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Regel 1: |
Regel 1: |
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− | __NUMBEREDHEADINGS__
| + | Deze wiki-pagina is in voorbereiding. |
− | {{DISPLAYTITLE:e-overdracht: addendum inhoudelijke gegevens aanmeldbericht '''[dit laatste nog toe laten voegen]'''}}
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− | | |
− | =Addenda voor inhoudelijke gegevens=
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− | <section begin=eovd-saa-tst-1.1-alle_zibs />
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− | ==Aanmeldbericht==
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− | | |
− | === Administratieve gegevens===
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− | | |
− | {| class="wikitable" width="85%"
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− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Administratieve gegevens
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− | |-style="background-color: #1F497D;; color: white; text-align:left;"
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− | |colspan="6" width="30%"| Gegevenselement
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− | || Waarde
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− | | |
− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="6"|Datum overplaatsing
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− | |style="background-color: white;"|T + 1 dag
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="7"|Persoonsgegevens
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="47"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="6"|Patient
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="18"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="5"|Naamgegevens
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="6"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="3"|Voornamen
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− | |style="background-color: white;"|Erik
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="3"|Initialen
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− | |style="background-color: white;"|E
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Geslachtsnaam
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="2"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Achternaam
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− | |style="background-color: white;"|XXX_Altenborg
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="5"|Adresgegevens
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="6"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="3"|Straat
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− | |style="background-color: white;"|Knolweg
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="3"|Huisnummer
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− | |style="background-color: white;"|1000
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="3"|Postcode
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− | |style="background-color: white;"|9999XA
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="3"|Woonplaats
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− | |style="background-color: white;"|Stitswerd
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="3"|Adres soort
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− | |style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse')
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Identificatienummer
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− | |style="background-color: white;"|999911612 (in identificerend systeem: BSN)
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Geboortedatum
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− | |style="background-color: white;"|14 aug 1964
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Geslacht
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− | |style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender')
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="6"|Betaler
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="7"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="5"|Verzekeraar
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="5"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Verzekering
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="3"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Eind datum tijd
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− | |style="background-color: white;"|T + 1 jaar
| |
− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Verzekeringssoort
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− | |style="background-color: white;"|Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1')
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="6"|Contactpersoon
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="18"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="5"|Naamgegevens
| |
− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="7"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="3"|Voornamen
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− | |style="background-color: white;"|Johanna
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="3"|Initialen
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− | |style="background-color: white;"|J
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="3"|Roepnaam
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− | |style="background-color: white;"|Hanna
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Geslachtsnaam
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="2"|
| |
− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Achternaam
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− | |style="background-color: white;"|Bakker
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="5"|Contactgegevens
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="7"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Telefoonnummers
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="2"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Telefoonnummer
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− | |style="background-color: white;"|+31645678912
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Email adressen
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
− | |rowspan="2"|
| |
− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Email adres
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− | |style="background-color: white;"|jbakker@123net.nl
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Relatie
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− | |style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="7"|Sturende organisatie
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="16"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="6"|Zorgaanbieder
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="14"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Zorgaanbieder identificatienummer
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− | |style="background-color: white;"|06590457 (in identificerend systeem: AGB-Z)
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Organisatie naam
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− | |style="background-color: white;"|AB-zkh
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Organisatie locatie
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− | |style="background-color: white;"|Noord
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Afdeling specialisme
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− | |style="background-color: white;"|Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="5"|Contactgegevens
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
− | |rowspan="7"|
| |
− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Telefoonnummers
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="2"|
| |
− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Telefoonnummer
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− | |style="background-color: white;"|+31182435770
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Email adressen
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
− | |rowspan="2"|
| |
− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Email adres
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− | |style="background-color: white;"|neurologie@ABZ.nl
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Organisatie type
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− | |style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060')
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="7"|Ontvangende organisatie
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="5"|
| |
− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="6"|Zorgaanbieder
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="3"|
| |
− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Afdeling specialisme
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− | |style="background-color: white;"|Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Organisatie type
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− | |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%"
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− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Algemene patienten context
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− | |-style="background-color: #1F497D;; color: white; text-align:left;"
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− | |colspan="4" width="30%"| Gegevenselement
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− | || Waarde
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− | | |
− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="5"|Juridische situatie
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="5"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |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>
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="3"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Vertegenwoordiging
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− | |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')
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Datum aanvang
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− | |style="background-color: white;"|T - 1 jaar
| |
− | |}
| |
− | === Medische context===
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− | | |
− | {| class="wikitable" width="85%"
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− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Medische context
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− | |-style="background-color: #1F497D;; color: white; text-align:left;"
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− | |colspan="4" width="30%"| Gegevenselement
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− | || Waarde
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− | | |
− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="5"|Medische diagnose
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="18"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Probleem
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="4"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Probleem naam
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− | |style="background-color: white;"|ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT')
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Probleem status
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− | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Toelichting
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− | |style="background-color: white;"|niet bekend met neurologische klachten
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Probleem
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="3"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Probleem naam
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− | |style="background-color: white;"|neoplasma van colon (code = '126838000')
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Probleem status
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− | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Probleem
| |
− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="3"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Probleem naam
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− | |style="background-color: white;"|oksel (code = '238600001' in codeSystem 'SNOMED Clinical Terms')
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Probleem status
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− | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Probleem
| |
− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="3"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Probleem naam
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− | |style="background-color: white;"|inverse psoriasis (code = '238600001')
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Probleem status
| |
− | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="5"|Voorgeschiedenis
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="5"|
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− | |-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;;"
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− | |colspan="2"|Probleem naam
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− | |style="background-color: white;"|diabetes mellitus (code = '73211009')
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Probleem status
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− | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="5"|Let op
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="7"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Alert
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="2"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Alert naam
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− | |style="background-color: white;"|Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT')
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="4"|Alert
| |
− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="2"|
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="2"|Alert naam
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− | |style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |colspan="5"|Vrijheidsbeperking
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |rowspan="9"|
| |
− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |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;;"
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− | |colspan="2"|Juridische situatie
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− | |style="background-color: white;"|Zie [[#tst-1.1-juridischesituatie-01|Juridische situatie: tst-1.1-juridischesituatie-01]]
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |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')
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− | |-style="vertical-align:top; background-color: #E3E3E3;;"
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− | |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 />
| |