vpk:V4.1 Testgegevens eOverdracht addendum: verschil tussen versies
(NICTIZ-26996/EOVDR-676: Publicatie Minimale eOverdracht+ Zib Gezinssituatie (eOverdracht 4.1.0-alpha.3)) |
(EOVDR-730 VermogenTotUiterlijkeVerzorging toegevoegd) |
||
| Regel 1: | Regel 1: | ||
__NOINDEX__ | __NOINDEX__ | ||
| + | |||
__NUMBEREDHEADINGS__ | __NUMBEREDHEADINGS__ | ||
| − | {{DISPLAYTITLE:e-overdracht | + | {{DISPLAYTITLE:e-overdracht: addendum inhoudelijke gegevens}} |
=Addenda voor inhoudelijke gegevens= | =Addenda voor inhoudelijke gegevens= | ||
| Regel 313: | Regel 314: | ||
|style="background-color: white;"|Thuiszorg (code = 'T2' in codeSystem '<span title="2.16.840.1.113883.2.4.15.1060">HL7 RoleCodeNL Care provider type (organizations)</span>') | |style="background-color: white;"|Thuiszorg (code = 'T2' in codeSystem '<span title="2.16.840.1.113883.2.4.15.1060">HL7 RoleCodeNL Care provider type (organizations)</span>') | ||
|} | |} | ||
| + | |||
=== Algemene patienten context=== | === Algemene patienten context=== | ||
| Regel 416: | Regel 418: | ||
|style="background-color: white;"|T - 1 jaar | |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="7" | Medische context | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="6" width="30%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|Behandelaar | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="16"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Zorgverlener | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="14"| | ||
| + | |-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;"|Joshua Pieter | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Initialen | ||
| + | |style="background-color: white;"|J. P. | ||
| + | |-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;"|Helmond | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|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"|Zorgaanbieder | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Zorgaanbieder identificatienummer | ||
| + | |style="background-color: white;"|06590457 (in identificerend systeem: AGB-Z) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Organisatie naam | ||
| + | |style="background-color: white;"|AB-zkh | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Organisatie locatie | ||
| + | |style="background-color: white;"|Noord | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|Behandelaar | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="16"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Zorgverlener | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="14"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Zorgverlener identificatienummer | ||
| + | |style="background-color: white;"|03898989 (in identificerend systeem: AGB-Z) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Naamgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Initialen | ||
| + | |style="background-color: white;"|G. | ||
| + | |-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;"|Spijkerman | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Specialisme | ||
| + | |style="background-color: white;"|Medisch specialisten, gastro-enterologie (maag-darm-lever-arts) (code = '0318' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Zorgaanbieder | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Zorgaanbieder identificatienummer | ||
| + | |style="background-color: white;"|06590457 (in identificerend systeem: AGB-Z) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Organisatie naam | ||
| + | |style="background-color: white;"|AB-zkh | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Organisatie locatie | ||
| + | |style="background-color: white;"|Noord | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|Medische diagnose | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="23"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Probleem | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem type | ||
| + | |style="background-color: white;"|Diagnose (code = '282291009' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem naam | ||
| + | |style="background-color: white;"|ischemisch cerebrovasculair accident (code = '422504002' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem begin datum | ||
| + | |style="background-color: white;"|T - 100 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem status | ||
| + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Verificatie status | ||
| + | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Toelichting | ||
| + | |style="background-color: white;"|niet bekend met neurologische klachten | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Probleem | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem type | ||
| + | |style="background-color: white;"|Diagnose (code = '282291009' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem naam | ||
| + | |style="background-color: white;"|neoplasma van colon (code = '126838000') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem begin datum | ||
| + | |style="background-color: white;"|T - 150 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem status | ||
| + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Probleem | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem anatomische locatie | ||
| + | |style="background-color: white;"|oksel (code = '91470000' in codeSystem 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem lateraliteit | ||
| + | |style="background-color: white;"|Rechts en links (code = '51440002' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem type | ||
| + | |style="background-color: white;"|Diagnose (code = '282291009' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem naam | ||
| + | |style="background-color: white;"|inverse psoriasis (code = '238600001') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem begin datum | ||
| + | |style="background-color: white;"|T - 10 jaar | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem status | ||
| + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|Voorgeschiedenis | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Probleem | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem type | ||
| + | |style="background-color: white;"|Diagnose (code = '282291009' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem naam | ||
| + | |style="background-color: white;"|diabetes mellitus (code = '73211009') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem begin datum | ||
| + | |style="background-color: white;"|T - 12 jaar | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Probleem status | ||
| + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|Allergie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="37"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Allergie intolerantie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="12"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Veroorzakende stof | ||
| + | |style="background-color: white;"|nikkelsulfaat (code = '255848005' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Allergie categorie | ||
| + | |style="background-color: white;"|Stof of product (code = '419199007' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Allergie status | ||
| + | |style="background-color: white;"|Actief (code = 'active' in codeSystem '<span title="2.16.840.1.113883.5.14">HL7 ActStatus</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Begin datum tijd | ||
| + | |style="background-color: white;"|T - 10 jaar | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Mate van kritiek zijn | ||
| + | |style="background-color: white;"|Matig (code = '6736007' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Toelichting | ||
| + | |style="background-color: white;"|opgemerkt bij het dragen van nikkel bevattende sieraden. | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Reactie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Symptoom | ||
| + | |style="background-color: white;"|Contactdermatitis (code = '40275004' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Reactie beschrijving | ||
| + | |style="background-color: white;"|last van jeuk, roodheid en irritatie op de contactplek van nikkel bevattende sieraden. | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Wijze van blootstelling | ||
| + | |style="background-color: white;"|intra-epidermale route (code = '448077001' in codeSystem 'SNOMED Clinical Terms') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Allergie intolerantie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="22"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Veroorzakende stof | ||
| + | |style="background-color: white;"|pollen (code = '256259004') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Allergie categorie | ||
| + | |style="background-color: white;"|Omgeving (code = '426232007' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Allergie status | ||
| + | |style="background-color: white;"|Actief (code = 'active' in codeSystem '<span title="2.16.840.1.113883.5.14">HL7 ActStatus</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Begin datum tijd | ||
| + | |style="background-color: white;"|T - 500 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Mate van kritiek zijn | ||
| + | |style="background-color: white;"|Matig (code = '6736007' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Laatste reactie datum tijd | ||
| + | |style="background-color: white;"|T - 99 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Reactie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Symptoom | ||
| + | |style="background-color: white;"|Overgevoeligheidsreactie van de bovenste luchtwegen (code = '490008' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Specifieke stof | ||
| + | |style="background-color: white;"|graspollen (code = '256277009') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Reactie beschrijving | ||
| + | |style="background-color: white;"|veelvuldig niezen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Ernst | ||
| + | |style="background-color: white;"|Matig (code = '6736007' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Reactie tijdstip | ||
| + | |style="background-color: white;"|T - 99 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Reactie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Symptoom | ||
| + | |style="background-color: white;"|Kortademigheid (code = '267036007' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Symptoom | ||
| + | |style="background-color: white;"|Koorts (code = '386661006' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Specifieke stof | ||
| + | |style="background-color: white;"|pollen van paprikaplant (code = '110181000146104') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Reactie beschrijving | ||
| + | |style="background-color: white;"|ernstige benauwdheid en koorts | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Ernst | ||
| + | |style="background-color: white;"|Ernstig (code = '24484000' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Reactie tijdstip | ||
| + | |style="background-color: white;"|T - 200 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|Let op | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="10"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Alert | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Alert naam | ||
| + | |style="background-color: white;"|Drager MRSA (code = '432415000' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Begin datum tijd | ||
| + | |style="background-color: white;"|T - 20 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Alert type | ||
| + | |style="background-color: white;"|waarschuwing (code = '74018-3' in codeSystem '<span title="2.16.840.1.113883.6.1">LOINC</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Alert | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Alert naam | ||
| + | |style="background-color: white;"|Anders (code = 'OTH' in codeSystem '<span title="2.16.840.1.113883.5.1008">HL7 NullFlavor</span>'): ernstige claustrofobie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Begin datum tijd | ||
