# Uniform vastleggen proactieve zorgplanning (PZP) o.b.v. zibs2017 - Release 17-08-2026 - Advance Care Planning (PZP) STU3 v1.0.0

## Questionnaire: Uniform vastleggen proactieve zorgplanning (PZP) o.b.v. zibs2017 - Release 17-08-2026 

 
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. Enter '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. 

*  [Tree view](#tabs-tree) 
*  [Sample Rendering](#tabs-sample) 
*  [Form Logic](#tabs-logic) 

### Test this Questionnaire

### Responses for this Questionnaire

There are currently no QuestionnaireResponse instances for this Questionnaire defined in this IG.



## Resource Content

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  "meta" : {
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  "url" : "https://api.iknl.nl/docs/pzp/stu3/Questionnaire/ACP-zib2017",
  "version" : "1.0.0",
  "name" : "ACPzib2017",
  "title" : "Uniform vastleggen proactieve zorgplanning (PZP) o.b.v. zibs2017 - Release 17-08-2026",
  "status" : "draft",
  "experimental" : false,
  "date" : "2026-08-11T11:10:11+02:00",
  "publisher" : "IKNL",
  "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",
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  "item" : [{
    "linkId" : "385",
    "text" : "Datum van invullen",
    "type" : "dateTime",
    "required" : false,
    "repeats" : false
  },
  {
    "linkId" : "7",
    "text" : "Naam patiënt",
    "type" : "group",
    "repeats" : false,
    "item" : [{
      "linkId" : "386",
      "text" : "Voornamen",
      "type" : "string",
      "required" : false,
      "repeats" : false
    },
    {
      "linkId" : "387",
      "text" : "Voorvoegsels",
      "type" : "string",
      "required" : false,
      "repeats" : false
    },
    {
      "linkId" : "388",
      "text" : "Achternaam",
      "type" : "string",
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      "repeats" : false
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  {
    "linkId" : "8",
    "text" : "Gesprek gevoerd door:",
    "type" : "group",
    "repeats" : false,
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      "text" : "Naam zorgverlener",
      "type" : "group",
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        "text" : "Voornamen",
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      },
      {
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        "linkId" : "391",
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        "type" : "string",
        "required" : false,
        "repeats" : false
      }]
    },
    {
      "linkId" : "786",
      "text" : "Functie (Specialisme)",
      "type" : "choice",
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      "repeats" : false,
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    },
    {
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      "text" : "Wilsbekwaamheid & Wettelijke vertegenwoordiging",
      "type" : "group",
      "repeats" : false,
      "item" : [{
        "linkId" : "1037",
        "text" : "Is de patiënt op dit moment wilsbekwaam m.b.t. medische behandelbeslissingen?",
        "type" : "boolean",
        "required" : false,
        "repeats" : false,
        "item" : [{
          "linkId" : "788",
          "text" : "Toelichting",
          "type" : "string",
          "required" : false,
          "repeats" : false
        }]
      },
      {
        "linkId" : "29",
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        "type" : "group",
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        "item" : [{
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            "linkId" : "392",
            "text" : "Voornamen",
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          {
            "linkId" : "393",
            "text" : "Voorvoegsels",
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            "repeats" : false
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            "repeats" : false
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        },
        {
          "linkId" : "39",
          "prefix" : "b)",
          "text" : "Contactgegevens wettelijk vertegenwoordiger",
          "type" : "group",
          "repeats" : false,
          "item" : [{
            "linkId" : "40",
            "text" : "Telefoonnummers",
            "type" : "group",
            "repeats" : true,
            "item" : [{
              "linkId" : "398",
              "text" : "Telefoonnummer",
              "type" : "string",
              "required" : false,
              "repeats" : false
            },
            {
              "linkId" : "399",
              "text" : "TelecomType",
              "type" : "choice",
              "required" : false,
              "repeats" : false,
              "option" : [{
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                  "display" : "Vast telefoonnummer"
                }
              },
              {
                "valueCoding" : {
                  "system" : "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4.22.1",
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                  "display" : "Fax"
                }
              },
              {
                "valueCoding" : {
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              },
              {
                "valueCoding" : {
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                  "code" : "PG",
                  "display" : "Pieper"
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              }]
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              "linkId" : "400",
              "text" : "NummerSoort",
              "type" : "choice",
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              "repeats" : false,
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                  "display" : "Telefoonnummer thuis"
                }
              },
              {
                "valueCoding" : {
