vpk:V4.1 Testgegevens eOverdracht Aanmeldbericht addendum: verschil tussen versies

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Deze wordt gevuld met de de inhoud uit ADA voor de transactie Sturen Aanmeldbericht.
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__NUMBEREDHEADINGS__
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{{DISPLAYTITLE:e-overdracht: addendum inhoudelijke gegevens aanmeldbericht '''[dit laatste nog toe laten voegen]'''}}
 +
 
 +
=Addenda voor inhoudelijke gegevens=
 +
<section begin=eovd-saa-tst-1.1-alle_zibs />
 +
==Aanmeldbericht==
 +
 
 +
=== Administratieve gegevens===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Administratieve gegevens
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="6" width="30%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Datum overplaatsing
 +
|style="background-color: white;"|T + 1 dag
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Persoonsgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="47"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Patient
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="18"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Naamgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Voornamen
 +
|style="background-color: white;"|Erik
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Initialen
 +
|style="background-color: white;"|E
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Geslachtsnaam
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Achternaam
 +
|style="background-color: white;"|XXX_Altenborg
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Adresgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Straat
 +
|style="background-color: white;"|Knolweg
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Huisnummer
 +
|style="background-color: white;"|1000
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Postcode
 +
|style="background-color: white;"|9999XA
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Woonplaats
 +
|style="background-color: white;"|Stitswerd
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Adres soort
 +
|style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Identificatienummer
 +
|style="background-color: white;"|999911612 (in identificerend systeem: BSN)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geboortedatum
 +
|style="background-color: white;"|14 aug 1964
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geslacht
 +
|style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Betaler
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verzekeraar
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Verzekering
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eind datum tijd
 +
|style="background-color: white;"|T + 1 jaar
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Verzekeringssoort
 +
|style="background-color: white;"|Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Contactpersoon
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="18"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Naamgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Voornamen
 +
|style="background-color: white;"|Johanna
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Initialen
 +
|style="background-color: white;"|J
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Roepnaam
 +
|style="background-color: white;"|Hanna
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Geslachtsnaam
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Achternaam
 +
|style="background-color: white;"|Bakker
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Contactgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Telefoonnummers
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Telefoonnummer
 +
|style="background-color: white;"|+31645678912
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Email adressen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Email adres
 +
|style="background-color: white;"|jbakker@123net.nl
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Relatie
 +
|style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Sturende organisatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="16"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Zorgaanbieder
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="14"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Zorgaanbieder identificatienummer
 +
|style="background-color: white;"|06590457 (in identificerend systeem: AGB-Z)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Organisatie naam
 +
|style="background-color: white;"|AB-zkh
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Organisatie locatie
 +
|style="background-color: white;"|Noord
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Afdeling specialisme
 +
|style="background-color: white;"|Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Contactgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Telefoonnummers
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Telefoonnummer
 +
|style="background-color: white;"|+31182435770
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Email adressen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Email adres
 +
|style="background-color: white;"|neurologie@ABZ.nl
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Organisatie type
 +
|style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Ontvangende organisatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Zorgaanbieder
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Afdeling specialisme
 +
|style="background-color: white;"|Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Organisatie type
 +
|style="background-color: white;"|Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060')
 +
|}
 +
=== Algemene patienten context===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Algemene patienten context
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="4" width="30%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Juridische situatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|<span id="tst-1.1-juridischesituatie-01" title="Intern ID = tst-1.1-juridischesituatie-01">Juridische situatie tst-1.1-juridischesituatie-01</span>
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Vertegenwoordiging
 +
|style="background-color: white;"|Onder curatele stelling (code = '9' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.3')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum aanvang
 +
|style="background-color: white;"|T - 1 jaar
 +
|}
 +
=== Medische context===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Medische context
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="4" width="30%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Medische diagnose
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="18"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Toelichting
 +
|style="background-color: white;"|niet bekend met neurologische klachten
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|neoplasma van colon (code = '126838000')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|oksel (code = '238600001' in codeSystem 'SNOMED Clinical Terms')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|inverse psoriasis (code = '238600001')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Voorgeschiedenis
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|diabetes mellitus (code = '73211009')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Let op
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Alert
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Alert naam
 +
|style="background-color: white;"|Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Alert
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Alert naam
 +
|style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Vrijheidsbeperking
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Vrijheidsbeperkende interventie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Wilsbekwaam
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Juridische situatie
 +
|style="background-color: white;"|Zie [[#tst-1.1-juridischesituatie-01|Juridische situatie: tst-1.1-juridischesituatie-01]]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Soort interventie
 +
|style="background-color: white;"|geforceerd toedienen van voeding bij patiënt (code = '37041007' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Reden van toepassen