| + | |style="background-color: white;"|T - 10 jaar | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|Meetwaarden | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="24"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Bloeddruk | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="11"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Meetmethode | ||
| + | |style="background-color: white;"|Niet-invasief (code = '22762002' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Manchet type | ||
| + | |style="background-color: white;"|Standaard (code = 'STD' in codeSystem '<span title="2.16.840.1.113883.2.4.3.11.60.40.4.15.1">ZIB ManchetType</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Meet locatie | ||
| + | |style="background-color: white;"|Rechter bovenarm (code = '368209003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Diastolisch eindpunt | ||
| + | |style="background-color: white;"|Fase V (code = '255272007' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Systolische bloeddruk | ||
| + | |style="background-color: white;"|170 mmHg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Diastolische bloeddruk | ||
| + | |style="background-color: white;"|90 mmHg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Gemiddelde bloeddruk | ||
| + | |style="background-color: white;"|110 mmHg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Bloeddruk datum tijd | ||
| + | |style="background-color: white;"|T - 20 dagen om 14:45 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Toelichting | ||
| + | |style="background-color: white;"|meneer gebruikt medicatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Houding | ||
| + | |style="background-color: white;"|Liggende positie (code = '102538003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Lichaamsgewicht | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Gewicht waarde | ||
| + | |style="background-color: white;"|74 kg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Toelichting | ||
| + | |style="background-color: white;"|meneer volgt afvaldieet | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Gewicht datum tijd | ||
| + | |style="background-color: white;"|T - 5 dagen om 14:30 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Kleding | ||
| + | |style="background-color: white;"|Volledig gekleed, inclusief schoenen (code = 'FULL' in codeSystem '<span title="2.16.840.1.113883.2.4.3.11.60.40.4.8.1">ZIB ContextKleding</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Lichaamslengte | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Lengte waarde | ||
| + | |style="background-color: white;"|170 cm | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Lengte datum tijd | ||
| + | |style="background-color: white;"|T - 5 dagen om 14:30 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Toelichting | ||
| + | |style="background-color: white;"|zonder schoenen aan | ||
| + | |} | ||
| + | === Verpleegkundige context specificatie gezondheidstoestand=== | ||
| + | |||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Verpleegkundige context specificatie gezondheidstoestand | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="4" width="30%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Voedingvocht | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="9"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Voedingsadvies | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|Dieet type | ||
| + | |style="background-color: white;"|suikervrij, diabetes dieet | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|Consistentie | ||
| + | |style="background-color: white;"|dik vloeibaar | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|Toelichting | ||
| + | |style="background-color: white;"|eet naar eigen keuze minder vlees | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Voedingsadvies | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|Dieet type | ||
| + | |style="background-color: white;"|geen varkensvlees | ||
| + | |}<section end=eOvd-SOV-tst-1.1e-alle_zibs /> | ||
| + | <section begin=eOvd-SOV-tst-1.2e-VermogenTotUiterlijkeVerzorging /> | ||
| + | ==Test Overdracht 1.2e== | ||
| + | |||
| + | === 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="75"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Patient | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="26"| | ||
| + | |-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 '<span title="2.16.840.1.113883.5.1119">HL7 AddressUse</span>') | ||
| + | |-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;"|+31634567891 | ||
| + | |-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;"|evertaltenborg@hotmail.com | ||
| + | |-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 '<span title="2.16.840.1.113883.5.1">HL7 AdministrativeGender</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Betaler | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="10"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Verzekeraar | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="8"| | ||
| + | |-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 '<span title="2.16.840.1.113883.2.4.3.11.60.101.5.1">ZIB Verzekeringssoort</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Identificatie nummer | ||
| + | |style="background-color: white;"|9664 (in identificerend systeem: UZOVI) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Organisatie naam | ||
| + | |style="background-color: white;"|Trias | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Verzekerde nummer | ||
| + | |style="background-color: white;"|12345678 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|<span id="eovd-1-1b-contactpersoon-01" title="Intern ID = eovd-1-1b-contactpersoon-01">Contactpersoon eovd-1-1b-contactpersoon-01</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="19"| | ||
