|
|
| (173 tussenliggende versies door 2 gebruikers niet weergegeven) |
| Regel 1: |
Regel 1: |
| <noinclude>
| | {{anchor|tabel1}} |
| {{DISPLAYTITLE:Kernset Neonatologie 3.0 - inhoud kwalificatie}} | | {| class="wikitable" "cellpadding="10" |
| __NUMBEREDHEADINGS__
| | |+Tabel 1. Overzicht situaties specifieke en generieke MBH-id voor EVS en AIS |
| | |- |
| | ! style="text-align:left;"|Situatie |
| | ! style="text-align:left;"|EVS |
| | ! style="text-align:left;"|AIS |
| | ! style="text-align:left;"|ETDR |
| | |- |
| | ! style="text-align:left;"|Migreren van actuele en recent gestopte medicatie |
| | | style="background-color: white;vertical-align:top;"|Specifieke MBH-id||Generieke MBH-id |
| | | style="background-color: white;vertical-align:top;"|Generieke MBH-id |
| | |- |
| | ! style="text-align:left;"|Migreren van historische medicatie |
| | | style="background-color: white;vertical-align:top;"|Generieke MBH-id||Generieke MBH-id |
| | | style="background-color: white;vertical-align:top;"|Generieke MBH-id |
| | |- |
| | ! style="text-align:left;"|Starten van nieuwe MBH |
| | | style="background-color: white;vertical-align:top;"|Specieke MBH-id||Generieke MBH-id<ref>AIS initieert in principe géén specifieke MBH-id. Alleen wanneer er geen PRK is, maakt het AIS een specifieke MBH-id aan (zie paragraaf [[#Bijzondere situaties|Bijzondere situaties]]).</ref> |
| | | style="background-color: white;vertical-align:top;"|Generieke MBH-id |
|
| |
|
| =Addenda voor inhoudelijke gegevens Kernset Neonatologie 3.0=</noinclude>
| | |- |
| ==Scenario Testscenario 1: uitgebreide problematiek ==
| |
|
| |
| === Documentgegevens ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Documentgegevens
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Identificatie
| |
| |style="background-color: white;"|0000 (in identificerend systeem: abc123)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Document datum
| |
| |style="background-color: white;"|T - 1 dag
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Set identificatie
| |
| |style="background-color: white;"|0000 (in identificerend systeem: abc123)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Versienummer
| |
| |style="background-color: white;"|1
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Software naam
| |
| |style="background-color: white;"|InformatieSysteemX
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Verificatie zorgverlener
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Geverifieerd door zorgverlener?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Verificatie datum
| |
| |style="background-color: white;"|T - 0 dagen
| |
| |}
| |
| === Zorgaanbieder ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgaanbieder
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorgaanbieder identificatienummer
| |
| |style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorgaanbieder identificatienummer
| |
| |style="background-color: white;"|0000 (in identificerend systeem: AGB-Z)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorgaanbieder identificatienummer
| |
| |style="background-color: white;"|0000 (in identificerend systeem: URA)
| |
| |}
| |
| === Zorgverlener ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zorgverlener
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Zorgverlener identificatienummer
| |
| |style="background-color: white;"|0000 (in identificerend systeem: 2.16.528.1.1007.5.1)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Naamgegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="12"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Voornamen
| |
| |style="background-color: white;"|Hans Peter
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Initialen
| |
| |style="background-color: white;"|HP
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Roepnaam
| |
| |style="background-color: white;"|Hans
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Naamgebruik
| |
| |style="background-color: white;"|Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Geslachtsnaam
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Voorvoegsels
| |
| |style="background-color: white;"|van den
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Achternaam
| |
| |style="background-color: white;"|Akker
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Geslachtsnaam partner
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Achternaam partner
| |
| |style="background-color: white;"|Pieterse
| |
| |}
| |
| === Vrouw ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Vrouw
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Demografische gegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Patient
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Identificatienummer
| |
| |style="background-color: white;"|000000000 (in identificerend systeem: BSN)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Geboortedatum
| |
| |style="background-color: white;"|T - 27 jaar
| |
| |}
| |
| === Zwangerschapsgegevens ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zwangerschapsgegevens
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Graviditeit
| |
| |style="background-color: white;"|1
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Pariteit voor deze zwangerschap
| |
| |style="background-color: white;"|0
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Complicaties tijdens zwangerschap
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="8"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Complicaties zwangerschap?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Probleem naam
| |
| |style="background-color: white;"|koorts (code = '386661006' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Verificatie status
| |
| |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Magnesiumsulfaat
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Antenatale steroiden gegeven?
