Gebz:Vdraft AddendaKwalificatieKernsetGeboortezorg23: verschil tussen versies
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Regel 16: | Regel 16: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Burgerservicenummer | |colspan="2"|Burgerservicenummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|999910413 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lokale persoonsidentificatie | |colspan="2"|Lokale persoonsidentificatie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Geboortedatum | |colspan="2"|Geboortedatum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1976-05-02 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Adres - postcode | |colspan="2"|Adres - postcode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|4563 AB |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Etniciteit | |colspan="2"|Etniciteit | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lengte gemeten | |colspan="2"|Lengte gemeten | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|170 cm |
|}<section end=999910413 /> | |}<section end=999910413 /> | ||
=== Anamnese === | === Anamnese === | ||
<section begin=anamnese_999910413 /> | <section begin=anamnese_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Onder behandeling geweest? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Algemene anamnese | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Cardiovasculaire aandoening | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Oncologische aandoening | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Infectieziekte | ||
+ | |style="background-color: white;"|Herpes (code = '23513009' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Type operatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Orthopedisch (code = '112697007' in codeSystem 'Snomed CT') |
|}<section end=anamnese_999910413 /> | |}<section end=anamnese_999910413 /> | ||
=== Zorgverlening === | === Zorgverlening === | ||
Regel 58: | Regel 71: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Datum start zorgverantwoordelijkheid | |colspan="2"|Datum start zorgverantwoordelijkheid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-03-01T00:00:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Datum einde zorgverantwoordelijkheid | |colspan="2"|Datum einde zorgverantwoordelijkheid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-11-12T00:00:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Conclusie risicostatus na intake | |colspan="2"|Conclusie risicostatus na intake | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') |
|}<section end=zorgverlening_999910413 /> | |}<section end=zorgverlening_999910413 /> | ||
=== Zorgverlenerzorginstelling === | === Zorgverlenerzorginstelling === | ||
Regel 97: | Regel 110: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1808 |
|}<section end=zorgverlenerzorginstelling_999910413 /> | |}<section end=zorgverlenerzorginstelling_999910413 /> | ||
=== Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === | === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === | ||
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 /> | <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="5" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Wijze einde zwangerschap |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|2011-12-01 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Irregulaire antistoffen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eerdere bevalling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Placenta - geboorte placenta | ||
+ | |style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Hoeveelheid bloedverlies | ||
+ | |style="background-color: white;"|550 ml | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Vorige uitkomst per kind - vorige baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Demografische gegevens - geboortedatum | ||
+ | |style="background-color: white;"|2011-12-08T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Kindspecifieke gegevens vorige uitkomsten | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type partus | ||
+ | |style="background-color: white;"|Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Percentiel van het geboortegewicht |
− | |style="background-color: white;"| | + | |style="background-color: white;"|50 ≤ P < 90 (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.50') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Apgarscore na 5 min |
− | |style="background-color: white;"| | + | |style="background-color: white;"|8 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Congenitale afwijkingen? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 /> | |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 /> | ||
=== Zwangerschap === | === Zwangerschap === | ||
<section begin=zwangerschap_999910413 /> | <section begin=zwangerschap_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Dossiernummer |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="3"|Graviditeit |
− | |style="background-color: white;"| | + | |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="3"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|2014-10-09 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voornemens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie | ||
+ | |style="background-color: white;"|Thuis (code = '169813005' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Prenatale controle | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum controle | ||
+ | |style="background-color: white;"|2014-03-02T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|59 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Leven voelen | ||
+ | |style="background-color: white;"|goed (code = '289431008' in codeSystem 'Snomed CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Rookgedrag | ||
+ | |style="background-color: white;"|niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Alcoholgebruik | ||
+ | |style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Drugsgebruik? | ||
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Gewicht gemeten |
− | |style="background-color: white;"| | + | |style="background-color: white;"|70 kg |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Diagnose | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="4"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-03-02T00:00:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Zwangerschapsduur |
− | |style="background-color: white;"| | + | |style="background-color: white;"|59 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Infectie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Urineweg infectie (code = '307534009' in codeSystem 'Snomed CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Maternale sterfte? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Wijze einde zwangerschap |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