| + | |-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"|Rol | ||
| + | |style="background-color: white;"|Eerste relatie/contactpersoon (code = '1' in codeSystem '<span title="2.16.840.1.113883.2.4.3.11.22.472">Vektis Rolcode COD472-VEKT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Relatie | ||
| + | |style="background-color: white;"|Dochter (code = 'DAUC' in codeSystem '<span title="2.16.840.1.113883.5.111">HL7 RoleCode</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Contactpersoon | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="15"| | ||
| + | |-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;"|Johannes | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Roepnaam | ||
| + | |style="background-color: white;"|Hans | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Geslachtsnaam | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|Voorvoegsels | ||
| + | |style="background-color: white;"|van | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|Achternaam | ||
| + | |style="background-color: white;"|Dijk | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Contactgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-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;"|+31612121212 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Relatie | ||
| + | |style="background-color: white;"|Anders (code = 'OTH' in codeSystem '<span title="2.16.840.1.113883.5.1008">HL7 NullFlavor</span>'): achterneef | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|Sturende organisatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="34"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Zorgaanbieder | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="21"| | ||
| + | |-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="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;"|10 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Postcode | ||
| + | |style="background-color: white;"|9999PO | ||
| + | |-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;"|Werkadres (code = 'WP' in codeSystem '<span title="2.16.840.1.113883.5.1119">HL7 AddressUse</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Organisatie type | ||
| + | |style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '<span title="2.16.840.1.113883.2.4.15.1060">HL7 RoleCodeNL Care provider type (organizations)</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Zorgverlener | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="10"| | ||
| + | |-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;"|Charlotte Maria | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Initialen | ||
| + | |style="background-color: white;"|C. M. | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Roepnaam | ||
| + | |style="background-color: white;"|Lotte | ||
| + | |-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;"|Bruinsma | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Specialisme | ||
| + | |style="background-color: white;"|Verpleegkundigen, niet nader gespecificeerd (code = '9100' in codeSystem 'Vektis AGB-medische specialismen') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|Ontvangende organisatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Zorgaanbieder | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Zorgaanbieder identificatienummer | ||
| + | |style="background-color: white;"|75131313 (in identificerend systeem: AGB-Z) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Organisatie naam | ||
| + | |style="background-color: white;"|ThuiszorgOrg | ||
| + | |-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;"|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 '<span title="2.16.840.1.113883.2.4.15.1060">HL7 RoleCodeNL Care provider type (organizations)</span>') | ||
| + | |} | ||
| + | === Algemene patienten context=== | ||
| + | |||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Algemene patienten context | ||
| + | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| + | |colspan="5" width="30%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Woonomgeving | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Woonsituatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Toelichting | ||
| + | |style="background-color: white;"|woning is op derde verdieping, is gelijkvloers en er is een lift aanwezig | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Woning type | ||
| + | |style="background-color: white;"|Appartement of flatwoning (code = 'FLATW' in codeSystem '<span title="2.16.840.1.113883.2.4.3.11.60.40.4.13.1">ZIB WoningType</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Levensovertuiging | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="13"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Wilsverklaring | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Wilsverklaring type | ||
| + | |style="background-color: white;"|Verklaring donorschap (code = 'DO' in codeSystem '<span title="2.16.840.1.113883.2.4.3.11.60.40.4.14.1">ZIB WilsverklaringType</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Wilsverklaring datum | ||
| + | |style="background-color: white;"|T - 4 jaar | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Vertegenwoordiger | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|Contactpersoon | ||
| + | |style="background-color: white;"|Zie [[#eovd-1-1b-contactpersoon-01|Contactpersoon: eovd-1-1b-contactpersoon-01]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Toelichting | ||
| + | |style="background-color: white;"|wilsverklaring bevindt zich in de portemonnee. | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Wilsverklaring | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Wilsverklaring type | ||
| + | |style="background-color: white;"|Anders (code = 'OTH' in codeSystem '<span title="2.16.840.1.113883.5.1008">HL7 NullFlavor</span>'): Wil niet gevaccineerd worden | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Wilsverklaring datum | ||
| + | |style="background-color: white;"|T - 1 jaar | ||
