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Auteur gegevens / gegevensverstrekker |
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Concept |
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Identificatie zorgaanbieder |
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Naam vestiging zorgaanbieder |
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Naam zorgaanbieder |
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Adres zorgaanbieder |
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Concept |
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Postadres |
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Postcode |
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Woonplaats |
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Uitvoerder |
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Concept |
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Zorgverlener |
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Concept |
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Identificatie uitvoerder |
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Zorgverlenertype |
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Zorginstelling |
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Concept |
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Type zorgaanbieder (instelling) |
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Burger |
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Concept |
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Burger Service Nummer |
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Lokaal patiëntnummer |
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Verrichting |
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Concept |
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Aanleiding verrichting |
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Aanvang verrichting |
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Einde verrichting |
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Incident/complicatie |
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Concept |
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Type incident/complicatie |
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Ernst incident/complicatie |
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Interventie n.a.v. complicatie |
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Overige interventie (tekst) |
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Doorgiftedatum uitslag doorgegeven zorgverlener |
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Coloscopie : medische observatie |
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Concept |
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Familiaire belasting |
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Voorbereiding coloscopie |
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Concept |
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Type voorbereiding |
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Dosis voorbereiding |
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Voorbereiding zoals voorgeschreven gebruikt |
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Boston Bowel Preparation |
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Concept |
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Boston Bowel Preparation Scale Sum Score |
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BBPS Score Colon ascendens |
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BBPS Score Colon transversum |
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BBPS Score Colon descendens |
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Medicatie |
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Concept |
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Medicatiemiddel |
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Concept |
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Medicatie tijdens coloscopie |
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Dosering medicatie |
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Sedatie ja/nee |
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Mate van sedatie |
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Antidotum |
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Concept |
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Naam middel |
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Intubatie tijd |
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CO2 insufflatie |
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Coecum vastgelegd |
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Appendix vastgelegd |
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Klep of terminaal ileum vastgelegd |
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Coecum intubatie |
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Lokatie bereikt |
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Totale terugtrektijd |
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Retroflexie rectum |
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Patiëntcomfort (GCS) |
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Reden afbreking coloscopie |
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Vervolgbeleid n.a.v. afbreking coloscopie |
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Terugkoppeling cliënt |
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Definitief Vervolgbeleid (groep) |
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Concept |
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Definitief Vervolgbeleid |
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Periode vervolg surveillance/coloscopie |
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Verwezen naar centrum |
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Overige bevinding |
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Eindconclusie |
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Laesie (coloscopiecentrum) |
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Concept |
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Nummer potje monster |
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Afnametijdstip |
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Lokalisatie laesie |
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Type afgenomen materiaal |
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Klinische diagnose |
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Overige klinische diagnose (tekst) |
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Poliep |
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Concept |
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Diameter poliep |
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Morfologie |
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Manier van verwijderen |
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Volledigheid wegname materiaal |
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Verdenking carcinoom ja/nee |
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(Verdenking van) carcinoom |
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Concept |
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Stenoserend ja/nee |
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Circumferentie |
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Lengte carcinoom |
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Specifieke afstand tumor vanaf anus |
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Te passeren ja/nee |
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Markering geplaatst |
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Uitslag pathologie (groep) |
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Concept |
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Uitslag pathologie |
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Radicaliteit |
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T-nummer pathologie verslag |
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