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 66: | Regel 66: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Postcode | |colspan="4"|Postcode | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|9999ZA |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Woonplaats | |colspan="4"|Woonplaats | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|Stitswerd |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Land | |colspan="4"|Land | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|Nederland |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Locatiebeschrijving | |colspan="4"|Locatiebeschrijving | ||
| Regel 79: | Regel 79: | ||
|colspan="6"|Overige Contactgegevens | |colspan="6"|Overige Contactgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="13"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Telefoonnummers | |colspan="5"|Telefoonnummers | ||
| Regel 103: | Regel 103: | ||
|colspan="6"|EmailAdressen | |colspan="6"|EmailAdressen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan | + | |rowspan="3"| |
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|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Emailadres | |colspan="3"|Emailadres | ||
| Regel 143: | Regel 137: | ||
|colspan="6"|Vaste huisarts | |colspan="6"|Vaste huisarts | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="5"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| ZorgverlenerIdentificatienummer | |colspan="4"| ZorgverlenerIdentificatienummer | ||
| − | |||
| − | |||
| − | |||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 160: | Regel 151: | ||
|colspan="6"|Vaste huisartsenpraktijk | |colspan="6"|Vaste huisartsenpraktijk | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="23"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Identificatie | |colspan="4"| Identificatie | ||
| Regel 198: | Regel 189: | ||
|colspan="5"| Overige contactgegevens | |colspan="5"| Overige contactgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="9"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Telefoonnummers | |colspan="4"| Telefoonnummers | ||
| Regel 208: | Regel 199: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| Telefoonnummer | |colspan="2"| Telefoonnummer | ||
| − | |||
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|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 248: | Regel 229: | ||
<section begin="WID-controleT1" /> | <section begin="WID-controleT1" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" | WID-controle |
| − | |-style="background-color: # | + | |-style="background-color: #FF9900;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
| Regel 270: | Regel 251: | ||
<section begin="IncidentgegevensT1" /> | <section begin="IncidentgegevensT1" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" | Incidentgegevens |
| − | |-style="background-color: # | + | |-style="background-color: #FF9900;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
| Regel 283: | Regel 264: | ||
<section begin="MeldingsgegevensT1" /> | <section begin="MeldingsgegevensT1" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" | Meldingsgegevens |
| − | |-style="background-color: # | + | |-style="background-color: #FF9900;; color: white; text-align:left;" |
| − | |colspan="5" width="25%"| Gegevenselement | + | |colspan="5" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 307: | Regel 288: | ||
|-style="vertical-align:top; background-color: #E3E3E3;; | |-style="vertical-align:top; background-color: #E3E3E3;; | ||
|colspan="5"|Meldkamerurgentie | |colspan="5"|Meldkamerurgentie | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
<section end="MeldingsgegevensT1" /> | <section end="MeldingsgegevensT1" /> | ||
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<section begin="RitgegevensT1" /> | <section begin="RitgegevensT1" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" | Ritgegevens |
| − | |-style="background-color: # | + | |-style="background-color: #FF9900;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="5"|Ambulancevoorziening | + | |colspan="5"|Ambulancevoorziening* |
|style="background-color: white;"| 25 (RAV identificatie) | |style="background-color: white;"| 25 (RAV identificatie) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="5"|Ritnummer | + | |colspan="5"|Ritnummer* |
|style="background-color: white;"| 25-2020-13-1 | |style="background-color: white;"| 25-2020-13-1 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="5"|Ambulancenummer | + | |colspan="5"|Ambulancenummer* |
|style="background-color: white;"| 25190 | |style="background-color: white;"| 25190 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="5"|Telefoon ambulance | + | |colspan="5"|Telefoon ambulance* |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="5"|Ambulanceverpleegkundige identificatie | + | |colspan="5"|Ambulanceverpleegkundige identificatie* |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="5"|Ambulancechauffeur identificatie | + | |colspan="5"|Ambulancechauffeur identificatie* |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;; | |-style="vertical-align:top; background-color: #E3E3E3;; | ||
|colspan="5"|Datum/tijd ritopdracht | |colspan="5"|Datum/tijd ritopdracht | ||
| Regel 387: | Regel 343: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| + | <nowiki>*</nowiki> Voor de vulling van gegevens bij Ambulancevoorziening, Ritnummer, Ambulancenummer, Ambulanceverpleegkundige indentificatie en Ambulancechauffer indentificatie geldt voor de opleverende partijen dat zij hier eigen gegevens kunnen invullen, al zijn bovenstaande invulgegevens ook mogelijk. De kwalificatiesimulator zal alleen controleren of er gegevens zijn ingevuld, niet op de exacte waarden. Voor de ontvangende partijen worden middels de kwalificatiesimulator de bovenstaande gegevens aangeboden. | ||
<section end="RitgegevensT1" /> | <section end="RitgegevensT1" /> | ||
<section begin="HaalgegevensT1" /> | <section begin="HaalgegevensT1" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" | Haalgegevens |
| − | |-style="background-color: # | + | |-style="background-color: #FF9900;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
| Regel 421: | Regel 378: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Patiënt vervoerd? | |colspan="5"|Patiënt vervoerd? | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Reden geen vervoer | |colspan="5"|Reden geen vervoer | ||
| Regel 450: | Regel 407: | ||
|colspan="6"|Hulpverleners ter plaatse | |colspan="6"|Hulpverleners ter plaatse | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="8"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Hulpverlenersnaam | |colspan="4"|Hulpverlenersnaam | ||
| Regel 459: | Regel 416: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Telefoonnummer | |colspan="4"|Telefoonnummer | ||
| − | |||
| − | |||
| − | |||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 469: | Regel 423: | ||
<section begin="BestemmingsgegevensT1" /> | <section begin="BestemmingsgegevensT1" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" | Bestemmingsgegevens |
| − | |-style="background-color: # | + | |-style="background-color: #FF9900;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Bestemmingsstatus in bericht op T1 | |colspan="5"|Bestemmingsstatus in bericht op T1 | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|Actief (Code = active in codesysteem 2.16.840.1.113883.5.14 'ActStatus') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Bestemmingscode | |colspan="5"|Bestemmingscode | ||
| Regel 521: | Regel 475: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Feedback adres | |colspan="4"|Feedback adres | ||
| − | |style="background-color: white;"|LSDV-code | + | |style="background-color: white;"|test-LSDV-code |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 528: | Regel 482: | ||
<section begin="MechanismeT1" /> | <section begin="MechanismeT1" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" | Mechanisme |
| − | |-style="background-color: # | + | |-style="background-color: #FF9900;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
| Regel 553: | Regel 507: | ||
<section begin="Toestandsbeelden/WerkdiagnoseT1 /> | <section begin="Toestandsbeelden/WerkdiagnoseT1 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" |Toestandsbeelden/Werkdiagnose |
| − | |-style="background-color: # | + | |-style="background-color: #FF9900;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
| Regel 579: | Regel 533: | ||
<section begin="MeetwaardenT1" /> | <section begin="MeetwaardenT1" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" | Meetwaarden |
| − | |-style="background-color: # | + | |-style="background-color: #FF9900;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
| Regel 589: | Regel 543: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Bloedsuiker waarde | |colspan="4"|Bloedsuiker waarde | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|BloedsuikerDatumTijd | |colspan="4"|BloedsuikerDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Hartritme | |colspan="6"|Hartritme | ||
| Regel 612: | Regel 566: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|SpO2waarde | |colspan="4"|SpO2waarde | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|O2SaturatieDatumTijd | |colspan="4"|O2SaturatieDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Capnometrie | |colspan="6"|Capnometrie | ||
| Regel 622: | Regel 576: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|CO2Waarde | |colspan="4"|CO2Waarde | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|CO2CapnometrieDatumTijd | |colspan="4"|CO2CapnometrieDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Hartfrequentie | |colspan="6"|Hartfrequentie | ||
| Regel 632: | Regel 586: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|HartfrequentieWaarde | |colspan="4"|HartfrequentieWaarde | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|HartfrequentieDatumTijd | |colspan="4"|HartfrequentieDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Bloeddruk | |colspan="6"|Bloeddruk | ||
| Regel 642: | Regel 596: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|SystolischeBloeddruk | |colspan="4"|SystolischeBloeddruk | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|DiastolischeBloeddruk | |colspan="4"|DiastolischeBloeddruk | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|BloeddrukDatumTijd | |colspan="4"|BloeddrukDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Lichaamstemperatuur | |colspan="6"|Lichaamstemperatuur | ||
| Regel 665: | Regel 619: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Ademfrequentie | |colspan="4"|Ademfrequentie | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|AdemhalingDatumTijd | |colspan="4"|AdemhalingDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|GlasgowComaScale | |colspan="6"|GlasgowComaScale | ||
| Regel 695: | Regel 649: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|RevisedTraumaScoreWaarde | |colspan="4"|RevisedTraumaScoreWaarde | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|RevisedTraumaScoreTijd | |colspan="4"|RevisedTraumaScoreTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Pediatric Trauma Score | |colspan="6"|Pediatric Trauma Score | ||
| Regel 732: | Regel 686: | ||
<section begin="BehandelingT1" /> | <section begin="BehandelingT1" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" | Behandeling |
| − | |-style="background-color: # | + | |-style="background-color: #FF9900;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
| Regel 853: | Regel 807: | ||
|colspan="6"|Medicatie | |colspan="6"|Medicatie | ||
|-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"| Medicatie toegediend? | |colspan="4"| Medicatie toegediend? | ||
| Regel 867: | Regel 821: | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| Medicatie | + | |colspan="4"| Medicatie toedieningsweg |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | + | |colspan="5"|Extra informatie behandeling | |
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |colspan="5"|Extra informatie behandeling | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 897: | Regel 832: | ||
<section begin="PatiëntliggingT1" /> | <section begin="PatiëntliggingT1" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" | Patiëntligging |
| − | |-style="background-color: # | + | |-style="background-color: #FF9900;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
| Regel 910: | Regel 845: | ||
<section begin="Primary SurveyT1" /> | <section begin="Primary SurveyT1" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" | Primary Survey |
| − | |-style="background-color: # | + | |-style="background-color: #FF9900;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="6"|Airway | + | |colspan="6"| Airway |
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Airway vrij? | ||
| + | |style="background-color: white;"|geen luchtwegobstructie (Code = 248553004 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"| Airway observaties | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="3"| Airway observatie code |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="3"| Airway observatie titel |
|style="background-color: white;"| | |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="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Breathing sufficient? | ||
| + | |style="background-color: white;"| afwijking van ademhaling (Code = 386813002 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"| Breathing observaties | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |rowspan="4"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | | | + | |colspan="3"| Breathing observatie code |
| + | |style="background-color: white;"| 49727002 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="3"| Breathing observatie titel |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| hoesten |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="3"| Lateraliteit |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| bilateraal (Code = 51440002 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="6"| Circulation |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"|Circulation sufficient? | + | |colspan="4"| Circulation sufficient? |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"|Capillaire refill > 2 seconde? | + | |colspan="4"| Capillaire refill > 2 seconde? |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"|Huid observatie | + | |colspan="4"| Huid observatie |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="6"|Disability | + | |colspan="6"| Disability |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="11"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"|AVPU | + | |colspan="4"| AVPU |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"|Duur buiten bewustzijn | + | |colspan="4"| Duur buiten bewustzijn |
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| FAST symptomen aanwezig | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"| Mogelijk trombolyse/trombectomie |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"| Intoxicatie |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="5"| Pupil observaties |
| − | |style="background-color: | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| + | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="3"| Pupil observatie code |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | + | |colspan="3"| Pupil observatie titel | |
| − | |||
| − | |colspan=" | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Lateraliteit | ||
| + | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 981: | Regel 940: | ||
<section begin="Secondary SurveyT1" /> | <section begin="Secondary SurveyT1" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" | Secondary Survey |
| − | |-style="background-color: # | + | |-style="background-color: #FF9900;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
| Regel 1.006: | Regel 965: | ||
|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"|Besmettingsrisico |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| Verdenking | + | |colspan="4"| Verdenking op besmettelijke ziekte? |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| Toelichting | + | |colspan="4"| Toelichting besmettingsrisico |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.047: | Regel 1.006: | ||
|colspan="6"|Thorax | |colspan="6"|Thorax | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="4"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Thorax observaties | |colspan="4"|Thorax observaties | ||
| Regel 1.053: | Regel 1.012: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Pijn bij compressie | |colspan="4"|Pijn bij compressie | ||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.076: | Regel 1.029: | ||
