6.4. Scenario 3

This test scenario contains test data of both the BgLZ and BgLZ+ (for completeness purposes). The following CIMs are part of the BgLZ:

  • AdvanceDirective
  • AllergyIntolerance
  • LaboratoryTestResult
  • NursingIntervention
  • Problem
  • Procedure
  • TreatmentDirective
  • TreatmentObjective

6.4.1. Patient data

NameInformation.FirstNames Maria
NameInformation.Initials M.
NameInformation.GivenName
NameInformation.NameUsage Eigen geslachtsnaam (code 'NL1' from code system 'NaamGebruik')
NameInformation.LastName.Prefix
NameInformation.LastName.LastName XXX_Molog
NameInformation.LastNamePartner.PartnerPrefix
NameInformation.LastNamePartner.PartnerLastName
AddressInformation.Street Knolweg
AddressInformation.HouseNumber 1001
AddressInformation.HouseNumberLetter
AddressInformation.HouseNumberAddition
AddressInformation.HouseNumberIndication
AddressInformation.Postcode 9999XX
AddressInformation.PlaceOfResidence Stitswerd
AddressInformation.Municipality
AddressInformation.Country Nederland (code '6030' from code system 'GBA Tabel 34 (Landentabel)')
AddressInformation.AdditionalInformation
AddressInformation.AddressType Woon-/verblijfadres (code 'PHYS' from code system 'AddressUse')
ContactInformation.TelephoneNumbers.TelephoneNumber +31620202020
ContactInformation.TelephoneNumbers.TelecomType Mobiel telefoonnummer (code 'MC' from code system 'AddressUse')
ContactInformation.TelephoneNumbers.NumberType Telefoonnummer thuis (code 'HP' from code system 'AddressUse')
ContactInformation.EmailAddresses.EmailAddress mariamolog@provider.nl
ContactInformation.EmailAddresses.EmailAddressType Privé e-mailadres (code 'HP' from code system 'AddressUse')
DateOfBirth 18-09-1963
Gender Vrouw (code 'F' from code system 'AdministrativeGender')
MultipleBirthIndicator Nee
DeathIndicator
DateOfDeath

6.4.2. Health Professional data

HealthProfessionalIdentificationNumber
NameInformation.FirstNames Julia
NameInformation.Initials J.
NameInformation.GivenName Lieke
NameInformation.NameUsage Eigen geslachtsnaam (code 'NL1' from code system 'NaamGebruik')
NameInformation.LastName.Prefix van den
NameInformation.LastName.LastName Bos
NameInformation.LastNamePartner.PartnerPrefix
NameInformation.LastNamePartner.PartnerLastName
Speciality Verpleegkundigen, niet nader gespecificeerd (code '9100' from code system 'Vektis AGB-medische specialismen')
AddressInformation.Street
AddressInformation.HouseNumber
AddressInformation.HouseNumberLetter
AddressInformation.HouseNumberAddition
AddressInformation.HouseNumberIndication
AddressInformation.Postcode
AddressInformation.PlaceOfResidence
AddressInformation.Municipality
AddressInformation.Country
AddressInformation.AdditionalInformation
AddressInformation.AddressType
ContactInformation.TelephoneNumbers.TelephoneNumber
ContactInformation.TelephoneNumbers.TelecomType
ContactInformation.TelephoneNumbers.NumberType
ContactInformation.EmailAddresses.EmailAddress
ContactInformation.EmailAddresses.EmailAddressType
HealthcareProvider WijZorgen Honselerdijk
HealthProfessionalRole

6.4.3. Healthcare Provider data

HealthProviderIdentificationNumber 75191919 (in identifier system 'UZI register abonneenummer (URA)')
OrganizationName WijZorgen Honselerdijk
OrganizationLocation
DepartmentSpeciality Thuiszorg, kruiswerk en gezinsverzorging (code '7500' from code system 'Vektis AGB-medische specialismen')
ContactInformation.TelephoneNumbers.TelephoneNumber
ContactInformation.TelephoneNumbers.TelecomType
ContactInformation.TelephoneNumbers.NumberType
ContactInformation.EmailAddresses.EmailAddress
ContactInformation.EmailAddresses.EmailAddressType
AddressInformation.Street
AddressInformation.HouseNumber
AddressInformation.HouseNumberLetter
AddressInformation.HouseNumberAddition
AddressInformation.HouseNumberIndication
AddressInformation.Postcode
AddressInformation.PlaceOfResidence
AddressInformation.Municipality
AddressInformation.Country
AddressInformation.AdditionalInformation
AddressInformation.AddressType
OrganizationType Thuiszorg (code 'T2' from code system 'RoleCodeNL')

