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