| |
| |style="background-color: white;"|Nee
| |
| |}
| |
| === Kind ===
| |
| | |
| {| 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="14"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Patient
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="12"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Adresgegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Adresgegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Postcode
| |
| |style="background-color: white;"|1234 AB
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Identificatienummer
| |
| |style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Geboortedatum
| |
| |style="background-color: white;"|T - 90 dagen om 12:13 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Geslacht
| |
| |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;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Rangnummer kind
| |
| |style="background-color: white;"|2
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Overlijdens indicator
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Bevallingsgegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="9"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Zwangerschapsduur
| |
| |style="background-color: white;"|179 dagen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Aantal geboren kinderen
| |
| |style="background-color: white;"|2
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Type partus
| |
| |style="background-color: white;"|Primair (code = '177141003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Locatie partus
| |
| |style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Zorgaanbieder
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Zorgaanbieder identificatienummer
| |
| |style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Organisatie naam
| |
| |style="background-color: white;"|UMC Papendorp
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Ondersteuning opvang
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="7"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Verrichting type
| |
| |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Verrichting type
| |
| |style="background-color: white;"|endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Opname gegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="37"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Opname
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="7"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Opname datum
| |
| |style="background-color: white;"|T - 90 dagen om 13:30 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Ic opname?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Heropname?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Herkomst kind
| |
| |style="background-color: white;"|In-hospital admission from obstetrical ward (procedure) (code = '59151000146103' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Opname indicatie
| |
| |style="background-color: white;"|Finding of length of gestation (finding) (code = '366323009' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Ontslag datum
| |
| |style="background-color: white;"|T - 31 dagen om 12 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Onderzoek
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="27"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Lichaamslengte
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Lengte waarde
| |
| |style="background-color: white;"|31 cm
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Lengte datum tijd
| |
| |style="background-color: white;"|T - 90 dagen om 13:20 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Lichaamsgewicht
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Gewicht waarde
| |
| |style="background-color: white;"|710 g
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Gewicht datum tijd
| |
| |style="background-color: white;"|T - 90 dagen om 13:21 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Lichaamstemperatuur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Temperatuur waarde
| |
| |style="background-color: white;"|37.4 graden celsius
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Temperatuur datum tijd
| |
| |style="background-color: white;"|T - 90 dagen om 13:22 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Toelichting
| |
| |style="background-color: white;"|abc
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Temperatuur type
| |
| |style="background-color: white;"|Rectale temperatuur (code = '307047009' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Schedelomvang
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Schedelomvang waarde
| |
| |style="background-color: white;"|22.5 cm
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Schedelomvang datum tijd
| |
| |style="background-color: white;"|T - 90 dagen om 13:23 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Apgar score na 1 min
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Apgar score totaal
| |
| |style="background-color: white;"|1
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Apgar score na 5 min
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Apgar score totaal
| |
| |style="background-color: white;"|5
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Nsp h arterieel
| |
| |style="background-color: white;"|7.05 ph
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Be
| |
| |style="background-color: white;"|-12.0 mmol/l
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Problematiek kind
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | |
| |rowspan="100"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Geboortetrauma
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Ademhalingsondersteuning
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="13"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Ademhalingsondersteuning?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting start datum
| |
| |style="background-color: white;"|T - 90 dagen om 13:35 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting eind datum
| |
| |style="background-color: white;"|T - 33 dagen om 12 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Oxygen therapy using high flow oxygen nasal cannula (procedure) (code = '57485005:424226004=426854004' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting start datum
| |
| |style="background-color: white;"|T - 33 dagen om 12 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting eind datum
| |
| |style="background-color: white;"|T - 31 dagen om 10 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|O2 op dag 28?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Respiratoir
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="14"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|Respiratory distress syndrome in the newborn (disorder) (code = '46775006' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verificatie status
| |
| |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Aanvang
| |
| |style="background-color: white;"|Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Medicatie
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Stimulatie ademhaling
| |
| |style="background-color: white;"|COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Surfactant
| |
| |style="background-color: white;"|NATUURLIJKE FOSFOLIPIDEN - LONGSURFACTANTS (code = 'R07AA02' in codeSystem 'ATC-NL')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Medicatie
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Stimulatie ademhaling
| |
| |style="background-color: white;"|DOXAPRAM (code = 'R07AB01' in codeSystem 'ATC-NL')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Circulatoir
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="9"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|Patent ductus arteriosus (disorder) (code = '83330001' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verificatie status
| |
| |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Drug therapy for patent ductus arteriosus (procedure) (code = '58801000146104' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Infectieus
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="13"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="9"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|Suspected sepsis (situation) (code = '9331000146100' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem begin datum
| |
| |style="background-color: white;"|T - 89 dagen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem eind datum
| |
| |style="background-color: white;"|T - 86 dagen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verificatie status
| |
| |style="background-color: white;"|Werk (code = '415684004' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Aanvang
| |
| |style="background-color: white;"|Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Microorganisme sepsis meningitis
| |
| |style="background-color: white;"|Other, specify (code = 'OTH' in codeSystem 'HL7 NullFlavor'): abc
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Lijnsepsis?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Onset
| |
| |style="background-color: white;"|vroege neonatale periode (kwalificatiewaarde) (code = '303114002' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Antibiotica eerste 3 dagen?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Gastrointestinaal
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Hematologisch
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Transfusion for anemia (procedure) (code = '59071000146107' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Metabool en endocrien
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="12"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|<span id="hyperbilirubemie" title="Intern ID = hyperbilirubemie">Probleem hyperbilirubemie</span>
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verificatie status
| |
| |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Indicatie
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Probleem
| |
| |style="background-color: white;"|Zie [[#hyperbilirubemie|Probleem: hyperbilirubemie]]
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Neurologisch
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Zintuigen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="11"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|Retinopathy of prematurity stage 2 - intraretinal ridge (disorder) (code = '408848001' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verificatie status
| |
| |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Rop screening verricht?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Rop screening afgesloten?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Aabr verricht?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Aabr afwijkend?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Bera verricht?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Congenitale aandoeningen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Ontslagoverplaatsing
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="15"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Nog opgenomen?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Bestemming kind
| |
| |style="background-color: white;"|Discharge to other hospital (procedure) (code = '115851000146108' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Lichamelijk onderzoek
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="10"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Lichaamsgewicht
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Gewicht waarde
| |
| |style="background-color: white;"|1740 gram
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Gewicht datum tijd
| |
| |style="background-color: white;"|T - 31 dagen om 09 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Schedelomvang
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Schedelomvang meetmethode
| |
| |style="background-color: white;"|Meten van schedelomvang m.b.v. meetlint (code = '31551000146109' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Schedelomvang waarde
| |
| |style="background-color: white;"|30 cm
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Schedelomvang datum tijd
| |
| |style="background-color: white;"|T - 31 dagen om 09:01 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Voeding kind
| |
| |style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Mortaliteit
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Overlijden lt12 uur na opname nicu?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Overleden op verloskamer?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Staken icbehandeling?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Follow up
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="8"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Na ontslag
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="6"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|O2 op dag 28?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Gradatie bpd
| |
| |style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Zintuigen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Problemen aanwezig?