|colspan="6"|Abdomen | |colspan="6"|Abdomen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="5"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Abdomen observaties | |colspan="4"| Abdomen observaties | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| Locatie | + | |colspan="4"| Locatie drukpijn |
| − | |||
| − | |||
| − | |||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| Locatie | + | |colspan="4"| Locatie loslaatpijn |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.101: | Regel 1.051: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Wond | |colspan="4"| Wond | ||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.148: | Regel 1.081: | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="3"|Observaties | + | |colspan="3"|Observaties |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.185: | Regel 1.118: | ||
<section begin="Consultgever op afstandT1" /> | <section begin="Consultgever op afstandT1" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" | Consultgever op afstand |
| − | |-style="background-color: # | + | |-style="background-color: #FF9900;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
| Regel 1.213: | Regel 1.146: | ||
<section begin="Afspraken met patiëntT1" /> | <section begin="Afspraken met patiëntT1" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" | Afspraken met patiënt |
| − | |-style="background-color: # | + | |-style="background-color: #FF9900;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
| Regel 1.229: | Regel 1.162: | ||
<section begin="BijlagenT1" /> | <section begin="BijlagenT1" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" | Bijlagen T1 |
| − | |-style="background-color: # | + | |-style="background-color: #FF9900;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Type Bijlage | |colspan="5"|Type Bijlage | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Bijlage id | |colspan="5"|Bijlage id | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Versie | |colspan="5"|Versie | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Bijlageset id | |colspan="5"|Bijlageset id | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 1.251: | Regel 1.184: | ||
<section begin="ToestemmingsgegevensT1" /> | <section begin="ToestemmingsgegevensT1" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" | Toestemmingsgegevens |
| − | |-style="background-color: # | + | |-style="background-color: #FF9900;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
| Regel 1.274: | Regel 1.207: | ||
<section begin="ToelichtingsgegevensT1" /> | <section begin="ToelichtingsgegevensT1" /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: # | + | |style="background-color: #FF9900;; color: white; font-weight: bold; text-align:center;" colspan="6" | Toelichtingsgegevens |
| − | |-style="background-color: # | + | |-style="background-color: #FF9900;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
| Regel 1.285: | Regel 1.218: | ||
<section end="ToelichtingsgegevensT1" /> | <section end="ToelichtingsgegevensT1" /> | ||
| − | ==T2: | + | ==T2: annulering== |
| − | {| class="wikitable" width="85% | + | {| class="wikitable" width="85%2 |
| − | |style="background-color: # | + | |style="background-color: #ED2939;; color: white; font-weight: bold; text-align:center;" colspan="6" | T2 |
|} | |} | ||
<section begin="patientT2" /> | <section begin="patientT2" /> | ||
{| 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" | Patient |
| − | |-style="background-color: # | + | |-style="background-color: #ED2939;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Persoonidentificatie | |colspan="5"|Persoonidentificatie | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|999910322 [BSN] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Naamgegevens | |colspan="6"|Naamgegevens | ||
| Regel 1.307: | Regel 1.240: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Initialen | |colspan="3"|Initialen | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|H. |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Achternaam | |colspan="6"|Achternaam | ||
| Regel 1.320: | Regel 1.253: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Achternaam | |colspan="3"|Achternaam | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|XXX_Verschuur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Geslacht | |colspan="5"|Geslacht | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|vrouw (Code = F in codesysteem 2.16.840.1.113883.5.1 'Administrative Gender') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Geboortegegevens | |colspan="6"|Geboortegegevens | ||
| Regel 1.330: | Regel 1.263: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geboortedatum | |colspan="4"|Geboortedatum | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|19540725 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Geschatte leeftijd | |colspan="5"|Geschatte leeftijd | ||
| Regel 1.340: | Regel 1.273: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Straat | |colspan="4"|Straat | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|Knolweg |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Huisnummer | |colspan="4"|Huisnummer | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|1003 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |colspan="4"|Huisletter |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.352: | Regel 1.285: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Postcode | |colspan="4"|Postcode | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|9999ZA |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Woonplaats | |colspan="4"|Woonplaats | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|Stitswerd |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Land | |colspan="4"|Land | ||
| Regel 1.365: | Regel 1.298: | ||
|colspan="6"|Overige Contactgegevens | |colspan="6"|Overige Contactgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="13"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Telefoonnummers | |colspan="5"|Telefoonnummers | ||
| Regel 1.389: | Regel 1.322: | ||
|colspan="6"|EmailAdressen | |colspan="6"|EmailAdressen | ||
|-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="3"|Emailadres | |colspan="3"|Emailadres | ||
| Regel 1.429: | Regel 1.356: | ||
|colspan="6"|Vaste huisarts | |colspan="6"|Vaste huisarts | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="5"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| ZorgverlenerIdentificatienummer | |colspan="4"| ZorgverlenerIdentificatienummer | ||
| − | |||
| − | |||
| − | |||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.446: | Regel 1.370: | ||
|colspan="6"|Vaste huisartsenpraktijk | |colspan="6"|Vaste huisartsenpraktijk | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="23"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Identificatie | |colspan="4"| Identificatie | ||
| Regel 1.484: | Regel 1.408: | ||
|colspan="5"| Overige contactgegevens | |colspan="5"| Overige contactgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="9"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Telefoonnummers | |colspan="4"| Telefoonnummers | ||
| Regel 1.494: | Regel 1.418: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| Telefoonnummer | |colspan="2"| Telefoonnummer | ||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.534: | Regel 1.448: | ||
<section begin="WID-controleT2" /> | <section begin="WID-controleT2" /> | ||
{| 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" | WID-controle |
| − | |-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 1.556: | Regel 1.470: | ||
<section begin="IncidentgegevensT2" /> | <section begin="IncidentgegevensT2" /> | ||
{| 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" | Incidentgegevens |
| − | |-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 1.569: | Regel 1.483: | ||
<section begin="MeldingsgegevensT2" /> | <section begin="MeldingsgegevensT2" /> | ||
{| 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" | Meldingsgegevens |
| − | |-style="background-color: # | + | |-style="background-color: #ED2939;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Datum/tijd melding | |colspan="5"|Datum/tijd melding | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Geplande brengtijd | |colspan="5"|Geplande brengtijd | ||
| Regel 1.593: | Regel 1.507: | ||
|-style="vertical-align:top; background-color: #E3E3E3;; | |-style="vertical-align:top; background-color: #E3E3E3;; | ||
|colspan="5"|Meldkamerurgentie | |colspan="5"|Meldkamerurgentie | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
<section end="MeldingsgegevensT2" /> | <section end="MeldingsgegevensT2" /> | ||
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| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
<section begin="RitgegevensT2" /> | <section begin="RitgegevensT2" /> | ||
{| 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" | Ritgegevens |
| − | |-style="background-color: # | + | |-style="background-color: #ED2939;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="5"|Ambulancevoorziening | + | |colspan="5"|Ambulancevoorziening* |
|style="background-color: white;"| 25 (RAV identificatie) | |style="background-color: white;"| 25 (RAV identificatie) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="5"|Ritnummer | + | |colspan="5"|Ritnummer* |
|style="background-color: white;"| 25-2020-13-1 | |style="background-color: white;"| 25-2020-13-1 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="5"|Ambulancenummer | + | |colspan="5"|Ambulancenummer* |
|style="background-color: white;"| 25190 | |style="background-color: white;"| 25190 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="5"|Telefoon ambulance | + | |colspan="5"|Telefoon ambulance* |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="5"|Ambulanceverpleegkundige identificatie | + | |colspan="5"|Ambulanceverpleegkundige identificatie* |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="5"|Ambulancechauffeur identificatie | + | |colspan="5"|Ambulancechauffeur identificatie* |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;; | |-style="vertical-align:top; background-color: #E3E3E3;; | ||
|colspan="5"|Datum/tijd ritopdracht | |colspan="5"|Datum/tijd ritopdracht | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Datum/tijd uitruk/vertrek | |colspan="5"|Datum/tijd uitruk/vertrek | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Datum/tijd aankomst patiënt | |colspan="5"|Datum/tijd aankomst patiënt | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-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 | ||
| Regel 1.673: | Regel 1.562: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| + | <nowiki>*</nowiki> Voor de vulling van gegevens bij Ambulancevoorziening, Ritnummer, Ambulancenummer, Ambulanceverpleegkundige indentificatie en Ambulancechauffer indentificatie geldt voor de opleverende partijen dat zij hier eigen gegevens kunnen invullen, al zijn bovenstaande invulgegevens ook mogelijk. De kwalificatiesimulator zal alleen controleren of er gegevens zijn ingevuld, niet op de exacte waarden. Voor de ontvangende partijen worden middels de kwalificatiesimulator de bovenstaande gegevens aangeboden. | ||
<section end="RitgegevensT2" /> | <section end="RitgegevensT2" /> | ||
<section begin="HaalgegevensT2" /> | <section begin="HaalgegevensT2" /> | ||
{| 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" | Haalgegevens |
| − | |-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 1.707: | Regel 1.597: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Patiënt vervoerd? | |colspan="5"|Patiënt vervoerd? | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Reden geen vervoer | |colspan="5"|Reden geen vervoer | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Tijdstip overlijden patiënt | |colspan="5"|Tijdstip overlijden patiënt | ||
| Regel 1.736: | Regel 1.626: | ||
|colspan="6"|Hulpverleners ter plaatse | |colspan="6"|Hulpverleners ter plaatse | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="8"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Hulpverlenersnaam | |colspan="4"|Hulpverlenersnaam | ||
| Regel 1.745: | Regel 1.635: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Telefoonnummer | |colspan="4"|Telefoonnummer | ||
| − | |||
| − | |||
| − | |||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.755: | Regel 1.642: | ||
<section begin="BestemmingsgegevensT2" /> | <section begin="BestemmingsgegevensT2" /> | ||
{| 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" | Bestemmingsgegevens |
| − | |-style="background-color: # | + | |-style="background-color: #ED2939;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="5"|Bestemmingsstatus in bericht op | + | |colspan="5"|Bestemmingsstatus in bericht op T2 |
| − | |style="background-color: white;"| | + | |style="background-color: white;"|Geannuleerd (Code = cancelled in codesysteem 2.16.840.1.113883.5.14 'ActStatus') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Bestemmingscode | |colspan="5"|Bestemmingscode | ||
| Regel 1.767: | Regel 1.654: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Locatie of afdeling | |colspan="5"|Locatie of afdeling | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Straat | |colspan="5"|Straat | ||
| Regel 1.803: | Regel 1.690: | ||
|rowspan="9"| | |rowspan="9"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"|Feedback gewenst | + | |colspan="4"|Feedback op overdracht/behandeling gewenst |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Feedback adres | |colspan="4"|Feedback adres | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"|test-LSDV-code |
| − | |||
| − | |||
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 1.817: | Regel 1.701: | ||
<section begin="MechanismeT2" /> | <section begin="MechanismeT2" /> | ||
{| 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" | Mechanisme |
| − | |-style="background-color: # | + | |-style="background-color: #ED2939;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Mechanisme type | |colspan="5"|Mechanisme type | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Vervoermiddel patiënt | |colspan="5"|Vervoermiddel patiënt | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Patiënt was bestuurder? | |colspan="5"|Patiënt was bestuurder? | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Vervoermiddel contra | |colspan="5"|Vervoermiddel contra | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="5"|Beschermingsmiddelen patiënt | + | |colspan="5"|Beschermingsmiddelen patiënt |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
| − | |||
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 1.844: | Regel 1.726: | ||
<section begin="Toestandsbeelden/WerkdiagnoseT2" /> | <section begin="Toestandsbeelden/WerkdiagnoseT2" /> | ||
{| 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" |Toestandsbeelden/Werkdiagnose |
| − | |-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 1.854: | Regel 1.736: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Toestandsbeeld code | |colspan="4"|Toestandsbeeld code | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Toestandsbeeld titel | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Lateraliteit | ||
| + | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Toelichting Toestandsbeeld | |colspan="4"|Toelichting Toestandsbeeld | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 1.864: | Regel 1.752: | ||
<section begin="MeetwaardenT2" /> | <section begin="MeetwaardenT2" /> | ||
{| 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" | Meetwaarden |
| − | |-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 1.874: | Regel 1.762: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Bloedsuiker waarde | |colspan="4"|Bloedsuiker waarde | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|BloedsuikerDatumTijd | |colspan="4"|BloedsuikerDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Hartritme | |colspan="6"|Hartritme | ||
| Regel 1.897: | Regel 1.785: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|SpO2waarde | |colspan="4"|SpO2waarde | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|O2SaturatieDatumTijd | |colspan="4"|O2SaturatieDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Capnometrie | |colspan="6"|Capnometrie | ||
| Regel 1.907: | Regel 1.795: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|CO2Waarde | |colspan="4"|CO2Waarde | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|CO2CapnometrieDatumTijd | |colspan="4"|CO2CapnometrieDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Hartfrequentie | |colspan="6"|Hartfrequentie | ||
| Regel 1.917: | Regel 1.805: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|HartfrequentieWaarde | |colspan="4"|HartfrequentieWaarde | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|HartfrequentieDatumTijd | |colspan="4"|HartfrequentieDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Bloeddruk | |colspan="6"|Bloeddruk | ||