|}<section end=zwangerschap_999910413 /> | |}<section end=zwangerschap_999910413 /> | ||
=== Bevalling === | === Bevalling === | ||
<section begin=bevalling_999910413 /> | <section begin=bevalling_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="3"|Partusnummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|000000 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Aantal geboren kinderen | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Risicostatus voor baring | ||
+ | |style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Interventies begin baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Interventie begin baring | ||
+ | |style="background-color: white;"|Strippen (code = '236960006' in codeSystem 'Snomed CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Indicatie interventie begin baring |
− | |style="background-color: white;"| | + | |style="background-color: white;"|wens patiënt (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Wijze waarop de baring begon |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Tijdstip begin actieve ontsluiting |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-10-08T14:30:00 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Medicatie nageboortetijdperk groep | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="3"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Medicatie nageboortetijdperk? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Soort medicatie nageboortetijdperk |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Placenta - geboorte placenta |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Hoeveelheid bloedverlies |
− | |style="background-color: white;"| | + | |style="background-color: white;"|615 ml |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Conditie perineum postpartum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1e graads perineumruptuur (code = '199916005' in codeSystem 'Snomed CT') |
|}<section end=bevalling_999910413 /> | |}<section end=bevalling_999910413 /> | ||
=== Uitkomst per kind === | === Uitkomst per kind === | ||
<section begin=uitkomst_per_kind_999910413 /> | <section begin=uitkomst_per_kind_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Uitkomst per kind |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="5" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Baring | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |rowspan="34"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="4"|Werkelijke plaats baring type locatie | ||
+ | |style="background-color: white;"|Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Identificaties kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Bsn kind | ||
+ | |style="background-color: white;"|999910383 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Geslacht medische observatie | ||
+ | |style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Geboortedatum | ||
+ | |style="background-color: white;"|2014-10-08T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Rangnummer kind | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Perinatale sterfte groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Perinatale sterfte? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kindspecifieke maternale gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Tijdstip breken vliezen | ||
+ | |style="background-color: white;"|2014-10-08T09:15:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Kleur en consistentie vruchtwater | ||
+ | |style="background-color: white;"|Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Tijdstip actief meepersen | ||
+ | |style="background-color: white;"|2014-10-08T12:13:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Episiotomie? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Ruggeprik gewenst niet gekregen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pijnbestrijding? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Sedatie? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kindspecifieke uitkomstgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="11"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Type partus | ||
+ | |style="background-color: white;"|Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Ligging bij geboorte | ||
+ | |style="background-color: white;"|Achterhoofd-achter (code = '37235006' in codeSystem 'Snomed CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Aanpakker kind - rol aanpakker kind | ||
+ | |style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Supervisor - rol supervisor | ||
+ | |style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Lichamelijk onderzoek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Geboortegewicht | ||
+ | |style="background-color: white;"|3450 gram | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Congenitale afwijkingen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Problematiek kind? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Kinderarts betrokken? | ||
+ | |style="background-color: white;"|Nee | ||
|}<section end=uitkomst_per_kind_999910413 /> | |}<section end=uitkomst_per_kind_999910413 /> | ||
=== Medisch onderzoek === | === Medisch onderzoek === | ||
<section begin=medisch_onderzoek_999910413 /> | <section begin=medisch_onderzoek_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="2"|Irregulaire antistoffen? | ||
+ | |style="background-color: white;"|Nee | ||
|}<section end=medisch_onderzoek_999910413 /> | |}<section end=medisch_onderzoek_999910413 /> | ||
=== Postnatale fase === | === Postnatale fase === | ||
<section begin=postnatale_fase_999910413 /> | <section begin=postnatale_fase_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="4" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kindspecifieke gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voeding kind groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voeding kind datum | ||
+ | |style="background-color: white;"|2014-10-12 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Substantie voeding kind | ||
+ | |style="background-color: white;"|borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Substantie voeding kind |
− | |style="background-color: white;"| | + | |style="background-color: white;"|kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
|}<section end=postnatale_fase_999910413 /> | |}<section end=postnatale_fase_999910413 /> | ||
==Scenario 2. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)== | ==Scenario 2. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)== | ||