| |
| |style="background-color: white;"|NullFlavor: UNK
| |
| |}
| |
| ==Scenario Testscenario 2: geb.trauma + neurologisch + anat afw + overlijden ==
| |
|
| |
| === Documentgegevens ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Documentgegevens
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Identificatie
| |
| |style="background-color: white;"|0000 (in identificerend systeem: abc123)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Document datum
| |
| |style="background-color: white;"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Set identificatie
| |
| |style="background-color: white;"|0000 (in identificerend systeem: abc123)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Versienummer
| |
| |style="background-color: white;"|2
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Software naam
| |
| |style="background-color: white;"|XIS
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Verificatie zorgverlener
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Geverifieerd door zorgverlener?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Verificatie datum
| |
| |style="background-color: white;"|
| |
| |}
| |
| === Zorgaanbieder ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgaanbieder
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorgaanbieder identificatienummer
| |
| |style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2)
| |
| |}
| |
| === Zorgverlener ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zorgverlener
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Zorgverlener identificatienummer
| |
| |style="background-color: white;"|0000 (in identificerend systeem: UZI Personen)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Naamgegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="8"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Voornamen
| |
| |style="background-color: white;"|Hans Paul
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Initialen
| |
| |style="background-color: white;"|H.P.
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Roepnaam
| |
| |style="background-color: white;"|Hans
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Naamgebruik
| |
| |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;;"
| |
| |colspan="4"|Geslachtsnaam
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Achternaam
| |
| |style="background-color: white;"|Pieterse
| |
| |}
| |
| === Vrouw ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Vrouw
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Demografische gegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Patient
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Identificatienummer
| |
| |style="background-color: white;"|(in identificerend systeem: BSN)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Geboortedatum
| |
| |style="background-color: white;"|T - 26 jaar
| |
| |}
| |
| === Zwangerschapsgegevens ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zwangerschapsgegevens
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Graviditeit
| |
| |style="background-color: white;"|3
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Pariteit voor deze zwangerschap
| |
| |style="background-color: white;"|2
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Complicaties tijdens zwangerschap
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="8"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Complicaties zwangerschap?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Probleem naam
| |
| |style="background-color: white;"|hypertensieve aandoening (aandoening) (code = '38341003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Verificatie status
| |
| |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Magnesiumsulfaat
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Antenatale steroiden gegeven?
| |
| |style="background-color: white;"|NullFlavor: NA
| |
| |}
| |
| === Kind ===
| |
| | |
| {| 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="9"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Patient
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="7"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Identificatienummer
| |
| |style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Geboortedatum
| |
| |style="background-color: white;"|T - 10 dagen om 10:44 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Geslacht
| |
| |style="background-color: white;"|Man (code = 'M' 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;;"
| |
| |colspan="4"|Overlijdens indicator
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Datum overlijden
| |
| |style="background-color: white;"|T - 10 dagen om 21 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Bevallingsgegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="9"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Zwangerschapsduur
| |
| |style="background-color: white;"|254 dagen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Aantal geboren kinderen
| |
| |style="background-color: white;"|1
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Type partus
| |
| |style="background-color: white;"|Primair (code = '177141003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Locatie partus
| |
| |style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Zorgaanbieder
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Zorgaanbieder identificatienummer
| |
| |style="background-color: white;"|234 (in identificerend systeem: AGB-Z)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Organisatie naam
| |
| |style="background-color: white;"|UMC Papendorp
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Ondersteuning opvang
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Verrichting type
| |
| |style="background-color: white;"|endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Opname gegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="28"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Opname
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="9"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Opname datum
| |
| |style="background-color: white;"|T - 10 dagen om 11:15 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Ic opname?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Heropname?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Herkomst kind
| |
| |style="background-color: white;"|In-hospital admission from obstetrical ward (procedure) (code = '59151000146103' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Opname indicatie
| |
| |style="background-color: white;"|Perinatal asphyxia (disorder) (code = '281578009' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Opname indicatie
| |
| |style="background-color: white;"|Infant in poor condition at birth (finding) (code = '276707008' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Opname indicatie
| |
| |style="background-color: white;"|Congenital disease (disorder) (code = '66091009' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Ontslag datum
| |
| |style="background-color: white;"|T - 10 dagen om 21 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Onderzoek
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="16"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Lichaamsgewicht
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Gewicht waarde
| |
| |style="background-color: white;"|3870 g
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Gewicht datum tijd
| |
| |style="background-color: white;"|T - 10 dagen om 11:01 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Lichaamstemperatuur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Temperatuur waarde
| |
| |style="background-color: white;"|36.1 graden celsius
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Temperatuur datum tijd
| |
| |style="background-color: white;"|T - 10 dagen om 11:02 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Temperatuur type
| |
| |style="background-color: white;"|Rectale temperatuur (code = '307047009' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Apgar score na 1 min
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Apgar score totaal
| |
| |style="background-color: white;"|0
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Apgar score na 5 min
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Apgar score totaal
| |
| |style="background-color: white;"|2
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Problematiek kind
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="71"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Geboortetrauma
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="6"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|Spinal cord injury due to birth trauma (disorder) (code = '698500002' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verificatie status
| |
| |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Ademhalingsondersteuning
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="7"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Ademhalingsondersteuning?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-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 - 10 dagen om 11:16 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|O2 op dag 28?
