MedMij:Vdraft InhoudelijkeGegevens Integrale Zwangerschapskaart: verschil tussen versies
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| Regel 4: | Regel 4: | ||
=Addenda voor inhoudelijke gegevens Integrale zwangerschapskaart 3.2=</noinclude> | =Addenda voor inhoudelijke gegevens Integrale zwangerschapskaart 3.2=</noinclude> | ||
==Vrouw 1, Kaart 1 - data 1e lijn (actieve zwangerschap)== | ==Scenario Vrouw 1, Kaart 1 - data 1e lijn (actieve zwangerschap)== | ||
<section begin= /> | <section begin= /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| Regel 31: | Regel 31: | ||
|colspan="6"|<span id="Vrouw1" title="Intern ID = Vrouw1">Patient Vrouw1</span> | |colspan="6"|<span id="Vrouw1" title="Intern ID = Vrouw1">Patient Vrouw1</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="20"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Naamgegevens | |colspan="5"|Naamgegevens | ||
| Regel 74: | Regel 74: | ||
|colspan="3"|Adres soort | |colspan="3"|Adres soort | ||
|style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Identificatienummer | |||
|style="background-color: white;"|999900717 (in identificerend systeem: BSN) | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geboortedatum | |colspan="4"|Geboortedatum | ||
|style="background-color: white;"|18 okt 1985 | |style="background-color: white;"|18 okt 1985 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geslacht | |colspan="4"|Geslacht administratief | ||
|style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 169: | Regel 172: | ||
<section begin=zwangerschapsgegevens_ /> | <section begin=zwangerschapsgegevens_ /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zwangerschapsgegevens | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="4" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Coordinerend zorgverlener | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Zorgverlener | ||
|style="background-color: white;"|Zie [[#ZV1|Zorgverlener: ZV1]] | |style="background-color: white;"|Zie [[#ZV1|Zorgverlener: ZV1]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Zwangerschap | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="10"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="3"|Zwangerschapsduur | ||
|style="background-color: white;"|56 dagen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Pariteit | ||
|style="background-color: white;"|1 | |style="background-color: white;"|1 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Graviditeit | ||
|style="background-color: white;"|3 | |style="background-color: white;"|3 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Aterme datum items | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Aterme datum | ||
|style="background-color: white;"|T + 99 dagen | |style="background-color: white;"|T + 99 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Bepalings methode | ||
|style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): zwangerschapstest clearlypink met zwangerschapsduur-indicator | |style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): zwangerschapstest clearlypink met zwangerschapsduur-indicator | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Datum bepaling | ||
|style="background-color: white;"| | |style="background-color: white;"|NullFlavor: UNK | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Datum laatste menstruatie | |||
|style="background-color: white;"|T - 209 dagen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Definitieve a terme datum observatie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Definitieve a terme datum tijd | ||
|style="background-color: white;"|T - 125 dagen | |style="background-color: white;"|T - 125 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Definitieve a terme waarde | ||
|style="background-color: white;"|T + 94 dagen | |style="background-color: white;"|T + 94 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Definitieve a terme methode | ||
|style="background-color: white;"|echografie van foetus (verrichting) (code = '241491007' in codeSystem 'SNOMED CT') | |style="background-color: white;"|echografie van foetus (verrichting) (code = '241491007' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Aantal foetussen observatie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Aantal foetussen waarde | |||
|style="background-color: white;"|1 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Aantal levende kinderen observatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Aantal levende kinderen datum tijd | ||
|style="background-color: white;"|T - 125 dagen | |style="background-color: white;"|T - 125 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Aantal levende kinderen waarde | ||
|style="background-color: white;"|1 | |style="background-color: white;"|1 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Observatie methode | ||
|style="background-color: white;"|echografie van foetus (verrichting) (code = '241491007' in codeSystem 'SNOMED CT') | |style="background-color: white;"|echografie van foetus (verrichting) (code = '241491007' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Fetal loss observatie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Fetal loss datum tijd | ||
|style="background-color: white;"| | |style="background-color: white;"|NullFlavor: ASKU | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Fetal loss waarde | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Toelichting | ||
|style="background-color: white;"|mw. zegt vroege miskraam te hebben gehad enkele maanden na eerste kind, destijds geen verloskundige gezien | |style="background-color: white;"|mw. zegt vroege miskraam te hebben gehad enkele maanden na eerste kind, destijds geen verloskundige gezien | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Foliumzuurgebruik observatie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Foliumzuurgebruik datum tijd | ||
|style="background-color: white;"|T - 139 dagen | |style="background-color: white;"|T - 139 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Foliumzuurgebruik waarde | ||
|style="background-color: white;"|preconceptionele intake van foliumzuur via voeding (bevinding) (code = '29761000146100' in codeSystem 'SNOMED CT') | |style="background-color: white;"|preconceptionele intake van foliumzuur via voeding (bevinding) (code = '29761000146100' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Prenatale controle | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="13"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="3"|Lichaamsgewicht | ||
|style="background-color: white;"|Zie [[#Gewicht-139D|Lichaamsgewicht: Gewicht-139D]] | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| | |colspan="3"|Bloeddruk | ||
|style="background-color: white;"| | |style="background-color: white;"|Zie [[#BP-139D|Bloeddruk: BP-139D]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Alcohol gebruik | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Toelichting | ||
|style="background-color: white;"|tbv conceptie al gestopt met alcohol consumptie | |style="background-color: white;"|tbv conceptie al gestopt met alcohol consumptie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Alcohol gebruik status | ||
|style="background-color: white;"|drinkt geen alcohol | |style="background-color: white;"|drinkt geen alcohol (code = '105542008' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Drugs gebruik | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Drugs gebruik status | ||
|style="background-color: white;"|heeft nooit drugs gebruikt (code = '228368007' in codeSystem 'SNOMED CT') | |style="background-color: white;"|heeft nooit drugs gebruikt (code = '228368007' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Tabak gebruik | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Tabak gebruik status | ||
|style="background-color: white;"|heeft nooit gerookt (code = '266919005' in codeSystem 'SNOMED CT') | |style="background-color: white;"|heeft nooit gerookt (code = '266919005' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Prenatale controle | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="8"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Leven voelen observatie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Leven voelen datum tijd | |||
|style="background-color: white;"|T - 10 dagen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Leven voelen waarde | ||
|style="background-color: white;"| | |style="background-color: white;"|zwakke foetale bewegingen (bevinding) (code = '276372004' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="2"|Toelichting | ||
|style="background-color: white;"|voelt sinds enkele dagen minder frequent bewegingen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| | |colspan="3"|Lichaamsgewicht | ||
|style="background-color: white;"|Zie [[# | |style="background-color: white;"|Zie [[#Gewicht-6D|Lichaamsgewicht: Gewicht-6D]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Bloeddruk | |||
|style="background-color: white;"|Zie [[#BP-6D|Bloeddruk: BP-6D]] | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|<span id="Probleem1" title="Intern ID = Probleem1">Probleem zwangerschap Probleem1</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="7"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| | |colspan="3"|Probleem type | ||
|style="background-color: white;"| | |style="background-color: white;"|Symptoom gerapporteerd door patiënt of andere bron van voorgeschiedenis (code = '418799008' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| | |colspan="3"|Probleem naam | ||
|style="background-color: white;"|zwakke foetale bewegingen (bevinding) (code = '276372004' in codeSystem 'SNOMED CT') | |style="background-color: white;"|zwakke foetale bewegingen (bevinding) (code = '276372004' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| | |colspan="3"|Probleem begin datum | ||
|style="background-color: white;"| | |style="background-color: white;"|T - 10 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| | |colspan="3"|Probleem eind datum | ||
|style="background-color: white;"| | |style="background-color: white;"|T - 6 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Zwangerschapsduur | ||
|style="background-color: white;"| | |style="background-color: white;"|189 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Probleem status | ||
|style="background-color: white;"| | |style="background-color: white;"|Niet actueel (code = '73425007' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|Verrichting zwangerschap | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="3"|Verrichting start datum | ||
|style="background-color: white;"|T - 139 dagen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Verrichting type | ||
|style="background-color: white;"| | |style="background-color: white;"|echografie van foetus (verrichting) (code = '241491007' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verrichting zwangerschap | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Verrichting start datum | ||
|style="background-color: white;"| | |style="background-color: white;"|T - 139 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Verrichting type | ||
|style="background-color: white;"| | |style="background-color: white;"|aanbieden van voorlichtingsmateriaal (verrichting) (code = '445283009' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Verrichting zwangerschap | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Verrichting start datum | ||
|style="background-color: white;"| | |style="background-color: white;"|T - 6 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Verrichting type | ||
|style="background-color: white;"| | |style="background-color: white;"|monitoren van foetale hart (regime/therapie) (code = '281568006' in codeSystem 'SNOMED CT') | ||
|}<section end=zwangerschapsgegevens_ /> | |||
=== Medisch onderzoek === | |||
<section begin=medisch_onderzoek_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Medisch onderzoek | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="6" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Maternale onderzoeksgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="17"| | ||