Regel 241: | Regel 440: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Burgerservicenummer | |colspan="2"|Burgerservicenummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|961921821 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lokale persoonsidentificatie | |colspan="2"|Lokale persoonsidentificatie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|* (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Geboortedatum | |colspan="2"|Geboortedatum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1974-09-11 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Adres - postcode | |colspan="2"|Adres - postcode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|5689 CZ |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Etniciteit | |colspan="2"|Etniciteit | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lengte gemeten | |colspan="2"|Lengte gemeten | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|184 cm |
|}<section end=961921821 /> | |}<section end=961921821 /> | ||
=== Anamnese === | === Anamnese === | ||
Regel 268: | Regel 467: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Onder behandeling geweest? | |colspan="2"|Onder behandeling geweest? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|}<section end=anamnese_961921821 /> | |}<section end=anamnese_961921821 /> | ||
=== Zorgverlening === | === Zorgverlening === | ||
<section begin=zorgverlening_961921821 /> | <section begin=zorgverlening_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Zorgverlening |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="6" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Datum start zorgverantwoordelijkheid |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2018-08-28 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Datum einde zorgverantwoordelijkheid | ||
+ | |style="background-color: white;"|2018-11-28 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Conclusie risicostatus na intake | ||
+ | |style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Verwijsdetails | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="20"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Datum verwijzing | ||
+ | |style="background-color: white;"|2014-05-06T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Verwijzing van | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zorginstelling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Zorgaanbieder identificatie nummer | ||
+ | |style="background-color: white;"|1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Verwijzing naar | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zorginstelling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Specialisme | ||
+ | |style="background-color: white;"|Gynaecoloog 2e lijn (code = '02' in codeSystem 'Specialisme, specifiek voor perinatologie.') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Redenen van verwijzing | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="6"| |
− | |style="background-color: | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="5"|Van 1e naar 2e lijn | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="4"| |
− | |style="background-color: | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="4"|Zwangerschap | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Hypertensieve aandoening |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Perinatale periode |
− | |style="background-color: white;"| | + | |style="background-color: white;"|voor 28e week (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') |
|}<section end=zorgverlening_961921821 /> | |}<section end=zorgverlening_961921821 /> | ||
=== Zorgverlenerzorginstelling === | === Zorgverlenerzorginstelling === | ||
Regel 307: | Regel 550: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1504 |
|}<section end=zorgverlenerzorginstelling_961921821 /> | |}<section end=zorgverlenerzorginstelling_961921821 /> | ||
=== Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === | === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === | ||
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Wijze einde zwangerschap |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|2013-06-05 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Diagnose | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Bloedverlies? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Hyperemesis gravidarum? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Irregulaire antistoffen? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | ||
=== Zwangerschap === | === Zwangerschap === | ||
<section begin=zwangerschap_961921821 /> | <section begin=zwangerschap_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Dossiernummer |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="3"|Graviditeit |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pariteit voor deze zwangerschap | ||
+ | |style="background-color: white;"|0 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|2014-09-08 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voornemens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie | ||
+ | |style="background-color: white;"|Nog niet bepaald (code = '05' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Prenatale controle | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum controle | ||
+ | |style="background-color: white;"|2014-05-06T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|155 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Leven voelen | ||
+ | |style="background-color: white;"|Weak fetal movements (finding) (code = '276372004' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Rookgedrag | ||
+ | |style="background-color: white;"|gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Alcoholgebruik | ||
+ | |style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Drugsgebruik? | ||
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Gewicht gemeten |
− | |style="background-color: white;"| | + | |style="background-color: white;"|85 kg |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Diagnose | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="4"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-05-06T00:00:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Zwangerschapsduur |
− | |style="background-color: white;"| | + | |style="background-color: white;"|155 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Hypertensieve aandoening |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Pregnancy-induced hypertension (disorder) (code = '48194001' in codeSystem '2.16.840.1.113883.6.96') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Maternale sterfte? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|}<section end=zwangerschap_961921821 /> | |}<section end=zwangerschap_961921821 /> | ||