| |
| |style="background-color: white;"|NullFlavor: NA
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Respiratoir
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Circulatoir
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="6"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|Neonatal hypotension (disorder) (code = '276519002' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verificatie status
| |
| |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Infectieus
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Gastrointestinaal
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Hematologisch
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Metabool en endocrien
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Neurologisch
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="20"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|<span id="neonatal_encephalopathy" title="Intern ID = neonatal_encephalopathy">Probleem neonatal_encephalopathy</span>
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|Neonatal encephalopathy (disorder) (code = '95628005' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Ernst encefalopathie
| |
| |style="background-color: white;"|Ernstig (code = '24484000' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verificatie status
| |
| |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|asfyxie bij geboorte (code = '413654009' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verificatie status
| |
| |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|Intraventricular (nontraumatic) hemorrhage, grade 2, of fetus and newborn (disorder) (code = '206396002' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Indicatie
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Probleem
| |
| |style="background-color: white;"|Zie [[#neonatal_encephalopathy|Probleem: neonatal_encephalopathy]]
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|echografische beeldvorming van hoofd (verrichting) (code = '241449005' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Zintuigen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|NullFlavor: UNK
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Congenitale aandoeningen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="8"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Aangeboren anatomische afwijkingen majorsyndromen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Probleem naam
| |
| |style="background-color: white;"|Overige congenitale afwijkingen zenuwstelsel (code = '09' in codeSystem '2.16.840.1.113883.2.4.4.13.8')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Verificatie status
| |
| |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Ontslagoverplaatsing
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Nog opgenomen?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Voeding kind
| |
| |style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Mortaliteit
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Overlijden lt12 uur na opname nicu?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Overleden op verloskamer?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Oorzaak overlijden
| |
| |style="background-color: white;"|multiorgaanfalen (aandoening) (code = '57653000' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Staken icbehandeling?
| |
| |style="background-color: white;"|Ja
| |
| |}
| |
| ==Scenario Testscenario 3: stofwisselingsziekte ==
| |
|
| |
| === Documentgegevens ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Documentgegevens
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Identificatie
| |
| |style="background-color: white;"|0000 (in identificerend systeem: abc123)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Document datum
| |
| |style="background-color: white;"|T - 0 dagen om 17 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Set identificatie
| |
| |style="background-color: white;"|0000 (in identificerend systeem: abc123)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Versienummer
| |
| |style="background-color: white;"|3
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Software naam
| |
| |style="background-color: white;"|XIS
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Verificatie zorgverlener
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Geverifieerd door zorgverlener?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Verificatie datum
| |
| |style="background-color: white;"|
| |
| |}
| |
| === Zorgaanbieder ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgaanbieder
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorgaanbieder identificatienummer
| |
| |style="background-color: white;"|0000 (in identificerend systeem: AGB-Z)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorgaanbieder identificatienummer
| |
| |style="background-color: white;"|(in identificerend systeem: URA)
| |
| |}
| |
| === Zorgverlener ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zorgverlener
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Zorgverlener identificatienummer
| |
| |style="background-color: white;"|0000 (in identificerend systeem: AGB-Z)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Naamgegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="9"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Voornamen
| |
| |style="background-color: white;"|Hans Peter
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Initialen
| |
| |style="background-color: white;"|HP
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Roepnaam
| |
| |style="background-color: white;"|Hans
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Naamgebruik
| |
| |style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Geslachtsnaam
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Voorvoegsels
| |
| |style="background-color: white;"|van de
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Achternaam
| |
| |style="background-color: white;"|Velde
| |
| |}
| |
| === Zwangerschapsgegevens ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschapsgegevens
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Graviditeit
| |
| |style="background-color: white;"|4
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Pariteit voor deze zwangerschap
| |
| |style="background-color: white;"|2
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Complicaties tijdens zwangerschap
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Complicaties zwangerschap?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Antenatale steroiden gegeven?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Antenatale steroiden
| |
| |style="background-color: white;"|Complete steroid therapy for fetal lung maturation (procedure) (code = '255594003434601000124108' in codeSystem 'SNOMED CT')
| |
| |}
| |
| === Kind ===
| |
| | |
| {| 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="7"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Patient
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Identificatienummer
| |
| |style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Geboortedatum
| |
| |style="background-color: white;"|T - 76 dagen om 06:55 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Geslacht
| |
| |style="background-color: white;"|Ongedifferentieerd (code = 'UN' in codeSystem 'HL7 AdministrativeGender')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Overlijdens indicator
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Bevallingsgegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Zwangerschapsduur
| |
| |style="background-color: white;"|215 dagen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Aantal geboren kinderen
| |
| |style="background-color: white;"|1
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Type partus
| |
| |style="background-color: white;"|Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Locatie partus
| |
| |style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Opname gegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="29"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Opname
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="7"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Opname datum
| |
| |style="background-color: white;"|T - 0 dagen om 09:15 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Ic opname?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Heropname?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Herkomst kind
| |
| |style="background-color: white;"|Hospital admission from home or birth center (procedure) (code = '59141000146101' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Opname indicatie
| |
| |style="background-color: white;"|Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): vaccinatie onder observatie
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Ontslag datum
| |
| |style="background-color: white;"|T - 0 dagen om 16 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Onderzoek
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="19"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Lichaamslengte
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Lengte waarde
| |
| |style="background-color: white;"|43 cm
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Lengte datum tijd
| |
| |style="background-color: white;"|T - 0 dagen om 09:30 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Lichaamsgewicht
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Gewicht waarde
| |
| |style="background-color: white;"|1800 g
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Gewicht datum tijd
| |
| |style="background-color: white;"|T - 0 dagen om 09:30 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Lichaamstemperatuur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Temperatuur waarde
| |
| |style="background-color: white;"|37.1