 +
|style="background-color: white;"|bevorderen van fysieke gezondheid (code = '121581000146106' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Instemming
 +
|style="background-color: white;"|Instemming patiënt (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.6.1')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Begin
 +
|style="background-color: white;"|T - 50 dagen
 +
|}
 +
=== Verpleegkundige context zorgplan===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Verpleegkundige context zorgplan
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="6" width="30%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Actuele patientproblemen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="64"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Patientprobleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="15"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|<span id="tst-1.1-patientprobleem-01" title="Intern ID = tst-1.1-patientprobleem-01">Probleem tst-1.1-patientprobleem-01</span>
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|probleem met zichzelf wassen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Toelichting
 +
|style="background-color: white;"|meneer kan niet buigen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verpleegkundige interventie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Interventie
 +
|style="background-color: white;"|ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED Clinical Terms')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Indicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem
 +
|style="background-color: white;"|Zie [[#tst-1.1-patientprobleem-01|Probleem: tst-1.1-patientprobleem-01]]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Uitvoerder
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorgverlener
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Patientprobleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="11"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|<span id="tst-1.1-patientprobleem-02" title="Intern ID = tst-1.1-patientprobleem-02">Probleem tst-1.1-patientprobleem-02</span>
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|probleem met zichzelf kleden (code = '284972002' in codeSystem 'Referentieset Nationale kernset patientproblemen')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verpleegkundige interventie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Interventie
 +
|style="background-color: white;"|ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Indicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem
 +
|style="background-color: white;"|Zie [[#tst-1.1-patientprobleem-02|Probleem: tst-1.1-patientprobleem-02]]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Patientprobleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="22"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|<span id="tst-1.1-patientprobleem-03" title="Intern ID = tst-1.1-patientprobleem-03">Probleem tst-1.1-patientprobleem-03</span>
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|decubitus (code = '399912005' in codeSystem 'Referentieset Nationale kernset patientproblemen')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verpleegkundige interventie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Interventie
 +
|style="background-color: white;"|aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED Clinical Terms')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Indicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem
 +
|style="background-color: white;"|Zie [[#tst-1.1-patientprobleem-03|Probleem: tst-1.1-patientprobleem-03]]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verpleegkundige interventie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="10"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Interventie
 +
|style="background-color: white;"|wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED Clinical Terms')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Indicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem
 +
|style="background-color: white;"|Zie [[#tst-1.1-patientprobleem-03|Probleem: tst-1.1-patientprobleem-03]]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Actie start datum tijd
 +
|style="background-color: white;"|T - 10 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Actie eind datum tijd
 +
|style="background-color: white;"|T - 1 dag
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Uitvoerder
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorgverlener
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Patientprobleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="11"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|<span id="tst-1.1-patientprobleem-04" title="Intern ID = tst-1.1-patientprobleem-04">Probleem tst-1.1-patientprobleem-04</span>
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|loopt risico op delier (code = '430794006' in codeSystem 'Referentieset Nationale kernset patientproblemen')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verpleegkundige interventie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Interventie
 +
|style="background-color: white;"|bevorderen van vochtinname (code = '113148007' in codeSystem 'SNOMED Clinical Terms')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Indicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem
 +
|style="background-color: white;"|Zie [[#tst-1.1-patientprobleem-04|Probleem: tst-1.1-patientprobleem-04]]
 +
|}
 +
=== Verpleegkundige context specificatie gezondheidstoestand===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="8" | Verpleegkundige context specificatie gezondheidstoestand
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="7" width="30%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="8"|Voedingvocht
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="32"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Sonde systeem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Sonde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Medisch hulpmiddel
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Product
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Product type
 +
|style="background-color: white;"|PEJ sonde (code = '8911000146104' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Product omschrijving
 +
|style="background-color: white;"|PEJ sonde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Infuus
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="10"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Infuuskatheter
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Medisch hulpmiddel
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Product
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Product type
 +
|style="background-color: white;"|Centraal veneuze katheter (code = '52124006' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Product omschrijving
 +
|style="background-color: white;"|centraal veneuze katheter
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Toelichting
 +
|style="background-color: white;"|voor voeding
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Infuus
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Infuuskatheter
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Medisch hulpmiddel
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Product
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Product type
 +
|style="background-color: white;"|Perifeer intraveneus infuus (code = '82449006' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Product omschrijving
 +
|style="background-color: white;"|voor medicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="8"|Uitscheiding
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Stoma
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Stoma type
 +
|style="background-color: white;"|eindstandige ileostoma (code = '311412005' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Toelichting
 +
|style="background-color: white;"|na subtotale darmresectie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Stoma
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Stoma type
 +
|style="background-color: white;"|urostoma (code = '281601009' in codeSystem 'SNOMED CT')
 +
|}<section end=eovd-saa-tst-1.1-alle_zibs />
 +
<section begin=eovd-saa-tst-1.1b-alle_zibs />
 +
==Aanmeldbericht - overlap BgZ==
 +
 