==Scenario 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)== | ==Scenario 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)== | ||
Regel 373: | Regel 659: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Burgerservicenummer | |colspan="2"|Burgerservicenummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|961921821 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lokale persoonsidentificatie | |colspan="2"|Lokale persoonsidentificatie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|* (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Geboortedatum | |colspan="2"|Geboortedatum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1974-09-11 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Adres - postcode | |colspan="2"|Adres - postcode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|5689 CZ |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Etniciteit | |colspan="2"|Etniciteit | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lengte gemeten | |colspan="2"|Lengte gemeten | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|184 cm |
|}<section end=961921821 /> | |}<section end=961921821 /> | ||
=== Anamnese === | === Anamnese === | ||
Regel 400: | Regel 686: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Onder behandeling geweest? | |colspan="2"|Onder behandeling geweest? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|}<section end=anamnese_961921821 /> | |}<section end=anamnese_961921821 /> | ||
=== Zorgverlening === | === Zorgverlening === | ||
<section begin=zorgverlening_961921821 /> | <section begin=zorgverlening_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Zorgverlening |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="6" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Datum start zorgverantwoordelijkheid |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-05-12T00:00:00 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Datum einde zorgverantwoordelijkheid | ||
+ | |style="background-color: white;"|2014-10-09T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Verwijsdetails | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="18"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Verwijzing van | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zorginstelling | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Zorgaanbieder identificatie nummer |
− | |style="background-color: | + | |style="background-color: white;"|1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Verwijzing naar | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="4"| |
− | |style="background-color: | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="5"|Zorginstelling | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Zorgaanbieder identificatie nummer |
− | |style="background-color: | + | |style="background-color: white;"|0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Redenen van verwijzing | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="6"| |
− | |style="background-color: | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="5"|Van 1e naar 2e lijn | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="4"| |
− | |style="background-color: | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="4"|Zwangerschap | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Hypertensieve aandoening |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT') |
|}<section end=zorgverlening_961921821 /> | |}<section end=zorgverlening_961921821 /> | ||
=== Zorgverlenerzorginstelling === | === Zorgverlenerzorginstelling === | ||
Regel 451: | Regel 775: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|0003 |
|}<section end=zorgverlenerzorginstelling_961921821 /> | |}<section end=zorgverlenerzorginstelling_961921821 /> | ||
=== Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === | === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === | ||
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Wijze einde zwangerschap |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|2013-06-05 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Diagnose | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Gynaecologische aandoening | ||
+ | |style="background-color: white;"|Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Bloedverlies? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Hyperemesis gravidarum? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Irregulaire antistoffen? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | ||
=== Zwangerschap === | === Zwangerschap === | ||
<section begin=zwangerschap_961921821 /> | <section begin=zwangerschap_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Dossiernummer |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="3"|Graviditeit |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pariteit voor deze zwangerschap | ||
+ | |style="background-color: white;"|0 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|2014-09-08 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voornemens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="1"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Prenatale controle | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum controle | ||
+ | |style="background-color: white;"|2014-05-12T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|161 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Leven voelen | ||
+ | |style="background-color: white;"|Reduced fetal movement (finding) (code = '276369006' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Rookgedrag | ||
+ | |style="background-color: white;"|gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Alcoholgebruik | ||
+ | |style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Drugsgebruik? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Gewicht gemeten | ||
+ | |style="background-color: white;"|85 kg | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Diagnose | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-05-12T00:00:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Zwangerschapsduur |
− | |style="background-color: white;"| | + | |style="background-color: white;"|161 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Gynaecologische aandoening |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Partiele mola? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Hypertensieve aandoening |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Pre-eclampsia (disorder) (code = '398254007' in codeSystem '2.16.840.1.113883.6.96') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Maternale sterfte? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Wijze einde zwangerschap |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