| + | |} | ||
=== Medische context=== | === Medische context=== | ||
| Regel 788: | Regel 1.559: | ||
|style="background-color: white;"|zonder schoenen aan | |style="background-color: white;"|zonder schoenen aan | ||
|} | |} | ||
| − | |||
=== Verpleegkundige context specificatie gezondheidstoestand=== | === Verpleegkundige context specificatie gezondheidstoestand=== | ||
| Regel 797: | Regel 1.567: | ||
|| Waarde | || Waarde | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Zelfzorg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="4"|Vermogen tot uiterlijke verzorging | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|Uiterlijke verzorging | ||
| + | |style="background-color: white;"|Hulp nodig (code = '27941000146109' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span> (ordinal = '') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Voedingvocht | |colspan="5"|Voedingvocht | ||
| Regel 821: | Regel 1.602: | ||
|colspan="2"|Dieet type | |colspan="2"|Dieet type | ||
|style="background-color: white;"|geen varkensvlees | |style="background-color: white;"|geen varkensvlees | ||
| − | |}<section end=eOvd-SOV-tst-1. | + | |}<section end=eOvd-SOV-tst-1.2e-VermogenTotUiterlijkeVerzorging /> |
Versie van 5 jun 2025 om 08:34
1 Addenda voor inhoudelijke gegevens
1.1 Test Overdracht 1.1e
1.1.1 Administratieve gegevens
| Administratieve gegevens | ||||||
| Gegevenselement | Waarde | |||||
| Datum overplaatsing | T + 1 dag | |||||
| Persoonsgegevens | ||||||
| Patient | ||||||
| Naamgegevens | ||||||
| Voornamen | Erik | |||||
| Initialen | E | |||||
| Geslachtsnaam | ||||||
| Achternaam | XXX_Altenborg | |||||
| Adresgegevens | ||||||
| Straat | Knolweg | |||||
| Huisnummer | 1000 | |||||
| Postcode | 9999XA | |||||
| Woonplaats | Stitswerd | |||||
| Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31634567891 | |||||
| Email adressen | ||||||
| Email adres | evertaltenborg@hotmail.com | |||||
| Identificatienummer | 999911612 (in identificerend systeem: BSN) | |||||
| Geboortedatum | 14 aug 1964 | |||||
| Geslacht | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |||||
| Betaler | ||||||
| Verzekeraar | ||||||
| Verzekering | ||||||
| Eind datum tijd | T + 1 jaar | |||||
| Verzekeringssoort | Basis (code = 'B' in codeSystem 'ZIB Verzekeringssoort') | |||||
| Identificatie nummer | 9664 (in identificerend systeem: UZOVI) | |||||
| Organisatie naam | Trias | |||||
| Verzekerde nummer | 12345678 | |||||
| Contactpersoon eovd-1-1b-contactpersoon-01 | ||||||
| Naamgegevens | ||||||
| Voornamen | Johanna | |||||
| Initialen | J | |||||
| Roepnaam | Hanna | |||||
| Geslachtsnaam | ||||||
| Achternaam | Bakker | |||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31645678912 | |||||
| Email adressen | ||||||
| Email adres | jbakker@123net.nl | |||||
| Rol | Eerste relatie/contactpersoon (code = '1' in codeSystem 'Vektis Rolcode COD472-VEKT') | |||||
| Relatie | Dochter (code = 'DAUC' in codeSystem 'HL7 RoleCode') | |||||
| Contactpersoon | ||||||
| Naamgegevens | ||||||
| Voornamen | Johannes | |||||
| Roepnaam | Hans | |||||
| Geslachtsnaam | ||||||
| Voorvoegsels | van | |||||
| Achternaam | Dijk | |||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31612121212 | |||||
| Relatie | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef | |||||
| Sturende organisatie | ||||||
| Zorgaanbieder | ||||||
| Zorgaanbieder identificatienummer | 06590457 (in identificerend systeem: AGB-Z) | |||||
| Organisatie naam | AB-zkh | |||||
| Organisatie locatie | Noord | |||||
| Afdeling specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31182435770 | |||||
| Email adressen | ||||||
| Email adres | neurologie@ABZ.nl | |||||
| Adresgegevens | ||||||
| Straat | Knolweg | |||||
| Huisnummer | 10 | |||||
| Postcode | 9999PO | |||||
| Woonplaats | Stitswerd | |||||
| Adres soort | Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | |||||
| Organisatie type | Algemeen ziekenhuis (code = 'V6' in codeSystem 'HL7 RoleCodeNL Care provider type (organizations)') | |||||
| Zorgverlener | ||||||
| Naamgegevens | ||||||
| Voornamen | Charlotte Maria | |||||
| Initialen | C. M. | |||||
| Roepnaam | Lotte | |||||
| Geslachtsnaam | ||||||
| Achternaam | Bruinsma | |||||
| Specialisme | Verpleegkundigen, niet nader gespecificeerd (code = '9100' in codeSystem 'Vektis AGB-medische specialismen') | |||||
| Ontvangende organisatie | ||||||
| Zorgaanbieder | ||||||
| Zorgaanbieder identificatienummer | 75131313 (in identificerend systeem: AGB-Z) | |||||
| Organisatie naam | ThuiszorgOrg | |||||
| Organisatie locatie | Noord | |||||
| Afdeling specialisme | Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
| Organisatie type | Thuiszorg (code = 'T2' in codeSystem 'HL7 RoleCodeNL Care provider type (organizations)') | |||||
1.1.2 Algemene patienten context
| Algemene patienten context | |||||
| Gegevenselement | Waarde | ||||
| Gezinssituatie | |||||
| Gezinssituatie | |||||
| Gezinssamenstelling | Samenwonend met partner (code = '408821002' in codeSystem 'SNOMED CT') | ||||
| Aantal kinderen | 2 | ||||
| Aantal kinderen inwonend | 0 | ||||
| Zorgtaak | zorgt voor zijn vrouw die slecht ter been is | ||||
| Zorgtaak | zorgt voor de hond | ||||
| Kind | |||||
| Geboortedatum | T - 30 jaar | ||||
| Inwonend | Nee | ||||
| Kind | |||||
| Geboortedatum | T - 25 jaar | ||||
| Inwonend | Nee | ||||
| Toelichting | kinderen wonen ver weg en kunnen niet helpen bij dagelijkse zorg | ||||
| Woonomgeving | |||||
| Woonsituatie | |||||
| Toelichting | woning is op derde verdieping, is gelijkvloers en er is een lift aanwezig | ||||
| Woning type | Appartement of flatwoning (code = 'FLATW' in codeSystem 'ZIB WoningType') | ||||
| Levensovertuiging | |||||
| Wilsverklaring | |||||
| Wilsverklaring type | Verklaring donorschap (code = 'DO' in codeSystem 'ZIB WilsverklaringType') | ||||
| Wilsverklaring datum | T - 4 jaar | ||||
| Vertegenwoordiger | |||||
| Contactpersoon | Zie Contactpersoon: eovd-1-1b-contactpersoon-01 | ||||
