{
"description": "This form was developed to clearly document agreements resulting from the advance care planning (ACP) process. It is NOT a checklist. It can only be completed by a healthcare provider after a professional and nuanced conversation. For advice on conducting these conversations, please refer to the guideline for advance care planning in the palliative phase and Palliaweb, see https://palliaweb.nl/zorgpraktijk/proactieve-zorgplanning. \\nEnter 'unknown' if a topic is not discussed or if the patient does not (yet) have an opinion.When transferring to a long-term care setting, consider adding conversation records about advance care planning (ACP) to the transfer documents.\\n",
"_filename": "Questionnaire-ACP-zib2017.json",
"package_name": "iknl.fhir.stu3.pzp",
"date": "2026-06-03T16:00:06+02:00",
"meta": {
"tag": [ {
"code": "lformsVersion: 42.2.0"
} ]
},
"publisher": "IKNL",
"jurisdiction": [ {
"coding": [ {
"code": "001",
"system": "http://unstats.un.org/unsd/methods/m49/m49.htm"
} ]
} ],
"purpose": "This form was developed to clearly document agreements resulting from the advance care planning (ACP) process.",
"name": "ACPzib2017",
"item": [ {
"text": "Datum van invullen",
"type": "dateTime",
"linkId": "385",
"repeats": false,
"required": false
}, {
"item": [ {
"text": "Voornamen",
"type": "string",
"linkId": "386",
"repeats": false,
"required": false
}, {
"text": "Voorvoegsels",
"type": "string",
"linkId": "387",
"repeats": false,
"required": false
}, {
"text": "Achternaam",
"type": "string",
"linkId": "388",
"repeats": false,
"required": false
} ],
"text": "Naam patiënt",
"type": "group",
"linkId": "7",
"repeats": false
}, {
"text": "Geboortedatum patiënt",
"type": "date",
"linkId": "6",
"repeats": false,
"required": false
}, {
"item": [ {
"item": [ {
"text": "Voornamen",
"type": "string",
"linkId": "389",
"repeats": false,
"required": false
}, {
"text": "Voorvoegsels",
"type": "string",
"linkId": "390",
"repeats": false,
"required": false
}, {
"text": "Achternaam",
"type": "string",
"linkId": "391",
"repeats": false,
"required": false
} ],
"text": "Naam zorgverlener",
"type": "group",
"linkId": "16",
"repeats": false
}, {
"text": "Functie (Specialisme)",
"type": "choice",
"linkId": "786",
"options": {
"reference": "https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-HealthProfessionalSpecialtyVS|1.0.0-rc3"
},
"repeats": false,
"required": false
}, {
"item": [ {
"item": [ {
"text": "Toelichting",
"type": "string",
"linkId": "788",
"repeats": false,
"required": false
} ],
"text": "Is de patiënt op dit moment wilsbekwaam m.b.t. medische behandelbeslissingen?",
"type": "boolean",
"linkId": "787",
"repeats": false,
"required": false
}, {
"item": [ {
"item": [ {
"text": "Voornamen",
"type": "string",
"linkId": "392",
"repeats": false,
"required": false
}, {
"text": "Voorvoegsels",
"type": "string",
"linkId": "393",
"repeats": false,
"required": false
}, {
"text": "Achternaam",
"type": "string",
"linkId": "394",
"repeats": false,
"required": false
} ],
"text": "Naam wettelijk vertegenwoordiger",
"type": "group",
"linkId": "30",
"prefix": "a)",
"repeats": false
}, {
"item": [ {
"item": [ {
"text": "Telefoonnummer",
"type": "string",
"linkId": "398",
"repeats": false,
"required": false
}, {
"text": "TelecomType",
"type": "choice",
"linkId": "399",
"option": [ {
"valueCoding": {
"code": "LL",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4.22.1",
"display": "Vast telefoonnummer"
}
}, {
"valueCoding": {
"code": "FAX",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4.22.1",
"display": "Fax"
}
}, {
"valueCoding": {
"code": "MC",
"system": "http://terminology.hl7.org/CodeSystem/v3-AddressUse",
"display": "Mobiel telefoonnummer"
}
}, {
"valueCoding": {
"code": "PG",
"system": "http://terminology.hl7.org/CodeSystem/v3-AddressUse",
"display": "Pieper"
}
} ],
"repeats": false,
"required": false
}, {
"text": "NummerSoort",
"type": "choice",
"linkId": "400",
"option": [ {
"valueCoding": {
"code": "HP",
"system": "http://terminology.hl7.org/CodeSystem/v3-AddressUse",
"display": "Telefoonnummer thuis"
}
}, {
"valueCoding": {
"code": "TMP",
"system": "http://terminology.hl7.org/CodeSystem/v3-AddressUse",
"display": "Tijdelijk telefoonnummer"
}
}, {
"valueCoding": {
"code": "WP",
"system": "http://terminology.hl7.org/CodeSystem/v3-AddressUse",
"display": "Zakelijk telefoonnummer"
}
} ],
"repeats": false,
"required": false
} ],
"text": "Telefoonnummers",
"type": "group",
"linkId": "40",
"repeats": true
}, {
"item": [ {
"text": "EmailAdres",