                  "system" : "http://terminology.hl7.org/CodeSystem/v3-AddressUse",
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              },
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              }]
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          },
          {
            "linkId" : "41",
            "text" : "EmailAdressen",
            "type" : "group",
            "repeats" : true,
            "item" : [{
              "linkId" : "401",
              "text" : "EmailAdres",
              "type" : "string",
              "required" : false,
              "repeats" : false
            },
            {
              "linkId" : "402",
              "text" : "EmailSoort",
              "type" : "choice",
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              {
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          },
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          },
          {
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              "system" : "http://snomed.info/sct",
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              "display" : "Curator (juridisch)"
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          },
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              "display" : "Mentor"
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          },
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              "display" : "Anders"
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        {
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              "display" : "Echtgenoot"
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              "display" : "Vader"
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          },
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            "valueCoding" : {
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              "display" : "Moeder"
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          },
          {
            "valueCoding" : {
              "system" : "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
              "code" : "SONC",
              "display" : "Zoon"
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          },
          {
            "valueCoding" : {
              "system" : "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
              "code" : "DAUC",
              "display" : "Dochter"
            }
          },
          {
            "valueCoding" : {
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              "display" : "Broer"
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          {
            "valueCoding" : {
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              "code" : "SIS",
              "display" : "Zuster"
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          },
          {
            "valueCoding" : {
              "system" : "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
              "code" : "OTH",
              "display" : "Anders"
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            "required" : false,
            "repeats" : false
          }]
        },
        {
          "linkId" : "52",
          "prefix" : "d)",
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          "required" : false,
          "repeats" : false
        },
        {
          "linkId" : "53",
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          "type" : "group",
          "enableWhen" : [{
            "question" : "52",
            "answerBoolean" : false
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          "repeats" : false,
          "item" : [{
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            "text" : "Voornamen",
            "type" : "string",
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            "repeats" : false
          },
          {
            "linkId" : "396",
            "text" : "Voorvoegsels",
            "type" : "string",
            "required" : false,
            "repeats" : false
          },
          {
            "linkId" : "397",
            "text" : "Achternaam",
            "type" : "string",
            "required" : false,
            "repeats" : false
          }]
        },
        {
          "linkId" : "61",
          "prefix" : "f)",
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          "type" : "group",
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            "answerBoolean" : false
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          "repeats" : false,
          "item" : [{
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            "text" : "Telefoonnummers",
            "type" : "group",
            "repeats" : true,
            "item" : [{
              "linkId" : "403",
              "text" : "Telefoonnummer",
              "type" : "string",
              "required" : false,
              "repeats" : false
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            {
              "linkId" : "404",
              "text" : "TelecomType",
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              "repeats" : false,
              "option" : [{
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                }
              },
              {
                "valueCoding" : {
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              },
              {
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              },
              {
                "valueCoding" : {
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              },
              {
                "valueCoding" : {
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          },
          {
            "linkId" : "66",
            "text" : "EmailAdressen",
            "type" : "group",
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            {
              "linkId" : "407",