| Toelichting | wilsverklaring bevindt zich in de portemonnee. | ||||
| Wilsverklaring | |||||
| Wilsverklaring type | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Wil niet gevaccineerd worden | ||||
| Wilsverklaring datum | T - 1 jaar | ||||
1.1.3 Medische context
| Medische context | ||||||
| Gegevenselement | Waarde | |||||
| Behandelaar | ||||||
| Zorgverlener | ||||||
| Naamgegevens | ||||||
| Voornamen | Joshua Pieter | |||||
| Initialen | J. P. | |||||
| Geslachtsnaam | ||||||
| Achternaam | Helmond | |||||
| Specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
| Zorgaanbieder | ||||||
| Zorgaanbieder identificatienummer | 06590457 (in identificerend systeem: AGB-Z) | |||||
| Organisatie naam | AB-zkh | |||||
| Organisatie locatie | Noord | |||||
| Behandelaar | ||||||
| Zorgverlener | ||||||
| Zorgverlener identificatienummer | 03898989 (in identificerend systeem: AGB-Z) | |||||
| Naamgegevens | ||||||
| Initialen | G. | |||||
| Geslachtsnaam | ||||||
| Achternaam | Spijkerman | |||||
| Specialisme | Medisch specialisten, gastro-enterologie (maag-darm-lever-arts) (code = '0318' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
| Zorgaanbieder | ||||||
| Zorgaanbieder identificatienummer | 06590457 (in identificerend systeem: AGB-Z) | |||||
| Organisatie naam | AB-zkh | |||||
| Organisatie locatie | Noord | |||||
| Medische diagnose | ||||||
| Probleem | ||||||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||||
| Probleem naam | ischemisch cerebrovasculair accident (code = '422504002' in codeSystem 'SNOMED CT') | |||||
| Probleem begin datum | T - 100 dagen | |||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
| Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
| Toelichting | niet bekend met neurologische klachten | |||||
| Probleem | ||||||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||||
| Probleem naam | neoplasma van colon (code = '126838000') | |||||
| Probleem begin datum | T - 150 dagen | |||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
| Probleem | ||||||
| Probleem anatomische locatie | oksel (code = '91470000' in codeSystem 'SNOMED Clinical Terms') | |||||
| Probleem lateraliteit | Rechts en links (code = '51440002' in codeSystem 'SNOMED CT') | |||||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||||
| Probleem naam | inverse psoriasis (code = '238600001') | |||||
| Probleem begin datum | T - 10 jaar | |||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
| Voorgeschiedenis | ||||||
| Probleem | ||||||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||||
| Probleem naam | diabetes mellitus (code = '73211009') | |||||
| Probleem begin datum | T - 12 jaar | |||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
| Allergie | ||||||
| Allergie intolerantie | ||||||
| Veroorzakende stof | nikkelsulfaat (code = '255848005' in codeSystem 'SNOMED CT') | |||||
| Allergie categorie | Stof of product (code = '419199007' in codeSystem 'SNOMED CT') | |||||
| Allergie status | Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||||
| Begin datum tijd | T - 10 jaar | |||||
| Mate van kritiek zijn | Matig (code = '6736007' in codeSystem 'SNOMED CT') | |||||
| Toelichting | opgemerkt bij het dragen van nikkel bevattende sieraden. | |||||
| Reactie | ||||||
| Symptoom | Contactdermatitis (code = '40275004' in codeSystem 'SNOMED CT') | |||||
| Reactie beschrijving | last van jeuk, roodheid en irritatie op de contactplek van nikkel bevattende sieraden. | |||||
| Wijze van blootstelling | intra-epidermale route (code = '448077001' in codeSystem 'SNOMED Clinical Terms') | |||||
| Allergie intolerantie | ||||||
| Veroorzakende stof | pollen (code = '256259004') | |||||
| Allergie categorie | Omgeving (code = '426232007' in codeSystem 'SNOMED CT') | |||||
| Allergie status | Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||||
| Begin datum tijd | T - 500 dagen | |||||
| Mate van kritiek zijn | Matig (code = '6736007' in codeSystem 'SNOMED CT') | |||||
| Laatste reactie datum tijd | T - 99 dagen | |||||
| Reactie | ||||||
| Symptoom | Overgevoeligheidsreactie van de bovenste luchtwegen (code = '490008' in codeSystem 'SNOMED CT') | |||||
| Specifieke stof | graspollen (code = '256277009') | |||||
| Reactie beschrijving | veelvuldig niezen | |||||
| Ernst | Matig (code = '6736007' in codeSystem 'SNOMED CT') | |||||
| Reactie tijdstip | T - 99 dagen | |||||
| Reactie | ||||||
| Symptoom | Kortademigheid (code = '267036007' in codeSystem 'SNOMED CT') | |||||
| Symptoom | Koorts (code = '386661006' in codeSystem 'SNOMED CT') | |||||
| Specifieke stof | pollen van paprikaplant (code = '110181000146104') | |||||
| Reactie beschrijving | ernstige benauwdheid en koorts | |||||
| Ernst | Ernstig (code = '24484000' in codeSystem 'SNOMED CT') | |||||
| Reactie tijdstip | T - 200 dagen | |||||
| Let op | ||||||
| Alert | ||||||
| Alert naam | Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT') | |||||
| Begin datum tijd | T - 20 dagen | |||||
| Alert type | waarschuwing (code = '74018-3' in codeSystem 'LOINC') | |||||
| Alert | ||||||
| Alert naam | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie | |||||
| Begin datum tijd | T - 10 jaar | |||||
| Meetwaarden | ||||||
| Bloeddruk | ||||||
| Meetmethode | Niet-invasief (code = '22762002' in codeSystem 'SNOMED CT') | |||||
| Manchet type | Standaard (code = 'STD' in codeSystem 'ZIB ManchetType') | |||||
| Meet locatie | Rechter bovenarm (code = '368209003' in codeSystem 'SNOMED CT') | |||||
| Diastolisch eindpunt | Fase V (code = '255272007' in codeSystem 'SNOMED CT') | |||||
| Systolische bloeddruk | 170 mmHg | |||||
| Diastolische bloeddruk | 90 mmHg | |||||
| Gemiddelde bloeddruk | 110 mmHg | |||||
| Bloeddruk datum tijd | T - 20 dagen om 14:45 uur | |||||
| Toelichting | meneer gebruikt medicatie | |||||
| Houding | Liggende positie (code = '102538003' in codeSystem 'SNOMED CT') | |||||
| Lichaamsgewicht | ||||||
| Gewicht waarde | 74 kg | |||||