"type": "string",
"linkId": "401",
"repeats": false,
"required": false
}, {
"text": "EmailSoort",
"type": "choice",
"linkId": "402",
"option": [ {
"valueCoding": {
"code": "HP",
"system": "http://terminology.hl7.org/CodeSystem/v3-AddressUse",
"display": "Privé e-mailadres"
}
}, {
"valueCoding": {
"code": "WP",
"system": "http://terminology.hl7.org/CodeSystem/v3-AddressUse",
"display": "Zakelijk e-mailadres"
}
} ],
"repeats": false,
"required": false
} ],
"text": "EmailAdressen",
"type": "group",
"linkId": "41",
"repeats": true
} ],
"text": "Contactgegevens wettelijk vertegenwoordiger",
"type": "group",
"linkId": "39",
"prefix": "b)",
"repeats": false
}, {
"linkId": "410",
"repeats": true,
"item": [ {
"text": "Anders, namelijk:",
"type": "string",
"linkId": "411",
"repeats": false,
"required": false,
"enableWhen": [ {
"question": "410",
"answerCoding": {
"code": "9",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.22.472"
}
} ]
} ],
"type": "choice",
"prefix": "c)",
"option": [ {
"valueCoding": {
"code": "24",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.22.472",
"display": "Wettelijke vertegenwoordiger"
}
}, {
"valueCoding": {
"code": "1",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.22.472",
"display": "Eerste relatie/contactpersoon"
}
}, {
"valueCoding": {
"code": "310141000146103",
"system": "http://snomed.info/sct",
"display": "Schriftelijk gemachtigde"
}
}, {
"valueCoding": {
"code": "3",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.22.472",
"display": "Curator (juridisch)"
}
}, {
"valueCoding": {
"code": "15",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.22.472",
"display": "Mentor"
}
}, {
"valueCoding": {
"code": "9",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.22.472",
"display": "Anders"
}
} ],
"initialCoding": {
"code": "24",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.22.472",
"display": "Wettelijke vertegenwoordiger"
},
"required": false,
"text": "Relatie tot patiënt (1)"
}, {
"item": [ {
"text": "Anders, namelijk:",
"type": "string",
"linkId": "408",
"repeats": false,
"required": false,
"enableWhen": [ {
"question": "51",
"answerCoding": {
"code": "OTH",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor"
}
} ]
} ],
"text": "Relatie tot patiënt (2)",
"type": "choice",
"linkId": "51",
"option": [ {
"valueCoding": {
"code": "DOMPART",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Partner"
}
}, {
"valueCoding": {
"code": "HUSB",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Echtgenoot"
}
}, {
"valueCoding": {
"code": "WIFE",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Echtgenote"
}
}, {
"valueCoding": {
"code": "FTH",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Vader"
}
}, {
"valueCoding": {
"code": "MTH",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Moeder"
}
}, {
"valueCoding": {
"code": "SONC",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Zoon"
}
}, {
"valueCoding": {
"code": "DAUC",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Dochter"
}
}, {
"valueCoding": {
"code": "BRO",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Broer"
}
}, {
"valueCoding": {
"code": "SIS",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Zuster"
}
}, {
"valueCoding": {
"code": "OTH",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"display": "Anders"
}
} ],
"prefix": "c)",
"repeats": false,
"required": false
}, {
"text": "Is de wettelijk vertegenwoordiger ook de eerste contactpersoon?",
"type": "boolean",
"linkId": "52",
"prefix": "d)",
"repeats": false,
"required": false
}, {
"item": [ {
"text": "Voornamen",
"type": "string",
"linkId": "395",
"repeats": false,
"required": false
}, {
"text": "Voorvoegsels",
"type": "string",
"linkId": "396",
"repeats": false,
"required": false
}, {
"text": "Achternaam",
"type": "string",
"linkId": "397",
"repeats": false,
"required": false
} ],
"text": "Naam eerste contactpersoon",
"type": "group",
"linkId": "53",
"prefix": "e)",
"repeats": false,
"enableWhen": [ {
"question": "52",
"answerBoolean": false
} ]
}, {
"item": [ {
"item": [ {
"text": "Telefoonnummer",
"type": "string",
"linkId": "403",
"repeats": false,
"required": false
}, {
"text": "TelecomType",
"type": "choice",
"linkId": "404",
"option": [ {
"valueCoding": {
"code": "LL",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4.22.1",
"display": "Vast telefoonnummer"
}
}, {
"valueCoding": {
"code": "FAX",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4.22.1",
"display": "Fax"
}
}, {
"valueCoding": {
"code": "MC",