|style="background-color: | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Urine bloed en aanvullende onderzoeken | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="15"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Psie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="13"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|<span id="ABO" title="Intern ID = ABO">Laboratorium test bloedgroep ABO</span> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Test code | ||
|style="background-color: white;"| | |style="background-color: white;"|ABO group [Type] in Blood (code = '883-9' in codeSystem 'LOINC') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Test uitslag | ||
|style="background-color: white;"| | |style="background-color: white;"|bloedgroep A (bevinding) (code = '112144000' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|<span id="RhD" title="Intern ID = RhD">Laboratorium test rhesus d RhD</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Test code | ||
|style="background-color: white;"| | |style="background-color: white;"|D Ag [Presence] in Blood (code = '1305-2' in codeSystem 'LOINC') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Test uitslag | ||
|style="background-color: white;"| | |style="background-color: white;"|Rh D Positief (code = '165747007' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|<span id="Rhc" title="Intern ID = Rhc">Laboratorium test rhesus c Rhc</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Test code | ||
|style="background-color: white;"| | |style="background-color: white;"|Kleine c Ag [aanwezigheid] in erytrocyten (code = '1159-3' in codeSystem 'LOINC') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Test uitslag | ||
|style="background-color: white;"| | |style="background-color: white;"|Rh c Positief (code = '733120009' in codeSystem 'SNOMED CT') | ||
|}<section end= | |}<section end=medisch_onderzoek_ /> | ||
=== | === Bouwstenen === | ||
<section begin= | <section begin=bouwstenen_ /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Bouwstenen | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="4" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Metingen | |||
|colspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="17"| | |rowspan="17"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|<span id="BP-139D" title="Intern ID = BP-139D">Bloeddruk BP-139D</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="2"|Systolische bloeddruk | ||
| | |style="background-color: white;"|133 | ||
| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="2"|Diastolische bloeddruk | ||
|style="background-color: white;"|89 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Bloeddruk datum tijd | ||
|style="background-color: white;"| | |style="background-color: white;"|T - 139 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|<span id="BP-6D" title="Intern ID = BP-6D">Bloeddruk BP-6D</span> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="2"|Systolische bloeddruk | ||
|style="background-color: white;"|155 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Diastolische bloeddruk | ||
|style="background-color: white;"| | |style="background-color: white;"|97 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Bloeddruk datum tijd | ||
|style="background-color: white;"| | |style="background-color: white;"|T - 6 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|<span id=" | |colspan="4"|<span id="Gewicht-139D" title="Intern ID = Gewicht-139D">Lichaamsgewicht Gewicht-139D</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="2"|Gewicht waarde | ||
|style="background-color: white;"|71 kg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|<span id="Gewicht-6D" title="Intern ID = Gewicht-6D">Lichaamsgewicht Gewicht-6D</span> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Gewicht waarde | ||
|style="background-color: white;"| | |style="background-color: white;"|78 kg | ||
|}<section end= | |}<section end=bouwstenen_ /> | ||
== | ==Scenario Vrouw 1, Kaart 2 - data 1e lijn (vorige zwangerschap)== | ||
<section begin= | <section begin= /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Vrouw | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Demografische gegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="2"|Patient | ||
|style="background-color: white;"|Zie [[#Vrouw1|Patient: Vrouw1]] | |||
|}<section end= /> | |||
=== Administratief === | |||
<section begin=administratief_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Administratief | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="5" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|<span id="Vrouw1" title="Intern ID = Vrouw1">Patient Vrouw1</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="20"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |rowspan="7"| | ||
|style="background-color: white;"| | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Voornamen | |||
|style="background-color: white;"|Hanna | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Initialen | |||
|style="background-color: white;"|H | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Naamgebruik | ||
|style="background-color: white;"| | |style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| | |colspan="4"|Geslachtsnaam | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Achternaam | ||
|style="background-color: white;"| | |style="background-color: white;"|XXX_Kooij | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|Adresgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="7"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="3"|Straat | ||
|style="background-color: white;"|Knolweg | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Huisnummer | ||
|style="background-color: white;"| | |style="background-color: white;"|1002 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Postcode | ||
|style="background-color: white;"| | |style="background-color: white;"|9999ZZ | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Woonplaats | ||
|style="background-color: white;"|STITSWERD | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Land | |||
|style="background-color: white;"|Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Adres soort | |||
|style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Identificatienummer | |||
|style="background-color: white;"|999900717 (in identificerend systeem: BSN) | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="4"|Geboortedatum | ||
|style="background-color: white;"|18 okt 1985 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Geslacht administratief | ||
|style="background-color: white;"| | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|<span id="Kind1" title="Intern ID = Kind1">Patient Kind1</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="18"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Naamgegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="7"| | |||
|rowspan="7"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Voornamen | |colspan="3"|Voornamen | ||
|style="background-color: white;"| | |style="background-color: white;"|Helen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Initialen | |colspan="3"|Initialen | ||
|style="background-color: white;"|H | |style="background-color: white;"|H.I. | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Naamgebruik | |colspan="3"|Naamgebruik | ||
| Regel 574: | Regel 589: | ||
|colspan="5"|Adresgegevens | |colspan="5"|Adresgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Straat | |colspan="3"|Straat | ||
| Regel 587: | Regel 602: | ||
|colspan="3"|Woonplaats | |colspan="3"|Woonplaats | ||
|style="background-color: white;"|STITSWERD | |style="background-color: white;"|STITSWERD | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geboortedatum | |colspan="4"|Geboortedatum | ||
|style="background-color: white;"| | |style="background-color: white;"|T - 587 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geslacht | |colspan="4"|Geslacht administratief | ||
|style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Meerling indicator | |||
|style="background-color: white;"|Nee | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|<span id=" | |colspan="6"|<span id="ZA1" title="Intern ID = ZA1">Zorgaanbieder ZA1</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="12"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="4"|Zorgaanbieder identificatienummer | ||
|style="background-color: white;"|08001234 (in identificerend systeem: AGB-Z) | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Organisatie naam | ||
|style="background-color: white;"|Verloskundigenpraktijk 't Groen | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Adresgegevens | |colspan="5"|Adresgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="7"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Straat | |colspan="3"|Straat | ||
|style="background-color: white;"| | |style="background-color: white;"|Groeneweg | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Huisnummer | |colspan="3"|Huisnummer | ||
|style="background-color: white;"|1000 | |||
|style="background-color: white;"|1000 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Postcode | |colspan="3"|Postcode | ||
| Regel 749: | Regel 712: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|Coordinerend zorgverlener | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
| Regel 758: | Regel 721: | ||
|colspan="5"|Zwangerschap | |colspan="5"|Zwangerschap | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="10"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Zwangerschapsduur | |||
|style="background-color: white;"|294 dagen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Pariteit | |colspan="3"|Pariteit | ||
| Regel 768: | Regel 734: | ||
|colspan="4"|Aterme datum items | |colspan="4"|Aterme datum items | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Aterme datum | |colspan="2"|Aterme datum | ||
| Regel 777: | Regel 743: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Datum bepaling | |colspan="2"|Datum bepaling | ||
|style="background-color: white;"| | |style="background-color: white;"|NullFlavor: UNK | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Datum laatste menstruatie | |||
|style="background-color: white;"|T - 895 dagen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Definitieve a terme datum observatie | |colspan="5"|Definitieve a terme datum observatie | ||
| Regel 791: | Regel 760: | ||
|colspan="3"|Definitieve a terme methode | |colspan="3"|Definitieve a terme methode | ||
|style="background-color: white;"|observatie (regime/therapie) (code = '225308005' in codeSystem 'SNOMED CT') | |style="background-color: white;"|observatie (regime/therapie) (code = '225308005' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Aantal foetussen observatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Aantal foetussen waarde | |||
|style="background-color: white;"|1 | |||
|}<section end=zwangerschapsgegevens_ /> | |}<section end=zwangerschapsgegevens_ /> | ||
=== Bevalling === | === Bevalling === | ||
| Regel 803: | Regel 779: | ||
|colspan="4"|Partusnummer | |colspan="4"|Partusnummer | ||
|style="background-color: white;"|1 | |style="background-color: white;"|1 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zwangerschapsduur | |||
|style="background-color: white;"|294 dagen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|<span id="Probleem1" title="Intern ID = Probleem1">Probleem maternaal Probleem1</span> | |colspan="5"|<span id="Probleem1" title="Intern ID = Probleem1">Probleem maternaal Probleem1</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Probleem naam | |colspan="3"|Probleem naam | ||
| Regel 816: | Regel 795: | ||
|colspan="3"|Probleem eind datum | |colspan="3"|Probleem eind datum | ||
|style="background-color: white;"|T - 587 dagen om 12:04 uur | |style="background-color: white;"|T - 587 dagen om 12:04 uur | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Zwangerschapsduur | |||