 +
=== Administratieve gegevens===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Administratieve gegevens
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="6" width="30%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Datum overplaatsing
 +
|style="background-color: white;"|T + 1 dag
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Persoonsgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="47"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Patient
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="18"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Naamgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Voornamen
 +
|style="background-color: white;"|Erik
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Initialen
 +
|style="background-color: white;"|E
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Geslachtsnaam
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Achternaam
 +
|style="background-color: white;"|XXX_Altenborg
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Adresgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Straat
 +
|style="background-color: white;"|Knolweg
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Huisnummer
 +
|style="background-color: white;"|1000
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Postcode
 +
|style="background-color: white;"|9999XA
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Woonplaats
 +
|style="background-color: white;"|Stitswerd
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Adres soort
 +
|style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Identificatienummer
 +
|style="background-color: white;"|999911612 (in identificerend systeem: BSN)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geboortedatum
 +
|style="background-color: white;"|14 aug 1964
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geslacht
 +
|style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Betaler
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verzekeraar
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Verzekering
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eind datum tijd
 +
|style="background-color: white;"|T + 1 jaar
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Verzekeringssoort
 +
|style="background-color: white;"|Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Contactpersoon
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="18"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Naamgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Voornamen
 +
|style="background-color: white;"|Johanna
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Initialen
 +
|style="background-color: white;"|J
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Roepnaam
 +
|style="background-color: white;"|Hanna
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Geslachtsnaam
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Achternaam
 +
|style="background-color: white;"|Bakker
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Contactgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Telefoonnummers
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Telefoonnummer
 +
|style="background-color: white;"|+31645678912
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Email adressen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Email adres
 +
|style="background-color: white;"|jbakker@123net.nl
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Relatie
 +
|style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Sturende organisatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="16"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Zorgaanbieder
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="14"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Zorgaanbieder identificatienummer
 +
|style="background-color: white;"|06590457 (in identificerend systeem: AGB-Z)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Organisatie naam
 +
|style="background-color: white;"|AB-zkh
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Organisatie locatie
 +
|style="background-color: white;"|Noord
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Afdeling specialisme
 +
|style="background-color: white;"|Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Contactgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Telefoonnummers
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Telefoonnummer
 +
|style="background-color: white;"|+31182435770
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Email adressen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Email adres
 +
|style="background-color: white;"|neurologie@ABZ.nl
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Organisatie type
 +
|style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Ontvangende organisatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Zorgaanbieder
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Afdeling specialisme
 +
|style="background-color: white;"|Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Organisatie type
 +
|style="background-color: white;"|Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060')
 +
|}
 +
=== Medische context===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Medische context
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="4" width="30%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Medische diagnose
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="18"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Toelichting
 +
|style="background-color: white;"|niet bekend met neurologische klachten
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|neoplasma van colon (code = '126838000')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|oksel (code = '238600001' in codeSystem 'SNOMED Clinical Terms')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|inverse psoriasis (code = '238600001')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Voorgeschiedenis
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|diabetes mellitus (code = '73211009')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Let op
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Alert
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Alert naam
 +
|style="background-color: white;"|Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Alert
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Alert naam
 +
|style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie
 +
|}<section end=eovd-saa-tst-1.1b-alle_zibs />
 +
<section begin=eovd-saa-tst-q.qb-alle_zibs_kind_0-1_jaar />
 +
==Aanmeldbericht Kinderen 0-1 jaar - overlap BgZ (concept)==
 +
 