"system": "http://terminology.hl7.org/CodeSystem/v3-AddressUse",
"display": "Mobiel telefoonnummer"
}
}, {
"valueCoding": {
"code": "PG",
"system": "http://terminology.hl7.org/CodeSystem/v3-AddressUse",
"display": "Pieper"
}
} ],
"repeats": false,
"required": false
}, {
"text": "NummerSoort",
"type": "choice",
"linkId": "405",
"option": [ {
"valueCoding": {
"code": "HP",
"system": "http://terminology.hl7.org/CodeSystem/v3-AddressUse",
"display": "Telefoonnummer thuis"
}
}, {
"valueCoding": {
"code": "TMP",
"system": "http://terminology.hl7.org/CodeSystem/v3-AddressUse",
"display": "Tijdelijk telefoonnummer"
}
}, {
"valueCoding": {
"code": "WP",
"system": "http://terminology.hl7.org/CodeSystem/v3-AddressUse",
"display": "Zakelijk telefoonnummer"
}
} ],
"repeats": false,
"required": false
} ],
"text": "Telefoonnummers",
"type": "group",
"linkId": "62",
"repeats": true
}, {
"item": [ {
"text": "EmailAdres",
"type": "string",
"linkId": "406",
"repeats": false,
"required": false
}, {
"text": "EmailSoort",
"type": "choice",
"linkId": "407",
"option": [ {
"valueCoding": {
"code": "HP",
"system": "http://terminology.hl7.org/CodeSystem/v3-AddressUse",
"display": "Privé e-mailadres"
}
}, {
"valueCoding": {
"code": "WP",
"system": "http://terminology.hl7.org/CodeSystem/v3-AddressUse",
"display": "Zakelijk e-mailadres"
}
} ],
"repeats": false,
"required": false
} ],
"text": "EmailAdressen",
"type": "group",
"linkId": "66",
"repeats": true
} ],
"text": "Contactgegevens eerste contactpersoon",
"type": "group",
"linkId": "61",
"prefix": "f)",
"repeats": false,
"enableWhen": [ {
"question": "52",
"answerBoolean": false
} ]
}, {
"text": "Rol",
"type": "choice",
"linkId": "819",
"option": [ {
"valueCoding": {
"code": "1",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.22.472",
"display": "Eerste relatie/contactpersoon"
}
} ],
"repeats": false,
"readOnly": true,
"required": false,
"initialCoding": {
"code": "1",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.22.472",
"display": "Eerste relatie/contactpersoon"
}
}, {
"linkId": "77",
"repeats": false,
"item": [ {
"text": "Anders, namelijk:",
"type": "string",
"linkId": "412",
"repeats": false,
"required": false,
"enableWhen": [ {
"question": "77",
"answerCoding": {
"code": "OTH",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor"
}
} ]
} ],
"type": "choice",
"enableWhen": [ {
"question": "52",
"answerBoolean": false
} ],
"prefix": "g)",
"option": [ {
"valueCoding": {
"code": "DOMPART",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Partner"
}
}, {
"valueCoding": {
"code": "HUSB",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Echtgenoot"
}
}, {
"valueCoding": {
"code": "WIFE",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Echtgenote"
}
}, {
"valueCoding": {
"code": "FTH",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Vader"
}
}, {
"valueCoding": {
"code": "MTH",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Moeder"
}
}, {
"valueCoding": {
"code": "SONC",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Zoon"
}
}, {
"valueCoding": {
"code": "DAUC",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Dochter"
}
}, {
"valueCoding": {
"code": "BRO",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Broer"
}
}, {
"valueCoding": {
"code": "SIS",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Zuster"
}
}, {
"valueCoding": {
"code": "OTH",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"display": "Anders"
}
} ],
"required": false,
"text": "Relatie tot patiënt"
} ],
"text": "Bij wilsonbekwaamheid m.b.t. medische behandelbeslissingen is/wordt de wettelijke vertegenwoordiger:",
"type": "group",
"linkId": "29",
"repeats": false
} ],
"text": "Wilsbekwaamheid & Wettelijke vertegenwoordiging",
"type": "group",
"linkId": "26",
"prefix": "1",
"repeats": false
}, {
"item": [ {
"text": "Patiënt",
"type": "choice",
"linkId": "82",
"option": [ {
"valueCoding": {
"code": "Patiënt",
"display": "Patiënt"
}
} ],
"repeats": false,
"required": false
}, {
"item": [ {
"item": [ {
"text": "Anders, namelijk:",
"type": "string",
"linkId": "414",
"repeats": false,
"required": false
} ],
"text": "Rol",
"type": "choice",
"linkId": "415",
"option": [ {
"valueCoding": {
"code": "3",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.22.472",
"display": "Curator (juridisch)"
}
}, {
"valueCoding": {
"code": "15",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.22.472",
"display": "Mentor"
}
}, {
"valueCoding": {
"code": "310141000146103",
"system": "http://snomed.info/sct",
"display": "Schriftelijk gemachtigde"
