Sum EHR - Layout

Layout

  • Date of creation
  • Author
  • Patient Identification
    • Health Number (mandatory item – empty if no available number)
  • Patient Presentation
    • Family name
    • Forenames
    • Sex
    • Birth date
    • Usual language
  • Contact person
  • Risks
    • Allergies
    • Adverse drug reactions
    • Social factors
    • Other factors
  • Relevant personal antecedents
    • IBUI (French: Identificateur Belge Unique, Dutch: Belgische Unieke Identificator) and ICPC-2 and ICD-10 (empty IBUI allowed)
    • Begin date
    • End date
    • Text
  • Actual problems list
    • IBUI and ICPC-2 and ICD-10 (empty IBUI allowed)
    • Begin date
    • Text
  • Relevant medications
    • CNK (Code National(e) Kode) or other ID (if no available CNK)
    • Administration information
    • Instructions for patient
    • Begin date
    • End date
    • Text
  • Vaccination status
    • Administrated
      • CNK and/or ATC (Anatomical Therapeutic Chemical-code)
      • Date
    • To be administered
      • CNK and/or ATC
      • Date
  • Contextual comment

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