 +
=== Administratieve gegevens===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Administratieve gegevens
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="6" width="30%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Datum overplaatsing
 +
|style="background-color: white;"|T + 2 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Persoonsgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="47"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Patient
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="18"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Naamgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Voornamen
 +
|style="background-color: white;"|Erik
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Initialen
 +
|style="background-color: white;"|E
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Geslachtsnaam
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Achternaam
 +
|style="background-color: white;"|XXX_Altenborg
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Adresgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Straat
 +
|style="background-color: white;"|Knolweg
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Huisnummer
 +
|style="background-color: white;"|1000
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Postcode
 +
|style="background-color: white;"|9999XA
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Woonplaats
 +
|style="background-color: white;"|Stitswerd
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Adres soort
 +
|style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Identificatienummer
 +
|style="background-color: white;"|999911612 (in identificerend systeem: BSN)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geboortedatum
 +
|style="background-color: white;"|14 aug 1964
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geslacht
 +
|style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Betaler
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verzekeraar
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Verzekering
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eind datum tijd
 +
|style="background-color: white;"|T + 1 jaar
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Verzekeringssoort
 +
|style="background-color: white;"|Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Contactpersoon
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="18"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Naamgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Voornamen
 +
|style="background-color: white;"|Johanna
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Initialen
 +
|style="background-color: white;"|J
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Roepnaam
 +
|style="background-color: white;"|Hanna
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Geslachtsnaam
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Achternaam
 +
|style="background-color: white;"|Bakker
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Contactgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Telefoonnummers
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Telefoonnummer
 +
|style="background-color: white;"|+31645678912
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Email adressen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Email adres
 +
|style="background-color: white;"|jbakker@123net.nl
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Relatie
 +
|style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Sturende organisatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="16"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Zorgaanbieder
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="14"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Zorgaanbieder identificatienummer
 +
|style="background-color: white;"|06590457 (in identificerend systeem: AGB-Z)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Organisatie naam
 +
|style="background-color: white;"|AB-zkh
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Organisatie locatie
 +
|style="background-color: white;"|Noord
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Afdeling specialisme
 +
|style="background-color: white;"|Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Contactgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Telefoonnummers
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Telefoonnummer
 +
|style="background-color: white;"|+31182435770
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Email adressen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Email adres
 +
|style="background-color: white;"|neurologie@ABZ.nl
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Organisatie type
 +
|style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Ontvangende organisatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Zorgaanbieder
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Afdeling specialisme
 +
|style="background-color: white;"|Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Organisatie type
 +
|style="background-color: white;"|Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060')
 +
|}
 +
=== Algemene patienten context===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Algemene patienten context
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="4" width="30%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Juridische situatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|<span id="JuridischeSituatie-01" title="Intern ID = JuridischeSituatie-01">Juridische situatie JuridischeSituatie-01</span>
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Vertegenwoordiging
 +
|style="background-color: white;"|Onder curatele stelling (code = '9' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.3')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum aanvang
 +
|style="background-color: white;"|T - 1 jaar
 +
|}
 +
=== Medische context===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Medische context
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="4" width="30%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Medische diagnose
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="18"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Toelichting
 +
|style="background-color: white;"|niet bekend met neurologische klachten
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|neoplasma van colon (code = '126838000')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|oksel (code = '238600001' in codeSystem 'SNOMED Clinical Terms')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|inverse psoriasis (code = '238600001')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Voorgeschiedenis
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|diabetes mellitus (code = '73211009')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Let op
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Alert
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Alert naam
 +
|style="background-color: white;"|Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Alert
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Alert naam
 +
|style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Vrijheidsbeperking
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Vrijheidsbeperkende interventie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Wilsbekwaam
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Juridische situatie
 +
|style="background-color: white;"|Zie [[#JuridischeSituatie-01|Juridische situatie: JuridischeSituatie-01]]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Soort interventie
 +
|style="background-color: white;"|geforceerd toedienen van voeding bij patiënt (code = '37041007' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Reden van toepassen
 +
|style="background-color: white;"|bevorderen van fysieke gezondheid (code = '121581000146106' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Instemming
 +
|style="background-color: white;"|Instemming patiënt (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.6.1')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Begin