}
}, {
"valueCoding": {
"code": "9",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.22.472",
"display": "Anders"
}
} ],
"repeats": true,
"required": false
}, {
"item": [ {
"text": "Anders, namelijk:",
"type": "string",
"linkId": "413",
"repeats": false,
"required": false,
"enableWhen": [ {
"question": "80",
"answerCoding": {
"code": "OTH",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor"
}
} ]
} ],
"text": "Relatie tot patiënt",
"type": "choice",
"linkId": "80",
"option": [ {
"valueCoding": {
"code": "DOMPART",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Partner"
}
}, {
"valueCoding": {
"code": "HUSB",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Echtgenoot"
}
}, {
"valueCoding": {
"code": "WIFE",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Echtgenote"
}
}, {
"valueCoding": {
"code": "FTH",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Vader"
}
}, {
"valueCoding": {
"code": "MTH",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Moeder"
}
}, {
"valueCoding": {
"code": "SONC",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Zoon"
}
}, {
"valueCoding": {
"code": "DAUC",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Dochter"
}
}, {
"valueCoding": {
"code": "BRO",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Broer"
}
}, {
"valueCoding": {
"code": "SIS",
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"display": "Zuster"
}
}, {
"valueCoding": {
"code": "OTH",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"display": "Anders"
}
} ],
"repeats": true,
"required": false
} ],
"text": "Contactperso(o)n(en)",
"type": "group",
"linkId": "1038",
"repeats": false
} ],
"text": "Gesprek gevoerd in bijzijn van",
"type": "group",
"linkId": "78",
"prefix": "2",
"repeats": false
}, {
"item": [ {
"text": "MetingNaam voor Belangrijkste doel van behandeling",
"type": "choice",
"linkId": "790",
"option": [ {
"valueCoding": {
"code": "180771000146100",
"system": "http://snomed.info/sct",
"display": "Focus van behandeling (waarneembare entiteit)"
}
} ],
"repeats": false,
"readOnly": true,
"required": false,
"initialCoding": {
"code": "180771000146100",
"system": "http://snomed.info/sct",
"display": "Focus van behandeling (waarneembare entiteit)"
}
}, {
"text": "Doel (UitslagWaarde)",
"type": "choice",
"linkId": "784",
"options": {
"reference": "https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-MedicalPolicyGoalVS|1.0.0-rc3"
},
"repeats": false,
"required": false
} ],
"text": "Belangrijkste overeengekomen doel van medisch beleid",
"type": "group",
"linkId": "586",
"prefix": "3",
"repeats": false
}, {
"item": [ {
"item": [ {
"text": "Behandeling",
"type": "choice",
"linkId": "791",
"option": [ {
"valueCoding": {
"code": "89666000",
"system": "http://snomed.info/sct",
"display": "Cardiopulmonale resuscitatie (verrichting)"
}
} ],
"repeats": false,
"readOnly": true,
"required": false,
"initialCoding": {
"code": "89666000",
"system": "http://snomed.info/sct",
"display": "Cardiopulmonale resuscitatie (verrichting)"
}
}, {
"item": [ {
"text": "Beperkingen",
"type": "string",
"linkId": "122",
"repeats": false,
"required": false,
"enableWhen": [ {
"question": "587",
"answerCoding": {
"code": "JA_MAAR",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"
}
} ]
}, {
"text": "Toelichting",
"type": "string",
"linkId": "86",
"repeats": false,
"required": false
} ],
"text": "BehandelingToegestaan",
"type": "choice",
"linkId": "587",
"option": [ {
"valueCoding": {
"code": "JA",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Ja"
}
}, {
"valueCoding": {
"code": "JA_MAAR",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Ja, maar met beperkingen"
}
}, {
"valueCoding": {
"code": "NEE",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Nee"
}
}, {
"valueCoding": {
"code": "UNK",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"display": "Onbekend"
}
} ],
"repeats": false,
"required": false
} ],
"text": "Reanimatie",
"type": "group",
"linkId": "792",
"prefix": "a)",
"repeats": false
}, {
"item": [ {
"text": "Behandeling",
"type": "choice",
"linkId": "794",
"option": [ {
"valueCoding": {
"code": "40617009",
"system": "http://snomed.info/sct",
"display": "Kunstmatige beademing (verrichting)"
}
} ],
"repeats": false,
"readOnly": true,
"required": false,
"initialCoding": {
"code": "40617009",
"system": "http://snomed.info/sct",
"display": "Kunstmatige beademing (verrichting)"
}
}, {
"item": [ {
"text": "Beperkingen",
"type": "string",
"linkId": "123",
"repeats": false,
"required": false,