| Regel 1.927: | Regel 1.815: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|SystolischeBloeddruk | |colspan="4"|SystolischeBloeddruk | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|DiastolischeBloeddruk | |colspan="4"|DiastolischeBloeddruk | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|BloeddrukDatumTijd | |colspan="4"|BloeddrukDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Lichaamstemperatuur | |colspan="6"|Lichaamstemperatuur | ||
| Regel 1.950: | Regel 1.838: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Ademfrequentie | |colspan="4"|Ademfrequentie | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|AdemhalingDatumTijd | |colspan="4"|AdemhalingDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|GlasgowComaScale | |colspan="6"|GlasgowComaScale | ||
| Regel 1.960: | Regel 1.848: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|GlasgowComaScaleDatumTijd | |colspan="4"|GlasgowComaScaleDatumTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|GCS_Eyes | |colspan="4"|GCS_Eyes | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|GCS_Motor | |colspan="4"|GCS_Motor | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|GCS_Verbal | |colspan="4"|GCS_Verbal | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|TotaalScore | |colspan="4"|TotaalScore | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-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 1.980: | Regel 1.868: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|RevisedTraumaScoreWaarde | |colspan="4"|RevisedTraumaScoreWaarde | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|RevisedTraumaScoreTijd | |colspan="4"|RevisedTraumaScoreTijd | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Pediatric Trauma Score | |colspan="6"|Pediatric Trauma Score | ||
| Regel 2.000: | Regel 1.888: | ||
|-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 2.018: | Regel 1.905: | ||
<section begin="BehandelingT2" /> | <section begin="BehandelingT2" /> | ||
{| 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 2.139: | Regel 2.026: | ||
|colspan="6"|Medicatie | |colspan="6"|Medicatie | ||
|-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"| Medicatie toegediend? | |colspan="4"| Medicatie toegediend? | ||
| Regel 2.153: | Regel 2.040: | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| Medicatie | + | |colspan="4"| Medicatie toedieningsweg |
| − | |||
| − | |||
| − | |||
|style="background-color: white;"| | |style="background-color: white;"| | ||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Extra informatie behandeling | |colspan="5"|Extra informatie behandeling | ||
| Regel 2.183: | Regel 2.051: | ||
<section begin="PatiëntliggingT2" /> | <section begin="PatiëntliggingT2" /> | ||
{| 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 2.196: | Regel 2.064: | ||
<section begin="Primary SurveyT2" /> | <section begin="Primary SurveyT2" /> | ||
{| 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 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="6"|Airway | + | |colspan="6"| Airway |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-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"|Airway vrij? | + | |colspan="4"| Airway vrij? |
| − | |||
| − | |||
| − | |||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | + | |colspan="5"| Airway observaties | |
| − | |colspan=" | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="3"| Airway observatie code |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="3"| Airway observatie titel |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="5"| | + | |colspan="6"| Breathing |
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Breathing sufficient? | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"| Breathing observaties | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="3"| Breathing observatie code |
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="3"| Breathing observatie titel |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="3"| Lateraliteit |
|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"| Circulation |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="4"| |
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Circulation sufficient? | ||
| + | |style="background-color: white;"| | ||
| + | |-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="11"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"|AVPU | + | |colspan="4"| AVPU |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"|Duur buiten bewustzijn | + | |colspan="4"| Duur buiten bewustzijn |
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| FAST symptomen aanwezig | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"|Pupil | + | |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"| Pupil observaties | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Pupil observatie code | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="3"| Pupil observatie titel |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="3"| Lateraliteit |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="5"| Toelichting Primary Survey |
|style="background-color: white;"| | |style="background-color: white;"| | ||
| − | |||
| − | |||
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 2.265: | Regel 2.159: | ||
<section begin="Secondary SurveyT2" /> | <section begin="Secondary SurveyT2" /> | ||
{| 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 2.290: | Regel 2.184: | ||
|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"|Besmettingsrisico |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| Verdenking | + | |colspan="4"| Verdenking op besmettelijke ziekte? |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| Toelichting | + | |colspan="4"| Toelichting besmettingsrisico |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 2.331: | Regel 2.225: | ||
|colspan="6"|Thorax | |colspan="6"|Thorax | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="4"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Thorax observaties | |colspan="4"|Thorax observaties | ||
| Regel 2.337: | Regel 2.231: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Pijn bij compressie | |colspan="4"|Pijn bij compressie | ||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 2.360: | Regel 2.248: | ||
|colspan="6"|Abdomen | |colspan="6"|Abdomen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |rowspan=" | + | |rowspan="5"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| Abdomen observaties | |colspan="4"| Abdomen observaties | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| Locatie | + | |colspan="4"| Locatie drukpijn |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| Locatie | + | |colspan="4"| Locatie loslaatpijn |
| − | |||
| − | |||
| − | |||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 2.404: | Regel 2.289: | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="6"|Extremiteiten | + | |colspan="6"|Extremiteiten Benen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="6"| | |rowspan="6"| | ||
| Regel 2.415: | Regel 2.300: | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="3"|Observaties | + | |colspan="3"|Observaties |
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
| − | |||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 2.469: | Regel 2.337: | ||
<section begin="Consultgever op afstandT2" /> | <section begin="Consultgever op afstandT2" /> | ||
{| 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 2.497: | Regel 2.365: | ||
<section begin="Afspraken met patiëntT2" /> | <section begin="Afspraken met patiëntT2" /> | ||
{| 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 2.511: | Regel 2.379: | ||
<section end="Afspraken met patiëntT2" /> | <section end="Afspraken met patiëntT2" /> | ||
| − | <section begin=" | + | <section begin="BijlagenT2" /> |
{| 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 T2 |
| − | |-style="background-color: # | + | |-style="background-color: #ED2939;; color: white; text-align:left;" |
|colspan="5" width="25%"| Gegevenselement | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Type Bijlage | |colspan="5"|Type Bijlage | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Bijlage id | |colspan="5"|Bijlage id | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Versie | |colspan="5"|Versie | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Bijlageset id | |colspan="5"|Bijlageset id | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|} | |} | ||
| Regel 2.535: | Regel 2.403: | ||
<section begin="ToestemmingsgegevensT2" /> | <section begin="ToestemmingsgegevensT2" /> | ||
{| 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 2.558: | Regel 2.426: | ||
<section begin="ToelichtingsgegevensT2" /> | <section begin="ToelichtingsgegevensT2" /> | ||
{| 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 | ||
| Regel 2.568: | Regel 2.436: | ||
|} | |} | ||
<section end="ToelichtingsgegevensT2" /> | <section end="ToelichtingsgegevensT2" /> | ||
| + | |||
| + | ==T3: aankomst bij de patient== | ||
| + | |||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | T3 | ||
| + | |} | ||
| + | <section begin="patientT3" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Patient | ||
| + | |-style="background-color: #1F497D;; 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;"|999910310 [BSN] | ||
| + | |-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;"|P. | ||
| + | |-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_Dierx | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Geslacht | ||
| + | |style="background-color: white;"|man (Code = M in codesysteem 2.16.840.1.113883.5.1 'Administrative Gender') | ||
| + | |-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;"|25-07-1954 | ||
| + | |-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;"|Knolweg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Huisnummer | ||
| + | |style="background-color: white;"|1002 | ||
| + | |-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;"|9999ZZ | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Woonplaats | ||
| + | |style="background-color: white;"|Stitswerd | ||
| + | |-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="23"| | ||
| + | |-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="9"| | ||
| + | |-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"| 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="patientT3" /> | ||
| + | |||
| + | <section begin="WID-controleT3" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | WID-controle | ||
| + | |-style="background-color: #1F497D;; 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-controleT3" /> | ||
| + | |||
| + | <section begin="IncidentgegevensT3" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Incidentgegevens | ||
| + | |-style="background-color: #1F497D;; 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="IncidentgegevensT3" /> | ||
| + | |||
| + | <section begin="MeldingsgegevensT3" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Meldingsgegevens | ||
| + | |-style="background-color: #1F497D;; 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;"| T3-15min | ||
| + | |-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 Spoedrit, zonder gebruik van optische- en geluidssignalen (code = A2 in codesysteem 2.16.840.1.113883.2.4.3.11.60.55.5.2 'acutezorg-codesysteem-2') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="MeldingsgegevensT3" /> | ||
| + | |||
| + | <section begin="RitgegevensT3" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Ritgegevens | ||
| + | |-style="background-color: #1F497D;; 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;"| 25-2020-13-2 | ||
| + | |-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;"| T3-10 min | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd uitruk/vertrek | ||
| + | |style="background-color: white;"| T3-10 min | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd aankomst patiënt | ||
| + | |style="background-color: white;"| T3 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd vertrek patiënt | ||
| + | |style="background-color: white;"| | ||
| + | |-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;;" | ||
| + | |} | ||
| + | <nowiki>*</nowiki> Voor de vulling van gegevens bij Ambulancevoorziening, Ritnummer, Ambulancenummer, Ambulanceverpleegkundige indentificatie en Ambulancechauffer indentificatie geldt voor de opleverende partijen dat zij hier eigen gegevens kunnen invullen, al zijn bovenstaande invulgegevens ook mogelijk. De kwalificatiesimulator zal alleen controleren of er gegevens zijn ingevuld, niet op de exacte waarden. Voor de ontvangende partijen worden middels de kwalificatiesimulator de bovenstaande gegevens aangeboden. | ||
| + | <section end="RitgegevensT3" /> | ||
| + | |||
| + | <section begin="HaalgegevensT3" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Haalgegevens | ||
| + | |-style="background-color: #1F497D;; 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="4"| | ||
| + | |-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;;" | ||
| + | |} | ||
| + | <section end="HaalgegevensT3" /> | ||
| + | |||
| + | <section begin="BestemmingsgegevensT3" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Bestemmingsgegevens | ||
| + | |-style="background-color: #1F497D;; 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;"|Actief (Code = active in codesysteem 2.16.840.1.113883.5.14 'ActStatus') | ||
| + | |-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 op overdracht/behandeling 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;;" | ||
| + | |} | ||
| + | <section end="BestemmingsgegevensT3" /> | ||
| + | |||
| + | <section begin="MechanismeT3" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Mechanisme | ||
| + | |-style="background-color: #1F497D;; 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;"| bekneld geraakt tussen voorwerpen (Code = 35468003 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Vervoermiddel patiënt | ||
| + | |style="background-color: white;"| auto (Code = 71783008 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-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;"| auto (Code = 71783008 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Beschermingsmiddelen patiënt (3x) | ||
| + | |style="background-color: white;"| helm (Code = 285695004 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') <br/> | ||
| + | autogordel (Code = 60054005 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') <br/> | ||
| + | airbag van motorvoertuig (Code = 102384007 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="MechanismeT3" /> | ||
| + | |||
| + | <section begin="Toestandsbeelden/WerkdiagnoseT3" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" |Toestandsbeelden/Werkdiagnose | ||
| + | |-style="background-color: #1F497D;; 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;"| 1156538002 (in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Toestandsbeeld titel | ||
| + | |style="background-color: white;"| letsel regio wervelkolom | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Lateraliteit | ||
| + | |style="background-color: white;"| | ||
| + | |-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/WerkdiagnoseT3" /> | ||
| + | |||
| + | <section begin="MeetwaardenT3" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Meetwaarden | ||
| + | |-style="background-color: #1F497D;; 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;"|99% | ||
| + | |-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;"|60 mm[Hg] <br/>8,0 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;"|120/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;"|90 mm[Hg] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|DiastolischeBloeddruk | ||
| + | |style="background-color: white;"|60 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;"|T3 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|GCS_Eyes | ||
| + | |style="background-color: white;"|Spontaan (Code = E4 uit codesysteem 2.16.840.1.113883.2.4.3.11.60.40.4.2.1 'GCS_Eyes') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|GCS_Motor | ||
| + | |style="background-color: white;"|Voert opdracht uit (Code = M6 uit codesysteem 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 'GCS_Motor') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|GCS_Verbal | ||
| + | |style="background-color: white;"|Georiënteerd (Code = V5 uit codesysteem 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 'GCS_Verbal') | ||
| + | |-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;;" | ||
| + | |colspan="6"|Revised Trauma Score | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|RevisedTraumaScoreWaarde | ||
| + | |style="background-color: white;"|8 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|RevisedTraumaScoreTijd | ||