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Temperatuur datum tijd
| |
| |style="background-color: white;"|T - 0 dagen om 09:30 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Schedelomvang
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Schedelomvang waarde
| |
| |style="background-color: white;"|31 centimeter
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Schedelomvang datum tijd
| |
| |style="background-color: white;"|T - 0 dagen om 09:32 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Nsp h arterieel
| |
| |style="background-color: white;"|7.35 ph
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Be
| |
| |style="background-color: white;"|0.0 mmol/l
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Problematiek kind
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="10"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Congenitale aandoeningen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="8"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Stofwisselingsziekten
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Probleem naam
| |
| |style="background-color: white;"|stoornis van mineraalstofwisseling (aandoening) (code = '45744005' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Verificatie status
| |
| |style="background-color: white;"|Differentiaal (code = '410590009' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Ontslagoverplaatsing
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Nog opgenomen?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Bestemming kind
| |
| |style="background-color: white;"|Discharge to home (procedure) (code = '306689006' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Voeding kind
| |
| |style="background-color: white;"|moedermelk (substantie) (code = '226789007' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Ondersteuning bij ontslag naar huis
| |
| |style="background-color: white;"|monitoren met cardiotachometer (regime/therapie) (code = '63818009' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Mortaliteit
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Overlijden lt12 uur na opname nicu?
| |
| |style="background-color: white;"|NullFlavor: NA
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Overleden op verloskamer?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Staken icbehandeling?
| |
| |style="background-color: white;"|NullFlavor: NA
| |
| |}
| |
| ==Scenario Testscenario 4: gastro + chirurgie ==
| |
|
| |
| === Documentgegevens ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Documentgegevens
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Identificatie
| |
| |style="background-color: white;"|0000
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Document datum
| |
| |style="background-color: white;"|T - 10 dagen om 10 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Set identificatie
| |
| |style="background-color: white;"|0000
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Versienummer
| |
| |style="background-color: white;"|1
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Software naam
| |
| |style="background-color: white;"|InformatieSysteemX
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Verificatie zorgverlener
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Geverifieerd door zorgverlener?
| |
| |style="background-color: white;"|NullFlavor: NI
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Verificatie datum
| |
| |style="background-color: white;"|
| |
| |}
| |
| === Zorgaanbieder ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgaanbieder
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorgaanbieder identificatienummer
| |
| |style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2)
| |
| |}
| |
| === Vrouw ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Vrouw
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Demografische gegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Patient
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Identificatienummer
| |
| |style="background-color: white;"|(in identificerend systeem: BSN)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Geboortedatum
| |
| |style="background-color: white;"|
| |
| |}
| |
| === Zwangerschapsgegevens ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zwangerschapsgegevens
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Graviditeit
| |
| |style="background-color: white;"|1
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Pariteit voor deze zwangerschap
| |
| |style="background-color: white;"|0
| |
| |}
| |
| === Kind ===
| |
| | |
| {| 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="9"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Patient
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="7"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Identificatienummer
| |
| |style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Geboortedatum
| |
| |style="background-color: white;"|T - 87 dagen om 13 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Geslacht
| |
| |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;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Rangnummer kind
| |
| |style="background-color: white;"|2
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Overlijdens indicator
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Bevallingsgegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Zwangerschapsduur
| |
| |style="background-color: white;"|236 dagen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Aantal geboren kinderen
| |
| |style="background-color: white;"|2
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Type partus
| |
| |style="background-color: white;"|Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Locatie partus
| |
| |style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Ondersteuning opvang
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Verrichting type
| |
| |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Opname gegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="23"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Opname
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="11"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Opname datum
| |
| |style="background-color: white;"|T - 80 dagen om 09 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Ic opname?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Heropname?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Herkomst kind
| |
| |style="background-color: white;"|Hospital admission, transfer from other hospital or health care facility (procedure) (code = '4563007' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Zorgaanbieder
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Zorgaanbieder identificatienummer
| |
| |style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Organisatie naam
| |
| |style="background-color: white;"|AZ Papendorp
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Opname indicatie
| |
| |style="background-color: white;"|Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): abc
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Ontslag datum
| |
| |style="background-color: white;"|T - 11 dagen om 16 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Onderzoek
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="9"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Lichaamslengte
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Lengte waarde
| |
| |style="background-color: white;"|43 cm
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Lengte datum tijd
| |
| |style="background-color: white;"|T - 80 dagen om 09:30 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Lichaamsgewicht
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Gewicht waarde
| |
| |style="background-color: white;"|1530 g
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Gewicht datum tijd
| |
| |style="background-color: white;"|T - 80 dagen om 09:30 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Problematiek kind
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="104"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Geboortetrauma
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Ademhalingsondersteuning
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="6"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Ademhalingsondersteuning?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|O2 op dag 28?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Respiratoir
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="9"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|Bronchopulmonary dysplasia of newborn (disorder) (code = '67569000' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verificatie status
| |
| |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Medicatie
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Stimulatie ademhaling
| |
| |style="background-color: white;"|COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Circulatoir
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|Neonatal hypotension (disorder) (code = '276519002' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Infectieus
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="9"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|neonatale sepsis (aandoening) (code = '206376005' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Microorganisme sepsis meningitis
| |
| |style="background-color: white;"|Listeria monocytogenes (organism) (code = '36094007' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Lijnsepsis?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Onset
| |
| |style="background-color: white;"|late neonatale periode (kwalificatiewaarde) (code = '303115001' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Antibiotica eerste 3 dagen?