"enableWhen": [ {
"question": "588",
"answerCoding": {
"code": "JA_MAAR",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"
}
} ]
}, {
"text": "Toelichting",
"type": "string",
"linkId": "92",
"repeats": false,
"required": false
} ],
"text": "BehandelingToegestaan",
"type": "choice",
"linkId": "588",
"option": [ {
"valueCoding": {
"code": "JA",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Ja"
}
}, {
"valueCoding": {
"code": "JA_MAAR",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Ja, maar met beperkingen"
}
}, {
"valueCoding": {
"code": "NEE",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Nee"
}
}, {
"valueCoding": {
"code": "UNK",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"display": "Onbekend"
}
} ],
"repeats": false,
"required": false
} ],
"text": "Kunstmatige invasieve beademing",
"type": "group",
"linkId": "793",
"prefix": "b)",
"repeats": false
}, {
"item": [ {
"text": "Behandeling",
"type": "choice",
"linkId": "795",
"option": [ {
"valueCoding": {
"code": "305351004",
"system": "http://snomed.info/sct",
"display": "Opname op intensive care (verrichting)"
}
} ],
"repeats": false,
"readOnly": true,
"required": false,
"initialCoding": {
"code": "305351004",
"system": "http://snomed.info/sct",
"display": "Opname op intensive care (verrichting)"
}
}, {
"item": [ {
"text": "Beperkingen",
"type": "string",
"linkId": "124",
"repeats": false,
"required": false,
"enableWhen": [ {
"question": "589",
"answerCoding": {
"code": "JA_MAAR",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"
}
} ]
}, {
"text": "Toelichting",
"type": "string",
"linkId": "88",
"repeats": false,
"required": false
} ],
"text": "BehandelingToegestaan",
"type": "choice",
"linkId": "589",
"option": [ {
"valueCoding": {
"code": "JA",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Ja"
}
}, {
"valueCoding": {
"code": "JA_MAAR",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Ja, maar met beperkingen"
}
}, {
"valueCoding": {
"code": "NEE",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Nee"
}
}, {
"valueCoding": {
"code": "UNK",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"display": "Onbekend"
}
} ],
"repeats": false,
"required": false
} ],
"text": "Opname op intensive care",
"type": "group",
"linkId": "796",
"prefix": "c)",
"repeats": false
}, {
"item": [ {
"text": "Behandeling",
"type": "choice",
"linkId": "799",
"option": [ {
"valueCoding": {
"code": "32485007",
"system": "http://snomed.info/sct",
"display": "Opname in ziekenhuis (verrichting)"
}
} ],
"repeats": false,
"readOnly": true,
"required": false,
"initialCoding": {
"code": "32485007",
"system": "http://snomed.info/sct",
"display": "Opname in ziekenhuis (verrichting)"
}
}, {
"item": [ {
"text": "Beperkingen",
"type": "string",
"linkId": "125",
"repeats": false,
"required": false,
"enableWhen": [ {
"question": "590",
"answerCoding": {
"code": "JA_MAAR",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"
}
} ]
}, {
"text": "Toelichting",
"type": "string",
"linkId": "94",
"repeats": false,
"required": false
} ],
"text": "BehandelingToegestaan",
"type": "choice",
"linkId": "590",
"option": [ {
"valueCoding": {
"code": "JA",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Ja"
}
}, {
"valueCoding": {
"code": "JA_MAAR",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Ja, maar met beperkingen"
}
}, {
"valueCoding": {
"code": "NEE",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Nee"
}
}, {
"valueCoding": {
"code": "UNK",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"display": "Onbekend"
}
} ],
"repeats": false,
"required": false
} ],
"text": "Opname in ziekenhuis",
"type": "group",
"linkId": "798",
"prefix": "d)",
"repeats": false
}, {
"item": [ {
"text": "Behandeling",
"type": "choice",
"linkId": "801",
"option": [ {
"valueCoding": {
"code": "281789004",
"system": "http://snomed.info/sct",
"display": "Antibiotische therapie (verrichting)"
}
} ],
"repeats": false,
"readOnly": true,
"required": false,
"initialCoding": {
"code": "281789004",
"system": "http://snomed.info/sct",
"display": "Antibiotische therapie (verrichting)"
}
}, {
"item": [ {
"text": "Beperkingen",
"type": "string",
"linkId": "126",
"repeats": false,
"required": false,
"enableWhen": [ {
"question": "591",
"answerCoding": {
"code": "JA_MAAR",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"
}
} ]
}, {
"text": "Toelichting",
"type": "string",
"linkId": "96",
"repeats": false,
"required": false
} ],
"text": "BehandelingToegestaan",
"type": "choice",
"linkId": "591",
"option": [ {