| + | |style="background-color: white;"|T3 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Pediatric Trauma Score | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|PediatricTraumaScoreWaarde | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|PediatricTraumaScoreTijd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Pijnschaal | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|PijnschaalWaarde | ||
| + | |style="background-color: white;"|3 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|PijnschaalTijd | ||
| + | |style="background-color: white;"|T3 | ||
| + | |-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;;" | ||
| + | |} | ||
| + | <section end="MeetwaardenT3" /> | ||
| + | |||
| + | <section begin="BehandelingT3" /> | ||
| + | {| 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;;" | ||
| + | |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;"| insertie van nasofaryngeale tube (Code = 182692007 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-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="6"| | ||
| + | |-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 toedieningsweg | ||
| + | |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="BehandelingT3" /> | ||
| + | |||
| + | <section begin="PatiëntliggingT3" /> | ||
| + | {| 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="PatiëntliggingT3" /> | ||
| + | |||
| + | <section begin="Primary SurveyT3" /> | ||
| + | {| 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="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Airway vrij? | ||
| + | |style="background-color: white;"| geen luchtwegobstructie (Code = 248553004 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"| Airway observaties | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Airway observatie code | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Airway observatie titel | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"| Breathing | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Breathing sufficient? | ||
| + | |style="background-color: white;"| normale ademhalingsfunctie (Code = 22803001 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"| Breathing observaties | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Breathing observatie code | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Breathing observatie titel | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Lateraliteit | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"| 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;"| cardiovasculaire functie normaal (Code = 61618002 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-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="11"| | ||
| + | |-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"| 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;"| intoxicatie door gasvormige stof (Code = 1156755000 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"| Pupil observaties | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Pupil observatie code | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Pupil observatie titel | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Lateraliteit | ||
| + | |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 SurveyT3" /> | ||
| + | |||
| + | <section begin="Secondary SurveyT3" /> | ||
| + | {| 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"|Besmettingsrisico | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Verdenking op besmettelijke ziekte? | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Toelichting besmettingsrisico | ||
| + | |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="4"| | ||
| + | |-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"|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="5"| | ||
| + | |-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 drukpijn | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Locatie loslaatpijn | ||
| + | |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 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 | ||
| + | |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 SurveyT3" /> | ||
| + | |||
| + | <section begin="Consultgever op afstandT3" /> | ||
| + | {| 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 afstandT3" /> | ||
| + | |||
| + | <section begin="Afspraken met patiëntT3" /> | ||
| + | {| 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 patiëntT3" /> | ||
| + | |||
| + | <section begin="BijlagenT3" /> | ||
| + | {| 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;"|intern rapport/overdracht (Code = 006 in codesysteem 2.16.840.1.113883.2.4.3.11.60.55.5.16 'acutezorg-codesysteem-16') | ||
| + | |-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="BijlagenT3" /> | ||
| + | |||
| + | <section begin="ToestemmingsgegevensT3" /> | ||
| + | {| 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="ToestemmingsgegevensT3" /> | ||
| + | |||
| + | <section begin="ToelichtingsgegevensT3" /> | ||
| + | {| 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="ToelichtingsgegevensT3" /> | ||
| + | |||
| + | ==T4: gedurende de rit== | ||
| + | |||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | T4 | ||
| + | |} | ||
| + | <section begin="patientT4" /> | ||
| + | {| 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;"|999910310 [BSN] | ||
| + | |-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;"|P. | ||
| + | |-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_Dierx | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Geslacht | ||
| + | |style="background-color: white;"|man (Code = M in codesysteem 2.16.840.1.113883.5.1 'Administrative Gender') | ||
| + | |-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;"|25-07-1954 | ||
| + | |-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;"|Knolweg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Huisnummer | ||
| + | |style="background-color: white;"|1002 | ||
| + | |-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;"|9999ZZ | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Woonplaats | ||
| + | |style="background-color: white;"|Stitswerd | ||
| + | |-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="23"| | ||
| + | |-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="9"| | ||
| + | |-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"| 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="patientT4" /> | ||
| + | |||
| + | <section begin="WID-controleT4" /> | ||
| + | {| 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-controleT4" /> | ||
| + | |||
| + | <section begin="IncidentgegevensT4" /> | ||
| + | {| 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="IncidentgegevensT4" /> | ||
| + | |||
| + | <section begin="MeldingsgegevensT4" /> | ||
| + | {| 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;"| T3-15min | ||
| + | |-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 Spoedrit, zonder gebruik van optische- en geluidssignalen (code = A2 in codesysteem 2.16.840.1.113883.2.4.3.11.60.55.5.2 'acutezorg-codesysteem-2') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="MeldingsgegevensT4" /> | ||
| + | |||
| + | <section begin="RitgegevensT4" /> | ||
| + | {| 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;"| 25-2020-13-2 | ||
| + | |-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;"| T3-10 min | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd uitruk/vertrek | ||
| + | |style="background-color: white;"| T3-10 min | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd aankomst patiënt | ||
| + | |style="background-color: white;"| T3 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd vertrek patiënt | ||
| + | |style="background-color: white;"| T3+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;;" | ||
| + | |} | ||
| + | <nowiki>*</nowiki> Voor de vulling van gegevens bij Ambulancevoorziening, Ritnummer, Ambulancenummer, Ambulanceverpleegkundige indentificatie en Ambulancechauffer indentificatie geldt voor de opleverende partijen dat zij hier eigen gegevens kunnen invullen, al zijn bovenstaande invulgegevens ook mogelijk. De kwalificatiesimulator zal alleen controleren of er gegevens zijn ingevuld, niet op de exacte waarden. Voor de ontvangende partijen worden middels de kwalificatiesimulator de bovenstaande gegevens aangeboden. | ||
| + | <section end="RitgegevensT4" /> | ||
| + | |||
| + | <section begin="HaalgegevensT4" /> | ||
| + | {| 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="4"| | ||
| + | |-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;;" | ||
| + | |} | ||
| + | <section end="HaalgegevensT"4 /> | ||
| + | |||
| + | <section begin="BestemmingsgegevensT4" /> | ||
| + | {| 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 T4 | ||
| + | |style="background-color: white;"|Actief (Code = active in codesysteem 2.16.840.1.113883.5.14 'ActStatus') | ||
| + | |-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 op overdracht/behandeling 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;;" | ||
| + | |} | ||
| + | <section end="BestemmingsgegevensT4" /> | ||
| + | |||
| + | <section begin="MechanismeT4" /> | ||
| + | {| 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;"| bekneld geraakt tussen voorwerpen (Code = 35468003 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Vervoermiddel patiënt | ||
| + | |style="background-color: white;"| auto (Code = 71783008 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-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;"| auto (Code = 71783008 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Beschermingsmiddelen patiënt (3x) | ||
| + | |style="background-color: white;"| helm (Code = 285695004 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') <br/> | ||
| + | autogordel (Code = 60054005 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') <br/> | ||
| + | airbag van motorvoertuig (Code = 102384007 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="MechanismeT4" /> | ||
| + | |||
| + | <section begin="Toestandsbeelden/WerkdiagnoseT4" /> | ||
| + | {| 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;"| 1156538002 (in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Toestandsbeeld titel | ||
| + | |style="background-color: white;"| letsel regio wervelkolom | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Lateraliteit | ||
| + | |style="background-color: white;"| | ||
| + | |-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/WerkdiagnoseT4" /> | ||
| + | |||
| + | <section begin="MeetwaardenT4" /> | ||
| + | {| 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;"| T4 | ||
| + | |-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;"|T4 | ||
| + | |-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;"|T4 | ||
| + | |-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;"|T4 | ||
| + | |-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;"|T4 | ||
| + | |-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;"|T4 | ||
| + | |-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;"|T4 | ||
| + | |-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;"|T4 | ||
| + | |-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;;" | ||
| + | |} | ||
| + | <section end="MeetwaardenT4" /> | ||
| + | |||
| + | <section begin="BehandelingT4" /> | ||
| + | {| 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;"|insertie van nasofaryngeale tube(Code = 182692007 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-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;"| continue positievedrukbeademing (Code = 47545007 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-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;"| infusie met gebruik van drukzak (Code = 390231000146100 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-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;"|gebruik van hydrogel kompres (Code = 430371000146108 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-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="6"| | ||
| + | |-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 toedieningsweg | ||
| + | |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="BehandelingT4" /> | ||
| + | |||
| + | <section begin="PatiëntliggingT4" /> | ||
| + | {| 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="PatiëntliggingT4" /> | ||
| + | |||
| + | <section begin="Primary SurveyT4" /> | ||
| + | {| 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="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Airway vrij? | ||
| + | |style="background-color: white;"| geen luchtwegobstructie (Code = 248553004 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"| Airway observaties | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Airway observatie code | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Airway observatie titel | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"| Breathing | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Breathing sufficient? | ||
| + | |style="background-color: white;"| normale ademhalingsfunctie (Code = 22803001 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"| Breathing observaties | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Breathing observatie code | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Breathing observatie titel | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Lateraliteit | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"| 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;"| cardiovasculaire functie normaal (Code = 61618002 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-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="11"| | ||
| + | |-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"| 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;"| intoxicatie door gasvormige stof (Code = 1156755000 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"| Pupil observaties | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Pupil observatie code | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Pupil observatie titel | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Lateraliteit | ||
| + | |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 SurveyT4" /> | ||
| + | |||
| + | <section begin="Secondary SurveyT4" /> | ||
| + | {| 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"|Besmettingsrisico | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Verdenking op besmettelijke ziekte? | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Toelichting besmettingsrisico | ||
| + | |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="4"| | ||
| + | |-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"|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="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Abdomen observaties | ||
| + | |style="background-color: white;"| zwelling (Code = 65124004 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Locatie drukpijn | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Locatie loslaatpijn | ||
| + | |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 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 | ||
| + | |style="background-color: white;"|pijn (Code = 22253000 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-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 SurveyT4" /> | ||
| + | |||
| + | <section begin="Consultgever op afstandT4" /> | ||
| + | {| 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 afstandT4" /> | ||
| + | |||
| + | <section begin="Afspraken met patiëntT4" /> | ||
| + | {| 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 patiëntT4" /> | ||
| + | |||
| + | <section begin="BijlagenT4" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #8F00FF;; color: white; font-weight: bold; text-align:center;" colspan="6" | Bijlagen | ||
| + | |-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;"| intern rapport/overdracht (Code = 006 in codesysteem 2.16.840.1.113883.2.4.3.11.60.55.5.16 'acutezorg-codesysteem-16') | ||
| + | |-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="BijlagenT4" /> | ||
| + | |||
| + | <section begin="ToestemmingsgegevensT4" /> | ||
| + | {| 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="ToestemmingsgegevensT4" /> | ||
| + | |||
| + | <section begin="ToelichtingsgegevensT4" /> | ||
| + | {| 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="ToelichtingsgegevensT4" /> | ||
| + | |||
| + | ==T5: Bij overdracht bij de SEH== | ||
| + | |||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" | T5 | ||
| + | |} | ||
| + | <section begin="patientT5" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" | Patient | ||
| + | |-style="background-color: #69BE28;; 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;"|999910310 [BSN] | ||
| + | |-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;"|P. | ||
| + | |-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_Dierx | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Geslacht | ||
| + | |style="background-color: white;"|man (Code = M in codesysteem 2.16.840.1.113883.5.1 'Administrative Gender') | ||