|style="background-color: white;"|294 dagen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|<span id="Verrichting1" title="Intern ID = Verrichting1">Verrichting maternaal Verrichting1</span> | |colspan="5"|<span id="Verrichting1" title="Intern ID = Verrichting1">Verrichting maternaal Verrichting1</span> | ||
| Regel 869: | Regel 851: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Observatie datum tijd | |colspan="2"|Observatie datum tijd | ||
|style="background-color: white;"|T - | |style="background-color: white;"|T - 588 dagen om 23:50 uur | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Begin baring waarde | |colspan="2"|Begin baring waarde | ||
| Regel 875: | Regel 857: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Observatie methode | |colspan="2"|Observatie methode | ||
|style="background-color: white;"| | |style="background-color: white;"|evaluatie (kwalificatiewaarde) (code = '129265001' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Uitdrijvingsfase | |colspan="5"|Uitdrijvingsfase | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="14"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Patient | |colspan="3"|Patient | ||
| Regel 893: | Regel 875: | ||
|colspan="2"|Type partus waarde | |colspan="2"|Type partus waarde | ||
|style="background-color: white;"|begeleiding van normale bevalling (verrichting) (code = '177184002' in codeSystem 'SNOMED CT') | |style="background-color: white;"|begeleiding van normale bevalling (verrichting) (code = '177184002' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Werkelijke plaats baring type locatie observatie | |colspan="4"|Werkelijke plaats baring type locatie observatie | ||
| Regel 935: | Regel 907: | ||
|colspan="7"|Demografische gegevens | |colspan="7"|Demografische gegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Patient | |colspan="5"|Patient | ||
|style="background-color: white;"|Zie [[#Kind1|Patient: Kind1]] | |style="background-color: white;"|Zie [[#Kind1|Patient: Kind1]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="7"|Lichamelijk onderzoek kind | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="23"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|Geboortegewicht lichaamsgewicht | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Gewicht waarde | |colspan="4"|Gewicht waarde | ||
| Regel 1.025: | Regel 977: | ||
|colspan="5"|Metingen | |colspan="5"|Metingen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="9"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|<span id="BP1" title="Intern ID = BP1">Bloeddruk BP1</span> | |colspan="4"|<span id="BP1" title="Intern ID = BP1">Bloeddruk BP1</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Systolische bloeddruk | |colspan="2"|Systolische bloeddruk | ||
| Regel 1.036: | Regel 988: | ||
|colspan="2"|Diastolische bloeddruk | |colspan="2"|Diastolische bloeddruk | ||
|style="background-color: white;"|50 | |style="background-color: white;"|50 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="2"|Bloeddruk datum tijd | |||
|style="background-color: white;"|T - 587 dagen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|<span id="gew1" title="Intern ID = gew1">Lichaamsgewicht gew1</span> | |colspan="4"|<span id="gew1" title="Intern ID = gew1">Lichaamsgewicht gew1</span> | ||
| Regel 1.044: | Regel 999: | ||
|style="background-color: white;"|63 kg | |style="background-color: white;"|63 kg | ||
|}<section end=bouwstenen_ /> | |}<section end=bouwstenen_ /> | ||
==Scenario Vrouw 2, Kaart 3 - data 1e lijn (meerling)== | |||
==Vrouw 2, Kaart 3 - data 1e lijn (meerling)== | |||
<section begin= /> | <section begin= /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| Regel 1.085: | Regel 1.039: | ||
|colspan="6"|<span id="Vrouw2" title="Intern ID = Vrouw2">Patient Vrouw2</span> | |colspan="6"|<span id="Vrouw2" title="Intern ID = Vrouw2">Patient Vrouw2</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="19"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Naamgegevens | |colspan="5"|Naamgegevens | ||
| Regel 1.122: | Regel 1.076: | ||
|colspan="3"|Woonplaats | |colspan="3"|Woonplaats | ||
|style="background-color: white;"|STITSWERD | |style="background-color: white;"|STITSWERD | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Identificatienummer | |||
|style="background-color: white;"|999900730 (in identificerend systeem: BSN) | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geboortedatum | |colspan="4"|Geboortedatum | ||
|style="background-color: white;"|20 okt 1985 | |style="background-color: white;"|20 okt 1985 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geslacht | |colspan="4"|Geslacht administratief | ||
|style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.235: | Regel 1.192: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"| | |colspan="6"|Coordinerend zorgverlener | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
| Regel 1.244: | Regel 1.201: | ||
|colspan="6"|Zwangerschap | |colspan="6"|Zwangerschap | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="10"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zwangerschapsduur | |||
|style="background-color: white;"|59 dagen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Pariteit | |colspan="4"|Pariteit | ||
| Regel 1.254: | Regel 1.214: | ||
|colspan="5"|Aterme datum items | |colspan="5"|Aterme datum items | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Aterme datum | |colspan="3"|Aterme datum | ||
| Regel 1.264: | Regel 1.224: | ||
|colspan="3"|Datum bepaling | |colspan="3"|Datum bepaling | ||
|style="background-color: white;"|T + 10 dagen | |style="background-color: white;"|T + 10 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Datum laatste menstruatie | |||
|style="background-color: white;"|T - 278 dagen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|<span id="AantalFoetussen" title="Intern ID = AantalFoetussen">Aantal foetussen observatie AantalFoetussen</span> | |colspan="6"|<span id="AantalFoetussen" title="Intern ID = AantalFoetussen">Aantal foetussen observatie AantalFoetussen</span> | ||
| Regel 1.289: | Regel 1.252: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Observatie methode | |colspan="4"|Observatie methode | ||
|style="background-color: white;"| | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Foliumzuurgebruik observatie | |colspan="6"|Foliumzuurgebruik observatie | ||
| Regel 1.303: | Regel 1.266: | ||
|colspan="6"|Prenatale controle | |colspan="6"|Prenatale controle | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="17"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Lichaamsgewicht | |colspan="4"|Lichaamsgewicht | ||
| Regel 1.330: | Regel 1.279: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Alcohol gebruik status | |colspan="3"|Alcohol gebruik status | ||
|style="background-color: white;"|drinkt geen alcohol | |style="background-color: white;"|drinkt geen alcohol (code = '105542008' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Drugs gebruik | |colspan="5"|Drugs gebruik | ||
| Regel 1.342: | Regel 1.291: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="7"| | |rowspan="7"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Tabak gebruik status | |||
|style="background-color: white;"|rookt soms sigaretten (code = '230059006' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Soort tabak gebruik | |colspan="3"|Soort tabak gebruik | ||
|style="background-color: white;"|gebruiker van elektronische sigaret (code = '722499006' in codeSystem 'SNOMED CT') | |style="background-color: white;"|gebruiker van elektronische sigaret (code = '722499006' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Waarneming gebruik | |colspan="4"|Waarneming gebruik | ||
| Regel 1.361: | Regel 1.310: | ||
|colspan="6"|<span id="Probleem1" title="Intern ID = Probleem1">Probleem zwangerschap Probleem1</span> | |colspan="6"|<span id="Probleem1" title="Intern ID = Probleem1">Probleem zwangerschap Probleem1</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Probleem naam | |colspan="4"|Probleem naam | ||
| Regel 1.368: | Regel 1.317: | ||
|colspan="4"|Probleem begin datum | |colspan="4"|Probleem begin datum | ||
|style="background-color: white;"|T - 205 dagen | |style="background-color: white;"|T - 205 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zwangerschapsduur | |||
|style="background-color: white;"|59 dagen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Toelichting | |colspan="4"|Toelichting | ||
| Regel 1.403: | Regel 1.355: | ||
|colspan="7"|Verrichting onderzoek | |colspan="7"|Verrichting onderzoek | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verrichting start datum | |colspan="5"|Verrichting start datum | ||
|style="background-color: white;"|T-195D | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verrichting eind datum | |||
|style="background-color: white;"|T - 195 dagen | |style="background-color: white;"|T - 195 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.499: | Regel 1.454: | ||
|style="background-color: white;"|Lichte kleding/ondergoed (code = 'MINIMAL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1') | |style="background-color: white;"|Lichte kleding/ondergoed (code = 'MINIMAL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1') | ||
|}<section end=bouwstenen_ /> | |}<section end=bouwstenen_ /> | ||
==Vrouw 2, Kaart 3 - data 2e lijn (meerling)== | ==Scenario Vrouw 2, Kaart 3 - data 2e lijn (meerling)== | ||
<section begin= /> | <section begin= /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| Regel 1.539: | Regel 1.494: | ||
|colspan="6"|<span id="Vrouw2" title="Intern ID = Vrouw2">Patient Vrouw2</span> | |colspan="6"|<span id="Vrouw2" title="Intern ID = Vrouw2">Patient Vrouw2</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="19"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Naamgegevens | |colspan="5"|Naamgegevens | ||
| Regel 1.576: | Regel 1.531: | ||
|colspan="3"|Woonplaats | |colspan="3"|Woonplaats | ||
|style="background-color: white;"|STITSWERD | |style="background-color: white;"|STITSWERD | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Identificatienummer | |||
|style="background-color: white;"|999900730 (in identificerend systeem: BSN) | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geboortedatum | |colspan="4"|Geboortedatum | ||
|style="background-color: white;"|20 okt 1985 | |style="background-color: white;"|20 okt 1985 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geslacht | |colspan="4"|Geslacht administratief | ||
|style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.626: | Regel 1.584: | ||
|style="background-color: white;"|T - 5 dagen | |style="background-color: white;"|T - 5 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geslacht | |colspan="4"|Geslacht administratief | ||
|style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.675: | Regel 1.633: | ||
|style="background-color: white;"|T - 5 dagen | |style="background-color: white;"|T - 5 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geslacht | |colspan="4"|Geslacht administratief | ||
|style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.781: | Regel 1.739: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"| | |colspan="6"|Coordinerend zorgverlener | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
| Regel 1.790: | Regel 1.748: | ||
|colspan="6"|Zwangerschap | |colspan="6"|Zwangerschap | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="10"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Zwangerschapsduur | |||
|style="background-color: white;"|259 dagen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Pariteit | |colspan="4"|Pariteit | ||
| Regel 1.800: | Regel 1.761: | ||
|colspan="5"|Aterme datum items | |colspan="5"|Aterme datum items | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Aterme datum | |colspan="3"|Aterme datum | ||
| Regel 1.810: | Regel 1.771: | ||
|colspan="3"|Datum bepaling | |colspan="3"|Datum bepaling | ||
|style="background-color: white;"|T - 205 dagen | |style="background-color: white;"|T - 205 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Datum laatste menstruatie | |||
|style="background-color: white;"|T - 278 dagen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Definitieve a terme datum observatie | |colspan="6"|Definitieve a terme datum observatie | ||