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              "repeats" : false,
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              },
              {
                "valueCoding" : {
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                  "display" : "Zakelijk e-mailadres"
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        {
          "linkId" : "819",
          "text" : "Rol",
          "type" : "choice",
          "required" : false,
          "repeats" : false,
          "readOnly" : true,
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            }
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          "initialCoding" : {
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            "display" : "Eerste relatie/contactpersoon"
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        },
        {
          "linkId" : "77",
          "prefix" : "g)",
          "text" : "Relatie tot patiënt",
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            "answerBoolean" : false
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              "display" : "Partner"
            }
          },
          {
            "valueCoding" : {
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          },
          {
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              "display" : "Echtgenote"
            }
          },
          {
            "valueCoding" : {
              "system" : "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
              "code" : "FTH",
              "display" : "Vader"
            }
          },
          {
            "valueCoding" : {
              "system" : "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
              "code" : "MTH",
              "display" : "Moeder"
            }
          },
          {
            "valueCoding" : {
              "system" : "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
              "code" : "SONC",
              "display" : "Zoon"
            }
          },
          {
            "valueCoding" : {
              "system" : "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
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              "display" : "Dochter"
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          },
          {
            "valueCoding" : {
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              "code" : "BRO",
              "display" : "Broer"
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          },
          {
            "valueCoding" : {
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              "code" : "SIS",
              "display" : "Zuster"
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          },
          {
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              "display" : "Anders"
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      }]
    },
    {
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      "prefix" : "2",
      "text" : "Gesprek gevoerd in bijzijn van",
      "type" : "group",
      "repeats" : false,
      "item" : [{
        "linkId" : "82",
        "text" : "Patiënt",
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            "repeats" : false
          }]
        }]
      },
      {
        "linkId" : "249",
        "prefix" : "h)",
        "text" : "Heeft de patiënt een ICD?",
        "type" : "choice",
        "required" : false,
        "repeats" : false,
        "options" : {
          "reference" : "https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-YesNoUnknownVS|1.0.0"
        },
        "item" : [{
          "linkId" : "600",
          "text" : "ProductType van ICD",
          "type" : "choice",
          "enableWhen" : [{
            "question" : "249",
            "answerCoding" : {
              "system" : "http://snomed.info/sct",
              "code" : "373066001"
            }
          }],
          "required" : false,
          "repeats" : false,
          "options" : {
            "reference" : "https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-MedicalDeviceProductType-ICDVS|1.0.0"
          }
        },
        {
          "linkId" : "599",
          "text" : "Toelichting",
          "type" : "string",
          "enableWhen" : [{
            "question" : "249",
            "answerCoding" : {
              "system" : "http://snomed.info/sct",
              "code" : "373066001"
            }
          }],
          "required" : false,
          "repeats" : false
        }]
      },
      {
        "linkId" : "808",
        "prefix" : "i)",
        "text" : "Is er een afspraak over het moment van uitzetten ICD?",
        "type" : "group",
        "enableWhen" : [{
          "question" : "249",
          "answerCoding" : {
            "system" : "http://snomed.info/sct",
            "code" : "373066001"
          }
        }],
        "repeats" : false,
        "item" : [{
          "linkId" : "809",
          "text" : "Behandeling van uitzetten ICD",
          "type" : "choice",
          "required" : false,
          "repeats" : false,
          "readOnly" : true,
          "option" : [{
            "valueCoding" : {
              "system" : "http://snomed.info/sct",
              "code" : "400231000146108",
              "display" : "uitzetten van cardioverter-defibrillator in laatste levensfase (verrichting)"
            }
          }],
          "initialCoding" : {
            "system" : "http://snomed.info/sct",
            "code" : "400231000146108",
            "display" : "uitzetten van cardioverter-defibrillator in laatste levensfase (verrichting)"
          }
        },
        {
          "linkId" : "595",
          "text" : "Afspraak uitzetten ICD (BehandelingToegestaan)",
          "type" : "choice",
          "enableWhen" : [{
            "question" : "249",
            "answerCoding" : {
              "system" : "http://snomed.info/sct",
              "code" : "373066001"
            }