|}<section end=zwangerschap_961921821 /> | |}<section end=zwangerschap_961921821 /> | ||
=== Bevalling === | === Bevalling === | ||
<section begin=bevalling_961921821 /> | <section begin=bevalling_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Partusnummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|000000 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Aantal geboren kinderen | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Risicostatus voor baring | ||
+ | |style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Interventies begin baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Interventie begin baring |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Indicatie interventie begin baring |
− | |style="background-color: white;"| | + | |style="background-color: white;"|acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Wijze waarop de baring begon |
− | |style="background-color: white;"| | + | |style="background-color: white;"|interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Tijdstip begin actieve ontsluiting |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-08-30T14:09:00 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Medicatie nageboortetijdperk groep | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"|Medicatie nageboortetijdperk | + | |colspan="2"|Medicatie nageboortetijdperk? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|UNK |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Placenta - geboorte placenta |
− | |style="background-color: white;"| | + | |style="background-color: white;"|placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Hoeveelheid bloedverlies |
− | |style="background-color: white;"| | + | |style="background-color: white;"|980 ml |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Conditie perineum postpartum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') |
|}<section end=bevalling_961921821 /> | |}<section end=bevalling_961921821 /> | ||
=== Uitkomst per kind === | === Uitkomst per kind === | ||
<section begin=uitkomst_per_kind_961921821 /> | <section begin=uitkomst_per_kind_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Uitkomst per kind |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="6" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="51"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Werkelijke plaats baring type locatie | ||
+ | |style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Ziekenhuis baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ziekenhuisnummer lvrid | ||
+ | |style="background-color: white;"|0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Identificaties kind | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |rowspan="2"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="3"|Bsn kind | ||
+ | |style="background-color: white;"|951847624 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslacht medische observatie | ||
+ | |style="background-color: white;"|mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortedatum | ||
+ | |style="background-color: white;"|2014-09-01T02:34:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Rangnummer kind | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Perinatale sterfte groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Perinatale sterfte? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Kindspecifieke maternale gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Tijdstip breken vliezen | ||
+ | |style="background-color: white;"|2014-08-30T23:04:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Kleur en consistentie vruchtwater | ||
+ | |style="background-color: white;"|geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ruggeprik gewenst niet gekregen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Pijnbestrijding? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Pijnbestrijding | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Methode | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Methode | ||
+ | |style="background-color: white;"|Epidural anesthesia (procedure) (code = '18946005' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Periode | ||
+ | |style="background-color: white;"|tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Sedatie? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Kindspecifieke uitkomstgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="21"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Type partus | ||
+ | |style="background-color: white;"|Cesarean section (procedure) (code = '11466000' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ligging bij geboorte | ||
+ | |style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Aanpakker kind - rol aanpakker kind | ||
+ | |style="background-color: white;"|gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Supervisor - rol supervisor | ||
+ | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Sectio caesarea group | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Indicatie primaire sectio | ||
+ | |style="background-color: white;"|Suspected fetal distress (situation) (code = '444433005:246090004=130955003' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Indicatie primaire sectio | ||
+ | |style="background-color: white;"|Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Lichamelijk onderzoek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Geboortegewicht | ||
+ | |style="background-color: white;"|3620 gram | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Congenitale afwijkingen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problematiek kind? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Kinderarts betrokken? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Betrokkenheid kinderarts | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Datum betrokkenheid | ||
+ | |style="background-color: white;"|2014-09-01T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Reden betrokkenheid | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Type betrokkenheid | ||
+ | |style="background-color: white;"|consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Zorginstelling lvrid | ||
+ | |style="background-color: white;"|0003 | ||
|}<section end=uitkomst_per_kind_961921821 /> | |}<section end=uitkomst_per_kind_961921821 /> | ||
=== Medisch onderzoek === | === Medisch onderzoek === | ||
<section begin=medisch_onderzoek_961921821 /> | <section begin=medisch_onderzoek_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Irregulaire antistoffen? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Welke irregulaire antistoffen vrouw aanwezig |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96') |
|}<section end=medisch_onderzoek_961921821 /> | |}<section end=medisch_onderzoek_961921821 /> | ||