"valueCoding": {
"code": "JA",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Ja"
}
}, {
"valueCoding": {
"code": "JA_MAAR",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Ja, maar met beperkingen"
}
}, {
"valueCoding": {
"code": "NEE",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Nee"
}
}, {
"valueCoding": {
"code": "UNK",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"display": "Onbekend"
}
} ],
"repeats": false,
"required": false
} ],
"text": "Behandeling met antibiotica",
"type": "group",
"linkId": "800",
"prefix": "e)",
"repeats": false
}, {
"item": [ {
"text": "Behandeling",
"type": "choice",
"linkId": "803",
"option": [ {
"valueCoding": {
"code": "116762002",
"system": "http://snomed.info/sct",
"display": "Toediening van bloedproduct (verrichting)"
}
} ],
"repeats": false,
"readOnly": true,
"required": false,
"initialCoding": {
"code": "116762002",
"system": "http://snomed.info/sct",
"display": "Toediening van bloedproduct (verrichting)"
}
}, {
"item": [ {
"text": "Beperkingen",
"type": "string",
"linkId": "127",
"repeats": false,
"required": false,
"enableWhen": [ {
"question": "592",
"answerCoding": {
"code": "JA_MAAR",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"
}
} ]
}, {
"text": "Toelichting",
"type": "string",
"linkId": "98",
"repeats": false,
"required": false
} ],
"text": "BehandelingToegestaan",
"type": "choice",
"linkId": "592",
"option": [ {
"valueCoding": {
"code": "JA",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Ja"
}
}, {
"valueCoding": {
"code": "JA_MAAR",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Ja, maar met beperkingen"
}
}, {
"valueCoding": {
"code": "NEE",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Nee"
}
}, {
"valueCoding": {
"code": "UNK",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"display": "Onbekend"
}
} ],
"repeats": false,
"required": false
} ],
"text": "Toediening van een bloedproduct",
"type": "group",
"linkId": "802",
"prefix": "f)",
"repeats": false
}, {
"item": [ {
"linkId": "805",
"repeats": false,
"item": [ {
"text": "Overige behandelingen, namelijk:",
"type": "string",
"linkId": "1033",
"repeats": false,
"required": false
} ],
"type": "choice",
"option": [ {
"valueCoding": {
"code": "OTH",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"display": "Overige behandelingen"
}
} ],
"readOnly": true,
"initialCoding": {
"code": "OTH",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"display": "Overige behandelingen"
},
"required": false,
"text": "Behandeling"
}, {
"item": [ {
"text": "Toelichting",
"type": "string",
"linkId": "100",
"repeats": false,
"required": false
} ],
"text": "BehandelingToegestaan",
"type": "choice",
"linkId": "593",
"option": [ {
"valueCoding": {
"code": "JA",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Ja"
}
}, {
"valueCoding": {
"code": "NEE",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Nee"
}
}, {
"valueCoding": {
"code": "UNK",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"display": "Onbekend"
}
} ],
"repeats": false,
"required": false
} ],
"text": "Overige behandelgrenzen",
"type": "group",
"linkId": "804",
"prefix": "g)",
"repeats": false
}, {
"item": [ {
"text": "ProductType van ICD",
"type": "choice",
"linkId": "600",
"options": {
"reference": "https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-MedicalDeviceProductType-ICDVS|1.0.0-rc3"
},
"repeats": false,
"required": false,
"enableWhen": [ {
"question": "249",
"answerCoding": {
"code": "373066001",
"system": "http://snomed.info/sct"
}
} ]
}, {
"text": "Toelichting",
"type": "string",
"linkId": "599",
"repeats": false,
"required": false,
"enableWhen": [ {
"question": "249",
"answerCoding": {
"code": "373066001",
"system": "http://snomed.info/sct"
}
} ]
} ],
"text": "Heeft de patiënt een ICD?",
"type": "choice",
"linkId": "249",
"prefix": "h)",
"options": {
"reference": "https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-YesNoUnknownVS|1.0.0-rc3"
},
"repeats": false,
"required": false
}, {
"item": [ {
"text": "Behandeling van uitzetten ICD",
"type": "choice",
"linkId": "809",
"option": [ {
"valueCoding": {
"code": "400231000146108",
"system": "http://snomed.info/sct",
"display": "uitzetten van cardioverter-defibrillator in laatste levensfase (verrichting)"
}
} ],
"repeats": false,
"readOnly": true,
"required": false,
"initialCoding": {
"code": "400231000146108",
"system": "http://snomed.info/sct",
"display": "uitzetten van cardioverter-defibrillator in laatste levensfase (verrichting)"
}
}, {
"item": [ {