 +
|style="background-color: white;"|T - 50 dagen
 +
|}
 +
=== Verpleegkundige context zorgplan===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Verpleegkundige context zorgplan
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="6" width="30%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Actuele patientproblemen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="64"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Patientprobleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="15"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|<span id="patientprobleem-01" title="Intern ID = patientprobleem-01">Probleem patientprobleem-01</span>
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|probleem met zichzelf wassen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Toelichting
 +
|style="background-color: white;"|meneer kan niet buigen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verpleegkundige interventie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Interventie
 +
|style="background-color: white;"|ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED Clinical Terms')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Indicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem
 +
|style="background-color: white;"|Zie [[#patientprobleem-01|Probleem: patientprobleem-01]]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Uitvoerder
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorgverlener
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Patientprobleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="11"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|<span id="patientprobleem-02" title="Intern ID = patientprobleem-02">Probleem patientprobleem-02</span>
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|probleem met zichzelf kleden (code = '284972002' in codeSystem 'Referentieset Nationale kernset patientproblemen')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verpleegkundige interventie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Interventie
 +
|style="background-color: white;"|ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Indicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem
 +
|style="background-color: white;"|Zie [[#patientprobleem-02|Probleem: patientprobleem-02]]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Patientprobleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="22"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|<span id="eovd-saa-tst-patientprobleem-03" title="Intern ID = eovd-saa-tst-patientprobleem-03">Probleem eovd-saa-tst-patientprobleem-03</span>
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|decubitus (code = '399912005' in codeSystem 'Referentieset Nationale kernset patientproblemen')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verpleegkundige interventie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Interventie
 +
|style="background-color: white;"|aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED Clinical Terms')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Indicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem
 +
|style="background-color: white;"|Zie [[#eovd-saa-tst-patientprobleem-03|Probleem: eovd-saa-tst-patientprobleem-03]]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verpleegkundige interventie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="10"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Interventie
 +
|style="background-color: white;"|wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED Clinical Terms')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Indicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem
 +
|style="background-color: white;"|Zie [[#eovd-saa-tst-patientprobleem-03|Probleem: eovd-saa-tst-patientprobleem-03]]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Actie start datum tijd
 +
|style="background-color: white;"|T - 10 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Actie eind datum tijd
 +
|style="background-color: white;"|T - 1 dag
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Uitvoerder
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorgverlener
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Patientprobleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="11"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|<span id="eovd-saa-tst-patientprobleem-04" title="Intern ID = eovd-saa-tst-patientprobleem-04">Probleem eovd-saa-tst-patientprobleem-04</span>
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|loopt risico op delier (code = '430794006' in codeSystem 'Referentieset Nationale kernset patientproblemen')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem status
 +
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verpleegkundige interventie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Interventie
 +
|style="background-color: white;"|bevorderen van vochtinname (code = '113148007' in codeSystem 'SNOMED Clinical Terms')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Indicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem
 +
|style="background-color: white;"|Zie [[#eovd-saa-tst-patientprobleem-04|Probleem: eovd-saa-tst-patientprobleem-04]]
 +
|}
 +
=== Verpleegkundige context specificatie gezondheidstoestand===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="8" | Verpleegkundige context specificatie gezondheidstoestand
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="7" width="30%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="8"|Voedingvocht
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="32"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Sonde systeem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Sonde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Medisch hulpmiddel
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Product
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Product type
 +
|style="background-color: white;"|PEJ sonde (code = '8911000146104' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Product omschrijving
 +
|style="background-color: white;"|PEJ sonde
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Infuus
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="10"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Infuuskatheter
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Medisch hulpmiddel
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Product
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Product type
 +
|style="background-color: white;"|Centraal veneuze katheter (code = '52124006' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Product omschrijving
 +
|style="background-color: white;"|centraal veneuze katheter
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Toelichting
 +
|style="background-color: white;"|voor voeding
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Infuus
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Infuuskatheter
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Medisch hulpmiddel
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Product
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Product type
 +
|style="background-color: white;"|Perifeer intraveneus infuus (code = '82449006' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Product omschrijving
 +
|style="background-color: white;"|voor medicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="8"|Uitscheiding
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Stoma
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Stoma type
 +
|style="background-color: white;"|eindstandige ileostoma (code = '311412005' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Toelichting
 +
|style="background-color: white;"|na subtotale darmresectie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Stoma
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Stoma type
 +
|style="background-color: white;"|urostoma (code = '281601009' in codeSystem 'SNOMED CT')
 +
|}<section end=eovd-saa-tst-q.qb-alle_zibs_kind_0-1_jaar />