| + | |-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;"|25-07-1954 | ||
| + | |-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;"|Knolweg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Huisnummer | ||
| + | |style="background-color: white;"|1002 | ||
| + | |-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;"|9999ZZ | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Woonplaats | ||
| + | |style="background-color: white;"|Stitswerd | ||
| + | |-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="23"| | ||
| + | |-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="9"| | ||
| + | |-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"| 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="patientT5" /> | ||
| + | |||
| + | <section begin="WID-controleT5" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" | WID-controle | ||
| + | |-style="background-color: #69BE28;; 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-controleT5" /> | ||
| + | |||
| + | <section begin="IncidentgegevensT5" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" | Incidentgegevens | ||
| + | |-style="background-color: #69BE28;; 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="IncidentgegevensT5" /> | ||
| + | |||
| + | <section begin="MeldingsgegevensT5" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" | Meldingsgegevens | ||
| + | |-style="background-color: #69BE28;; 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;"| T3-15min | ||
| + | |-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 Spoedrit, zonder gebruik van optische- en geluidssignalen (code = A2 in codesysteem 2.16.840.1.113883.2.4.3.11.60.55.5.2 'acutezorg-codesysteem-2') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="MeldingsgegevensT5" /> | ||
| + | |||
| + | <section begin="RitgegevensT5" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" | Ritgegevens | ||
| + | |-style="background-color: #69BE28;; 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;"| 25-2020-13-2 | ||
| + | |-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;"| T3-10 min | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd uitruk/vertrek | ||
| + | |style="background-color: white;"| T3-10 min | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd aankomst patiënt | ||
| + | |style="background-color: white;"| T3 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Datum/tijd vertrek patiënt | ||
| + | |style="background-color: white;"| T3+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;;" | ||
| + | |} | ||
| + | <nowiki>*</nowiki> Voor de vulling van gegevens bij Ambulancevoorziening, Ritnummer, Ambulancenummer, Ambulanceverpleegkundige indentificatie en Ambulancechauffer indentificatie geldt voor de opleverende partijen dat zij hier eigen gegevens kunnen invullen, al zijn bovenstaande invulgegevens ook mogelijk. De kwalificatiesimulator zal alleen controleren of er gegevens zijn ingevuld, niet op de exacte waarden. Voor de ontvangende partijen worden middels de kwalificatiesimulator de bovenstaande gegevens aangeboden. | ||
| + | <section end="RitgegevensT5" /> | ||
| + | |||
| + | <section begin="HaalgegevensT5" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" | Haalgegevens | ||
| + | |-style="background-color: #69BE28;; 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="4"| | ||
| + | |-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;;" | ||
| + | |} | ||
| + | <section end="HaalgegevensT5" /> | ||
| + | |||
| + | <section begin="BestemmingsgegevensT5" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" | Bestemmingsgegevens | ||
| + | |-style="background-color: #69BE28;; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Bestemmingsstatus in bericht op T5 | ||
| + | |style="background-color: white;"|Overgedragen (Code = completed in codesysteem 2.16.840.1.113883.5.14 'ActStatus') | ||
| + | |-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 op overdracht/behandeling 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;;" | ||
| + | |} | ||
| + | <section end="BestemmingsgegevensT5" /> | ||
| + | |||
| + | <section begin="MechanismeT5" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" | Mechanisme | ||
| + | |-style="background-color: #69BE28;; 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;"| bekneld geraakt tussen voorwerpen (Code = 35468003 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Vervoermiddel patiënt | ||
| + | |style="background-color: white;"| auto (Code = 71783008 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-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;"| auto (Code = 71783008 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Beschermingsmiddelen patiënt (3x) | ||
| + | |style="background-color: white;"| helm (Code = 285695004 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') <br/> | ||
| + | autogordel (Code = 60054005 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') <br/> | ||
| + | airbag van motorvoertuig (Code = 102384007 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |} | ||
| + | <section end="MechanismeT5" /> | ||
| + | |||
| + | <section begin="Toestandsbeelden/WerkdiagnoseT5" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" |Toestandsbeelden/Werkdiagnose | ||
| + | |-style="background-color: #69BE28;; 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;"| 1156538002 (in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Toestandsbeeld titel | ||
| + | |style="background-color: white;"| letsel regio wervelkolom | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Lateraliteit | ||
| + | |style="background-color: white;"| | ||
| + | |-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/WerkdiagnoseT5" /> | ||
| + | |||
| + | <section begin="MeetwaardenT5" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" | Meetwaarden | ||
| + | |-style="background-color: #69BE28;; 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;"| T5 | ||
| + | |-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;"|T5 | ||
| + | |-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;"|T5 | ||
| + | |-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;"|T5 | ||
| + | |-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;"|T5 | ||
| + | |-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;"|T5 | ||
| + | |-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;"|T5 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|GCS_Eyes | ||
| + | |style="background-color: white;"|Spontaan (Code = E4 uit codesysteem 2.16.840.1.113883.2.4.3.11.60.40.4.2.1 'GCS_Eyes') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|GCS_Motor | ||
| + | |style="background-color: white;"|Voert opdracht uit (Code = M6 uit codesysteem 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 'GCS_Motor') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|GCS_Verbal | ||
| + | |style="background-color: white;"|Georiënteerd (Code = V5 uit codesysteem 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 'GCS_Verbal') | ||
| + | |-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;;" | ||
| + | |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;"|T5 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Pediatric Trauma Score | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|PediatricTraumaScoreWaarde | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|PediatricTraumaScoreTijd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Pijnschaal | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|PijnschaalWaarde | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|PijnschaalTijd | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |-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="MeetwaardenT5" /> | ||
| + | |||
| + | <section begin="BehandelingT5" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" | Behandeling | ||
| + | |-style="background-color: #69BE28;; 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;"| insertie van nasofaryngeale tube (Code = 182692007 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-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;"| positieve drukbeademing (Code = 1149092001 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-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;"| infusie met gebruik van drukzak (Code = 390231000146100 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-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;"|gebruik van hydrogel kompres (Code = 430371000146108 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-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="6"| | ||
| + | |-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 toedieningsweg | ||
| + | |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="BehandelingT5" /> | ||
| + | |||
| + | <section begin="PatiëntliggingT5" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" | Patiëntligging | ||
| + | |-style="background-color: #69BE28;; 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="PatiëntliggingT5" /> | ||
| + | |||
| + | <section begin="Primary SurveyT5" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" | Primary Survey | ||
| + | |-style="background-color: #69BE28;; 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="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Airway vrij? | ||
| + | |style="background-color: white;"| geen luchtwegobstructie (Code = 248553004 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"| Airway observaties | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Airway observatie code | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Airway observatie titel | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"| Breathing | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Breathing sufficient? | ||
| + | |style="background-color: white;"| normale ademhalingsfunctie (Code = 22803001 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"| Breathing observaties | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Breathing observatie code | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Breathing observatie titel | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Lateraliteit | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"| 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;"| 61618002 cardiovasculaire functie normaal (bevinding) | ||
| + | |-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="11"| | ||
| + | |-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"| 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;"| intoxicatie door gasvormige stof (Code = 1156755000 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"| Pupil observaties | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Pupil observatie code | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Pupil observatie titel | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"| Lateraliteit | ||
| + | |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 SurveyT5" /> | ||
| + | |||
| + | <section begin="Secondary SurveyT5" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" | Secondary Survey | ||
| + | |-style="background-color: #69BE28;; 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"|Besmettingsrisico | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Verdenking op besmettelijke ziekte? | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Toelichting besmettingsrisico | ||
| + | |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="4"| | ||
| + | |-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"|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="5"| | ||
| + | |-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 drukpijn | ||
| + | |style="background-color: white;"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"| Locatie loslaatpijn | ||
| + | |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;"|oedeem (Code = 267038008 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-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 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 | ||
| + | |style="background-color: white;"|oedeem (Code = 267038008 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||
| + | |-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 SurveyT5" /> | ||
| + | |||
| + | <section begin="Consultgever op afstandT5" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" | Consultgever op afstand | ||
| + | |-style="background-color: #69BE28;; 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 afstandT5" /> | ||
| + | |||
| + | <section begin="Afspraken met patiëntT5" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" | Afspraken met patiënt | ||
| + | |-style="background-color: #69BE28;; 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 patiëntT5" /> | ||
| + | |||
| + | <section begin="BijlagenT5" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" | Bijlagen | ||
| + | |-style="background-color: #69BE28;; 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;"|intern rapport/overdracht (Code = 006 in codesysteem 2.16.840.1.113883.2.4.3.11.60.55.5.16 'acutezorg-codesysteem-16') | ||
| + | |-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;"| 6 | ||
| + | |-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="BijlagenT5" /> | ||
| + | |||
| + | <section begin="ToestemmingsgegevensT5" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" | Toestemmingsgegevens | ||
| + | |-style="background-color: #69BE28;; 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="ToestemmingsgegevensT5" /> | ||
| + | |||
| + | <section begin="ToelichtingsgegevensT5" /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #69BE28;; color: white; font-weight: bold; text-align:center;" colspan="6" | Toelichtingsgegevens | ||
| + | |-style="background-color: #69BE28;; 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="ToelichtingsgegevensT5" /> | ||
Huidige versie van 19 mei 2025 om 09:15
Inhoud
[verbergen]T1: fout BSN
| T1 |
| Patient | |||||
| Gegevenselement | Waarde | ||||
| Persoonidentificatie | 999910322 [BSN] | ||||
| Naamgegevens | |||||
| Initialen | H. | ||||
| Achternaam | |||||
| Soort naam | |||||
| Voorvoegsels | |||||
| Achternaam | XXX_Verschuur | ||||
| Geslacht | vrouw (Code = F in codesysteem 2.16.840.1.113883.5.1 'Administrative Gender') | ||||
| Geboortegegevens | |||||
| Geboortedatum | 19540725 | ||||
| Geschatte leeftijd | |||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1003 | ||||
| Huisletter | |||||
| Huisnummertoevoeging | |||||
| Postcode | 9999ZA | ||||
| Woonplaats | Stitswerd | ||||
| Land | Nederland | ||||
| Locatiebeschrijving | |||||
| Overige Contactgegevens | |||||
| Telefoonnummers | |||||
| Telefoonnummer | |||||
| Soort telefoonnummer | |||||
| Werktelefoon | |||||
| werknummer | |||||
| Soort nummer | |||||
| EmailAdressen | |||||
| Emailadres | |||||
| Soort e-mailadres | |||||
| Ziektekostenverzekering? | |||||
| Verzekeringsgegevens | |||||
| Verzekeraar | |||||
| Naam | |||||
| Identificatienummer | |||||
| Polis | |||||
| Polisnummer/Verzekerdenummer | |||||
| Vaste huisarts | |||||
| ZorgverlenerIdentificatienummer | |||||
| Naam | |||||
| Achternaam | |||||
| Vaste huisartsenpraktijk | |||||
| Identificatie | |||||
| Naam | |||||
| Adresgegevens | |||||
| Soort adres | |||||
| Straatnaam | |||||
| Huisnummer | |||||
| Huisnummertoevoeging | |||||
| Postcode | |||||
| Gemeente | |||||
| Woonplaats | |||||
| Land | |||||
| Overige contactgegevens | |||||
| Telefoonnummers | |||||
| Soort telefoonnummer | |||||
| Telefoonnummer | |||||
| 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 | |||||
| Geplande brengtijd | |||||
| Geplande haaltijd | |||||
| Wzd/Wvggz maatregel | |||||
| Datum/tijd aanvang TVZ | |||||
| Medische kladblok meldkamer | |||||
| Meldkamerurgentie | |||||
| Ritgegevens | |||||
| Gegevenselement | Waarde | ||||
| Ambulancevoorziening* | 25 (RAV identificatie) | ||||
| Ritnummer* | 25-2020-13-1 | ||||
| Ambulancenummer* | 25190 | ||||
| Telefoon ambulance* | |||||
| Ambulanceverpleegkundige identificatie* | |||||
| Ambulancechauffeur identificatie* | |||||
| Datum/tijd ritopdracht | |||||
| Datum/tijd uitruk/vertrek | |||||
| Datum/tijd aankomst patiënt | |||||
| Datum/tijd vertrek patiënt | |||||
| Verwachte aankomsttijd bestemming | |||||
| Datum/tijd aankomst bestemming | |||||
| Datum/tijd vrijmelding | |||||
| Soort vervoer | |||||
* Voor de vulling van gegevens bij Ambulancevoorziening, Ritnummer, Ambulancenummer, Ambulanceverpleegkundige indentificatie en Ambulancechauffer indentificatie geldt voor de opleverende partijen dat zij hier eigen gegevens kunnen invullen, al zijn bovenstaande invulgegevens ook mogelijk. De kwalificatiesimulator zal alleen controleren of er gegevens zijn ingevuld, niet op de exacte waarden. Voor de ontvangende partijen worden middels de kwalificatiesimulator de bovenstaande gegevens aangeboden.