| Regel 1.822: | Regel 1.786: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Definitieve a terme methode | |colspan="4"|Definitieve a terme methode | ||
|style="background-color: white;"| | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|<span id="AantalFoetussen" title="Intern ID = AantalFoetussen">Aantal foetussen observatie AantalFoetussen</span> | |colspan="6"|<span id="AantalFoetussen" title="Intern ID = AantalFoetussen">Aantal foetussen observatie AantalFoetussen</span> | ||
| Regel 1.835: | Regel 1.799: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Observatie methode | |colspan="4"|Observatie methode | ||
|style="background-color: white;"| | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Meerling zwangerschap observatie | |colspan="6"|Meerling zwangerschap observatie | ||
| Regel 1.851: | Regel 1.815: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Observatie methode | |colspan="4"|Observatie methode | ||
|style="background-color: white;"| | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Aantal levende kinderen observatie | |colspan="6"|Aantal levende kinderen observatie | ||
| Regel 1.864: | Regel 1.828: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Observatie methode | |colspan="4"|Observatie methode | ||
|style="background-color: white;"| | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Foliumzuurgebruik observatie | |colspan="6"|Foliumzuurgebruik observatie | ||
| Regel 1.881: | Regel 1.845: | ||
|colspan="6"|Prenatale controle | |colspan="6"|Prenatale controle | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="23"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Leven voelen observatie | |colspan="5"|Leven voelen observatie | ||
| Regel 1.921: | Regel 1.871: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Alcohol gebruik status | |colspan="3"|Alcohol gebruik status | ||
|style="background-color: white;"|drinkt geen alcohol | |style="background-color: white;"|drinkt geen alcohol (code = '105542008' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Drugs gebruik | |colspan="5"|Drugs gebruik | ||
| Regel 1.936: | Regel 1.886: | ||
|colspan="3"|Toelichting | |colspan="3"|Toelichting | ||
|style="background-color: white;"|gestopt op advies verloskundige | |style="background-color: white;"|gestopt op advies verloskundige | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Tabak gebruik status | |||
|style="background-color: white;"|rookte vroeger (code = '8517006' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Soort tabak gebruik | |colspan="3"|Soort tabak gebruik | ||
|style="background-color: white;"|gebruiker van elektronische sigaret (code = '722499006' in codeSystem 'SNOMED CT') | |style="background-color: white;"|gebruiker van elektronische sigaret (code = '722499006' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Waarneming gebruik | |colspan="4"|Waarneming gebruik | ||
| Regel 1.953: | Regel 1.903: | ||
|style="background-color: white;"|T - 198 dagen | |style="background-color: white;"|T - 198 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|Prenatale controle | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Bloeddruk | |||
|style="background-color: white;"|Zie [[#BP-76D|Bloeddruk: BP-76D]] | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|<span id="Probleem1" title="Intern ID = Probleem1">Probleem zwangerschap Probleem1</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Probleem naam | ||
|style="background-color: white;"|meerlingzwangerschap (aandoening) (code = '16356006' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Probleem begin datum | |||
|style="background-color: white;"|T - 193 dagen | |style="background-color: white;"|T - 193 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Zwangerschapsduur | ||
|style="background-color: white;"| | |style="background-color: white;"|71 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|<span id="Probleem2" title="Intern ID = Probleem2">Probleem zwangerschap Probleem2</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="6"| | |rowspan="6"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Probleem type | ||
|style="background-color: white;"| | |style="background-color: white;"|Klinische bevinding (code = '404684003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Probleem naam | ||
|style="background-color: white;"| | |style="background-color: white;"|intra-uteriene groeiretardatie (aandoening) (code = '22033007' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Probleem begin datum | ||
|style="background-color: white;"| | |style="background-color: white;"|T - 76 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Zwangerschapsduur | ||
|style="background-color: white;"| | |style="background-color: white;"|188 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Toelichting | ||
|style="background-color: white;"| | |style="background-color: white;"|tweede kind blijft erg achter in ontwikkeling | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"| | |colspan="6"|Verrichting zwangerschap | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="4"|Verrichting start datum | ||
|style="background-color: white;"|T - 193 dagen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Verrichting type | ||
|style="background-color: white;"| | |style="background-color: white;"|bloedonderzoek (verrichting) (code = '396550006' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|Verrichting zwangerschap | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Verrichting start datum | ||
|style="background-color: white;"| | |style="background-color: white;"|T - 5 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| | |colspan="4"|Verrichting type | ||
|style="background-color: white;"| | |style="background-color: white;"|opname in ziekenhuis (verrichting) (code = '32485007' in codeSystem 'SNOMED CT') | ||
| | |}<section end=zwangerschapsgegevens_ /> | ||
=== Bevalling === | |||
<section begin=bevalling_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Bevalling | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="5" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="5"|Partusnummer | ||
|style="background-color: white;"|1 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Zwangerschapsduur | ||
|style="background-color: white;"| | |style="background-color: white;"|259 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"| | |colspan="6"|Uitdrijvingsfase | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="30"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| | |colspan="4"|Patient | ||
|style="background-color: white;"| | |style="background-color: white;"|Zie [[#Kind2|Patient: Kind2]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Type partus observatie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Observatie datum tijd | ||
|style="background-color: white;"|T - | |style="background-color: white;"|T - 5 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Type partus waarde | ||
|style="background-color: white;"| | |style="background-color: white;"|sectio caesarea (verrichting) (code = '11466000' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Werkelijke plaats baring type locatie observatie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="4"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Observatie datum tijd | |||
|style="background-color: white;"|T - 5 dagen om 14:38 uur | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Werkelijke plaats baring waarde | |||
|style="background-color: white;"|geboorte in ziekenhuis (bevinding) (code = '56321000146103' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="3"|Toelichting | ||
|style="background-color: white;"|geplande sectio | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Ziekenhuis baring | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Zorgaanbieder | ||
|style="background-color: white;"| | |style="background-color: white;"|Zie [[#ZA2|Zorgaanbieder: ZA2]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|<span id="Probleem3" title="Intern ID = Probleem3">Probleem kindspecifieke maternale problemen Probleem3</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Probleem naam | ||
|style="background-color: white;"| | |style="background-color: white;"|liggingsafwijking van foetus (bevinding) (code = '15028002' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Probleem begin datum | ||
|style="background-color: white;"| | |style="background-color: white;"|T - 5 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verrichting kindspecifieke maternale verrichtingen | |||
|style=" | |||
|colspan="5 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="7"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="3"|Verrichting start datum | ||
|style="background-color: white;"|T - 5 dagen om 14:03 uur | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Verrichting eind datum | ||
|style="background-color: white;"| | |style="background-color: white;"|T - 5 dagen om 14:52 uur | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Indicatie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| | |colspan="2"|Probleem kindspecifieke maternale problemen | ||
|style="background-color: white;"|T - 5 dagen | |style="background-color: white;"|Zie [[#Probleem2|Probleem kindspecifieke maternale problemen: Probleem2]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting type | |||
|style="background-color: white;"|primaire sectio caesarea (verrichting) (code = '80771000146107' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Verrichting kindspecifieke maternale verrichtingen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting start datum | |||
|style="background-color: white;"|T - 5 dagen om 14:50 uur | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="3"|Verrichting type | |||
|style="background-color: white;"|vitamine K toediening aan neonaat (code = '698350008:370131001=133933007' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Uitdrijvingsfase | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="30"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Patient | ||
|style="background-color: white;"| | |style="background-color: white;"|Zie [[#Kind3|Patient: Kind3]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|Type partus observatie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Observatie datum tijd | |colspan="3"|Observatie datum tijd | ||
|style="background-color: white;"|T - 5 dagen | |style="background-color: white;"|T - 5 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| | |colspan="3"|Type partus waarde | ||
|style="background-color: white;"| | |style="background-color: white;"|sectio caesarea (verrichting) (code = '11466000' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Werkelijke plaats baring type locatie observatie | |colspan="5"|Werkelijke plaats baring type locatie observatie | ||
| Regel 2.121: | Regel 2.091: | ||
|style="background-color: white;"|Zie [[#ZA2|Zorgaanbieder: ZA2]] | |style="background-color: white;"|Zie [[#ZA2|Zorgaanbieder: ZA2]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|Verrichting kindspecifieke maternale verrichtingen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="7"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verrichting start datum | |||
|colspan="3"|Verrichting start datum | |||
|style="background-color: white;"|T - 5 dagen om 14:03 uur | |style="background-color: white;"|T - 5 dagen om 14:03 uur | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 2.156: | Regel 2.116: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verrichting start datum | |colspan="3"|Verrichting start datum | ||
|style="background-color: white;"|T - 5 dagen om 14: | |style="background-color: white;"|T - 5 dagen om 14:52 uur | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verrichting type | |colspan="3"|Verrichting type | ||
|style="background-color: white;"| | |style="background-color: white;"|inflatie van long door intermitterende compressie van reservoirballon (code = '243140006' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verrichting kindspecifieke maternale verrichtingen | |||