Versie van 22 dec 2021 om 10:04



1 Addenda voor inhoudelijke gegevens

1.1 Aanmeldbericht

1.1.1 Administratieve gegevens

Administratieve gegevens
Gegevenselement Waarde
Datum overplaatsing T + 1 dag
Persoonsgegevens
Patient
Naamgegevens
Voornamen Erik
Initialen E
Geslachtsnaam
Achternaam XXX_Altenborg
Adresgegevens
Straat Knolweg
Huisnummer 1000
Postcode 9999XA
Woonplaats Stitswerd
Adres soort Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse')
Identificatienummer 999911612 (in identificerend systeem: BSN)
Geboortedatum 14 aug 1964
Geslacht Man (code = 'M' in codeSystem 'HL7 AdministrativeGender')
Betaler
Verzekeraar
Verzekering
Eind datum tijd T + 1 jaar
Verzekeringssoort Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1')
Contactpersoon
Naamgegevens
Voornamen Johanna
Initialen J
Roepnaam Hanna
Geslachtsnaam
Achternaam Bakker
Contactgegevens
Telefoonnummers
Telefoonnummer +31645678912
Email adressen
Email adres jbakker@123net.nl
Relatie Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef
Sturende organisatie
Zorgaanbieder
Zorgaanbieder identificatienummer 06590457 (in identificerend systeem: AGB-Z)
Organisatie naam AB-zkh
Organisatie locatie Noord
Afdeling specialisme Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')
Contactgegevens
Telefoonnummers
Telefoonnummer +31182435770
Email adressen
Email adres neurologie@ABZ.nl
Organisatie type Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060')
Ontvangende organisatie
Zorgaanbieder
Afdeling specialisme Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')
Organisatie type Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060')

1.1.2 Algemene patienten context

Algemene patienten context
Gegevenselement Waarde
Juridische situatie
Juridische situatie tst-1.1-juridischesituatie-01
Vertegenwoordiging Onder curatele stelling (code = '9' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.3')
Datum aanvang T - 1 jaar

1.1.3 Medische context

Medische context
Gegevenselement Waarde
Medische diagnose
Probleem
Probleem naam ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Toelichting niet bekend met neurologische klachten
Probleem
Probleem naam neoplasma van colon (code = '126838000')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Probleem
Probleem naam oksel (code = '238600001' in codeSystem 'SNOMED Clinical Terms')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Probleem
Probleem naam inverse psoriasis (code = '238600001')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Voorgeschiedenis
Probleem
Probleem naam diabetes mellitus (code = '73211009')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Let op
Alert
Alert naam Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT')
Alert
Alert naam Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie
Vrijheidsbeperking
Vrijheidsbeperkende interventie
Wilsbekwaam Ja
Juridische situatie Zie Juridische situatie: tst-1.1-juridischesituatie-01
Soort interventie geforceerd toedienen van voeding bij patiënt (code = '37041007' in codeSystem 'SNOMED CT')
Reden van toepassen bevorderen van fysieke gezondheid (code = '121581000146106' in codeSystem 'SNOMED CT')
Instemming Instemming patiënt (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.6.1')
Begin T - 50 dagen

1.1.4 Verpleegkundige context zorgplan

Verpleegkundige context zorgplan
Gegevenselement Waarde
Actuele patientproblemen
Patientprobleem
Probleem tst-1.1-patientprobleem-01
Probleem naam probleem met zichzelf wassen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Toelichting meneer kan niet buigen
Verpleegkundige interventie
Interventie ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED Clinical Terms')
Indicatie
Probleem Zie Probleem: tst-1.1-patientprobleem-01
Uitvoerder
Zorgverlener Ja
Patientprobleem
Probleem tst-1.1-patientprobleem-02
Probleem naam probleem met zichzelf kleden (code = '284972002' in codeSystem 'Referentieset Nationale kernset patientproblemen')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Verpleegkundige interventie
Interventie ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms')
Indicatie
Probleem Zie Probleem: tst-1.1-patientprobleem-02
Patientprobleem
Probleem tst-1.1-patientprobleem-03
Probleem naam decubitus (code = '399912005' in codeSystem 'Referentieset Nationale kernset patientproblemen')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Verpleegkundige interventie
Interventie aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED Clinical Terms')
Indicatie
Probleem Zie Probleem: tst-1.1-patientprobleem-03
Verpleegkundige interventie
Interventie wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED Clinical Terms')
Indicatie
Probleem Zie Probleem: tst-1.1-patientprobleem-03
Actie start datum tijd T - 10 dagen
Actie eind datum tijd T - 1 dag
Uitvoerder
Zorgverlener Ja
Patientprobleem
Probleem tst-1.1-patientprobleem-04
Probleem naam loopt risico op delier (code = '430794006' in codeSystem 'Referentieset Nationale kernset patientproblemen')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Verpleegkundige interventie
Interventie bevorderen van vochtinname (code = '113148007' in codeSystem 'SNOMED Clinical Terms')
Indicatie
Probleem Zie Probleem: tst-1.1-patientprobleem-04