=== Postnatale fase === | === Postnatale fase === | ||
<section begin=postnatale_fase_961921821 /> | <section begin=postnatale_fase_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="4" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Diagnoseinterventie postpartum | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |rowspan="3"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="3"|Datum | ||
+ | |style="background-color: white;"|2014-09-03T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pathologie vrouw | ||
+ | |style="background-color: white;"|Urinary tract infectious disease (disorder) (code = '68566005' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kindspecifieke gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voeding kind groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voeding kind datum | ||
+ | |style="background-color: white;"|2014-10-07 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Substantie voeding kind |
− | |style="background-color: white;"| | + | |style="background-color: white;"|kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
|}<section end=postnatale_fase_961921821 /> | |}<section end=postnatale_fase_961921821 /> | ||
==Scenario 3. zorg volledig in 2e lijn, meerling, 1 kind overleden (voor vrouw met BSN: 895623146)== | ==Scenario 3. zorg volledig in 2e lijn, meerling, 1 kind overleden (voor vrouw met BSN: 895623146)== | ||
Regel 598: | Regel 1.136: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Burgerservicenummer | |colspan="2"|Burgerservicenummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|895623146 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lokale persoonsidentificatie | |colspan="2"|Lokale persoonsidentificatie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Geboortedatum | |colspan="2"|Geboortedatum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1985-08-05 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Adres - postcode | |colspan="2"|Adres - postcode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|5421 JG |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Etniciteit | |colspan="2"|Etniciteit | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lengte gemeten | |colspan="2"|Lengte gemeten | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|167 cm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Vrouwelijke genitale verminking? | |colspan="2"|Vrouwelijke genitale verminking? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Type vrouwelijke genitale verminking | |colspan="2"|Type vrouwelijke genitale verminking | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Female genital mutilation type 2 (disorder) (code = '130621000119105' in codeSystem '2.16.840.1.113883.6.96') |
|}<section end=895623146 /> | |}<section end=895623146 /> | ||
=== Anamnese === | === Anamnese === | ||
<section begin=anamnese_895623146 /> | <section begin=anamnese_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Onder behandeling geweest? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Algemene anamnese | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Cardiovasculaire aandoening | ||
+ | |style="background-color: white;"|Cardiac arrhythmia (disorder) (code = '698247007' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Schildklier aandoening | ||
+ | |style="background-color: white;"|Hyperthyroidism (disorder) (code = '34486009' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Anemie | ||
+ | |style="background-color: white;"|Iron deficiency anemia (disorder) (code = '87522002' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Bloedtransfusie? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Type operatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Operation on heart (procedure) (code = '64915003' in codeSystem '2.16.840.1.113883.6.96') |
|}<section end=anamnese_895623146 /> | |}<section end=anamnese_895623146 /> | ||
=== Zorgverlening === | === Zorgverlening === | ||
Regel 646: | Regel 1.200: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Datum start zorgverantwoordelijkheid | |colspan="2"|Datum start zorgverantwoordelijkheid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-03-10T00:00:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Datum einde zorgverantwoordelijkheid | |colspan="2"|Datum einde zorgverantwoordelijkheid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-11-03T00:00:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Conclusie risicostatus na intake | |colspan="2"|Conclusie risicostatus na intake | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') |
|}<section end=zorgverlening_895623146 /> | |}<section end=zorgverlening_895623146 /> | ||
=== Zorgverlenerzorginstelling === | === Zorgverlenerzorginstelling === | ||
Regel 688: | Regel 1.242: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
|}<section end=zorgverlenerzorginstelling_895623146 /> | |}<section end=zorgverlenerzorginstelling_895623146 /> | ||
=== Zwangerschap === | === Zwangerschap === | ||
<section begin=zwangerschap_895623146 /> | <section begin=zwangerschap_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Dossiernummer |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="3"|Graviditeit |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pariteit voor deze zwangerschap | ||
+ | |style="background-color: white;"|0 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|2014-09-22 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voornemens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie | ||
+ | |style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Prenatale controle | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum controle | ||
+ | |style="background-color: white;"|2014-05-21T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|156 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Leven voelen | ||
+ | |style="background-color: white;"|Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Rookgedrag | ||
+ | |style="background-color: white;"|niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Alcoholgebruik | ||
+ | |style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Drugsgebruik? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Gewicht gemeten | ||
+ | |style="background-color: white;"|67 kg | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Diagnose | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum | ||
+ | |style="background-color: white;"|2014-05-21T00:00:00 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Zwangerschapsduur |