| |
| |style="background-color: white;"|NullFlavor: NA
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Infuus
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="7"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Infuuskatheter
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Medisch hulpmiddel
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Begin datum
| |
| |style="background-color: white;"|T - 80 dagen om 10 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Einddatum
| |
| |style="background-color: white;"|T - 17 dagen om 09 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Gastrointestinaal
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="18"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|<span id="enterocolitis" title="Intern ID = enterocolitis">Probleem enterocolitis</span>
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|Necrotizing enterocolitis in fetus OR newborn - Bell stage IIIA (disorder) (code = '21941000146103' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verificatie status
| |
| |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Indicatie
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Probleem
| |
| |style="background-color: white;"|Zie [[#enterocolitis|Probleem: enterocolitis]]
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Laparotomy (procedure) (code = '86481000' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Indicatie
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Probleem
| |
| |style="background-color: white;"|Zie [[#enterocolitis|Probleem: enterocolitis]]
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Hematologisch
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Transfusion for anemia (procedure) (code = '59071000146107' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Metabool en endocrien
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="22"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|<span id="hyperbilirubinemie" title="Intern ID = hyperbilirubinemie">Probleem hyperbilirubinemie</span>
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verificatie status
| |
| |style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|<span id="hypoglycemia" title="Intern ID = hypoglycemia">Probleem hypoglycemia</span>
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|Hypoglycemia (disorder) (code = '302866003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verificatie status
| |
| |style="background-color: white;"|Differentiaal (code = '410590009' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Indicatie
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Probleem
| |
| |style="background-color: white;"|Zie [[#hyperbilirubinemie|Probleem: hyperbilirubinemie]]
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Indicatie
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Probleem
| |
| |style="background-color: white;"|Zie [[#hypoglycemia|Probleem: hypoglycemia]]
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Intravenous infusion of glucose in hypoglycemia (procedure) (code = '109091000146105' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Zintuigen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|NullFlavor: NI
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Congenitale aandoeningen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="7"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Chirurgische ingrepen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Verrichting type
| |
| |style="background-color: white;"|Endoscopie van oesofagus (verrichting) (code = '49230008' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Ontslagoverplaatsing
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="10"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Nog opgenomen?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Bestemming kind
| |
| |style="background-color: white;"|Discharge to other location within hospital premises (procedure) (code = '115841000146105' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Lichamelijk onderzoek
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Lichaamsgewicht
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Gewicht waarde
| |
| |style="background-color: white;"|2800 gram
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Gewicht datum tijd
| |
| |style="background-color: white;"|T - 11 dagen om 15 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Voeding kind
| |
| |style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Mortaliteit
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Overlijden lt12 uur na opname nicu?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Overleden op verloskamer?
| |
| |style="background-color: white;"|Nee
| |
| |}
| |
| ==Scenario Testscenario 5: zintuigen + FU ==
| |
|
| |
| === Documentgegevens ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Documentgegevens
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Identificatie
| |
| |style="background-color: white;"|0000
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Document datum
| |
| |style="background-color: white;"|T - 14 dagen om 10 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Set identificatie
| |
| |style="background-color: white;"|0000
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Versienummer
| |
| |style="background-color: white;"|1
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Software naam
| |
| |style="background-color: white;"|InformatieSysteemX
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Verificatie zorgverlener
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Geverifieerd door zorgverlener?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Verificatie datum
| |
| |style="background-color: white;"|T - 14 dagen om 11 uur
| |
| |}
| |
| === Zorgaanbieder ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgaanbieder
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorgaanbieder identificatienummer
| |
| |style="background-color: white;"|
| |
| |}
| |
| === Zwangerschapsgegevens ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zwangerschapsgegevens
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Graviditeit
| |
| |style="background-color: white;"|5
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Pariteit voor deze zwangerschap
| |
| |style="background-color: white;"|4
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Complicaties tijdens zwangerschap
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="9"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Complicaties zwangerschap?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Probleem naam
| |
| |style="background-color: white;"|preterm en prematuur gebroken vliezen (aandoening) (code = '312974005' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Verificatie status
| |
| |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Magnesiumsulfaat
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Antenatale steroiden gegeven?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Antenatale steroiden
| |
| |style="background-color: white;"|Complete steroid therapy for fetal lung maturation (procedure) (code = '255594003434601000124108' in codeSystem 'SNOMED CT')
| |
| |}
| |
| === Kind ===
| |
| | |
| {| 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="13"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Patient
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="11"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Adresgegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Adresgegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Postcode
| |
| |style="background-color: white;"|1234 AB
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Identificatienummer
| |
| |style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Geboortedatum
| |
| |style="background-color: white;"|T - 179 dagen om 14 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Geslacht
| |
| |style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Meerling indicator
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Overlijdens indicator
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Bevallingsgegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Zwangerschapsduur
| |
| |style="background-color: white;"|177 dagen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Type partus
| |
| |style="background-color: white;"|Sectio Caesarea (code = '11466000' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Locatie partus
| |
| |style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Ondersteuning opvang
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="7"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Verrichting type
| |
| |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Verrichting type
| |
| |style="background-color: white;"|endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Opname gegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="33"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Opname
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="7"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Opname datum
| |
| |style="background-color: white;"|T - 179 dagen om 14:30 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Ic opname?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Heropname?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Herkomst kind
| |