|colspan="5"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| | |colspan="3"|Verrichting start datum | ||
|style="background-color: white;"|T - 5 dagen | |style="background-color: white;"|T - 5 dagen om 14:55 uur | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"| | |colspan="3"|Verrichting type | ||
|style="background-color: white;"| | |style="background-color: white;"|vitamine K toediening aan neonaat (code = '698350008:370131001=133933007' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |}<section end=bevalling_ /> | ||
|colspan=" | === Kind === | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | <section begin=kind_ /> | ||
|rowspan=" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Kind | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="6" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Demografische gegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Patient | ||
|style="background-color: white;"| | |style="background-color: white;"|Zie [[#Kind2|Patient: Kind2]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="7"|Lichamelijk onderzoek kind | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="25"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|Geboortegewicht lichaamsgewicht | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Gewicht waarde | ||
|style="background-color: white;"| | |style="background-color: white;"|2605 gram | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Gewicht datum tijd | ||
|style="background-color: white;"| | |style="background-color: white;"|T - 5 dagen om 15:10 uur | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Kleding | ||
|style="background-color: white;"| | |style="background-color: white;"|Luier (code = 'DIAPER' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|Lichaamslengte | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Lengte waarde | ||
|style="background-color: white;"| | |style="background-color: white;"|48 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|Schedelomvang | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="2"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="4"|Schedelomvang waarde | ||
|style="background-color: white;"|32.6 cm | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Bevindingen | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="12"| | ||
|style="background-color: | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Algemene indruk | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="10"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| | |colspan="4"|Apgar score1min | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Apgar score totaal | ||
|style="background-color: white;"| | |style="background-color: white;"|7 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Apgar score5min | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Apgar score totaal | ||
|style="background-color: white;"| | |style="background-color: white;"|10 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Apgar score10min | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Apgar score totaal | ||
|style="background-color: white;"| | |style="background-color: white;"|10 | ||
|}<section end=kind_ /> | |||
|}<section end= | |||
=== Kind === | === Kind === | ||
<section begin=kind_ /> | <section begin=kind_ /> | ||
| Regel 2.259: | Regel 2.218: | ||
|colspan="7"|Demografische gegevens | |colspan="7"|Demografische gegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Patient | |colspan="5"|Patient | ||
|style="background-color: white;"|Zie [[# | |style="background-color: white;"|Zie [[#Kind3|Patient: Kind3]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="7"|Lichamelijk onderzoek kind | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="25"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|Geboortegewicht lichaamsgewicht | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Gewicht waarde | |||
|style="background-color: white;"|2089 gram | |||
|colspan="4"|Gewicht waarde | |||
|style="background-color: white;"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Gewicht datum tijd | |colspan="4"|Gewicht datum tijd | ||
|style="background-color: white;"|T - 5 dagen om 15: | |style="background-color: white;"|T - 5 dagen om 15:05 uur | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Kleding | |colspan="4"|Kleding | ||
|style="background-color: white;"| | |style="background-color: white;"|Zonder kleding. (code = 'UNDRESSED' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Lichaamslengte | |colspan="6"|Lichaamslengte | ||
| Regel 2.319: | Regel 2.245: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Lengte waarde | |colspan="4"|Lengte waarde | ||
|style="background-color: white;"| | |style="background-color: white;"|46 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Schedelomvang | |colspan="6"|Schedelomvang | ||
| Regel 2.326: | Regel 2.252: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Schedelomvang waarde | |colspan="4"|Schedelomvang waarde | ||
|style="background-color: white;"| | |style="background-color: white;"|31.8 cm | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Bevindingen | |colspan="6"|Bevindingen | ||
| Regel 2.341: | Regel 2.267: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Apgar score totaal | |colspan="2"|Apgar score totaal | ||
|style="background-color: white;"| | |style="background-color: white;"|5 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Apgar score5min | |colspan="4"|Apgar score5min | ||
| Regel 2.348: | Regel 2.274: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Apgar score totaal | |colspan="2"|Apgar score totaal | ||
|style="background-color: white;"| | |style="background-color: white;"|9 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Apgar score10min | |colspan="4"|Apgar score10min | ||
| Regel 2.357: | Regel 2.283: | ||
|style="background-color: white;"|10 | |style="background-color: white;"|10 | ||
|}<section end=kind_ /> | |}<section end=kind_ /> | ||
=== | === Medisch onderzoek === | ||
<section begin= | <section begin=medisch_onderzoek_ /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Medisch onderzoek | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="6" width="25%"| Gegevenselement | |colspan="6" width="25%"| Gegevenselement | ||
| Regel 2.366: | Regel 2.292: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"| | |colspan="7"|Verrichting onderzoek | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|rowspan="3"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="5"|Verrichting start datum | ||
|style="background-color: white;"|T-193D | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|Verrichting eind datum | ||
|style="background-color: white;"| | |style="background-color: white;"|T - 193 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="7"|Maternale onderzoeksgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="27"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|Urine bloed en aanvullende onderzoeken | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="25"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Psie | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="13"| | ||
|style="background-color: | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|<span id="ABO" title="Intern ID = ABO">Laboratorium test bloedgroep ABO</span> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |rowspan="3"| | ||
|style="background-color: white;"| | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test code | |||
|style="background-color: white;"|ABO group [Type] in Blood (code = '883-9' in codeSystem 'LOINC') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Test uitslag | ||
|style="background-color: white;"| | |style="background-color: white;"|bloedgroep O (bevinding) (code = '58460004' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|<span id="RhD" title="Intern ID = RhD">Laboratorium test rhesus d RhD</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Test code | ||
|style="background-color: white;"| | |style="background-color: white;"|D Ag [Presence] in Blood (code = '1305-2' in codeSystem 'LOINC') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Test uitslag | ||
|style="background-color: white;"| | |style="background-color: white;"|Rh D Positief (code = '165747007' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|<span id="Rhc" title="Intern ID = Rhc">Laboratorium test rhesus c Rhc</span> | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Test code | ||
|style="background-color: white;"| | |style="background-color: white;"|Kleine c Ag [aanwezigheid] in erytrocyten (code = '1159-3' in codeSystem 'LOINC') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="2"|Test uitslag | ||
|style="background-color: white;"|Rh c Positief (code = '733120009' in codeSystem 'SNOMED CT') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Laboratorium test hb | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Test code | ||
|style="background-color: white;"| | |style="background-color: white;"|Hemoglobin [Moles/volume] in Venous blood (code = '93846-4' in codeSystem 'LOINC') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Test uitslag | ||
|style="background-color: white;"| | |style="background-color: white;"|7.0 g/dl | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Torch | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Laboratorium test torch | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Test code | ||
|style="background-color: white;"| | |style="background-color: white;"|Toxoplasma gondii IgG Ab [Units/volume] in Serum (code = '8039-0' in codeSystem 'LOINC') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="2"|Test uitslag | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |style="background-color: white;"|9 k[arb'u]/l | ||
|colspan=" | |}<section end=medisch_onderzoek_ /> | ||
=== Medisch onderzoek === | |||
<section begin=medisch_onderzoek_ /> | |||
{| class="wikitable" width="85%" | |||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Medisch onderzoek | |||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |||
|colspan="5" width="25%"| Gegevenselement | |||
|| Waarde | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Verrichting onderzoek | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="4"|Verrichting start datum | ||
|style="background-color: white;"|T-76D | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Verrichting eind datum | ||
|style="background-color: white;"| | |style="background-color: white;"|T - 76 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|Maternale onderzoeksgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="7"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="5"|Urine bloed en aanvullende onderzoeken | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| | |colspan="4"|Laboratorium test hb | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test code | |||
|style="background-color: white;"|Hemoglobin [Moles/volume] in Venous blood (code = '93846-4' in codeSystem 'LOINC') | |||
|colspan="2"|Test code | |||
|style="background-color: white;"|Hemoglobin [Moles/volume] in Venous blood (code = '93846-4' in codeSystem 'LOINC') | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test uitslag | |colspan="2"|Test uitslag | ||
| Regel 2.593: | Regel 2.416: | ||
|colspan="6"|Verrichting onderzoek | |colspan="6"|Verrichting onderzoek | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Verrichting start datum | |colspan="4"|Verrichting start datum | ||
|style="background-color: white;"|T-5D | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Verrichting eind datum | |||
|style="background-color: white;"|T - 5 dagen | |style="background-color: white;"|T - 5 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 2.686: | Regel 2.512: | ||
|style="background-color: white;"|T - 5 dagen | |style="background-color: white;"|T - 5 dagen | ||
|}<section end=bouwstenen_ /> | |}<section end=bouwstenen_ /> | ||
==Vrouw 3, geen zwangerschapskaart beschikbaar== | ==Scenario Vrouw 3, geen zwangerschapskaart beschikbaar== | ||
<section begin= /><section end= /> | <section begin= /><section end= /> | ||
=== Administratief === | === Administratief === | ||