"text": "Toelichting gemaakte afspraken",
"type": "string",
"linkId": "596",
"repeats": false,
"required": false
} ],
"text": "Afspraak uitzetten ICD (BehandelingToegestaan)",
"type": "choice",
"linkId": "595",
"option": [ {
"valueCoding": {
"code": "JA",
"system": "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
"display": "Ja"
}
}, {
"valueCoding": {
"code": "ASKU",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"display": "Nee, nog geen besluit genomen"
}
}, {
"valueCoding": {
"code": "NASK",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"display": "Niet besproken"
}
} ],
"repeats": false,
"required": false,
"enableWhen": [ {
"question": "249",
"answerCoding": {
"code": "373066001",
"system": "http://snomed.info/sct"
}
} ]
} ],
"text": "Is er een afspraak over het moment van uitzetten ICD?",
"type": "group",
"linkId": "808",
"prefix": "i)",
"repeats": false,
"enableWhen": [ {
"question": "249",
"answerCoding": {
"code": "373066001",
"system": "http://snomed.info/sct"
}
} ]
} ],
"text": "Behandelgrenzen",
"type": "group",
"linkId": "83",
"prefix": "4",
"repeats": false
}, {
"item": [ {
"item": [ {
"text": "Wens en verwachting patient (MetingNaam)",
"type": "choice",
"linkId": "811",
"option": [ {
"valueCoding": {
"code": "153851000146100",
"system": "http://snomed.info/sct",
"display": "Wensen en verwachtingen met betrekking tot uitkomst van behandeling"
}
} ],
"repeats": false,
"readOnly": true,
"required": false,
"initialCoding": {
"code": "153851000146100",
"system": "http://snomed.info/sct",
"display": "Wensen en verwachtingen met betrekking tot uitkomst van behandeling"
}
}, {
"text": "Wens en verwachting patient (UitslagWaarde)",
"type": "string",
"linkId": "382",
"repeats": false,
"required": false
}, {
"text": "Vaststellen wens en verwachting patiënt (Meetmethode)",
"type": "choice",
"linkId": "1034",
"option": [ {
"valueCoding": {
"code": "370819000",
"system": "http://snomed.info/sct",
"display": "Vaststellen van persoonlijke waarden en wensen met betrekking tot zorg"
}
} ],
"repeats": false,
"readOnly": true,
"required": false,
"initialCoding": {
"code": "370819000",
"system": "http://snomed.info/sct",
"display": "Vaststellen van persoonlijke waarden en wensen met betrekking tot zorg"
}
} ],
"text": "Wat zouden zorgverleners, volgens de patiënt, moeten weten om goede zorg te kunnen verlenen? Heeft deze patiënt specifieke wensen met betrekking tot zijn zorg? (incl. culturele/religieuze/sociale/spirituele aspecten)",
"type": "group",
"linkId": "810",
"prefix": "a)",
"repeats": false
}, {
"item": [ {
"text": "MetingNaam voor Gewenste plek van overlijden",
"type": "choice",
"linkId": "1035",
"option": [ {
"valueCoding": {
"code": "395091006",
"system": "http://snomed.info/sct",
"display": "Voorkeur voor plaats van overlijden (waarneembare entiteit)"
}
} ],
"repeats": false,
"readOnly": true,
"required": false,
"initialCoding": {
"code": "395091006",
"system": "http://snomed.info/sct",
"display": "Voorkeur voor plaats van overlijden (waarneembare entiteit)"
}
}, {
"item": [ {
"text": "Toelichting",
"type": "string",
"linkId": "110",
"repeats": false,
"required": false
} ],
"text": "Voorkeursplek (UitslagWaarde)",
"type": "choice",
"linkId": "604",
"options": {
"reference": "https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-PreferredPlaceOfDeathVS|1.0.0-rc3"
},
"repeats": false,
"required": false
}, {
"item": [ {
"text": "MetingNaam voor Euthanasie standpunt",
"type": "choice",
"linkId": "816",
"option": [ {
"valueCoding": {
"code": "340171000146104",
"system": "http://snomed.info/sct",
"display": "Standpunt ten opzichte van euthanasie (waarneembare entiteit)"
}
} ],
"repeats": false,
"readOnly": true,
"required": false,
"initialCoding": {
"code": "340171000146104",
"system": "http://snomed.info/sct",
"display": "Standpunt ten opzichte van euthanasie (waarneembare entiteit)"
}
}, {
"item": [ {
"text": "Toelichting",
"type": "string",
"linkId": "112",
"repeats": false,
"required": false
} ],
"text": "Standpunt (UitslagWaarde)",
"type": "choice",
"linkId": "785",
"options": {
"reference": "https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-PositionRegardingEuthanasiaVS|1.0.0-rc3"
},
"repeats": false,
"required": false
} ],
"text": "Euthanasie standpunt",
"type": "group",
"linkId": "813",
"prefix": "c)",
"repeats": false
}, {
"item": [ {
"text": "MetingNaam voor Keuze orgaandonatie vastgelegd in donorregister?",
"type": "choice",
"linkId": "817",
"option": [ {
"valueCoding": {
"code": "570801000146104",