1.1.5 Verpleegkundige context specificatie gezondheidstoestand

Verpleegkundige context specificatie gezondheidstoestand
Gegevenselement Waarde
Voedingvocht
Sonde systeem
Sonde
Medisch hulpmiddel
Product
Product type PEJ sonde (code = '8911000146104' in codeSystem 'SNOMED CT')
Product omschrijving PEJ sonde
Infuus
Infuuskatheter
Medisch hulpmiddel
Product
Product type Centraal veneuze katheter (code = '52124006' in codeSystem 'SNOMED CT')
Product omschrijving centraal veneuze katheter
Toelichting voor voeding
Infuus
Infuuskatheter
Medisch hulpmiddel
Product
Product type Perifeer intraveneus infuus (code = '82449006' in codeSystem 'SNOMED CT')
Product omschrijving voor medicatie
Uitscheiding
Stoma
Stoma type eindstandige ileostoma (code = '311412005' in codeSystem 'SNOMED CT')
Toelichting na subtotale darmresectie
Stoma
Stoma type urostoma (code = '281601009' in codeSystem 'SNOMED CT')

1.2 Aanmeldbericht - overlap BgZ

1.2.1 Administratieve gegevens

Administratieve gegevens
Gegevenselement Waarde
Datum overplaatsing T + 1 dag
Persoonsgegevens
Patient
Naamgegevens
Voornamen Erik
Initialen E
Geslachtsnaam
Achternaam XXX_Altenborg
Adresgegevens
Straat Knolweg
Huisnummer 1000
Postcode 9999XA
Woonplaats Stitswerd
Adres soort Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse')
Identificatienummer 999911612 (in identificerend systeem: BSN)
Geboortedatum 14 aug 1964
Geslacht Man (code = 'M' in codeSystem 'HL7 AdministrativeGender')
Betaler
Verzekeraar
Verzekering
Eind datum tijd T + 1 jaar
Verzekeringssoort Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1')
Contactpersoon
Naamgegevens
Voornamen Johanna
Initialen J
Roepnaam Hanna
Geslachtsnaam
Achternaam Bakker
Contactgegevens
Telefoonnummers
Telefoonnummer +31645678912
Email adressen
Email adres jbakker@123net.nl
Relatie Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef
Sturende organisatie
Zorgaanbieder
Zorgaanbieder identificatienummer 06590457 (in identificerend systeem: AGB-Z)
Organisatie naam AB-zkh
Organisatie locatie Noord
Afdeling specialisme Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')
Contactgegevens
Telefoonnummers
Telefoonnummer +31182435770
Email adressen
Email adres neurologie@ABZ.nl
Organisatie type Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060')
Ontvangende organisatie
Zorgaanbieder
Afdeling specialisme Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')
Organisatie type Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060')

1.2.2 Medische context

Medische context
Gegevenselement Waarde
Medische diagnose
Probleem
Probleem naam ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Toelichting niet bekend met neurologische klachten
Probleem
Probleem naam neoplasma van colon (code = '126838000')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Probleem
Probleem naam oksel (code = '238600001' in codeSystem 'SNOMED Clinical Terms')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Probleem
Probleem naam inverse psoriasis (code = '238600001')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Voorgeschiedenis
Probleem
Probleem naam diabetes mellitus (code = '73211009')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Let op
Alert
Alert naam Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT')
Alert
Alert naam Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie

1.3 Aanmeldbericht Kinderen 0-1 jaar - overlap BgZ (concept)

1.3.1 Administratieve gegevens

Administratieve gegevens
Gegevenselement Waarde
Datum overplaatsing T + 2 dagen
Persoonsgegevens
Patient
Naamgegevens
Voornamen Erik
Initialen E
Geslachtsnaam
Achternaam XXX_Altenborg
Adresgegevens
Straat Knolweg
Huisnummer 1000
Postcode 9999XA
Woonplaats Stitswerd
Adres soort Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse')
Identificatienummer 999911612 (in identificerend systeem: BSN)
Geboortedatum 14 aug 1964
Geslacht Man (code = 'M' in codeSystem 'HL7 AdministrativeGender')
Betaler
Verzekeraar
Verzekering
Eind datum tijd T + 1 jaar
Verzekeringssoort Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1')
Contactpersoon
Naamgegevens
Voornamen Johanna
Initialen J
Roepnaam Hanna
Geslachtsnaam
Achternaam Bakker
Contactgegevens
Telefoonnummers
Telefoonnummer +31645678912
Email adressen
Email adres jbakker@123net.nl
Relatie Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef
Sturende organisatie
Zorgaanbieder
Zorgaanbieder identificatienummer 06590457 (in identificerend systeem: AGB-Z)
Organisatie naam AB-zkh
Organisatie locatie Noord
Afdeling specialisme Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')
Contactgegevens
Telefoonnummers
Telefoonnummer +31182435770
Email adressen
Email adres neurologie@ABZ.nl
Organisatie type Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060')
Ontvangende organisatie
Zorgaanbieder
Afdeling specialisme Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')
Organisatie type Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060')