| 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 | |||||
| Bestemmingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Bestemmingsstatus in bericht op T1 | Actief (Code = active in codesysteem 2.16.840.1.113883.5.14 'ActStatus') | ||||
| Bestemmingscode | AGB: 06010860 | ||||
| Locatie of afdeling | |||||
| Straat | |||||
| Huisnummer | |||||
| Huisletter | |||||
| Huisnummertoevoeging | |||||
| Postcode | |||||
| Locatiebeschrijving | |||||
| Woonplaats | |||||
| Land | |||||
| Bijzonderheden algemeen | |||||
| Verwacht specialisme | |||||
| Feedback | |||||
| Feedback op overdracht/behandeling gewenst | |||||
| Feedback adres | test-LSDV-code | ||||
| Mechanisme | |||||
| Gegevenselement | Waarde | ||||
| Mechanisme type | |||||
| Vervoermiddel patiënt | |||||
| Patiënt was bestuurder? | |||||
| Vervoermiddel contra | |||||
| Beschermingsmiddelen patiënt | |||||
| Toestandsbeelden/Werkdiagnose | |||||
| Gegevenselement | Waarde | ||||
| Toestandsbeeld | |||||
| Toestandsbeeld code | |||||
| Toestandsbeeld titel | |||||
| Lateraliteit | |||||
| Toelichting Toestandsbeeld | |||||
| Meetwaarden | |||||
| Gegevenselement | Waarde | ||||
| Bloedsuiker | |||||
| Bloedsuiker waarde | |||||
| BloedsuikerDatumTijd | |||||
| Hartritme | |||||
| Hartritme observatie | |||||
| HartritmeDatumTijd | |||||
| Toelichting hartritme/ECG | |||||
| O2Saturatie | |||||
| SpO2waarde | |||||
| O2SaturatieDatumTijd | |||||
| Capnometrie | |||||
| CO2Waarde | |||||
| CO2CapnometrieDatumTijd | |||||
| Hartfrequentie | |||||
| HartfrequentieWaarde | |||||
| HartfrequentieDatumTijd | |||||
| Bloeddruk | |||||
| SystolischeBloeddruk | |||||
| DiastolischeBloeddruk | |||||
| BloeddrukDatumTijd | |||||
| Lichaamstemperatuur | |||||
| TemperatuurWaarde | |||||
| TemperatuurDatumTijd | |||||
| Ademhaling | |||||
| Ademfrequentie | |||||
| AdemhalingDatumTijd | |||||
| GlasgowComaScale | |||||
| GlasgowComaScaleDatumTijd | |||||
| GCS_Eyes | |||||
| GCS_Motor | |||||
| GCS_Verbal | |||||
| TotaalScore | |||||
| Revised Trauma Score | |||||
| RevisedTraumaScoreWaarde | |||||
| RevisedTraumaScoreTijd | |||||
| 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 toedieningsweg | |||||
| Extra informatie behandeling | |||||
| Patiëntligging | |||||
| Gegevenselement | Waarde | ||||
| Type patiëntligging | |||||
| Primary Survey | |||||
| Gegevenselement | Waarde | ||||
| Airway | |||||
| Airway vrij? | geen luchtwegobstructie (Code = 248553004 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Airway observaties | |||||
| Airway observatie code | |||||
| Airway observatie titel | |||||
| Breathing | |||||
| Breathing sufficient? | afwijking van ademhaling (Code = 386813002 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Breathing observaties | |||||
| Breathing observatie code | 49727002 | ||||
| Breathing observatie titel | hoesten | ||||
| Lateraliteit | bilateraal (Code = 51440002 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Circulation | |||||
| Circulation sufficient? | |||||
| Capillaire refill > 2 seconde? | |||||
| Huid observatie | |||||
| Disability | |||||
| AVPU | |||||
| Duur buiten bewustzijn | |||||
| FAST symptomen aanwezig | |||||
| Mogelijk trombolyse/trombectomie | |||||
| Intoxicatie | |||||
| Pupil observaties | |||||
| Pupil observatie code | |||||
| Pupil observatie titel | |||||
| Lateraliteit | |||||
| Toelichting Primary Survey | |||||
| Secondary Survey | |||||
| Gegevenselement | Waarde | ||||
| Anamnese | |||||
| Ample | |||||
| Code | |||||
| Titel | |||||
| Omschrijving | |||||
| Toelichting anamnese | |||||
| Besmettingsrisico | |||||
| Verdenking op besmettelijke ziekte? | |||||
| Toelichting besmettingsrisico | |||||
| 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 | |||||
| Wond | |||||
| Rug | |||||
| Rug observaties | |||||
| Wond | |||||
| Abdomen | |||||
| Abdomen observaties | |||||
| Locatie drukpijn | |||||
| Locatie loslaatpijn | |||||
| Wond | |||||
| Bekken | |||||
| Bekken observaties | |||||
| Wond | |||||
| Extremiteiten Armen | |||||
| Extremiteit | |||||
| Lateraliteit | |||||
| Observaties | |||||
| Wond | |||||
| Extremiteiten Benen | |||||
| Extremiteit | |||||
| Lateraliteit | |||||
| Observaties | |||||
| 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 T1 | |||||
| Gegevenselement | Waarde | ||||
| Type Bijlage | |||||
| Bijlage id | |||||
| Versie | |||||
| Bijlageset id | |||||
| Toestemmingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Wetenschappelijk onderzoek | |||||
| Beschrijving | |||||
| Informed consent | |||||
| Toestemming informeren verwanten | |||||
| Toelichtingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Toelichting algemeen | |||||
T2: annulering
| T2 |
| Patient | |||||
| Gegevenselement | Waarde | ||||
| Persoonidentificatie | 999910322 [BSN] | ||||
| Naamgegevens | |||||
| Initialen | H. | ||||
| Achternaam | |||||
| Soort naam | |||||
| Voorvoegsels | |||||
| Achternaam | XXX_Verschuur | ||||
| Geslacht | vrouw (Code = F in codesysteem 2.16.840.1.113883.5.1 'Administrative Gender') | ||||
| Geboortegegevens | |||||
| Geboortedatum | 19540725 | ||||
| Geschatte leeftijd | |||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1003 | ||||
| Huisletter | |||||
| Huisnummertoevoeging | |||||
| Postcode | 9999ZA | ||||
| Woonplaats | Stitswerd | ||||
| Land | Nederland | ||||
| Locatiebeschrijving | |||||
| Overige Contactgegevens | |||||
| Telefoonnummers | |||||
| Telefoonnummer | |||||
| Soort telefoonnummer | |||||
| Werktelefoon | |||||
| werknummer | |||||
| Soort nummer | |||||
| EmailAdressen | |||||
| Emailadres | |||||
| Soort e-mailadres | |||||
| Ziektekostenverzekering? | |||||
| Verzekeringsgegevens | |||||
| Verzekeraar | |||||
| Naam | |||||
| Identificatienummer | |||||
| Polis | |||||
| Polisnummer/Verzekerdenummer | |||||
| Vaste huisarts | |||||
| ZorgverlenerIdentificatienummer | |||||
| Naam | |||||
| Achternaam | |||||
| Vaste huisartsenpraktijk | |||||
| Identificatie | |||||
| Naam | |||||
| Adresgegevens | |||||
| Soort adres | |||||
| Straatnaam | |||||
| Huisnummer | |||||
| Huisnummertoevoeging | |||||
| Postcode | |||||
| Gemeente | |||||
| Woonplaats | |||||
| Land | |||||
| Overige contactgegevens | |||||
| Telefoonnummers | |||||
| Soort telefoonnummer | |||||
| Telefoonnummer | |||||
| 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 | |||||
| Geplande brengtijd | |||||
| Geplande haaltijd | |||||
| Wzd/Wvggz maatregel | |||||
| Datum/tijd aanvang TVZ | |||||
| Medische kladblok meldkamer | |||||
| Meldkamerurgentie | |||||
| Ritgegevens | |||||
| Gegevenselement | Waarde | ||||
| Ambulancevoorziening* | 25 (RAV identificatie) | ||||
| Ritnummer* | 25-2020-13-1 | ||||
| Ambulancenummer* | 25190 | ||||
| Telefoon ambulance* | |||||
| Ambulanceverpleegkundige identificatie* | |||||
| Ambulancechauffeur identificatie* | |||||
| Datum/tijd ritopdracht | |||||
| Datum/tijd uitruk/vertrek | |||||
| Datum/tijd aankomst patiënt | |||||
| Datum/tijd vertrek patiënt | |||||
| Verwachte aankomsttijd bestemming | |||||
| Datum/tijd aankomst bestemming | |||||
| Datum/tijd vrijmelding | |||||
| Soort vervoer | |||||
* Voor de vulling van gegevens bij Ambulancevoorziening, Ritnummer, Ambulancenummer, Ambulanceverpleegkundige indentificatie en Ambulancechauffer indentificatie geldt voor de opleverende partijen dat zij hier eigen gegevens kunnen invullen, al zijn bovenstaande invulgegevens ook mogelijk. De kwalificatiesimulator zal alleen controleren of er gegevens zijn ingevuld, niet op de exacte waarden. Voor de ontvangende partijen worden middels de kwalificatiesimulator de bovenstaande gegevens aangeboden.
| 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 | |||||
| Bestemmingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Bestemmingsstatus in bericht op T2 | Geannuleerd (Code = cancelled in codesysteem 2.16.840.1.113883.5.14 'ActStatus') | ||||
| Bestemmingscode | AGB: 06010860 | ||||
| Locatie of afdeling | |||||
| Straat | |||||
| Huisnummer | |||||
| Huisletter | |||||
| Huisnummertoevoeging | |||||
| Postcode | |||||
| Locatiebeschrijving | |||||
| Woonplaats | |||||
| Land | |||||
| Bijzonderheden algemeen | |||||
| Verwacht specialisme | |||||
| Feedback | |||||
| Feedback op overdracht/behandeling gewenst | |||||
| Feedback adres | test-LSDV-code | ||||
| Mechanisme | |||||
| Gegevenselement | Waarde | ||||
| Mechanisme type | |||||
| Vervoermiddel patiënt | |||||
| Patiënt was bestuurder? | |||||
| Vervoermiddel contra | |||||
| Beschermingsmiddelen patiënt | |||||
| Toestandsbeelden/Werkdiagnose | |||||
| Gegevenselement | Waarde | ||||
| Toestandsbeeld | |||||
| Toestandsbeeld code | |||||
| Toestandsbeeld titel | |||||
| Lateraliteit | |||||
| Toelichting Toestandsbeeld | |||||
| Meetwaarden | |||||
| Gegevenselement | Waarde | ||||
| Bloedsuiker | |||||
| Bloedsuiker waarde | |||||
| BloedsuikerDatumTijd | |||||
| Hartritme | |||||
| Hartritme observatie | |||||
| HartritmeDatumTijd | |||||
| Toelichting hartritme/ECG | |||||
| O2Saturatie | |||||
| SpO2waarde | |||||
| O2SaturatieDatumTijd | |||||
| Capnometrie | |||||
| CO2Waarde | |||||
| CO2CapnometrieDatumTijd | |||||
| Hartfrequentie | |||||
| HartfrequentieWaarde | |||||
| HartfrequentieDatumTijd | |||||
| Bloeddruk | |||||
| SystolischeBloeddruk | |||||
| DiastolischeBloeddruk | |||||
| BloeddrukDatumTijd | |||||
| Lichaamstemperatuur | |||||
| TemperatuurWaarde | |||||
| TemperatuurDatumTijd | |||||
| Ademhaling | |||||
| Ademfrequentie | |||||
| AdemhalingDatumTijd | |||||
| GlasgowComaScale | |||||
| GlasgowComaScaleDatumTijd | |||||
| GCS_Eyes | |||||
| GCS_Motor | |||||
| GCS_Verbal | |||||
| TotaalScore | |||||
| Revised Trauma Score | |||||
| RevisedTraumaScoreWaarde | |||||
| RevisedTraumaScoreTijd | |||||
| 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 toedieningsweg | |||||
| Extra informatie behandeling | |||||
| Patiëntligging | |||||
| Gegevenselement | Waarde | ||||
| Type patiëntligging | |||||
| Primary Survey | |||||
| Gegevenselement | Waarde | ||||
| Airway | |||||
| Airway vrij? | |||||
| Airway observaties | |||||
| Airway observatie code | |||||
| Airway observatie titel | |||||
| Breathing | |||||
| Breathing sufficient? | |||||
| Breathing observaties | |||||
| Breathing observatie code | |||||
| Breathing observatie titel | |||||
| Lateraliteit | |||||
| Circulation | |||||
| Circulation sufficient? | |||||
| Capillaire refill > 2 seconde? | |||||
| Huid observatie | |||||
| Disability | |||||
| AVPU | |||||
| Duur buiten bewustzijn | |||||
| FAST symptomen aanwezig | |||||
| Mogelijk trombolyse/trombectomie | |||||
| Intoxicatie | |||||
| Pupil observaties | |||||
| Pupil observatie code | |||||
| Pupil observatie titel | |||||
| Lateraliteit | |||||
| Toelichting Primary Survey | |||||
| Secondary Survey | |||||
| Gegevenselement | Waarde | ||||
| Anamnese | |||||
| Ample | |||||
| Code | |||||
| Titel | |||||
| Omschrijving | |||||
| Toelichting anamnese | |||||
| Besmettingsrisico | |||||
| Verdenking op besmettelijke ziekte? | |||||
| Toelichting besmettingsrisico | |||||
| 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 | |||||
| Wond | |||||
| Rug | |||||
| Rug observaties | |||||
| Wond | |||||
| Abdomen | |||||
| Abdomen observaties | |||||
| Locatie drukpijn | |||||
| Locatie loslaatpijn | |||||
| Wond | |||||
| Bekken | |||||
| Bekken observaties | |||||
| Wond | |||||
| Extremiteiten Armen | |||||
| Extremiteit | |||||
| Lateraliteit | |||||
| Observaties | |||||
| Wond | |||||
| Extremiteiten Benen | |||||
| Extremiteit | |||||
| Lateraliteit | |||||
| Observaties | |||||
| 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 | |||||
| Bijlage id | |||||
| Versie | |||||
| Bijlageset id | |||||
| Toestemmingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Wetenschappelijk onderzoek | |||||
| Beschrijving | |||||
| Informed consent | |||||
| Toestemming informeren verwanten | |||||
| Toelichtingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Toelichting algemeen | |||||
T3: aankomst bij de patient
| T3 |
| Patient | |||||
| Gegevenselement | Waarde | ||||
| Persoonidentificatie | 999910310 [BSN] | ||||
| Naamgegevens | |||||
| Initialen | P. | ||||
| Achternaam | |||||
| Soort naam | |||||
| Voorvoegsels | |||||
| Achternaam | XXX_Dierx | ||||
| Geslacht | man (Code = M in codesysteem 2.16.840.1.113883.5.1 'Administrative Gender') | ||||
| Geboortegegevens | |||||
| Geboortedatum | 25-07-1954 | ||||
| Geschatte leeftijd | |||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1002 | ||||
| Huisnummerletter | |||||
| Huisnummertoevoeging | |||||
| Postcode | 9999ZZ | ||||
| Woonplaats | Stitswerd | ||||
| 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 | |||||
| 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 | T3-15min | ||||
| Geplande brengtijd | |||||
| Geplande haaltijd | |||||
| Wzd/Wvggz maatregel | |||||
| Datum/tijd aanvang TVZ | |||||
| Medische kladblok meldkamer | |||||
| Meldkamerurgentie | A2 Spoedrit, zonder gebruik van optische- en geluidssignalen (code = A2 in codesysteem 2.16.840.1.113883.2.4.3.11.60.55.5.2 'acutezorg-codesysteem-2') | ||||
| Ritgegevens | |||||
| Gegevenselement | Waarde | ||||
| Ambulancevoorziening* | 25 (RAV identificatie) | ||||
| Ritnummer* | 25-2020-13-2 | ||||
| Ambulancenummer* | 25190 | ||||
| Telefoon ambulance* | |||||
| Ambulanceverpleegkundige identificatie* | 596 | ||||
| Ambulancechauffeur identificatie* | 530 | ||||
| Datum/tijd ritopdracht | T3-10 min | ||||
| Datum/tijd uitruk/vertrek | T3-10 min | ||||
| Datum/tijd aankomst patiënt | T3 | ||||
| Datum/tijd vertrek patiënt | |||||
| Verwachte aankomsttijd bestemming | |||||
| Datum/tijd aankomst bestemming | |||||
| Datum/tijd vrijmelding | |||||
| Soort vervoer | |||||
* Voor de vulling van gegevens bij Ambulancevoorziening, Ritnummer, Ambulancenummer, Ambulanceverpleegkundige indentificatie en Ambulancechauffer indentificatie geldt voor de opleverende partijen dat zij hier eigen gegevens kunnen invullen, al zijn bovenstaande invulgegevens ook mogelijk. De kwalificatiesimulator zal alleen controleren of er gegevens zijn ingevuld, niet op de exacte waarden. Voor de ontvangende partijen worden middels de kwalificatiesimulator de bovenstaande gegevens aangeboden.