6.4.4. Contact Person data

NameInformation.FirstNames Johan
NameInformation.Initials J.
NameInformation.GivenName Han
NameInformation.NameUsage Eigen geslachtsnaam (code 'NL1' from code system 'NaamGebruik')
NameInformation.LastName.Prefix
NameInformation.LastName.LastName Timmerman
NameInformation.LastNamePartner.PartnerPrefix
NameInformation.LastNamePartner.PartnerLastName
ContactInformation.TelephoneNumbers.TelephoneNumber +31645678912
ContactInformation.TelephoneNumbers.TelecomType Mobiel telefoonnummer (code 'MC' from code system 'AddressUse')
ContactInformation.TelephoneNumbers.NumberType Telefoonnummer thuis (code 'HP' from code system 'AddressUse')
ContactInformation.EmailAddresses.EmailAddress jtimmerman@123net.nl
ContactInformation.EmailAddresses.EmailAddressType Privé e-mailadres (code 'HP' from code system 'AddressUse')
AddressInformation.Street
AddressInformation.HouseNumber
AddressInformation.HouseNumberLetter
AddressInformation.HouseNumberAddition
AddressInformation.HouseNumberIndication
AddressInformation.Postcode
AddressInformation.PlaceOfResidence
AddressInformation.Municipality
AddressInformation.Country
AddressInformation.AdditionalInformation
AddressInformation.AddressType
Role Eerste relatie/contactpersoon (code '1' from code system 'COD472-VEKT')
Relationship Zoon (code 'SONC' from code system 'RoleCode')

6.4.5. Advance Directive data

LivingWillType Niet reanimeren verklaring (code 'NR' from code system 'WilsverklaringType')
LivingWillDate 20-01-2020
Disorder
Representative Johan Timmerman
LivingWillDocument
Comment

6.4.6. Alert data

6.4.6.1. Alert - Drager VRE

Condition
AlertName Drager VRE (code '431109006' from code system 'SNOMED CT')
StartDateTime 18-02-2025
AlertType waarschuwing (code '74018-3' from code system 'LOINC')

6.4.6.2. Alert - verhoogd valrisico

Condition
AlertName Anders (code 'OTH' from code system 'NullFlavor'): verhoogd valrisico
StartDateTime 10-03-2015
AlertType waarschuwing (code '74018-3' from code system 'LOINC')

6.4.7. Allergy Intolerance data

CausativeAgent selderij (code '256326004' from code system 'SNOMED CT')
AllergyCategory Voeding (code '418471000' from code system 'SNOMED CT')
AllergyStatus Actief (code 'active' from code system 'ActStatus')
StartDateTime 15-05-2015
Criticality Matig (code '6736007' from code system 'SNOMED CT')
LastReactionDateTime
Comment betreft zowel gekookte als rauwe selderij
Reaction.Symptom Misselijk en braken (code '16932000' from code system 'SNOMED CT')
Reaction.SpecificSubstance
Reaction.ReactionDescription Misselijkheid en braken
Reaction.Severity
Reaction.RouteOfExposure
Reaction.ReactionTime

6.4.8. Blood Pressure data

MeasuringMethod Niet-invasief (code '22762002' from code system 'SNOMED CT')
CuffType Klein (code 'S' from code system 'ManchetType')
MeasuringLocation Linker bovenarm (code '368208006' from code system 'SNOMED CT')
DiastolicEndpoint
SystolicBloodPressure 160 mmHg
DiastolicBloodPressure 92 mmHg
AverageBloodPressure 109 mmHg
BloodPressureDateTime 15-03-2025 13:45
Comment mevrouw gebruikt medicatie
Position Zittende positie (code '33586001' from code system 'SNOMED CT')

6.4.9. Body Height data

HeightValue 160 cm
HeightDateTime 15-03-2025 12:30
Comment zonder schoenen aan
Position

6.4.10. Body Temperature data

TemperatureValue 38.6 °C
TemperatureDateTime 17-03-2025 06:00
Comment voeten voelen heel koud aan
TemperatureType Tympanische temperatuur (code '415974002' from code system 'SNOMED CT')

6.4.11. Body Weight data

WeightValue 58 kg
Comment mevrouw is aan het aansterken
WeightDateTime 12-03-2025 13:30
Clothing Lichte kleding/ondergoed (code 'MINIMAL' from code system 'ContextKleding')

6.4.12. Encounter data

ContactType Thuis (code 'HH' from code system 'ActCode')
ContactWith Julia van den Bos
Location
StartDateTime 30-03-2025 10:20
EndDateTime
ContactReason.Problem
ContactReason.Procedure
ContactReason.DeviatingResult advies over veilige en passende lichaamsbeweging
Origin
Destination

6.4.13. Fluid Balance data

Comment
FluidTotalIn 1400 mL
FluidTotalOut 1000 mL
FluidBalanceStartTime 14-03-2025 05:00
FluidBalanceStopTime 15-03-2025 05:00