| Regel 2.743: | Regel 2.569: | ||
|style="background-color: white;"|22 okt 1985 | |style="background-color: white;"|22 okt 1985 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geslacht | |colspan="4"|Geslacht administratief | ||
|style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Huidige versie van 12 mei 2022 om 11:40
__NUMBEREDHEADINGS__
Addenda voor inhoudelijke gegevens Integrale zwangerschapskaart 3.2
Scenario Vrouw 1, Kaart 1 - data 1e lijn (actieve zwangerschap)
| Vrouw | |||
| Gegevenselement | Waarde | ||
| Demografische gegevens | |||
| Patient | Zie Patient: Vrouw1 | ||
Administratief
| Administratief | |||||
| Gegevenselement | Waarde | ||||
| Patient Vrouw1 | |||||
| Naamgegevens | |||||
| Voornamen | Hanna | ||||
| Initialen | H | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Kooij | ||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1002 | ||||
| Postcode | 9999ZZ | ||||
| Woonplaats | STITSWERD | ||||
| Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||||
| Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | ||||
| Identificatienummer | 999900717 (in identificerend systeem: BSN) | ||||
| Geboortedatum | 18 okt 1985 | ||||
| Geslacht administratief | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
| Zorgaanbieder ZA1 | |||||
| Zorgaanbieder identificatienummer | 08001234 (in identificerend systeem: AGB-Z) | ||||
| Organisatie naam | Verloskundigenpraktijk 't Groen | ||||
| Adresgegevens | |||||
| Straat | Groeneweg | ||||
| Huisnummer | 1000 | ||||
| Postcode | 1234ZZ | ||||
| Woonplaats | STITSWERD | ||||
| Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||||
| Adres soort | Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
| Organisatie type | Verloskundigenpraktijk (code = 'G3' in codeSystem 'RoleCodeNL - zorgaanbiedertype (organisaties)') | ||||
| Zorgverlener ZV1 | |||||
| Zorgverlener identificatienummer | 12340001 (in identificerend systeem: UZI Personen) | ||||
| Naamgegevens | |||||
| Voornamen | Gemma | ||||
| Naamgebruik | Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Groeneboom | ||||
| Geslachtsnaam partner | |||||
| Achternaam partner | XXX_Gras | ||||
| Specialisme | eerstelijnsverloskundige (beroep) (code = '158999002' in codeSystem 'SNOMED CT') | ||||
Zorgverlening
| Zorgverlening | |||
| Gegevenselement | Waarde | ||
| Zorg episode | |||
| Begin datum | T - 139 dagen | ||
Zwangerschapsgegevens
| Zwangerschapsgegevens | ||||
| Gegevenselement | Waarde | |||
| Coordinerend zorgverlener | ||||
| Zorgverlener | Zie Zorgverlener: ZV1 | |||
| Zwangerschap | ||||
| Zwangerschapsduur | 56 dagen | |||
| Pariteit | 1 | |||
| Graviditeit | 3 | |||
| Aterme datum items | ||||
| Aterme datum | T + 99 dagen | |||
| Bepalings methode | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): zwangerschapstest clearlypink met zwangerschapsduur-indicator | |||
| Datum bepaling | NullFlavor: UNK | |||
| Datum laatste menstruatie | T - 209 dagen | |||
| Definitieve a terme datum observatie | ||||
| Definitieve a terme datum tijd | T - 125 dagen | |||
| Definitieve a terme waarde | T + 94 dagen | |||
| Definitieve a terme methode | echografie van foetus (verrichting) (code = '241491007' in codeSystem 'SNOMED CT') | |||
| Aantal foetussen observatie | ||||
| Aantal foetussen waarde | 1 | |||
| Aantal levende kinderen observatie | ||||
| Aantal levende kinderen datum tijd | T - 125 dagen | |||
| Aantal levende kinderen waarde | 1 | |||
| Observatie methode | echografie van foetus (verrichting) (code = '241491007' in codeSystem 'SNOMED CT') | |||
| Fetal loss observatie | ||||
| Fetal loss datum tijd | NullFlavor: ASKU | |||
| Fetal loss waarde | ||||
| Toelichting | mw. zegt vroege miskraam te hebben gehad enkele maanden na eerste kind, destijds geen verloskundige gezien | |||
| Foliumzuurgebruik observatie | ||||
| Foliumzuurgebruik datum tijd | T - 139 dagen | |||
| Foliumzuurgebruik waarde | preconceptionele intake van foliumzuur via voeding (bevinding) (code = '29761000146100' in codeSystem 'SNOMED CT') | |||
| Prenatale controle | ||||
| Lichaamsgewicht | Zie Lichaamsgewicht: Gewicht-139D | |||
| Bloeddruk | Zie Bloeddruk: BP-139D | |||
| Alcohol gebruik | ||||
| Toelichting | tbv conceptie al gestopt met alcohol consumptie | |||
| Alcohol gebruik status | drinkt geen alcohol (code = '105542008' in codeSystem 'SNOMED CT') | |||
| Drugs gebruik | ||||
| Drugs gebruik status | heeft nooit drugs gebruikt (code = '228368007' in codeSystem 'SNOMED CT') | |||
| Tabak gebruik | ||||
| Tabak gebruik status | heeft nooit gerookt (code = '266919005' in codeSystem 'SNOMED CT') | |||
| Prenatale controle | ||||
| Leven voelen observatie | ||||
| Leven voelen datum tijd | T - 10 dagen | |||
| Leven voelen waarde | zwakke foetale bewegingen (bevinding) (code = '276372004' in codeSystem 'SNOMED CT') | |||
| Toelichting | voelt sinds enkele dagen minder frequent bewegingen | |||
| Lichaamsgewicht | Zie Lichaamsgewicht: Gewicht-6D | |||
| Bloeddruk | Zie Bloeddruk: BP-6D | |||
| Probleem zwangerschap Probleem1 | ||||
| Probleem type | Symptoom gerapporteerd door patiënt of andere bron van voorgeschiedenis (code = '418799008' in codeSystem 'SNOMED CT') | |||
| Probleem naam | zwakke foetale bewegingen (bevinding) (code = '276372004' in codeSystem 'SNOMED CT') | |||
| Probleem begin datum | T - 10 dagen | |||
| Probleem eind datum | T - 6 dagen | |||
| Zwangerschapsduur | 189 dagen | |||
| Probleem status | Niet actueel (code = '73425007' in codeSystem 'SNOMED CT') | |||
| Verrichting zwangerschap | ||||
| Verrichting start datum | T - 139 dagen | |||
| Verrichting type | echografie van foetus (verrichting) (code = '241491007' in codeSystem 'SNOMED CT') | |||
| Verrichting zwangerschap | ||||
| Verrichting start datum | T - 139 dagen | |||
| Verrichting type | aanbieden van voorlichtingsmateriaal (verrichting) (code = '445283009' in codeSystem 'SNOMED CT') | |||
| Verrichting zwangerschap | ||||
| Verrichting start datum | T - 6 dagen | |||
| Verrichting type | monitoren van foetale hart (regime/therapie) (code = '281568006' in codeSystem 'SNOMED CT') | |||
Medisch onderzoek
| Medisch onderzoek | ||||||
| Gegevenselement | Waarde | |||||
| Maternale onderzoeksgegevens | ||||||
| Urine bloed en aanvullende onderzoeken | ||||||
| Psie | ||||||
| Laboratorium test bloedgroep ABO | ||||||
| Test code | ABO group [Type] in Blood (code = '883-9' in codeSystem 'LOINC') | |||||
| Test uitslag | bloedgroep A (bevinding) (code = '112144000' in codeSystem 'SNOMED CT') | |||||
| Laboratorium test rhesus d RhD | ||||||
| Test code | D Ag [Presence] in Blood (code = '1305-2' in codeSystem 'LOINC') | |||||
| Test uitslag | Rh D Positief (code = '165747007' in codeSystem 'SNOMED CT') | |||||
| Laboratorium test rhesus c Rhc | ||||||
| Test code | Kleine c Ag [aanwezigheid] in erytrocyten (code = '1159-3' in codeSystem 'LOINC') | |||||
| Test uitslag | Rh c Positief (code = '733120009' in codeSystem 'SNOMED CT') | |||||
Bouwstenen
| Bouwstenen | ||||
| Gegevenselement | Waarde | |||
| Metingen | ||||
| Bloeddruk BP-139D | ||||
| Systolische bloeddruk | 133 | |||
| Diastolische bloeddruk | 89 | |||
| Bloeddruk datum tijd | T - 139 dagen | |||
| Bloeddruk BP-6D | ||||
| Systolische bloeddruk | 155 | |||
| Diastolische bloeddruk | 97 | |||
| Bloeddruk datum tijd | T - 6 dagen | |||
| Lichaamsgewicht Gewicht-139D | ||||
| Gewicht waarde | 71 kg | |||
| Lichaamsgewicht Gewicht-6D | ||||
| Gewicht waarde | 78 kg | |||
Scenario Vrouw 1, Kaart 2 - data 1e lijn (vorige zwangerschap)
| Vrouw | |||
| Gegevenselement | Waarde | ||
| Demografische gegevens | |||
| Patient | Zie Patient: Vrouw1 | ||
Administratief
| Administratief | |||||
| Gegevenselement | Waarde | ||||
| Patient Vrouw1 | |||||
| Naamgegevens | |||||
| Voornamen | Hanna | ||||
| Initialen | H | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Kooij | ||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1002 | ||||
| Postcode | 9999ZZ | ||||
| Woonplaats | STITSWERD | ||||
| Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||||
| Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | ||||
| Identificatienummer | 999900717 (in identificerend systeem: BSN) | ||||
| Geboortedatum | 18 okt 1985 | ||||
| Geslacht administratief | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
| Patient Kind1 | |||||
| Naamgegevens | |||||
| Voornamen | Helen | ||||
| Initialen | H.I. | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Kooij | ||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1002 | ||||
| Postcode | 9999ZZ | ||||
| Woonplaats | STITSWERD | ||||
| Geboortedatum | T - 587 dagen | ||||
| Geslacht administratief | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
| Meerling indicator | Nee | ||||
| Zorgaanbieder ZA1 | |||||
| Zorgaanbieder identificatienummer | 08001234 (in identificerend systeem: AGB-Z) | ||||
| Organisatie naam | Verloskundigenpraktijk 't Groen | ||||
| Adresgegevens | |||||
| Straat | Groeneweg | ||||
| Huisnummer | 1000 | ||||
| Postcode | 1234ZZ | ||||
| Woonplaats | STITSWERD | ||||
| Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||||
| Adres soort | Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
| Organisatie type | Verloskundigenpraktijk (code = 'G3' in codeSystem 'RoleCodeNL - zorgaanbiedertype (organisaties)') | ||||
| Zorgverlener ZV1 | |||||
| Zorgverlener identificatienummer | 12340001 (in identificerend systeem: UZI Personen) | ||||
| Naamgegevens | |||||
| Roepnaam | Gemma | ||||
| Naamgebruik | Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Groeneboom | ||||
| Geslachtsnaam partner | |||||
| Achternaam partner | XXX_Gras | ||||
| Specialisme | Verloskundige (code = '03.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||
| Zorgverleners rol | Case manager (code = '768832004' in codeSystem 'SNOMED CT') | ||||
Zorgverlening
| Zorgverlening | |||
| Gegevenselement | Waarde | ||
| Zorg episode | |||
| Begin datum | T - 841 dagen | ||
| Eind datum | T - 587 dagen | ||
Zwangerschapsgegevens
| Zwangerschapsgegevens | ||||
| Gegevenselement | Waarde | |||
| Coordinerend zorgverlener | ||||
| Zorgverlener | Zie Zorgverlener: ZV1 | |||
| Zwangerschap | ||||
| Zwangerschapsduur | 294 dagen | |||
| Pariteit | 1 | |||
| Graviditeit | 1 | |||
| Aterme datum items | ||||
| Aterme datum | T - 587 dagen | |||
| Bepalings methode | aterme datum berekend door middel van diagnostische ultrasonografie (code = '31541000146106' in codeSystem 'SNOMED CT') | |||
| Datum bepaling | NullFlavor: UNK | |||
| Datum laatste menstruatie | T - 895 dagen | |||
| Definitieve a terme datum observatie | ||||
| Definitieve a terme datum tijd | T - 587 dagen | |||
| Definitieve a terme waarde | T - 587 dagen | |||
| Definitieve a terme methode | observatie (regime/therapie) (code = '225308005' in codeSystem 'SNOMED CT') | |||
| Aantal foetussen observatie | ||||
| Aantal foetussen waarde | 1 | |||
Bevalling
| Bevalling | ||||
| Gegevenselement | Waarde | |||
| Partusnummer | 1 | |||
| Zwangerschapsduur | 294 dagen | |||
| Probleem maternaal Probleem1 | ||||
| Probleem naam | niet vorderende uitdrijving (code = '249166003' in codeSystem 'SNOMED CT') | |||
| Probleem begin datum | T - 587 dagen om 12:02 uur | |||
| Probleem eind datum | T - 587 dagen om 12:04 uur | |||
| Zwangerschapsduur | 294 dagen | |||
| Verrichting maternaal Verrichting1 | ||||
| Verrichting start datum | T - 587 dagen om 02:19 uur | |||
| Verrichting type | vaginaal toucher (verrichting) (code = '51597003' in codeSystem 'SNOMED CT') | |||
| Verrichting maternaal Verrichting2 | ||||
| Verrichting start datum | T - 587 dagen om 12:04 uur | |||
| Indicatie | ||||
| Probleem maternaal | Zie Probleem zwangerschap: Probleem1 | |||
| Verrichting type | episiotomie mediolateraal rechts (verrichting) (code = '236992007' in codeSystem 'SNOMED CT') | |||
| Ontsluitingsfase | ||||
| Actieve ontsluiting observatie | ||||
| Observatie datum tijd | T - 587 dagen om 02:19 uur | |||
| Begin actieve ontsluiting waarde | T - 587 dagen om 02:19 uur | |||
| Observatie methode | palpatie (verrichting) (code = '113011001' in codeSystem 'SNOMED CT') | |||
| Toelichting | 5 cm ontsluiting | |||