"system": "http://snomed.info/sct",
"display": "Geregistreerd in orgaan donorregister (bevinding)"
}
} ],
"repeats": false,
"readOnly": true,
"required": false,
"initialCoding": {
"code": "570801000146104",
"system": "http://snomed.info/sct",
"display": "Geregistreerd in orgaan donorregister (bevinding)"
}
}, {
"text": "Keuze orgaandonatie in donorregister (UitslagWaarde)",
"type": "choice",
"linkId": "789",
"options": {
"reference": "https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-YesNoUnknownVS|1.0.0-rc3"
},
"repeats": false,
"required": false
}, {
"text": "Meetmethode voor Keuze orgaandonatie vastgelegd in donorregister?",
"type": "choice",
"linkId": "1036",
"option": [ {
"valueCoding": {
"code": "1156040003",
"system": "http://snomed.info/sct",
"display": "Self reported (qualifier value)"
}
} ],
"repeats": false,
"readOnly": true,
"required": false,
"initialCoding": {
"code": "1156040003",
"system": "http://snomed.info/sct",
"display": "Self reported (qualifier value)"
}
} ],
"text": "Keuze orgaandonatie vastgelegd in donorregister?",
"type": "group",
"linkId": "814",
"prefix": "d)",
"repeats": false
} ],
"text": "Gewenste plek van overlijden",
"type": "group",
"linkId": "812",
"prefix": "b)",
"repeats": false
}, {
"item": [ {
"text": "MetingNaam voor Wat verder nog belangrijk is",
"type": "choice",
"linkId": "818",
"option": [ {
"valueCoding": {
"code": "247751003",
"system": "http://snomed.info/sct",
"display": "Gevoel van zingeving (waarneembare entiteit)"
}
} ],
"repeats": false,
"readOnly": true,
"required": false,
"initialCoding": {
"code": "247751003",
"system": "http://snomed.info/sct",
"display": "Gevoel van zingeving (waarneembare entiteit)"
}
}, {
"text": "Wat verder nog belangrijk is (UitslagWaarde)",
"type": "string",
"linkId": "383",
"repeats": false,
"required": false
} ],
"text": "Wat verder nog belangrijk is",
"type": "group",
"linkId": "598",
"prefix": "6",
"repeats": false
}, {
"item": [ {
"item": [ {
"text": "Toelichting",
"type": "string",
"linkId": "254",
"repeats": false,
"required": false
} ],
"text": "Heeft de patiënt eerder behandelafspraken vastgelegd?",
"type": "choice",
"linkId": "253",
"prefix": "a)",
"options": {
"reference": "https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-YesNoUnknownVS|1.0.0-rc3"
},
"repeats": false,
"required": false
}, {
"text": "Staan in eerder vastgelegde behandelafspraken andere wensen dan nu in deze verklaring?",
"type": "choice",
"linkId": "255",
"prefix": "b)",
"options": {
"reference": "https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-YesNoUnknownVS|1.0.0-rc3"
},
"repeats": false,
"required": false,
"enableWhen": [ {
"question": "253",
"answerCoding": {
"code": "373066001",
"system": "http://snomed.info/sct"
}
} ]
} ],
"text": "Eerder vastgelegde behandelwensen",
"type": "group",
"linkId": "115",
"prefix": "7",
"repeats": false
}, {
"item": [ {
"text": "Heeft u patient geïnformeerd over eigen verantwoordelijkheid om deze behandelafspraken met naasten te bespreken?",
"type": "boolean",
"linkId": "256",
"prefix": "a)",
"repeats": false,
"required": false
}, {
"text": "Patiënt gaat akkoord met het delen van deze behandelafspraken met andere betrokken hulpverleners",
"type": "choice",
"linkId": "257",
"option": [ {
"valueCoding": {
"code": "441898007",
"system": "http://snomed.info/sct",
"display": "Akkoord"
}
}, {
"valueCoding": {
"code": "UNK",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"display": "Nog onbekend"
}
} ],
"prefix": "b)",
"repeats": false,
"required": false
} ],
"text": "Informatie delen",
"type": "group",
"linkId": "119",
"prefix": "8",
"repeats": false
} ],
"text": "Behandelwensen",
"type": "group",
"linkId": "107",
"prefix": "5",
"repeats": false
} ],
"text": "Gesprek gevoerd door:",
"type": "group",
"linkId": "8",
"repeats": false
} ],
"copyright": "This form is subject to copyright, user rights and a disclaimer, as specified for all IKNL information standards. For details, see the paragraph on Gebruikersrechten en disclaimer at https://iknl.nl/onderzoek/eenheid-van-taal.",
"type": null,
"experimental": "false",
"resourceType": "Questionnaire",
"title": "Uniform vastleggen proactieve zorgpanning (PZP) o.b.v. zibs2017 - ReleaseCandidate3 06-02-2026",
"package_version": "1.0.0-rc3",
"status": "draft",
"id": "34aa57f8-5ae8-4947-bb34-70dd4f7fbab3",
"kind": null,
"url": "https://api.iknl.nl/docs/pzp/stu3/Questionnaire/ACP-zib2017",
"version": "1.0.0-rc3",
"contact": [ {
"telecom": [ {
"value": "https://www.iknl.nl",
"system": "url"
} ]
} ]
}