1.3.2 Algemene patienten context

Algemene patienten context
Gegevenselement Waarde
Juridische situatie
Juridische situatie JuridischeSituatie-01
Vertegenwoordiging Onder curatele stelling (code = '9' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.3')
Datum aanvang T - 1 jaar

1.3.3 Medische context

Medische context
Gegevenselement Waarde
Medische diagnose
Probleem
Probleem naam ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Toelichting niet bekend met neurologische klachten
Probleem
Probleem naam neoplasma van colon (code = '126838000')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Probleem
Probleem naam oksel (code = '238600001' in codeSystem 'SNOMED Clinical Terms')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Probleem
Probleem naam inverse psoriasis (code = '238600001')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Voorgeschiedenis
Probleem
Probleem naam diabetes mellitus (code = '73211009')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Let op
Alert
Alert naam Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT')
Alert
Alert naam Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie
Vrijheidsbeperking
Vrijheidsbeperkende interventie
Wilsbekwaam Ja
Juridische situatie Zie Juridische situatie: JuridischeSituatie-01
Soort interventie geforceerd toedienen van voeding bij patiënt (code = '37041007' in codeSystem 'SNOMED CT')
Reden van toepassen bevorderen van fysieke gezondheid (code = '121581000146106' in codeSystem 'SNOMED CT')
Instemming Instemming patiënt (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.6.1')
Begin T - 50 dagen

1.3.4 Verpleegkundige context zorgplan

Verpleegkundige context zorgplan
Gegevenselement Waarde
Actuele patientproblemen
Patientprobleem
Probleem patientprobleem-01
Probleem naam probleem met zichzelf wassen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Toelichting meneer kan niet buigen
Verpleegkundige interventie
Interventie ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED Clinical Terms')
Indicatie
Probleem Zie Probleem: patientprobleem-01
Uitvoerder
Zorgverlener Ja
Patientprobleem
Probleem patientprobleem-02
Probleem naam probleem met zichzelf kleden (code = '284972002' in codeSystem 'Referentieset Nationale kernset patientproblemen')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Verpleegkundige interventie
Interventie ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms')
Indicatie
Probleem Zie Probleem: patientprobleem-02
Patientprobleem
Probleem eovd-saa-tst-patientprobleem-03
Probleem naam decubitus (code = '399912005' in codeSystem 'Referentieset Nationale kernset patientproblemen')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Verpleegkundige interventie
Interventie aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED Clinical Terms')
Indicatie
Probleem Zie Probleem: eovd-saa-tst-patientprobleem-03
Verpleegkundige interventie
Interventie wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED Clinical Terms')
Indicatie
Probleem Zie Probleem: eovd-saa-tst-patientprobleem-03
Actie start datum tijd T - 10 dagen
Actie eind datum tijd T - 1 dag
Uitvoerder
Zorgverlener Ja
Patientprobleem
Probleem eovd-saa-tst-patientprobleem-04
Probleem naam loopt risico op delier (code = '430794006' in codeSystem 'Referentieset Nationale kernset patientproblemen')
Probleem status Actueel (code = '55561003' in codeSystem 'SNOMED CT')
Verpleegkundige interventie
Interventie bevorderen van vochtinname (code = '113148007' in codeSystem 'SNOMED Clinical Terms')
Indicatie
Probleem Zie Probleem: eovd-saa-tst-patientprobleem-04

1.3.5 Verpleegkundige context specificatie gezondheidstoestand

Verpleegkundige context specificatie gezondheidstoestand
Gegevenselement Waarde
Voedingvocht
Sonde systeem
Sonde
Medisch hulpmiddel
Product
Product type PEJ sonde (code = '8911000146104' in codeSystem 'SNOMED CT')
Product omschrijving PEJ sonde
Infuus
Infuuskatheter
Medisch hulpmiddel
Product
Product type Centraal veneuze katheter (code = '52124006' in codeSystem 'SNOMED CT')
Product omschrijving centraal veneuze katheter
Toelichting voor voeding
Infuus
Infuuskatheter
Medisch hulpmiddel
Product
Product type Perifeer intraveneus infuus (code = '82449006' in codeSystem 'SNOMED CT')
Product omschrijving voor medicatie
Uitscheiding
Stoma
Stoma type eindstandige ileostoma (code = '311412005' in codeSystem 'SNOMED CT')
Toelichting na subtotale darmresectie
Stoma
Stoma type urostoma (code = '281601009' in codeSystem 'SNOMED CT')
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