| Toelichting | meneer volgt afvaldieet | |||||
| Gewicht datum tijd | T - 5 dagen om 14:30 uur | |||||
| Kleding | Volledig gekleed, inclusief schoenen (code = 'FULL' in codeSystem 'ZIB ContextKleding') | |||||
| Lichaamslengte | ||||||
| Lengte waarde | 170 cm | |||||
| Lengte datum tijd | T - 5 dagen om 14:30 uur | |||||
| Toelichting | zonder schoenen aan | |||||
1.1.4 Verpleegkundige context specificatie gezondheidstoestand
| Verpleegkundige context specificatie gezondheidstoestand | ||||
| Gegevenselement | Waarde | |||
| Voedingvocht | ||||
| Voedingsadvies | ||||
| Dieet type | suikervrij, diabetes dieet | |||
| Consistentie | dik vloeibaar | |||
| Toelichting | eet naar eigen keuze minder vlees | |||
| Voedingsadvies | ||||
| Dieet type | geen varkensvlees | |||
1.2 Test Overdracht 1.2e
1.2.1 Administratieve gegevens
| Administratieve gegevens | ||||||
| Gegevenselement | Waarde | |||||
| Datum overplaatsing | T + 1 dag | |||||
| Persoonsgegevens | ||||||
| Patient | ||||||
| Naamgegevens | ||||||
| Voornamen | Erik | |||||
| Initialen | E | |||||
| Geslachtsnaam | ||||||
| Achternaam | XXX_Altenborg | |||||
| Adresgegevens | ||||||
| Straat | Knolweg | |||||
| Huisnummer | 1000 | |||||
| Postcode | 9999XA | |||||
| Woonplaats | Stitswerd | |||||
| Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31634567891 | |||||
| Email adressen | ||||||
| Email adres | evertaltenborg@hotmail.com | |||||
| Identificatienummer | 999911612 (in identificerend systeem: BSN) | |||||
| Geboortedatum | 14 aug 1964 | |||||
| Geslacht | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |||||
| Betaler | ||||||
| Verzekeraar | ||||||
| Verzekering | ||||||
| Eind datum tijd | T + 1 jaar | |||||
| Verzekeringssoort | Basis (code = 'B' in codeSystem 'ZIB Verzekeringssoort') | |||||
| Identificatie nummer | 9664 (in identificerend systeem: UZOVI) | |||||
| Organisatie naam | Trias | |||||
| Verzekerde nummer | 12345678 | |||||
| Contactpersoon eovd-1-1b-contactpersoon-01 | ||||||
| Naamgegevens | ||||||
| Voornamen | Johanna | |||||
| Initialen | J | |||||
| Roepnaam | Hanna | |||||
| Geslachtsnaam | ||||||
| Achternaam | Bakker | |||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31645678912 | |||||
| Email adressen | ||||||
| Email adres | jbakker@123net.nl | |||||
| Rol | Eerste relatie/contactpersoon (code = '1' in codeSystem 'Vektis Rolcode COD472-VEKT') | |||||
| Relatie | Dochter (code = 'DAUC' in codeSystem 'HL7 RoleCode') | |||||
| Contactpersoon | ||||||
| Naamgegevens | ||||||
| Voornamen | Johannes | |||||
| Roepnaam | Hans | |||||
| Geslachtsnaam | ||||||
| Voorvoegsels | van | |||||
| Achternaam | Dijk | |||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31612121212 | |||||
| Relatie | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef | |||||
| Sturende organisatie | ||||||
| Zorgaanbieder | ||||||
| Zorgaanbieder identificatienummer | 06590457 (in identificerend systeem: AGB-Z) | |||||
| Organisatie naam | AB-zkh | |||||
| Organisatie locatie | Noord | |||||
| Afdeling specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
| Contactgegevens | ||||||
| Telefoonnummers | ||||||
| Telefoonnummer | +31182435770 | |||||
| Email adressen | ||||||
| Email adres | neurologie@ABZ.nl | |||||
| Adresgegevens | ||||||
| Straat | Knolweg | |||||
| Huisnummer | 10 | |||||
| Postcode | 9999PO | |||||
| Woonplaats | Stitswerd | |||||
| Adres soort | Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | |||||
| Organisatie type | Algemeen ziekenhuis (code = 'V6' in codeSystem 'HL7 RoleCodeNL Care provider type (organizations)') | |||||
| Zorgverlener | ||||||
| Naamgegevens | ||||||
| Voornamen | Charlotte Maria | |||||
| Initialen | C. M. | |||||
| Roepnaam | Lotte | |||||
| Geslachtsnaam | ||||||
| Achternaam | Bruinsma | |||||
| Specialisme | Verpleegkundigen, niet nader gespecificeerd (code = '9100' in codeSystem 'Vektis AGB-medische specialismen') | |||||
| Ontvangende organisatie | ||||||
| Zorgaanbieder | ||||||
| Zorgaanbieder identificatienummer | 75131313 (in identificerend systeem: AGB-Z) | |||||
| Organisatie naam | ThuiszorgOrg | |||||
| Organisatie locatie | Noord | |||||
| Afdeling specialisme | Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
| Organisatie type | Thuiszorg (code = 'T2' in codeSystem 'HL7 RoleCodeNL Care provider type (organizations)') | |||||
1.2.2 Algemene patienten context
| Algemene patienten context | |||||
| Gegevenselement | Waarde | ||||
| Woonomgeving | |||||
| Woonsituatie | |||||
| Toelichting | woning is op derde verdieping, is gelijkvloers en er is een lift aanwezig | ||||
| Woning type | Appartement of flatwoning (code = 'FLATW' in codeSystem 'ZIB WoningType') | ||||
| Levensovertuiging | |||||
| Wilsverklaring | |||||
| Wilsverklaring type | Verklaring donorschap (code = 'DO' in codeSystem 'ZIB WilsverklaringType') | ||||
| Wilsverklaring datum | T - 4 jaar | ||||
| Vertegenwoordiger | |||||
| Contactpersoon | Zie Contactpersoon: eovd-1-1b-contactpersoon-01 | ||||
| Toelichting | wilsverklaring bevindt zich in de portemonnee. | ||||
| Wilsverklaring | |||||
| Wilsverklaring type | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Wil niet gevaccineerd worden | ||||
| Wilsverklaring datum | T - 1 jaar | ||||
1.2.3 Medische context
| Medische context | ||||||
| Gegevenselement | Waarde | |||||
| Behandelaar | ||||||
| Zorgverlener | ||||||
| Naamgegevens | ||||||
| Voornamen | Joshua Pieter | |||||
| Initialen | J. P. | |||||
| Geslachtsnaam | ||||||
| Achternaam | Helmond | |||||
| Specialisme | Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
| Zorgaanbieder | ||||||
| Zorgaanbieder identificatienummer | 06590457 (in identificerend systeem: AGB-Z) | |||||
| Organisatie naam | AB-zkh | |||||
| Organisatie locatie | Noord | |||||
| Behandelaar | ||||||
| Zorgverlener | ||||||
| Zorgverlener identificatienummer | 03898989 (in identificerend systeem: AGB-Z) | |||||
| Naamgegevens | ||||||
| Initialen | G. | |||||
| Geslachtsnaam | ||||||