          }],
          "required" : false,
          "repeats" : false,
          "option" : [{
            "valueCoding" : {
              "system" : "urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4",
              "code" : "JA",
              "display" : "Ja"
            }
          },
          {
            "valueCoding" : {
              "system" : "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
              "code" : "ASKU",
              "display" : "Nee, nog geen besluit genomen"
            }
          },
          {
            "valueCoding" : {
              "system" : "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
              "code" : "NASK",
              "display" : "Niet besproken"
            }
          }],
          "item" : [{
            "linkId" : "596",
            "text" : "Toelichting gemaakte afspraken",
            "type" : "string",
            "required" : false,
            "repeats" : false
          }]
        }]
      }]
    },
    {
      "linkId" : "107",
      "prefix" : "5",
      "text" : "Behandelwensen",
      "type" : "group",
      "repeats" : false,
      "item" : [{
        "linkId" : "810",
        "prefix" : "a)",
        "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",
        "repeats" : false,
        "item" : [{
          "linkId" : "811",
          "text" : "Wens en verwachting patient (MetingNaam)",
          "type" : "choice",
          "required" : false,
          "repeats" : false,
          "readOnly" : true,
          "option" : [{
            "valueCoding" : {
              "system" : "http://snomed.info/sct",
              "code" : "153851000146100",
              "display" : "Wensen en verwachtingen met betrekking tot uitkomst van behandeling"
            }
          }],
          "initialCoding" : {
            "system" : "http://snomed.info/sct",
            "code" : "153851000146100",
            "display" : "Wensen en verwachtingen met betrekking tot uitkomst van behandeling"
          }
        },
        {
          "linkId" : "382",
          "text" : "Wens en verwachting patient (UitslagWaarde)",
          "type" : "string",
          "required" : false,
          "repeats" : false
        },
        {
          "linkId" : "1034",
          "text" : "Vaststellen wens en verwachting patiënt (Meetmethode)",
          "type" : "choice",
          "required" : false,
          "repeats" : false,
          "readOnly" : true,
          "option" : [{
            "valueCoding" : {
              "system" : "http://snomed.info/sct",
              "code" : "370819000",
              "display" : "Vaststellen van persoonlijke waarden en wensen met betrekking tot zorg"
            }
          }],
          "initialCoding" : {
            "system" : "http://snomed.info/sct",
            "code" : "370819000",
            "display" : "Vaststellen van persoonlijke waarden en wensen met betrekking tot zorg"
          }
        }]
      },
      {
        "linkId" : "812",
        "prefix" : "b)",
        "text" : "Gewenste plek van overlijden",
        "type" : "group",
        "repeats" : false,
        "item" : [{
          "linkId" : "1035",
          "text" : "MetingNaam voor Gewenste plek van overlijden",
          "type" : "choice",
          "required" : false,
          "repeats" : false,
          "readOnly" : true,
          "option" : [{
            "valueCoding" : {
              "system" : "http://snomed.info/sct",
              "code" : "395091006",
              "display" : "Voorkeur voor plaats van overlijden (waarneembare entiteit)"
            }
          }],
          "initialCoding" : {
            "system" : "http://snomed.info/sct",
            "code" : "395091006",
            "display" : "Voorkeur voor plaats van overlijden (waarneembare entiteit)"
          }
        },
        {
          "linkId" : "604",
          "text" : "Voorkeursplek (UitslagWaarde)",
          "type" : "choice",
          "required" : false,
          "repeats" : false,
          "options" : {
            "reference" : "https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-PreferredPlaceOfDeathVS|1.0.0"
          },
          "item" : [{
            "linkId" : "1039",
            "text" : "Anders, namelijk:",
            "type" : "string",
            "enableWhen" : [{
              "question" : "604",
              "answerCoding" : {
                "system" : "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
                "code" : "OTH"
              }
            }],
            "required" : false,
            "repeats" : false
          },
          {
            "linkId" : "110",
            "text" : "Toelichting",
            "type" : "string",
            "required" : false,
            "repeats" : false
          }]
        },
        {
          "linkId" : "813",
          "prefix" : "c)",
          "text" : "Euthanasie standpunt",
          "type" : "group",
          "repeats" : false,
          "item" : [{
            "linkId" : "816",
            "text" : "MetingNaam voor Euthanasie standpunt",
            "type" : "choice",
            "required" : false,
            "repeats" : false,
            "readOnly" : true,
            "option" : [{
              "valueCoding" : {
                "system" : "http://snomed.info/sct",
                "code" : "340171000146104",
                "display" : "Standpunt ten opzichte van euthanasie (waarneembare entiteit)"
              }
            }],
            "initialCoding" : {
              "system" : "http://snomed.info/sct",
              "code" : "340171000146104",
              "display" : "Standpunt ten opzichte van euthanasie (waarneembare entiteit)"
            }
          },
          {
            "linkId" : "785",
            "text" : "Standpunt (UitslagWaarde)",
            "type" : "choice",
            "required" : false,
            "repeats" : false,
            "options" : {