| |style="background-color: white;"|Hospital admission, transfer from other hospital or health care facility (procedure) (code = '4563007' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Opname indicatie
| |
| |style="background-color: white;"|Finding of length of gestation (finding) (code = '366323009' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Ontslag datum
| |
| |style="background-color: white;"|T - 44 dagen om 12 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Onderzoek
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="23"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Lichaamsgewicht
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Gewicht waarde
| |
| |style="background-color: white;"|710 g
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Gewicht datum tijd
| |
| |style="background-color: white;"|T - 179 dagen om 14:30 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Lichaamstemperatuur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Temperatuur waarde
| |
| |style="background-color: white;"|36.7
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Temperatuur datum tijd
| |
| |style="background-color: white;"|T - 179 dagen om 14:35 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Toelichting
| |
| |style="background-color: white;"|geen bijzonderheden
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Temperatuur type
| |
| |style="background-color: white;"|Orale temperatuur (onder de tong) (code = '415945006' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Schedelomvang
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Schedelomvang waarde
| |
| |style="background-color: white;"|25.5
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Schedelomvang datum tijd
| |
| |style="background-color: white;"|T - 179 dagen om 14:35 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Apgar score na 1 min
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Apgar score totaal
| |
| |style="background-color: white;"|1
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Apgar score na 5 min
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Apgar score totaal
| |
| |style="background-color: white;"|4
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Nsp h arterieel
| |
| |style="background-color: white;"|7.21 ph
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Be
| |
| |style="background-color: white;"|-11 mmol/l
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Problematiek kind
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="127"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Geboortetrauma
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Ademhalingsondersteuning
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="15"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Ademhalingsondersteuning?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|toedienen van zuurstof via neusbril (verrichting) (code = '371907003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Oxygen therapy using high flow oxygen nasal cannula (procedure) (code = '57485005:424226004=426854004' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Continuous positive airway pressure ventilation treatment (procedure) (code = '47545007' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Noninvasive ventilation (procedure) (code = '428311008' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|O2 op dag 28?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Respiratoir
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="21"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|Respiratory distress syndrome in the newborn (disorder) (code = '46775006' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem begin datum
| |
| |style="background-color: white;"|T - 152 dagen om 08 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Aanvang
| |
| |style="background-color: white;"|Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|Bronchopulmonary dysplasia of newborn - grade 3 (disorder) (code = '22041000146108' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Extracorporeal membrane oxygenation (procedure) (code = '233573008' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Medicatie
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Stimulatie ademhaling
| |
| |style="background-color: white;"|COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Surfactant
| |
| |style="background-color: white;"|NATUURLIJKE FOSFOLIPIDEN - LONGSURFACTANTS (code = 'R07AA02' in codeSystem 'ATC-NL')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Systemische steroiden
| |
| |style="background-color: white;"|CORTICOSTEROIDEN VOOR SYSTEMISCH GEBRUIK - SYSTEMISCHE HORMOONPREPARATEN, EXCL GESLACHTSHORMONEN (code = 'H02' in codeSystem 'ATC-NL')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Medicatie
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Stimulatie ademhaling
| |
| |style="background-color: white;"|DOXAPRAM (code = 'R07AB01' in codeSystem 'ATC-NL')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Circulatoir
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|Low blood pressure (disorder) (code = '45007003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Infectieus
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="15"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|neonatale sepsis (aandoening) (code = '206376005' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Lijnsepsis?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Onset
| |
| |style="background-color: white;"|vroege neonatale periode (kwalificatiewaarde) (code = '303114002' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|urineweginfectie (aandoening) (code = '68566005' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verificatie status
| |
| |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|Neonatal pneumonia (disorder) (code = '233619008' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Antibiotica eerste 3 dagen?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Infuus
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="7"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Infuuskatheter
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Medisch hulpmiddel
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Begin datum
| |
| |style="background-color: white;"|T - 179 dagen om 17 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Einddatum
| |
| |style="background-color: white;"|T - 148 dagen om 08 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Gastrointestinaal
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="8"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Indicatie
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Probleem
| |
| |style="background-color: white;"|Zie [[#|: ]]
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Hematologisch
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Treatment for trombocytopenia (procedure) (code = '59091000146106' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Metabool en endocrien
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="14"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|Hypoglycemia (disorder) (code = '302866003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Intravenous infusion of glucose in hypoglycemia (procedure) (code = '109091000146105' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Neurologisch
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="8"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|echografische beeldvorming van hoofd (verrichting) (code = '241449005' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|'magnetic resonance imaging' van hoofd (verrichting) (code = '241601008' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Zintuigen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="15"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Probleem naam
| |
| |style="background-color: white;"|Plus disease (disorder) (code = '56341000146109' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verificatie status
| |
| |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Rop screening verricht?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Rop screening afgesloten?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Aabr verricht?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Aabr afwijkend?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Bera verricht?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Bera
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Bera afwijkend?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Bera lateraliteit
| |
| |style="background-color: white;"|Links (code = '7771000' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Ontslagoverplaatsing
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="15"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Nog opgenomen?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Bestemming kind
| |
| |style="background-color: white;"|Discharge to other hospital (procedure) (code = '115851000146108' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Lichamelijk onderzoek
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="10"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Lichaamsgewicht
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Gewicht waarde
| |
| |style="background-color: white;"|4 kg
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Gewicht datum tijd
| |
| |style="background-color: white;"|T - 44 dagen om 09 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Schedelomvang