| Achternaam | Spijkerman | |||||
| Specialisme | Medisch specialisten, gastro-enterologie (maag-darm-lever-arts) (code = '0318' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | |||||
| Zorgaanbieder | ||||||
| Zorgaanbieder identificatienummer | 06590457 (in identificerend systeem: AGB-Z) | |||||
| Organisatie naam | AB-zkh | |||||
| Organisatie locatie | Noord | |||||
| Medische diagnose | ||||||
| Probleem eovd-1-1b-probleem-01 | ||||||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||||
| Probleem naam | ischemisch cerebrovasculair accident (code = '422504002' in codeSystem 'SNOMED CT') | |||||
| Probleem begin datum | T - 100 dagen | |||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
| Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
| Toelichting | niet bekend met neurologische klachten | |||||
| Probleem | ||||||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||||
| Probleem naam | neoplasma van colon (code = '126838000') | |||||
| Probleem begin datum | T - 150 dagen | |||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
| Probleem | ||||||
| Probleem anatomische locatie | oksel (code = '91470000' in codeSystem 'SNOMED Clinical Terms') | |||||
| Probleem lateraliteit | Rechts en links (code = '51440002' in codeSystem 'SNOMED CT') | |||||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||||
| Probleem naam | inverse psoriasis (code = '238600001') | |||||
| Probleem begin datum | T - 10 jaar | |||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
| Voorgeschiedenis | ||||||
| Probleem | ||||||
| Probleem type | Diagnose (code = '282291009' in codeSystem 'SNOMED CT') | |||||
| Probleem naam | diabetes mellitus (code = '73211009') | |||||
| Probleem begin datum | T - 12 jaar | |||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
| Allergie | ||||||
| Allergie intolerantie | ||||||
| Veroorzakende stof | nikkelsulfaat (code = '255848005' in codeSystem 'SNOMED CT') | |||||
| Allergie categorie | Stof of product (code = '419199007' in codeSystem 'SNOMED CT') | |||||
| Allergie status | Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||||
| Begin datum tijd | T - 10 jaar | |||||
| Mate van kritiek zijn | Matig (code = '6736007' in codeSystem 'SNOMED CT') | |||||
| Toelichting | opgemerkt bij het dragen van nikkel bevattende sieraden. | |||||
| Reactie | ||||||
| Symptoom | Contactdermatitis (code = '40275004' in codeSystem 'SNOMED CT') | |||||
| Reactie beschrijving | last van jeuk, roodheid en irritatie op de contactplek van nikkel bevattende sieraden. | |||||
| Wijze van blootstelling | intra-epidermale route (code = '448077001' in codeSystem 'SNOMED Clinical Terms') | |||||
| Allergie intolerantie | ||||||
| Veroorzakende stof | pollen (code = '256259004') | |||||
| Allergie categorie | Omgeving (code = '426232007' in codeSystem 'SNOMED CT') | |||||
| Allergie status | Actief (code = 'active' in codeSystem 'HL7 ActStatus') | |||||
| Begin datum tijd | T - 500 dagen | |||||
| Mate van kritiek zijn | Matig (code = '6736007' in codeSystem 'SNOMED CT') | |||||
| Laatste reactie datum tijd | T - 99 dagen | |||||
| Reactie | ||||||
| Symptoom | Overgevoeligheidsreactie van de bovenste luchtwegen (code = '490008' in codeSystem 'SNOMED CT') | |||||
| Specifieke stof | graspollen (code = '256277009') | |||||
| Reactie beschrijving | veelvuldig niezen | |||||
| Ernst | Matig (code = '6736007' in codeSystem 'SNOMED CT') | |||||
| Reactie tijdstip | T - 99 dagen | |||||
| Reactie | ||||||
| Symptoom | Kortademigheid (code = '267036007' in codeSystem 'SNOMED CT') | |||||
| Symptoom | Koorts (code = '386661006' in codeSystem 'SNOMED CT') | |||||
| Specifieke stof | pollen van paprikaplant (code = '110181000146104') | |||||
| Reactie beschrijving | ernstige benauwdheid en koorts | |||||
| Ernst | Ernstig (code = '24484000' in codeSystem 'SNOMED CT') | |||||
| Reactie tijdstip | T - 200 dagen | |||||
| Let op | ||||||
| Alert | ||||||
| Alert naam | Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT') | |||||
| Begin datum tijd | T - 20 dagen | |||||
| Alert type | waarschuwing (code = '74018-3' in codeSystem 'LOINC') | |||||
| Alert | ||||||
| Alert naam | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie | |||||
| Begin datum tijd | T - 10 jaar | |||||
| Meetwaarden | ||||||
| Bloeddruk | ||||||
| Meetmethode | Niet-invasief (code = '22762002' in codeSystem 'SNOMED CT') | |||||
| Manchet type | Standaard (code = 'STD' in codeSystem 'ZIB ManchetType') | |||||
| Meet locatie | Rechter bovenarm (code = '368209003' in codeSystem 'SNOMED CT') | |||||
| Diastolisch eindpunt | Fase V (code = '255272007' in codeSystem 'SNOMED CT') | |||||
| Systolische bloeddruk | 170 mmHg | |||||
| Diastolische bloeddruk | 90 mmHg | |||||
| Gemiddelde bloeddruk | 110 mmHg | |||||
| Bloeddruk datum tijd | T - 20 dagen om 14:45 uur | |||||
| Toelichting | meneer gebruikt medicatie | |||||
| Houding | Liggende positie (code = '102538003' in codeSystem 'SNOMED CT') | |||||
| Lichaamsgewicht | ||||||
| Gewicht waarde | 74 kg | |||||
| Toelichting | meneer volgt afvaldieet | |||||
| Gewicht datum tijd | T - 5 dagen om 14:30 uur | |||||
| Kleding | Volledig gekleed, inclusief schoenen (code = 'FULL' in codeSystem 'ZIB ContextKleding') | |||||
| Lichaamslengte | ||||||
| Lengte waarde | 170 cm | |||||
| Lengte datum tijd | T - 5 dagen om 14:30 uur | |||||
| Toelichting | zonder schoenen aan | |||||
1.2.4 Verpleegkundige context specificatie gezondheidstoestand
| Verpleegkundige context specificatie gezondheidstoestand | ||||
| Gegevenselement | Waarde | |||
| Zelfzorg | ||||
| Vermogen tot uiterlijke verzorging | ||||
| Uiterlijke verzorging | Hulp nodig (code = '27941000146109' in codeSystem 'SNOMED CT (ordinal = ) | |||
| Voedingvocht | ||||
| Voedingsadvies | ||||
| Dieet type | suikervrij, diabetes dieet | |||
| Consistentie | dik vloeibaar | |||
| Toelichting | eet naar eigen keuze minder vlees | |||
| Voedingsadvies | ||||
| Dieet type | geen varkensvlees | |||