| Wijze begin baring observatie | ||||
| Observatie datum tijd | T - 588 dagen om 23:50 uur | |||
| Begin baring waarde | spontaan breken van vliezen (bevinding) (code = '169734005' in codeSystem 'SNOMED CT') | |||
| Observatie methode | evaluatie (kwalificatiewaarde) (code = '129265001' in codeSystem 'SNOMED CT') | |||
| Uitdrijvingsfase | ||||
| Patient | Zie Patient: Kind1 | |||
| Type partus observatie | ||||
| Observatie datum tijd | T - 587 dagen om 12:04 uur | |||
| Type partus waarde | begeleiding van normale bevalling (verrichting) (code = '177184002' in codeSystem 'SNOMED CT') | |||
| Werkelijke plaats baring type locatie observatie | ||||
| Werkelijke plaats baring waarde | thuisbevalling (bevinding) (code = '169813005' in codeSystem 'SNOMED CT') | |||
| Probleem kindspecifieke maternale problemen Probleem2 | ||||
| Probleem naam | foetale nood durante partu (bevinding) (code = '288274003' in codeSystem 'SNOMED CT') | |||
| Probleem begin datum | T - 587 dagen om 12:02 uur | |||
| Probleem eind datum | T - 587 dagen om 12:04 uur | |||
Kind
| Kind | ||||||
| Gegevenselement | Waarde | |||||
| Demografische gegevens | ||||||
| Patient | Zie Patient: Kind1 | |||||
| Lichamelijk onderzoek kind | ||||||
| Geboortegewicht lichaamsgewicht | ||||||
| Gewicht waarde | 3415 gram | |||||
| Lichaamslengte | ||||||
| Lengte waarde | 49.7 cm | |||||
| Schedelomvang | ||||||
| Schedelomvang waarde | 33.6 cm | |||||
| Bevindingen | ||||||
| Algemene indruk | ||||||
| Apgar score1min | ||||||
| Apgar score totaal | 7 | |||||
| Apgar score5min | ||||||
| Apgar score totaal | 8 | |||||
| Apgar score10min | ||||||
| Apgar score totaal | 10 | |||||
Bouwstenen
| Bouwstenen | ||||
| Gegevenselement | Waarde | |||
| Metingen | ||||
| Bloeddruk BP1 | ||||
| Systolische bloeddruk | 95 | |||
| Diastolische bloeddruk | 50 | |||
| Bloeddruk datum tijd | T - 587 dagen | |||
| Lichaamsgewicht gew1 | ||||
| Gewicht waarde | 63 kg | |||
Scenario Vrouw 2, Kaart 3 - data 1e lijn (meerling)
| Vrouw | |||
| Gegevenselement | Waarde | ||
| Demografische gegevens | |||
| Patient | Zie Patient: Vrouw2 | ||
| Bloedonderzoek | |||
| Laboratorium test bloedgroep | Zie Laboratorium test bloedgroep: ABO | ||
| Laboratorium test rhesus d | Zie Laboratorium test rhesus d: RhD | ||
| Laboratorium test rhesus c | Zie Laboratorium test rhesus c: Rhc | ||
Administratief
| Administratief | |||||
| Gegevenselement | Waarde | ||||
| Patient Vrouw2 | |||||
| Naamgegevens | |||||
| Voornamen | Jamila | ||||
| Initialen | J | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Kwee | ||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1000 | ||||
| Postcode | 9999XA | ||||
| Woonplaats | STITSWERD | ||||
| Identificatienummer | 999900730 (in identificerend systeem: BSN) | ||||
| Geboortedatum | 20 okt 1985 | ||||
| Geslacht administratief | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
| Meerling indicator | Nee | ||||
| Zorgaanbieder ZA1 | |||||
| Zorgaanbieder identificatienummer | 08001234 (in identificerend systeem: AGB-Z) | ||||
| Organisatie naam | Verloskundigenpraktijk 't Groen | ||||
| Adresgegevens | |||||
| Straat | Groeneweg | ||||
| Huisnummer | 1000 | ||||
| Postcode | 9999XY | ||||
| Woonplaats | STITSWERD | ||||
| Land | Nederland (code = '6030' in codeSystem 'GBA Tabel 34 Landentabel') | ||||
| Adres soort | Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
| Organisatie type | Verloskundigenpraktijk (code = 'G3' in codeSystem 'RoleCodeNL - zorgaanbiedertype (organisaties)') | ||||
| Zorgverlener ZV1 | |||||
| Zorgverlener identificatienummer | 12340001 (in identificerend systeem: UZI Personen) | ||||
| Naamgegevens | |||||
| Roepnaam | Gemma | ||||
| Naamgebruik | Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Groeneboom | ||||
| Geslachtsnaam partner | |||||
| Achternaam partner | XXX_Gras | ||||
| Specialisme | eerstelijnsverloskundige (beroep) (code = '158999002' in codeSystem 'SNOMED CT') | ||||
| Zorgaanbieder | Zie Zorgaanbieder: ZA1 | ||||
| Zorgverleners rol | Case manager (code = '768832004' in codeSystem 'SNOMED CT') | ||||
Zorgverlening
| Zorgverlening | |||
| Gegevenselement | Waarde | ||
| Zorg episode | |||
| Begin datum | T - 205 dagen | ||
| Eind datum | T - 194 dagen | ||
Zwangerschapsgegevens
| Zwangerschapsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Coordinerend zorgverlener | |||||
| Zorgverlener | Zie Zorgverlener: ZV1 | ||||
| Zwangerschap | |||||
| Zwangerschapsduur | 59 dagen | ||||
| Pariteit | 0 | ||||
| Graviditeit | 1 | ||||
| Aterme datum items | |||||
| Aterme datum | T - 205 dagen | ||||
| Bepalings methode | aterme datum berekend door middel van diagnostische ultrasonografie (code = '31541000146106' in codeSystem 'SNOMED CT') | ||||
| Datum bepaling | T + 10 dagen | ||||
| Datum laatste menstruatie | T - 278 dagen | ||||
| Aantal foetussen observatie AantalFoetussen | |||||
| Aantal foetussen datum tijd | T - 205 dagen | ||||
| Aantal foetussen waarde | 2 | ||||
| Observatie methode | echografie van foetus (verrichting) (code = '241491007' in codeSystem 'SNOMED CT') | ||||
| Meerling zwangerschap observatie | |||||
| Meerling zwangerschap datum tijd | T - 205 dagen | ||||
| Aantal foetussen observatie | Zie Aantal foetussen observatie: AantalFoetussen | ||||
| Observatie methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | ||||
| Foliumzuurgebruik observatie | |||||
| Foliumzuurgebruik datum tijd | T - 205 dagen | ||||
| Foliumzuurgebruik waarde | geen preconceptionele intake van foliumzuur via voeding (bevinding) (code = '30391000146101' in codeSystem 'SNOMED CT') | ||||
| Prenatale controle | |||||
| Lichaamsgewicht | Zie Lichaamsgewicht: Gew-205D | ||||
| Bloeddruk | Zie Bloeddruk: BP-205D | ||||
| Alcohol gebruik | |||||
| Alcohol gebruik status | drinkt geen alcohol (code = '105542008' in codeSystem 'SNOMED CT') | ||||
| Drugs gebruik | |||||
| Drugs gebruik status | heeft nooit drugs gebruikt (code = '228368007' in codeSystem 'SNOMED CT') | ||||
| Tabak gebruik | |||||
| Tabak gebruik status | rookt soms sigaretten (code = '230059006' in codeSystem 'SNOMED CT') | ||||
| Soort tabak gebruik | gebruiker van elektronische sigaret (code = '722499006' in codeSystem 'SNOMED CT') | ||||
| Waarneming gebruik | |||||
| Start datum | 1 jun 2019 | ||||
| Hoeveelheid | 6 keer per dag inhaleren | ||||
| Probleem zwangerschap Probleem1 | |||||
| Probleem naam | meerlingzwangerschap (aandoening) (code = '16356006' in codeSystem 'SNOMED CT') | ||||
| Probleem begin datum | T - 205 dagen | ||||
| Zwangerschapsduur | 59 dagen | ||||
| Toelichting | mw.door verwijzen naar Sophia | ||||
| Verrichting zwangerschap | |||||
| Verrichting start datum | T - 205 dagen | ||||
| Verrichting type | bloedonderzoek (verrichting) (code = '396550006' in codeSystem 'SNOMED CT') | ||||
| Verrichting zwangerschap | |||||
| Verrichting start datum | T - 205 dagen | ||||
| Verrichting type | dieetmanagement (verrichting) (code = '410175003' in codeSystem 'SNOMED CT') | ||||
Medisch onderzoek
| Medisch onderzoek | ||||||
| Gegevenselement | Waarde | |||||
| Verrichting onderzoek | ||||||
| Verrichting start datum | T-195D | |||||
| Verrichting eind datum | T - 195 dagen | |||||
| Maternale onderzoeksgegevens | ||||||
| Urine bloed en aanvullende onderzoeken | ||||||
| Psie | ||||||
| Laboratorium test bloedgroep ABO | ||||||
| Test code | ABO group [Type] in Blood (code = '883-9' in codeSystem 'LOINC') | |||||
| Test uitslag | bloedgroep O (bevinding) (code = '58460004' in codeSystem 'SNOMED CT') | |||||
| Laboratorium test rhesus d RhD | ||||||
| Test code | D Ag [Presence] in Blood (code = '1305-2' in codeSystem 'LOINC') | |||||
| Test uitslag | Rh D Positief (code = '165747007' in codeSystem 'SNOMED CT') | |||||
| Laboratorium test rhesus c Rhc | ||||||
| Test code | Kleine c Ag [aanwezigheid] in erytrocyten (code = '1159-3' in codeSystem 'LOINC') | |||||
| Test uitslag | Rh c Positief (code = '733120009' in codeSystem 'SNOMED CT') | |||||
| Laboratorium test hb | ||||||
| Test code | Hemoglobin [Moles/volume] in Venous blood (code = '93846-4' in codeSystem 'LOINC') | |||||
| Test uitslag | 7.3 g/dl | |||||
Bouwstenen
| Bouwstenen | ||||
| Gegevenselement | Waarde | |||
| Metingen | ||||
| Bloeddruk BP-205D | ||||
| Systolische bloeddruk | 114 | |||
| Diastolische bloeddruk | 87 | |||
| Bloeddruk datum tijd | T - 205 dagen | |||
| Lichaamsgewicht Gew-205D | ||||
| Gewicht waarde | 63 kg | |||
| Gewicht datum tijd | T - 205 dagen | |||
| Kleding | Lichte kleding/ondergoed (code = 'MINIMAL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1') | |||
Scenario Vrouw 2, Kaart 3 - data 2e lijn (meerling)
| Vrouw | |||
| Gegevenselement | Waarde | ||
| Demografische gegevens | |||
| Patient | Zie Patient: Vrouw2 | ||
| Bloedonderzoek | |||
| Laboratorium test bloedgroep | Zie Laboratorium test bloedgroep: ABO | ||
| Laboratorium test rhesus d | Zie Laboratorium test rhesus d: RhD | ||
| Laboratorium test rhesus c | Zie Laboratorium test rhesus c: Rhc | ||
Administratief
| Administratief | |||||
| Gegevenselement | Waarde | ||||
| Patient Vrouw2 | |||||
| Naamgegevens | |||||
| Voornamen | Jamila | ||||
| Initialen | J | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Kwee | ||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1000 | ||||
| Postcode | 9999XA | ||||
| Woonplaats | STITSWERD | ||||
| Identificatienummer | 999900730 (in identificerend systeem: BSN) | ||||
| Geboortedatum | 20 okt 1985 | ||||
| Geslacht administratief | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
| Meerling indicator | Nee | ||||
| Patient Kind2 | |||||
| Naamgegevens | |||||
| Voornamen | Jusef | ||||
| Initialen | J | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Kwee | ||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1000 | ||||
| Postcode | 9999XA | ||||
| Woonplaats | STITSWERD | ||||
| Geboortedatum | T - 5 dagen | ||||
| Geslacht administratief | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | ||||
| Meerling indicator | Ja | ||||
| Rangnummer | 1 | ||||
| Patient Kind3 | |||||
| Naamgegevens | |||||
| Voornamen | Jamal | ||||
| Initialen | J | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Kwee | ||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1000 | ||||
| Postcode | 9999XA | ||||
| Woonplaats | STITSWERD | ||||
| Geboortedatum | T - 5 dagen | ||||
| Geslacht administratief | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | ||||
| Meerling indicator | Ja | ||||
| Rangnummer | 2 | ||||
| Zorgaanbieder ZA2 | |||||
| Zorgaanbieder identificatienummer | 06020806 (in identificerend systeem: AGB-Z) | ||||
| Organisatie naam | Erasmus MC, Sophia kinderziekenhuis | ||||
| Adresgegevens | |||||
| Straat | Dr. Molewaterplein | ||||
| Huisnummer | 60 | ||||
| Postcode | 3015 GJ | ||||
| Woonplaats | ROTTERDAM | ||||
| Adres soort | Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
| Organisatie type | Universitair Medisch Centrum (code = 'V5' in codeSystem 'RoleCodeNL - zorgaanbiedertype (organisaties)') | ||||
| Zorgverlener ZV2 | |||||
| Zorgverlener identificatienummer | 98765432 (in identificerend systeem: UZI Personen) | ||||
| Naamgegevens | |||||
| Roepnaam | Eduard | ||||
| Naamgebruik | Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Egelinks | ||||
| Geslachtsnaam partner | |||||
| Achternaam partner | XXX_Gras | ||||
| Specialisme | Gynaecoloog (code = '01.046' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||
| Zorgaanbieder | Zie Zorgaanbieder: ZA2 | ||||
| Zorgverleners rol | Hoofdbehandelaar (code = 'RESP' in codeSystem 'HL7 ParticipationType') | ||||
Zorgverlening
| Zorgverlening | |||
| Gegevenselement | Waarde | ||
| Zorg episode | |||
| Begin datum | T - 193 dagen | ||
Zwangerschapsgegevens
| Zwangerschapsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Coordinerend zorgverlener | |||||
| Zorgverlener | Zie Zorgverlener: ZV2 | ||||
| Zwangerschap | |||||
| Zwangerschapsduur | 259 dagen | ||||
| Pariteit | 1 | ||||
| Graviditeit | 1 | ||||
| Aterme datum items | |||||
| Aterme datum | T + 10 dagen | ||||
| Bepalings methode | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): uit verwijzing verloskundigenpraktijk | ||||