− | |style="background-color: white;"| | + | |style="background-color: white;"|156 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Bloedverlies? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Infectie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Afwijkende groei foetus |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Small for gestational age fetus (disorder) (code = '267258002' in codeSystem '2.16.840.1.113883.6.96') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Abruptio placentae? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Maternale sterfte? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Wijze einde zwangerschap |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
|}<section end=zwangerschap_895623146 /> | |}<section end=zwangerschap_895623146 /> | ||
=== Bevalling === | === Bevalling === | ||
<section begin=bevalling_895623146 /> | <section begin=bevalling_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="3"|Partusnummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|000000 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Diagnose bevalling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Pprom? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Verdenking foetale nood? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Aantal geboren kinderen |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Risicostatus voor baring |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Wijze waarop de baring begon |
− | |style="background-color: white;"| | + | |style="background-color: white;"|spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Tijdstip begin actieve ontsluiting |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-08-27T22:09:00 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Medicatie nageboortetijdperk groep | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"|Medicatie nageboortetijdperk | + | |colspan="2"|Medicatie nageboortetijdperk? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Placenta - geboorte placenta |
− | |style="background-color: white;"| | + | |style="background-color: white;"|controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Hoeveelheid bloedverlies |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1740 ml |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Conditie perineum postpartum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96') |
|}<section end=bevalling_895623146 /> | |}<section end=bevalling_895623146 /> | ||
=== Uitkomst per kind === | === Uitkomst per kind === | ||
<section begin=uitkomst_per_kind_895623146 /> | <section begin=uitkomst_per_kind_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="7" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="59"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Werkelijke plaats baring type locatie | ||
+ | |style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Ziekenhuis baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ziekenhuisnummer lvrid | ||
+ | |style="background-color: white;"|9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Identificaties kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Bsn kind | ||
+ | |style="background-color: white;"|847035116 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Geslacht medische observatie | ||
+ | |style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Geboortedatum | ||
+ | |style="background-color: white;"|2014-08-28T06:30:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Rangnummer kind | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Perinatale sterfte groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Perinatale sterfte? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Kindspecifieke maternale gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="19"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Tijdstip breken vliezen | ||
+ | |style="background-color: white;"|2014-08-27T22:09:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kleur en consistentie vruchtwater | ||
+ | |style="background-color: white;"|kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Tijdstip actief meepersen | ||
+ | |style="background-color: white;"|2014-08-27T23:49:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Episiotomie? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Locatie episiotomie | ||
+ | |style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ruggeprik gewenst niet gekregen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Pijnbestrijding? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Pijnbestrijding | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Methode | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Methode | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Overig middel | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Middel | ||
+ | |style="background-color: white;"|Administration of morphinomimetic analgesic (procedure) (code = '52685006:363701004=404642006' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Toediening | ||
+ | |style="background-color: white;"|Administration of substance via intravenous route (procedure) (code = '431215000' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Periode | ||
+ | |style="background-color: white;"|tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Sedatie? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Kindspecifieke uitkomstgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="22"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Type partus | ||
+ | |style="background-color: white;"|Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ligging bij geboorte | ||
+ | |style="background-color: white;"|Face presentation (finding) (code = '21882006' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Aanpakker kind - rol aanpakker kind | ||
+ | |style="background-color: white;"|arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Supervisor - rol supervisor | ||
+ | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Vaginale kunstverlossing groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="4"|Vaginale kunstverlossing |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Succes vaginale kunstverlossing? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Lichamelijk onderzoek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortegewicht | ||
+ | |style="background-color: white;"|2040 gram | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Congenitale afwijkingen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Problematiek kind? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Problematiek kind | ||
+ | |style="background-color: white;"|Birth trauma of fetus (disorder) (code = '56110009' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kinderarts betrokken? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Betrokkenheid kinderarts | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Datum betrokkenheid | ||