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Schedelomvang meetmethode
| |
| |style="background-color: white;"|Meten van schedelomvang m.b.v. echografisch onderzoek (code = '31561000146107' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Schedelomvang waarde
| |
| |style="background-color: white;"|34.6
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Schedelomvang datum tijd
| |
| |style="background-color: white;"|T - 45 dagen om 10:20 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Voeding kind
| |
| |style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Mortaliteit
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Overlijden lt12 uur na opname nicu?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Overleden op verloskamer?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Follow up
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="21"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Na ontslag
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="19"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|O2 op dag 28?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Gradatie bpd
| |
| |style="background-color: white;"|Bronchopulmonary dysplasia of newborn - grade 1 (disorder) (code = '22021000146102' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Zintuigen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="15"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Problemen aanwezig?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Probleem
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Probleem naam
| |
| |style="background-color: white;"|Plus disease (disorder) (code = '56341000146109' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Verificatie status
| |
| |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Rop screening verricht?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Rop screening afgesloten?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Aabr verricht?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Aabr afwijkend?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Bera verricht?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Bera
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Bera afwijkend?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Bera lateraliteit
| |
| |style="background-color: white;"|Links (code = '7771000' in codeSystem 'SNOMED CT')
| |
| |}
| |
| ==Scenario Testscenario 6: overleden op verloskamer ==
| |
|
| |
| === Documentgegevens ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Documentgegevens
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Verificatie zorgverlener
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Geverifieerd door zorgverlener?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Verificatie datum
| |
| |style="background-color: white;"|
| |
| |}
| |
| === Zorgaanbieder ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgaanbieder
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorgaanbieder identificatienummer
| |
| |style="background-color: white;"|
| |
| |}
| |
| === Vrouw ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Vrouw
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Demografische gegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Patient
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Identificatienummer
| |
| |style="background-color: white;"|000000000 (in identificerend systeem: BSN)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Geboortedatum
| |
| |style="background-color: white;"|T - 29 jaar
| |
| |}
| |
| === Zwangerschapsgegevens ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschapsgegevens
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Graviditeit
| |
| |style="background-color: white;"|2
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Pariteit voor deze zwangerschap
| |
| |style="background-color: white;"|1
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Complicaties tijdens zwangerschap
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Complicaties zwangerschap?
| |
| |style="background-color: white;"|Nee
| |
| |}
| |
| === Kind ===
| |
| | |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Kind
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="5" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Demografische gegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="9"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Patient
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="7"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Identificatienummer
| |
| |style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Geboortedatum
| |
| |style="background-color: white;"|T - 18 dagen om 13:20 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Geslacht
| |
| |style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Meerling indicator
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Overlijdens indicator
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Datum overlijden
| |
| |style="background-color: white;"|T - 18 dagen om 19 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Bevallingsgegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Zwangerschapsduur
| |
| |style="background-color: white;"|266 dagen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Aantal geboren kinderen
| |
| |style="background-color: white;"|1
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Type partus
| |
| |style="background-color: white;"|Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Locatie partus
| |
| |style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Ondersteuning opvang
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="10"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|mechanische thoraxcompressies (verrichting) (code = '33631000146101' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Verrichting
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Verrichting type
| |
| |style="background-color: white;"|injectie van adrenaline (verrichting) (code = '313191000' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Opname gegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="21"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Opname
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Opname datum
| |
| |style="background-color: white;"|T - 18 dagen om 13:30 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Ic opname?
| |
| |style="background-color: white;"|NullFlavor: NA
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Heropname?
| |
| |style="background-color: white;"|NullFlavor: NA
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Ontslag datum
| |
| |style="background-color: white;"|T - 18 dagen om 19 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Onderzoek
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="13"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Lichaamsgewicht
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Gewicht waarde
| |
| |style="background-color: white;"|3100 g
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Gewicht datum tijd
| |
| |style="background-color: white;"|T - 18 dagen om 13:30 uur
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Apgar score na 1 min
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Apgar score totaal
| |
| |style="background-color: white;"|1
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Apgar score na 5 min
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Apgar score totaal
| |
| |style="background-color: white;"|1
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Nsp h arterieel
| |
| |style="background-color: white;"|7.13 ph
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Be
| |
| |style="background-color: white;"|-6.9 mmol/l
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Problematiek kind
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="19"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Ademhalingsondersteuning
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Ademhalingsondersteuning?
| |
| |style="background-color: white;"|NullFlavor: NI
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Circulatoir
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Problemen aanwezig?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Infectieus
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Problemen aanwezig?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Hematologisch
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Problemen aanwezig?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Zintuigen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Problemen aanwezig?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Congenitale aandoeningen
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Problemen aanwezig?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Mortaliteit
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Overlijden lt12 uur na opname nicu?
| |
| |style="background-color: white;"|NullFlavor: NA
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Overleden op verloskamer?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Oorzaak overlijden
| |
| |style="background-color: white;"|ernstige asfyxie bij geboorte (aandoening) (code = '57284007' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Staken icbehandeling?
| |
| |style="background-color: white;"|NullFlavor: NA
| |
| |} | | |} |
| [[Categorie:Kwalificatie]]
| |