              "reference" : "https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-PositionRegardingEuthanasiaVS|1.0.0"
            },
            "item" : [{
              "linkId" : "112",
              "text" : "Toelichting",
              "type" : "string",
              "required" : false,
              "repeats" : false
            }]
          }]
        },
        {
          "linkId" : "814",
          "prefix" : "d)",
          "text" : "Keuze orgaandonatie vastgelegd in donorregister?",
          "type" : "group",
          "repeats" : false,
          "item" : [{
            "linkId" : "817",
            "text" : "MetingNaam voor Keuze orgaandonatie vastgelegd in donorregister?",
            "type" : "choice",
            "required" : false,
            "repeats" : false,
            "readOnly" : true,
            "option" : [{
              "valueCoding" : {
                "system" : "http://snomed.info/sct",
                "code" : "570801000146104",
                "display" : "Geregistreerd in orgaan donorregister (bevinding)"
              }
            }],
            "initialCoding" : {
              "system" : "http://snomed.info/sct",
              "code" : "570801000146104",
              "display" : "Geregistreerd in orgaan donorregister (bevinding)"
            }
          },
          {
            "linkId" : "789",
            "text" : "Keuze orgaandonatie in donorregister (UitslagWaarde)",
            "type" : "choice",
            "required" : false,
            "repeats" : false,
            "options" : {
              "reference" : "https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-YesNoUnknownVS|1.0.0"
            }
          },
          {
            "linkId" : "1036",
            "text" : "Meetmethode voor Keuze orgaandonatie vastgelegd in donorregister?",
            "type" : "choice",
            "required" : false,
            "repeats" : false,
            "readOnly" : true,
            "option" : [{
              "valueCoding" : {
                "system" : "http://snomed.info/sct",
                "code" : "1156040003",
                "display" : "Self reported (qualifier value)"
              }
            }],
            "initialCoding" : {
              "system" : "http://snomed.info/sct",
              "code" : "1156040003",
              "display" : "Self reported (qualifier value)"
            }
          }]
        }]
      },
      {
        "linkId" : "598",
        "prefix" : "6",
        "text" : "Wat verder nog belangrijk is",
        "type" : "group",
        "repeats" : false,
        "item" : [{
          "linkId" : "818",
          "text" : "MetingNaam voor Wat verder nog belangrijk is",
          "type" : "choice",
          "required" : false,
          "repeats" : false,
          "readOnly" : true,
          "option" : [{
            "valueCoding" : {
              "system" : "http://snomed.info/sct",
              "code" : "247751003",
              "display" : "Gevoel van zingeving (waarneembare entiteit)"
            }
          }],
          "initialCoding" : {
            "system" : "http://snomed.info/sct",
            "code" : "247751003",
            "display" : "Gevoel van zingeving (waarneembare entiteit)"
          }
        },
        {
          "linkId" : "383",
          "text" : "Wat verder nog belangrijk is (UitslagWaarde)",
          "type" : "string",
          "required" : false,
          "repeats" : false
        }]
      },
      {
        "linkId" : "115",
        "prefix" : "7",
        "text" : "Eerder vastgelegde behandelwensen",
        "type" : "group",
        "repeats" : false,
        "item" : [{
          "linkId" : "253",
          "prefix" : "a)",
          "text" : "Heeft de patiënt eerder behandelafspraken vastgelegd?",
          "type" : "choice",
          "required" : false,
          "repeats" : false,
          "options" : {
            "reference" : "https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-YesNoUnknownVS|1.0.0"
          },
          "item" : [{
            "linkId" : "254",
            "text" : "Toelichting",
            "type" : "string",
            "required" : false,
            "repeats" : false
          }]
        },
        {
          "linkId" : "255",
          "prefix" : "b)",
          "text" : "Staan in eerder vastgelegde behandelafspraken andere wensen dan nu in deze verklaring?",
          "type" : "choice",
          "enableWhen" : [{
            "question" : "253",
            "answerCoding" : {
              "system" : "http://snomed.info/sct",
              "code" : "373066001"
            }
          }],
          "required" : false,
          "repeats" : false,
          "options" : {
            "reference" : "https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-YesNoUnknownVS|1.0.0"
          }
        }]
      },
      {
        "linkId" : "119",
        "prefix" : "8",
        "text" : "Informatie delen",
        "type" : "group",
        "repeats" : false,
        "item" : [{
          "linkId" : "256",
          "prefix" : "a)",
          "text" : "Heeft u patient geïnformeerd over eigen verantwoordelijkheid om deze behandelafspraken met naasten te bespreken?",
          "type" : "boolean",
          "required" : false,
          "repeats" : false
        },
        {
          "linkId" : "257",
          "prefix" : "b)",
          "text" : "Patiënt gaat akkoord met het delen van deze behandelafspraken met andere betrokken hulpverleners",
          "type" : "choice",
          "required" : false,
          "repeats" : false,
          "option" : [{
            "valueCoding" : {
              "system" : "http://snomed.info/sct",
              "code" : "441898007",
              "display" : "Akkoord"
            }
          },
          {
            "valueCoding" : {
              "system" : "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
              "code" : "UNK",
              "display" : "Nog onbekend"
            }
          }]
        }]
      }]
    }]
  }]
}

```