6.4.14. Laboratory Test Result data

Specimen.SpecimenId
Specimen.SpecimenNumberExtension
Specimen.ContainerType
Specimen.SpecimenMaterial
Specimen.Microorganism
Specimen.CollectedVolume
Specimen.CollectionPeriod
Specimen.CollectionDateTime
Specimen.ReceivedDateTime
Specimen.CollectionMethod
Specimen.AnatomicalLocation
Specimen.Laterality
Specimen.Morphology
Specimen.SpecimenSource
Specimen.Comment
LaboratoryTest.TestCode Homocysteïne [mol/volume] in serum of plasma (code '13965-9' from code system 'LOINC')
LaboratoryTest.TestMethod
LaboratoryTest.TestDateTime 18-02-2025 14:00
LaboratoryTest.TestResult 18.2 mmol/L
LaboratoryTest.TestResultStatus
LaboratoryTest.ReferenceRangeUpperLimit 15 mmol/L
LaboratoryTest.ReferenceRangeLowerLimit
LaboratoryTest.InterpretationMethod
LaboratoryTest.ResultFlags Boven referentiewaarde (code '281302008' from code system 'SNOMED CT')
LaboratoryTest.ResultInterpretation
PanelOrBattery
ResultStatus
Comment Verhoogde homocysteïne geassocieerd met langdurig levodopa-gebruik bij Parkinson. Overweeg suppletie met B-vitamines.
ResultType Klinische chemie (code '275711006' from code system 'SNOMED CT')
RelatedResult
Requester

6.4.15. Living Situation data

Comment woning is op de begane grond
HouseType Aanleunwoning (code 'AANLW' from code system 'WoningType')

6.4.16. Nursing Intervention data

Intervention Ondersteunen bij aankleden (code '313332003' from code system 'SNOMED CT')
Indication ziekte van Parkinson
TreatmentObjective zelfstandig aankleden
NursingProcedure.Interval 1 d
NursingProcedure.Frequency 1
NursingProcedure.Activity
NursingProcedure.ProcedureStartDateTime
NursingProcedure.ProcedureEndDateTime
NursingProcedure.MedicalDevice
NursingProcedure.Instruction
NursingProcedure.Performer.HealthcareProvider
NursingProcedure.Performer.Caregiver
NursingProcedure.Performer.Patient
Requester
Comment Het aankleden gaat nog moeilijk.

6.4.17. Nursing Report data

6.4.17.1. Nursing Report - 17-05-2025

ReportTitle Dagrapportage
ReportDateTime 17-05-2025 06:00
Performer.HealthProfessional
Performer.HealthcareProvider WijZorgen Honselerdijk
ReportContent Mevrouw vertoont toenemende stijfheid bij het opstaan en lopen. Er is sprake van fijne tremor in de rechterhand. Tijdens het ochtendcontact had zij moeite om zich verbaal uit te drukken; gebruikt korte zinnen met lange pauzes. Zelfstandig toiletbezoek is mogelijk, maar met risico op vallen. Advies: looprek binnen handbereik houden en logopedie betrekken voor spraakondersteuning.

6.4.17.2. Nursing Report - 14-05-2025

ReportTitle Dagrapportage
ReportDateTime 14-05-2025 12:45
Performer.HealthProfessional
Performer.HealthcareProvider WijZorgen Honselerdijk
ReportContent Tijdens de middagdienst werd opgemerkt dat mevrouw vertraagd reageerde op vragen en aanwijzingen. Er is sprake van wisselende alertheid. Mobiliteit was verminderd: traag gangpatroon en neiging tot 'bevriezen' bij het draaien. Mevrouw gaf aan meer last te hebben van stijfheid in de schouders. Er is hulp geboden bij aan- en uitkleden. Geadviseerd om bewegingsoefeningen te stimuleren en fysiotherapie te informeren voor beoordeling van valrisico.

6.4.17.3. Nursing Report - 07-05-2025

ReportTitle Dagrapportage
ReportDateTime 07-05-2025 20:00
Performer.HealthProfessional
Performer.HealthcareProvider WijZorgen Honselerdijk
ReportContent Tijdens het avondmoment was mevrouw alert en aanspreekbaar, maar gaf aan toenemende vermoeidheid te ervaren na lichte inspanning. Lichte rigiditeit bij het opstaan vanuit stoel waargenomen. Geen tremoren zichtbaar. Gesprek verliep traag maar begrijpelijk. Zelfstandig gebruik van loophulpmiddel bij toiletgang zonder incidenten. Advies: rustmomenten inbouwen overdag en monitoren of vermoeidheid toeneemt.