| 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 | |||||
| Bestemmingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Bestemmingsstatus in bericht op T3 | Actief (Code = active in codesysteem 2.16.840.1.113883.5.14 'ActStatus') | ||||
| 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 op overdracht/behandeling gewenst | |||||
| Feedback adres | |||||
| Mechanisme | |||||
| Gegevenselement | Waarde | ||||
| Mechanisme type | bekneld geraakt tussen voorwerpen (Code = 35468003 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Vervoermiddel patiënt | auto (Code = 71783008 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Patiënt was bestuurder? | ja | ||||
| Vervoermiddel contra | auto (Code = 71783008 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Beschermingsmiddelen patiënt (3x) | helm (Code = 285695004 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') autogordel (Code = 60054005 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Toestandsbeelden/Werkdiagnose | |||||
| Gegevenselement | Waarde | ||||
| Toestandsbeeld | |||||
| Toestandsbeeld code | 1156538002 (in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Toestandsbeeld titel | letsel regio wervelkolom | ||||
| Lateraliteit | |||||
| 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 | 99% | ||||
| O2SaturatieDatumTijd | T3 | ||||
| Capnometrie | |||||
| CO2Waarde | 60 mm[Hg] 8,0 kPa | ||||
| CO2CapnometrieDatumTijd | T3 | ||||
| Hartfrequentie | |||||
| HartfrequentieWaarde | 120/min | ||||
| HartfrequentieDatumTijd | T3 | ||||
| Bloeddruk | |||||
| SystolischeBloeddruk | 90 mm[Hg] | ||||
| DiastolischeBloeddruk | 60 mm[Hg] | ||||
| BloeddrukDatumTijd | T3 | ||||
| Lichaamstemperatuur | |||||
| TemperatuurWaarde | |||||
| TemperatuurDatumTijd | |||||
| Ademhaling | |||||
| Ademfrequentie | 4/min | ||||
| AdemhalingDatumTijd | T3 | ||||
| GlasgowComaScale | |||||
| GlasgowComaScaleDatumTijd | T3 | ||||
| GCS_Eyes | Spontaan (Code = E4 uit codesysteem 2.16.840.1.113883.2.4.3.11.60.40.4.2.1 'GCS_Eyes') | ||||
| GCS_Motor | Voert opdracht uit (Code = M6 uit codesysteem 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 'GCS_Motor') | ||||
| GCS_Verbal | Georiënteerd (Code = V5 uit codesysteem 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 'GCS_Verbal') | ||||
| TotaalScore | 15 | ||||
| Revised Trauma Score | |||||
| RevisedTraumaScoreWaarde | 8 | ||||
| RevisedTraumaScoreTijd | T3 | ||||
| Pediatric Trauma Score | |||||
| PediatricTraumaScoreWaarde | |||||
| PediatricTraumaScoreTijd | |||||
| Pijnschaal | |||||
| PijnschaalWaarde | 3 | ||||
| PijnschaalTijd | T3 | ||||
| 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 | insertie van nasofaryngeale tube (Code = 182692007 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| 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 toedieningsweg | |||||
| Extra informatie behandeling | |||||
| Patiëntligging | |||||
| Gegevenselement | Waarde | ||||
| Type patiëntligging | |||||
| Primary Survey | |||||
| Gegevenselement | Waarde | ||||
| Airway | |||||
| Airway vrij? | geen luchtwegobstructie (Code = 248553004 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Airway observaties | |||||
| Airway observatie code | |||||
| Airway observatie titel | |||||
| Breathing | |||||
| Breathing sufficient? | normale ademhalingsfunctie (Code = 22803001 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Breathing observaties | |||||
| Breathing observatie code | |||||
| Breathing observatie titel | |||||
| Lateraliteit | |||||
| Circulation | |||||
| Circulation sufficient? | cardiovasculaire functie normaal (Code = 61618002 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Capillaire refill > 2 seconde? | |||||
| Huid observatie | |||||
| Disability | |||||
| AVPU | |||||
| Duur buiten bewustzijn | |||||
| FAST symptomen aanwezig | |||||
| Mogelijk trombolyse/trombectomie | |||||
| Intoxicatie | intoxicatie door gasvormige stof (Code = 1156755000 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Pupil observaties | |||||
| Pupil observatie code | |||||
| Pupil observatie titel | |||||
| Lateraliteit | |||||
| Toelichting Primary Survey | |||||
| Secondary Survey | |||||
| Gegevenselement | Waarde | ||||
| Anamnese | |||||
| Ample | |||||
| Code | |||||
| Titel | |||||
| Omschrijving | |||||
| Toelichting anamnese | |||||
| Besmettingsrisico | |||||
| Verdenking op besmettelijke ziekte? | |||||
| Toelichting besmettingsrisico | |||||
| 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 | |||||
| Wond | |||||
| Rug | |||||
| Rug observaties | |||||
| Wond | |||||
| Abdomen | |||||
| Abdomen observaties | |||||
| Locatie drukpijn | |||||
| Locatie loslaatpijn | |||||
| Wond | |||||
| Bekken | |||||
| Bekken observaties | |||||
| Wond | |||||
| Extremiteiten Armen | |||||
| Extremiteit | |||||
| Lateraliteit | |||||
| Observaties | |||||
| Wond | |||||
| Extremiteiten Benen | |||||
| Extremiteit | |||||
| Lateraliteit | |||||
| Observaties | |||||
| 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 | intern rapport/overdracht (Code = 006 in codesysteem 2.16.840.1.113883.2.4.3.11.60.55.5.16 'acutezorg-codesysteem-16') | ||||
| Bijlage id | 9068 | ||||
| Versie | 1 | ||||
| Bijlageset id | 12 | ||||
| Toestemmingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Wetenschappelijk onderzoek | |||||
| Beschrijving | |||||
| Informed consent | |||||
| Toestemming informeren verwanten | |||||
| Toelichtingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Toelichting algemeen | |||||
T4: gedurende de rit
| T4 |
| Patient | |||||
| Gegevenselement | Waarde | ||||
| Persoonidentificatie | 999910310 [BSN] | ||||
| Naamgegevens | |||||
| Initialen | P. | ||||
| Achternaam | |||||
| Soort naam | |||||
| Voorvoegsels | |||||
| Achternaam | XXX_Dierx | ||||
| Geslacht | man (Code = M in codesysteem 2.16.840.1.113883.5.1 'Administrative Gender') | ||||
| Geboortegegevens | |||||
| Geboortedatum | 25-07-1954 | ||||
| Geschatte leeftijd | |||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1002 | ||||
| Huisnummerletter | |||||
| Huisnummertoevoeging | |||||
| Postcode | 9999ZZ | ||||
| Woonplaats | Stitswerd | ||||
| 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 | |||||
| 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 | T3-15min | ||||
| Geplande brengtijd | |||||
| Geplande haaltijd | |||||
| Wzd/Wvggz maatregel | |||||
| Datum/tijd aanvang TVZ | |||||
| Medische kladblok meldkamer | |||||
| Meldkamerurgentie | A2 Spoedrit, zonder gebruik van optische- en geluidssignalen (code = A2 in codesysteem 2.16.840.1.113883.2.4.3.11.60.55.5.2 'acutezorg-codesysteem-2') | ||||
| Ritgegevens | |||||
| Gegevenselement | Waarde | ||||
| Ambulancevoorziening* | 25 (RAV identificatie) | ||||
| Ritnummer* | 25-2020-13-2 | ||||
| Ambulancenummer* | 25190 | ||||
| Telefoon ambulance* | |||||
| Ambulanceverpleegkundige identificatie* | 596 | ||||
| Ambulancechauffeur identificatie* | 530 | ||||
| Datum/tijd ritopdracht | T3-10 min | ||||
| Datum/tijd uitruk/vertrek | T3-10 min | ||||
| Datum/tijd aankomst patiënt | T3 | ||||
| Datum/tijd vertrek patiënt | T3+2 min | ||||
| Verwachte aankomsttijd bestemming | |||||
| Datum/tijd aankomst bestemming | |||||
| Datum/tijd vrijmelding | |||||
| Soort vervoer | |||||
* Voor de vulling van gegevens bij Ambulancevoorziening, Ritnummer, Ambulancenummer, Ambulanceverpleegkundige indentificatie en Ambulancechauffer indentificatie geldt voor de opleverende partijen dat zij hier eigen gegevens kunnen invullen, al zijn bovenstaande invulgegevens ook mogelijk. De kwalificatiesimulator zal alleen controleren of er gegevens zijn ingevuld, niet op de exacte waarden. Voor de ontvangende partijen worden middels de kwalificatiesimulator de bovenstaande gegevens aangeboden.
| 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 | |||||
| Bestemmingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Bestemmingsstatus in bericht op T4 | Actief (Code = active in codesysteem 2.16.840.1.113883.5.14 'ActStatus') | ||||
| 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 op overdracht/behandeling gewenst | |||||
| Feedback adres | |||||
| Mechanisme | |||||
| Gegevenselement | Waarde | ||||
| Mechanisme type | bekneld geraakt tussen voorwerpen (Code = 35468003 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Vervoermiddel patiënt | auto (Code = 71783008 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Patiënt was bestuurder? | ja | ||||
| Vervoermiddel contra | auto (Code = 71783008 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Beschermingsmiddelen patiënt (3x) | helm (Code = 285695004 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') autogordel (Code = 60054005 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Toestandsbeelden/Werkdiagnose | |||||
| Gegevenselement | Waarde | ||||
| Toestandsbeeld | |||||
| Toestandsbeeld code | 1156538002 (in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Toestandsbeeld titel | letsel regio wervelkolom | ||||
| Lateraliteit | |||||
| Toelichting Toestandsbeeld | Moeilijk observeren door weersomstandigheden | ||||
| Meetwaarden | |||||
| Gegevenselement | Waarde | ||||
| Bloedsuiker | |||||
| Bloedsuiker waarde | 5 mmol/L | ||||
| BloedsuikerDatumTijd | T4 | ||||
| Hartritme | |||||
| Hartritme observatie | |||||
| HartritmeDatumTijd | |||||
| Toelichting hartritme/ECG | |||||
| O2Saturatie | |||||
| SpO2waarde | 78% | ||||
| O2SaturatieDatumTijd | T4 | ||||
| Capnometrie | |||||
| CO2Waarde | 40 mm[Hg] 5,3 kPa | ||||
| CO2CapnometrieDatumTijd | T4 | ||||
| Hartfrequentie | |||||
| HartfrequentieWaarde | 110/min | ||||
| HartfrequentieDatumTijd | T4 | ||||
| Bloeddruk | |||||
| SystolischeBloeddruk | 100 mm[Hg] | ||||
| DiastolischeBloeddruk | 80 mm[Hg] | ||||
| BloeddrukDatumTijd | T4 | ||||
| Lichaamstemperatuur | |||||
| TemperatuurWaarde | |||||
| TemperatuurDatumTijd | |||||
| Ademhaling | |||||
| Ademfrequentie | 4/min | ||||
| AdemhalingDatumTijd | T4 | ||||
| GlasgowComaScale | |||||
| GlasgowComaScaleDatumTijd | |||||
| GCS_Eyes | |||||
| GCS_Motor | |||||
| GCS_Verbal | |||||
| TotaalScore | |||||
| Revised Trauma Score | |||||
| RevisedTraumaScoreWaarde | 8 | ||||
| RevisedTraumaScoreTijd | T4 | ||||
| Pediatric Trauma Score | |||||
| PediatricTraumaScoreWaarde | |||||
| PediatricTraumaScoreTijd | |||||
| Pijnschaal | |||||
| PijnschaalWaarde | 3 | ||||
| PijnschaalTijd | T4 | ||||
| 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 | insertie van nasofaryngeale tube(Code = 182692007 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Moeizame intubatie? | |||||
| Oxygenatie en ventilatie (therapeutisch) | |||||
| Handelingen oxygenatie en ventilatie | continue positievedrukbeademing (Code = 47545007 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Beademing machine Fi O2 | |||||
| Beademing machine AMV | |||||
| Beademing machine Freq. | |||||
| Beademing machine Peep | |||||
| Hoeveelheid zuurstof | |||||
| Circulatie (therapeutisch) | |||||
| Handelingen circulatie | infusie met gebruik van drukzak (Code = 390231000146100 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| 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 | gebruik van hydrogel kompres (Code = 430371000146108 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Koelen tijdsduur | |||||
| Obstetrie | |||||
| Handelingen obstetrie | |||||
| Wijze van isolatie | |||||
| Handelingen isolatie | |||||
| Medicatie | |||||
| Medicatie toegediend? | |||||
| Medicatienaam | |||||
| Toegediende hoeveelheid medicatie | |||||
| Tijd medicatietoediening | |||||
| Medicatie toedieningsweg | |||||
| Extra informatie behandeling | |||||
| Patiëntligging | |||||
| Gegevenselement | Waarde | ||||