| Datum bepaling | T - 205 dagen | ||||
| Datum laatste menstruatie | T - 278 dagen | ||||
| Definitieve a terme datum observatie | |||||
| Definitieve a terme datum tijd | T - 126 dagen om 13:45 uur | ||||
| Definitieve a terme waarde | T + 2 dagen | ||||
| Definitieve a terme methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | ||||
| Aantal foetussen observatie AantalFoetussen | |||||
| Aantal foetussen datum tijd | T - 193 dagen | ||||
| Aantal foetussen waarde | 2 | ||||
| Observatie methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | ||||
| Meerling zwangerschap observatie | |||||
| Meerling zwangerschap datum tijd | T - 193 dagen | ||||
| Typering gemellizwangerschap waarde | monochoriale diamniotische tweelingzwangerschap (aandoening) (code = '459168005' in codeSystem 'SNOMED CT') | ||||
| Aantal foetussen observatie | Zie Aantal foetussen observatie: AantalFoetussen | ||||
| Observatie methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | ||||
| Aantal levende kinderen observatie | |||||
| Aantal levende kinderen datum tijd | T - 76 dagen | ||||
| Aantal levende kinderen waarde | 2 | ||||
| Observatie methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | ||||
| Foliumzuurgebruik observatie | |||||
| Foliumzuurgebruik datum tijd | T - 193 dagen | ||||
| Foliumzuurgebruik waarde | intake van foliumzuur via voeding vanaf vastgestelde zwangerschap (bevinding) (code = '29771000146106' in codeSystem 'SNOMED CT') | ||||
| Toelichting | op advies verloskundigenpraktijk gestart | ||||
| Prenatale controle | |||||
| Leven voelen observatie | |||||
| Leven voelen datum tijd | T - 193 dagen om 13:40 uur | ||||
| Leven voelen waarde | foetale bewegingen aanwezig (bevinding) (code = '289431008' in codeSystem 'SNOMED CT') | ||||
| Observatie methode | palpatie (verrichting) (code = '113011001' in codeSystem 'SNOMED CT') | ||||
| Lichaamsgewicht | Zie Lichaamsgewicht: Gew-193D | ||||
| Bloeddruk | Zie Bloeddruk: BP-193D | ||||
| Alcohol gebruik | |||||
| Alcohol gebruik status | drinkt geen alcohol (code = '105542008' in codeSystem 'SNOMED CT') | ||||
| Drugs gebruik | |||||
| Drugs gebruik status | heeft nooit drugs gebruikt (code = '228368007' in codeSystem 'SNOMED CT') | ||||
| Tabak gebruik | |||||
| Toelichting | gestopt op advies verloskundige | ||||
| Tabak gebruik status | rookte vroeger (code = '8517006' in codeSystem 'SNOMED CT') | ||||
| Soort tabak gebruik | gebruiker van elektronische sigaret (code = '722499006' in codeSystem 'SNOMED CT') | ||||
| Waarneming gebruik | |||||
| Start datum | 1 jun 2019 | ||||
| Stop datum | T - 198 dagen | ||||
| Prenatale controle | |||||
| Bloeddruk | Zie Bloeddruk: BP-76D | ||||
| Probleem zwangerschap Probleem1 | |||||
| Probleem naam | meerlingzwangerschap (aandoening) (code = '16356006' in codeSystem 'SNOMED CT') | ||||
| Probleem begin datum | T - 193 dagen | ||||
| Zwangerschapsduur | 71 dagen | ||||
| Probleem zwangerschap Probleem2 | |||||
| Probleem type | Klinische bevinding (code = '404684003' in codeSystem 'SNOMED CT') | ||||
| Probleem naam | intra-uteriene groeiretardatie (aandoening) (code = '22033007' in codeSystem 'SNOMED CT') | ||||
| Probleem begin datum | T - 76 dagen | ||||
| Zwangerschapsduur | 188 dagen | ||||
| Toelichting | tweede kind blijft erg achter in ontwikkeling | ||||
| Verrichting zwangerschap | |||||
| Verrichting start datum | T - 193 dagen | ||||
| Verrichting type | bloedonderzoek (verrichting) (code = '396550006' in codeSystem 'SNOMED CT') | ||||
| Verrichting zwangerschap | |||||
| Verrichting start datum | T - 5 dagen | ||||
| Verrichting type | opname in ziekenhuis (verrichting) (code = '32485007' in codeSystem 'SNOMED CT') | ||||
Bevalling
| Bevalling | |||||
| Gegevenselement | Waarde | ||||
| Partusnummer | 1 | ||||
| Zwangerschapsduur | 259 dagen | ||||
| Uitdrijvingsfase | |||||
| Patient | Zie Patient: Kind2 | ||||
| Type partus observatie | |||||
| Observatie datum tijd | T - 5 dagen | ||||
| Type partus waarde | sectio caesarea (verrichting) (code = '11466000' in codeSystem 'SNOMED CT') | ||||
| Werkelijke plaats baring type locatie observatie | |||||
| Observatie datum tijd | T - 5 dagen om 14:38 uur | ||||
| Werkelijke plaats baring waarde | geboorte in ziekenhuis (bevinding) (code = '56321000146103' in codeSystem 'SNOMED CT') | ||||
| Toelichting | geplande sectio | ||||
| Ziekenhuis baring | |||||
| Zorgaanbieder | Zie Zorgaanbieder: ZA2 | ||||
| Probleem kindspecifieke maternale problemen Probleem3 | |||||
| Probleem naam | liggingsafwijking van foetus (bevinding) (code = '15028002' in codeSystem 'SNOMED CT') | ||||
| Probleem begin datum | T - 5 dagen | ||||
| Verrichting kindspecifieke maternale verrichtingen | |||||
| Verrichting start datum | T - 5 dagen om 14:03 uur | ||||
| Verrichting eind datum | T - 5 dagen om 14:52 uur | ||||
| Indicatie | |||||
| Probleem kindspecifieke maternale problemen | Zie Probleem kindspecifieke maternale problemen: Probleem2 | ||||
| Verrichting type | primaire sectio caesarea (verrichting) (code = '80771000146107' in codeSystem 'SNOMED CT') | ||||
| Verrichting kindspecifieke maternale verrichtingen | |||||
| Verrichting start datum | T - 5 dagen om 14:50 uur | ||||
| Verrichting type | vitamine K toediening aan neonaat (code = '698350008:370131001=133933007' in codeSystem 'SNOMED CT') | ||||
| Uitdrijvingsfase | |||||
| Patient | Zie Patient: Kind3 | ||||
| Type partus observatie | |||||
| Observatie datum tijd | T - 5 dagen | ||||
| Type partus waarde | sectio caesarea (verrichting) (code = '11466000' in codeSystem 'SNOMED CT') | ||||
| Werkelijke plaats baring type locatie observatie | |||||
| Observatie datum tijd | T - 5 dagen om 14:38 uur | ||||
| Werkelijke plaats baring waarde | geboorte in ziekenhuis (bevinding) (code = '56321000146103' in codeSystem 'SNOMED CT') | ||||
| Toelichting | geplande sectio | ||||
| Ziekenhuis baring | |||||
| Zorgaanbieder | Zie Zorgaanbieder: ZA2 | ||||
| Verrichting kindspecifieke maternale verrichtingen | |||||
| Verrichting start datum | T - 5 dagen om 14:03 uur | ||||
| Verrichting eind datum | T - 5 dagen om 14:52 uur | ||||
| Indicatie | |||||
| Probleem kindspecifieke maternale problemen | Zie Probleem kindspecifieke maternale problemen: Probleem2 | ||||
| Verrichting type | primaire sectio caesarea (verrichting) (code = '80771000146107' in codeSystem 'SNOMED CT') | ||||
| Verrichting kindspecifieke maternale verrichtingen | |||||
| Verrichting start datum | T - 5 dagen om 14:52 uur | ||||
| Verrichting type | inflatie van long door intermitterende compressie van reservoirballon (code = '243140006' in codeSystem 'SNOMED CT') | ||||
| Verrichting kindspecifieke maternale verrichtingen | |||||
| Verrichting start datum | T - 5 dagen om 14:55 uur | ||||
| Verrichting type | vitamine K toediening aan neonaat (code = '698350008:370131001=133933007' in codeSystem 'SNOMED CT') | ||||
Kind
| Kind | ||||||
| Gegevenselement | Waarde | |||||
| Demografische gegevens | ||||||
| Patient | Zie Patient: Kind2 | |||||
| Lichamelijk onderzoek kind | ||||||
| Geboortegewicht lichaamsgewicht | ||||||
| Gewicht waarde | 2605 gram | |||||
| Gewicht datum tijd | T - 5 dagen om 15:10 uur | |||||
| Kleding | Luier (code = 'DIAPER' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1') | |||||
| Lichaamslengte | ||||||
| Lengte waarde | 48 | |||||
| Schedelomvang | ||||||
| Schedelomvang waarde | 32.6 cm | |||||
| Bevindingen | ||||||
| Algemene indruk | ||||||
| Apgar score1min | ||||||
| Apgar score totaal | 7 | |||||
| Apgar score5min | ||||||
| Apgar score totaal | 10 | |||||
| Apgar score10min | ||||||
| Apgar score totaal | 10 | |||||
Kind
| Kind | ||||||
| Gegevenselement | Waarde | |||||
| Demografische gegevens | ||||||
| Patient | Zie Patient: Kind3 | |||||
| Lichamelijk onderzoek kind | ||||||
| Geboortegewicht lichaamsgewicht | ||||||
| Gewicht waarde | 2089 gram | |||||
| Gewicht datum tijd | T - 5 dagen om 15:05 uur | |||||
| Kleding | Zonder kleding. (code = 'UNDRESSED' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1') | |||||
| Lichaamslengte | ||||||
| Lengte waarde | 46 | |||||
| Schedelomvang | ||||||
| Schedelomvang waarde | 31.8 cm | |||||
| Bevindingen | ||||||
| Algemene indruk | ||||||
| Apgar score1min | ||||||
| Apgar score totaal | 5 | |||||
| Apgar score5min | ||||||
| Apgar score totaal | 9 | |||||
| Apgar score10min | ||||||
| Apgar score totaal | 10 | |||||
Medisch onderzoek
| Medisch onderzoek | ||||||
| Gegevenselement | Waarde | |||||
| Verrichting onderzoek | ||||||
| Verrichting start datum | T-193D | |||||
| Verrichting eind datum | T - 193 dagen | |||||
| Maternale onderzoeksgegevens | ||||||
| Urine bloed en aanvullende onderzoeken | ||||||
| Psie | ||||||
| Laboratorium test bloedgroep ABO | ||||||
| Test code | ABO group [Type] in Blood (code = '883-9' in codeSystem 'LOINC') | |||||
| Test uitslag | bloedgroep O (bevinding) (code = '58460004' in codeSystem 'SNOMED CT') | |||||
| Laboratorium test rhesus d RhD | ||||||
| Test code | D Ag [Presence] in Blood (code = '1305-2' in codeSystem 'LOINC') | |||||
| Test uitslag | Rh D Positief (code = '165747007' in codeSystem 'SNOMED CT') | |||||
| Laboratorium test rhesus c Rhc | ||||||
| Test code | Kleine c Ag [aanwezigheid] in erytrocyten (code = '1159-3' in codeSystem 'LOINC') | |||||
| Test uitslag | Rh c Positief (code = '733120009' in codeSystem 'SNOMED CT') | |||||
| Laboratorium test hb | ||||||
| Test code | Hemoglobin [Moles/volume] in Venous blood (code = '93846-4' in codeSystem 'LOINC') | |||||
| Test uitslag | 7.0 g/dl | |||||
| Torch | ||||||
| Laboratorium test torch | ||||||
| Test code | Toxoplasma gondii IgG Ab [Units/volume] in Serum (code = '8039-0' in codeSystem 'LOINC') | |||||
| Test uitslag | 9 k[arb'u]/l | |||||
Medisch onderzoek
| Medisch onderzoek | |||||
| Gegevenselement | Waarde | ||||
| Verrichting onderzoek | |||||
| Verrichting start datum | T-76D | ||||
| Verrichting eind datum | T - 76 dagen | ||||
| Maternale onderzoeksgegevens | |||||
| Urine bloed en aanvullende onderzoeken | |||||
| Laboratorium test hb | |||||
| Test code | Hemoglobin [Moles/volume] in Venous blood (code = '93846-4' in codeSystem 'LOINC') | ||||
| Test uitslag | 6.7 g/dl | ||||
Medisch onderzoek
| Medisch onderzoek | |||||
| Gegevenselement | Waarde | ||||
| Verrichting onderzoek | |||||
| Verrichting start datum | T-5D | ||||
| Verrichting eind datum | T - 5 dagen | ||||
| Maternale onderzoeksgegevens | |||||
| Urine bloed en aanvullende onderzoeken | |||||
| Laboratorium test hb | |||||
| Test code | Hemoglobin [Moles/volume] in Venous blood (code = '93846-4' in codeSystem 'LOINC') | ||||
| Test uitslag | 6.5 g/dl | ||||
Bouwstenen
| Bouwstenen | ||||
| Gegevenselement | Waarde | |||
| Metingen | ||||
| Bloeddruk BP-193D | ||||
| Systolische bloeddruk | 123 | |||
| Diastolische bloeddruk | 81 | |||
| Bloeddruk datum tijd | T - 193 dagen | |||
| Lichaamsgewicht Gew-193D | ||||
| Gewicht waarde | 65 kg | |||
| Gewicht datum tijd | T - 193 dagen | |||
| Metingen | ||||
| Bloeddruk BP-76D | ||||
| Systolische bloeddruk | 108 | |||
| Diastolische bloeddruk | 79 | |||
| Bloeddruk datum tijd | T - 76 dagen | |||
| Metingen | ||||
| Bloeddruk BP-5D | ||||
| Systolische bloeddruk | 91 | |||
| Diastolische bloeddruk | 57 | |||
| Bloeddruk datum tijd | T - 5 dagen | |||
Scenario Vrouw 3, geen zwangerschapskaart beschikbaar
Administratief
| Administratief | |||||
| Gegevenselement | Waarde | ||||
| Patient Vrouw3 | |||||
| Naamgegevens | |||||
| Voornamen | Julia | ||||
| Initialen | J | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Laarhoven | ||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1002 | ||||
| Postcode | 9999ZZ | ||||
| Woonplaats | STITSWERD | ||||
| Identificatienummer | 999900754 (in identificerend systeem: BSN) | ||||
| Geboortedatum | 22 okt 1985 | ||||
| Geslacht administratief | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
| Zorgaanbieder | |||||
| Zorgaanbieder identificatienummer | (in identificerend systeem: AGB-Z) | ||||
| Zorgverlener | |||||
| Zorgverlener identificatienummer | (in identificerend systeem: AGB-Z) | ||||