6.4.18. Nutrition Advice data

6.4.18.1. Nutrition Advice - lactosevrij

DietType lactosevrij
Consistency solide
Comment naar eigen zeggen lactose-intolerant
DateTime 23-02-2025

6.4.18.2. Nutrition Advice - geen selderij

DietType geen selderij
Consistency
Comment in verband met allergie
DateTime 17-03-2015

6.4.19. Payer data

PayerPerson.PayerName
PayerPerson.BankInformation.BankName
PayerPerson.BankInformation.BankCode
PayerPerson.BankInformation.AccountNumber
InsuranceCompany.Insurance.StartDateTime
InsuranceCompany.Insurance.EndDateTime 17-03-2026
InsuranceCompany.Insurance.InsuranceType Basis verzekerd (code 'B' from code system 'Verzekeringssoort')
InsuranceCompany.IdentificationNumber 3332 (in identifier system 'UZOVI')
InsuranceCompany.OrganizationName Menzis
InsuranceCompany.InsurantNumber 6318708200
AddressInformation.Street
AddressInformation.HouseNumber
AddressInformation.HouseNumberLetter
AddressInformation.HouseNumberAddition
AddressInformation.HouseNumberIndication
AddressInformation.Postcode
AddressInformation.PlaceOfResidence
AddressInformation.Municipality
AddressInformation.Country
AddressInformation.AdditionalInformation
AddressInformation.AddressType
ContactInformation.TelephoneNumbers.TelephoneNumber
ContactInformation.TelephoneNumbers.TelecomType
ContactInformation.TelephoneNumbers.NumberType
ContactInformation.EmailAddresses.EmailAddress
ContactInformation.EmailAddresses.EmailAddressType

6.4.20. Problem data

ProblemAnatomicalLocation
ProblemLaterality
ProblemType Diagnose (code '282291009' from code system 'SNOMED CT')
ProblemName ziekte van Parkinson (code '49049000' from code system 'SNOMED CT')
ProblemStartDate 14-05-2022 23:00
ProblemEndDate
ProblemStatus Actueel (code '55561003' from code system 'SNOMED CT')
VerificationStatus
Comment naast beven ook somberheid en moeheid

6.4.21. Procedure data

ProcedureStartDate 17-02-2025 23:00
ProcedureEndDate 17-02-2025 23:00
ProcedureAnatomicalLocation
ProcedureLaterality
Indication ziekte van Parkinson
ProcedureType ondersteunen bij wassen en/of persoonlijke hygiëne (code '386420003' from code system 'SNOMED CT')
ProcedureMethod
MedicalDevice
Location
Performer WijZorgen Honselerdijk
Requester

6.4.22. Pulse Rate data

PulseRateValue 67 /min
PulseRateDateTime 02-06-2024 22:00
Comment
PulseRegularity Polsslag regelmatig (code '271636001' from code system 'SNOMED CT')

6.4.23. Respiration data

BreathingFrequency 15 /min
BreathingDateTime 11-03-2015 14:47
Rhythm Normaal ademhalingsritme (code '5467003' from code system 'SNOMED CT')
Depth Normale ademhalingsdiepte (code '301284009' from code system 'SNOMED CT')
DeviatingBreathingPattern
ExtraOxygenAdministration Ja
Comment
AdministeredOxygen.FlowRate 2 l/min
AdministeredOxygen.FiO2 0.29
AdministeredOxygen.AdministrationDevice.Product.ProductID
AdministeredOxygen.AdministrationDevice.Product.ProductType neusbril (code '336623009' from code system 'SNOMED CT')
AdministeredOxygen.AdministrationDevice.ProductDescription
AdministeredOxygen.AdministrationDevice.StartDate 17-02-2015
AdministeredOxygen.AdministrationDevice.Indication
AdministeredOxygen.AdministrationDevice.Comment
AdministeredOxygen.AdministrationDevice.AnatomicalLocation
AdministeredOxygen.AdministrationDevice.Laterality
AdministeredOxygen.AdministrationDevice.Location
AdministeredOxygen.AdministrationDevice.HealthProfessional

6.4.24. Treatment Directive data

Verification.Verified Ja
Verification.VerifiedWith Patiënt (code '116154003' from code system 'SNOMED CT')
Verification.VerificationDate 19-03-2024 23:00
Treatment Kunstmatige beademing (code '40617009' from code system 'SNOMED CT')
TreatmentPermitted Behandeling niet toegestaan en/of wenselijk (code 'NEE' from code system 'NL-CM-CS')
Restrictions
StartDate 19-03-2024 23:00
EndDate
Comment
AdvanceDirective Niet reanimeren verklaring

6.4.25. Treatment Objective data

DesiredHealthcareResult zelfstandig aankleden
TargetValue
DesiredHealthCondition
Problem