| Type patiëntligging | |||||
| Primary Survey | |||||
| Gegevenselement | Waarde | ||||
| Airway | |||||
| Airway vrij? | geen luchtwegobstructie (Code = 248553004 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Airway observaties | |||||
| Airway observatie code | |||||
| Airway observatie titel | |||||
| Breathing | |||||
| Breathing sufficient? | normale ademhalingsfunctie (Code = 22803001 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Breathing observaties | |||||
| Breathing observatie code | |||||
| Breathing observatie titel | |||||
| Lateraliteit | |||||
| Circulation | |||||
| Circulation sufficient? | cardiovasculaire functie normaal (Code = 61618002 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Capillaire refill > 2 seconde? | |||||
| Huid observatie | |||||
| Disability | |||||
| AVPU | |||||
| Duur buiten bewustzijn | |||||
| FAST symptomen aanwezig | |||||
| Mogelijk trombolyse/trombectomie | |||||
| Intoxicatie | intoxicatie door gasvormige stof (Code = 1156755000 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Pupil observaties | |||||
| Pupil observatie code | |||||
| Pupil observatie titel | |||||
| Lateraliteit | |||||
| Toelichting Primary Survey | |||||
| Secondary Survey | |||||
| Gegevenselement | Waarde | ||||
| Anamnese | |||||
| Ample | |||||
| Code | |||||
| Titel | |||||
| Omschrijving | |||||
| Toelichting anamnese | |||||
| Besmettingsrisico | |||||
| Verdenking op besmettelijke ziekte? | |||||
| Toelichting besmettingsrisico | |||||
| 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 | |||||
| Wond | |||||
| Rug | |||||
| Rug observaties | |||||
| Wond | |||||
| Abdomen | |||||
| Abdomen observaties | zwelling (Code = 65124004 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Locatie drukpijn | |||||
| Locatie loslaatpijn | |||||
| Wond | |||||
| Bekken | |||||
| Bekken observaties | |||||
| Wond | |||||
| Extremiteiten Armen | |||||
| Extremiteit | |||||
| Lateraliteit | |||||
| Observaties | |||||
| Wond | |||||
| Extremiteiten Benen | |||||
| Extremiteit | |||||
| Lateraliteit | |||||
| Observaties | pijn (Code = 22253000 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| 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 | intern rapport/overdracht (Code = 006 in codesysteem 2.16.840.1.113883.2.4.3.11.60.55.5.16 'acutezorg-codesysteem-16') | ||||
| Bijlage id | 9068 | ||||
| Versie | 3 | ||||
| Bijlageset id | 12 | ||||
| Toestemmingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Wetenschappelijk onderzoek | |||||
| Beschrijving | |||||
| Informed consent | |||||
| Toestemming informeren verwanten | |||||
| Toelichtingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Toelichting algemeen | |||||
T5: Bij overdracht bij de SEH
| T5 |
| Patient | |||||
| Gegevenselement | Waarde | ||||
| Persoonidentificatie | 999910310 [BSN] | ||||
| Naamgegevens | |||||
| Initialen | P. | ||||
| Achternaam | |||||
| Soort naam | |||||
| Voorvoegsels | |||||
| Achternaam | XXX_Dierx | ||||
| Geslacht | man (Code = M in codesysteem 2.16.840.1.113883.5.1 'Administrative Gender') | ||||
| Geboortegegevens | |||||
| Geboortedatum | 25-07-1954 | ||||
| Geschatte leeftijd | |||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1002 | ||||
| Huisnummerletter | |||||
| Huisnummertoevoeging | |||||
| Postcode | 9999ZZ | ||||
| Woonplaats | Stitswerd | ||||
| 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 | |||||
| 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 | T3-15min | ||||
| Geplande brengtijd | |||||
| Geplande haaltijd | |||||
| Wzd/Wvggz maatregel | |||||
| Datum/tijd aanvang TVZ | |||||
| Medische kladblok meldkamer | |||||
| Meldkamerurgentie | A2 Spoedrit, zonder gebruik van optische- en geluidssignalen (code = A2 in codesysteem 2.16.840.1.113883.2.4.3.11.60.55.5.2 'acutezorg-codesysteem-2') | ||||
| Ritgegevens | |||||
| Gegevenselement | Waarde | ||||
| Ambulancevoorziening* | 25 (RAV identificatie) | ||||
| Ritnummer* | 25-2020-13-2 | ||||
| Ambulancenummer* | 25190 | ||||
| Telefoon ambulance* | |||||
| Ambulanceverpleegkundige identificatie* | 596 | ||||
| Ambulancechauffeur identificatie* | 530 | ||||
| Datum/tijd ritopdracht | T3-10 min | ||||
| Datum/tijd uitruk/vertrek | T3-10 min | ||||
| Datum/tijd aankomst patiënt | T3 | ||||
| Datum/tijd vertrek patiënt | T3+2 min | ||||
| Verwachte aankomsttijd bestemming | |||||
| Datum/tijd aankomst bestemming | |||||
| Datum/tijd vrijmelding | |||||
| Soort vervoer | |||||
* Voor de vulling van gegevens bij Ambulancevoorziening, Ritnummer, Ambulancenummer, Ambulanceverpleegkundige indentificatie en Ambulancechauffer indentificatie geldt voor de opleverende partijen dat zij hier eigen gegevens kunnen invullen, al zijn bovenstaande invulgegevens ook mogelijk. De kwalificatiesimulator zal alleen controleren of er gegevens zijn ingevuld, niet op de exacte waarden. Voor de ontvangende partijen worden middels de kwalificatiesimulator de bovenstaande gegevens aangeboden.
| 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 | |||||
| Bestemmingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Bestemmingsstatus in bericht op T5 | Overgedragen (Code = completed in codesysteem 2.16.840.1.113883.5.14 'ActStatus') | ||||
| 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 op overdracht/behandeling gewenst | |||||
| Feedback adres | |||||
| Mechanisme | |||||
| Gegevenselement | Waarde | ||||
| Mechanisme type | bekneld geraakt tussen voorwerpen (Code = 35468003 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Vervoermiddel patiënt | auto (Code = 71783008 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Patiënt was bestuurder? | ja | ||||
| Vervoermiddel contra | auto (Code = 71783008 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Beschermingsmiddelen patiënt (3x) | helm (Code = 285695004 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') autogordel (Code = 60054005 in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Toestandsbeelden/Werkdiagnose | |||||
| Gegevenselement | Waarde | ||||
| Toestandsbeeld | |||||
| Toestandsbeeld code | 1156538002 (in codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Toestandsbeeld titel | letsel regio wervelkolom | ||||
| Lateraliteit | |||||
| Toelichting Toestandsbeeld | Moeilijk observeren door weersomstandigheden | ||||
| Meetwaarden | |||||
| Gegevenselement | Waarde | ||||
| Bloedsuiker | |||||
| Bloedsuiker waarde | 6 mmol/L | ||||
| BloedsuikerDatumTijd | T5 | ||||
| Hartritme | |||||
| Hartritme observatie | |||||
| HartritmeDatumTijd | |||||
| Toelichting hartritme/ECG | |||||
| O2Saturatie | |||||
| SpO2waarde | 98% | ||||
| O2SaturatieDatumTijd | T5 | ||||
| Capnometrie | |||||
| CO2Waarde | 35 mm[Hg] 4,7 kPa | ||||
| CO2CapnometrieDatumTijd | T5 | ||||
| Hartfrequentie | |||||
| HartfrequentieWaarde | 90/min | ||||
| HartfrequentieDatumTijd | T5 | ||||
| Bloeddruk | |||||
| SystolischeBloeddruk | 60 mm[Hg] | ||||
| DiastolischeBloeddruk | 50 mm[Hg] | ||||
| BloeddrukDatumTijd | T5 | ||||
| Lichaamstemperatuur | |||||
| TemperatuurWaarde | |||||
| TemperatuurDatumTijd | |||||
| Ademhaling | |||||
| Ademfrequentie | 4/min | ||||
| AdemhalingDatumTijd | T5 | ||||
| GlasgowComaScale | |||||
| GlasgowComaScaleDatumTijd | T5 | ||||
| GCS_Eyes | Spontaan (Code = E4 uit codesysteem 2.16.840.1.113883.2.4.3.11.60.40.4.2.1 'GCS_Eyes') | ||||
| GCS_Motor | Voert opdracht uit (Code = M6 uit codesysteem 2.16.840.1.113883.2.4.3.11.60.40.4.2.2 'GCS_Motor') | ||||
| GCS_Verbal | Georiënteerd (Code = V5 uit codesysteem 2.16.840.1.113883.2.4.3.11.60.40.4.2.3 'GCS_Verbal') | ||||
| TotaalScore | 15 | ||||
| Revised Trauma Score | |||||
| RevisedTraumaScoreWaarde | 8 | ||||
| RevisedTraumaScoreTijd | T5 | ||||
| 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 | insertie van nasofaryngeale tube (Code = 182692007 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Moeizame intubatie? | |||||
| Oxygenatie en ventilatie (therapeutisch) | |||||
| Handelingen oxygenatie en ventilatie | positieve drukbeademing (Code = 1149092001 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Beademing machine Fi O2 | |||||
| Beademing machine AMV | |||||
| Beademing machine Freq. | |||||
| Beademing machine Peep | |||||
| Hoeveelheid zuurstof | |||||
| Circulatie (therapeutisch) | |||||
| Handelingen circulatie | infusie met gebruik van drukzak (Code = 390231000146100 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| 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 | gebruik van hydrogel kompres (Code = 430371000146108 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Koelen tijdsduur | |||||
| Obstetrie | |||||
| Handelingen obstetrie | |||||
| Wijze van isolatie | |||||
| Handelingen isolatie | |||||
| Medicatie | |||||
| Medicatie toegediend? | |||||
| Medicatienaam | |||||
| Toegediende hoeveelheid medicatie | |||||
| Tijd medicatietoediening | |||||
| Medicatie toedieningsweg | |||||
| Extra informatie behandeling | |||||
| Patiëntligging | |||||
| Gegevenselement | Waarde | ||||
| Type patiëntligging | |||||
| Primary Survey | |||||
| Gegevenselement | Waarde | ||||
| Airway | |||||
| Airway vrij? | geen luchtwegobstructie (Code = 248553004 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Airway observaties | |||||
| Airway observatie code | |||||
| Airway observatie titel | |||||
| Breathing | |||||
| Breathing sufficient? | normale ademhalingsfunctie (Code = 22803001 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Breathing observaties | |||||
| Breathing observatie code | |||||
| Breathing observatie titel | |||||
| Lateraliteit | |||||
| Circulation | |||||
| Circulation sufficient? | 61618002 cardiovasculaire functie normaal (bevinding) | ||||
| Capillaire refill > 2 seconde? | |||||
| Huid observatie | |||||
| Disability | |||||
| AVPU | |||||
| Duur buiten bewustzijn | |||||
| FAST symptomen aanwezig | |||||
| Mogelijk trombolyse/trombectomie | |||||
| Intoxicatie | intoxicatie door gasvormige stof (Code = 1156755000 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Pupil observaties | |||||
| Pupil observatie code | |||||
| Pupil observatie titel | |||||
| Lateraliteit | |||||
| Toelichting Primary Survey | |||||
| Secondary Survey | |||||
| Gegevenselement | Waarde | ||||
| Anamnese | |||||
| Ample | |||||
| Code | |||||
| Titel | |||||
| Omschrijving | |||||
| Toelichting anamnese | |||||
| Besmettingsrisico | |||||
| Verdenking op besmettelijke ziekte? | |||||
| Toelichting besmettingsrisico | |||||
| 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 | |||||
| Wond | |||||
| Rug | |||||
| Rug observaties | |||||
| Wond | |||||
| Abdomen | |||||
| Abdomen observaties | |||||
| Locatie drukpijn | |||||
| Locatie loslaatpijn | |||||
| Wond | |||||
| Bekken | |||||
| Bekken observaties | oedeem (Code = 267038008 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| Wond | |||||
| Extremiteiten Armen | |||||
| Extremiteit | |||||
| Lateraliteit | |||||
| Observaties | |||||
| Wond | |||||
| Extremiteiten Benen | |||||
| Extremiteit | |||||
| Lateraliteit | |||||
| Observaties | oedeem (Code = 267038008 uit codesysteem 2.16.840.1.113883.6.96 'SNOMED Clinical Terms') | ||||
| 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 | intern rapport/overdracht (Code = 006 in codesysteem 2.16.840.1.113883.2.4.3.11.60.55.5.16 'acutezorg-codesysteem-16') | ||||
| Bijlage id | 9068 | ||||
| Versie | 6 | ||||
| Bijlageset id | 12 | ||||
| Toestemmingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Wetenschappelijk onderzoek | |||||
| Beschrijving | |||||
| Informed consent | |||||
| Toestemming informeren verwanten | |||||
| Toelichtingsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Toelichting algemeen | |||||