+ | |style="background-color: white;"|2014-08-28T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Reden betrokkenheid | ||
+ | |style="background-color: white;"|Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Type betrokkenheid | ||
+ | |style="background-color: white;"|consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorginstelling lvrid | ||
+ | |style="background-color: white;"|9999 | ||
|}<section end=uitkomst_per_kind_895623146 /> | |}<section end=uitkomst_per_kind_895623146 /> | ||
=== Uitkomst per kind === | === Uitkomst per kind === | ||
<section begin=uitkomst_per_kind_895623146 /> | <section begin=uitkomst_per_kind_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="7" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="71"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Werkelijke plaats baring type locatie | ||
+ | |style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Ziekenhuis baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ziekenhuisnummer lvrid | ||
+ | |style="background-color: white;"|9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Identificaties kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Bsn kind | ||
+ | |style="background-color: white;"|847035128 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Geslacht medische observatie | ||
+ | |style="background-color: white;"|mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Geboortedatum | ||
+ | |style="background-color: white;"|2014-08-28T07:02:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Rangnummer kind | ||
+ | |style="background-color: white;"|2 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Perinatale sterfte groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Perinatale sterfte? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Fase perinatale sterfte | ||
+ | |style="background-color: white;"|Newborn death (event) (code = '276506001' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Datumtijd vaststelling perinatale sterfte | ||
+ | |style="background-color: white;"|2014-08-28T08:10:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Kindspecifieke maternale gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="19"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Tijdstip breken vliezen | ||
+ | |style="background-color: white;"|2014-08-27T23:13:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kleur en consistentie vruchtwater | ||
+ | |style="background-color: white;"|kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Tijdstip actief meepersen | ||
+ | |style="background-color: white;"|2014-08-28T06:45:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Episiotomie? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Locatie episiotomie | ||
+ | |style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ruggeprik gewenst niet gekregen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Pijnbestrijding? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Pijnbestrijding | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Methode | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Methode | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Overig middel | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Middel | ||
+ | |style="background-color: white;"|Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Toediening | ||
+ | |style="background-color: white;"|Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Periode | ||
+ | |style="background-color: white;"|tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Sedatie? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Kindspecifieke uitkomstgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |rowspan="32"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="5"|Type partus | ||
+ | |style="background-color: white;"|Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ligging bij geboorte | ||
+ | |style="background-color: white;"|Complete breech presentation (finding) (code = '49168004' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Aanpakker kind - rol aanpakker kind | ||
+ | |style="background-color: white;"|arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Supervisor - rol supervisor | ||
+ | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Vaginale kunstverlossing groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Vaginale kunstverlossing | ||
+ | |style="background-color: white;"|Total breech extraction (procedure) (code = '416055001' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Succes vaginale kunstverlossing? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Overige interventies | ||
+ | |style="background-color: white;"|Maneuvers for delivery in shoulder dystocia (procedure) (code = '237008007' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Lichamelijk onderzoek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortegewicht | ||
+ | |style="background-color: white;"|1580 gram | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Congenitale afwijkingen? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Congenitale afwijkingen groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Specificatie congenitale afwijking groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Specificatie congenitale afwijking | ||
+ | |style="background-color: white;"|Spina bifida occulta (disorder) (code = '76916001' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Specificatie congenitale afwijking groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Specificatie congenitale afwijking | ||
+ | |style="background-color: white;"|Multiple congenital cardiac defects (disorder) (code = '94702005' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Chromosomale afwijkingen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Problematiek kind? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Problematiek kind | ||
+ | |style="background-color: white;"|Subdural intracranial hemorrhage due to birth trauma (disorder) (code = '126941005' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kinderarts betrokken? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Betrokkenheid kinderarts | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Datum betrokkenheid | ||
+ | |style="background-color: white;"|2014-08-28T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Reden betrokkenheid | ||
+ | |style="background-color: white;"|Finding of neonatal condition (finding) (code = '364737004' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Type betrokkenheid | ||
+ | |style="background-color: white;"|overdracht (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorginstelling lvrid | ||
+ | |style="background-color: white;"|0001 | ||
|}<section end=uitkomst_per_kind_895623146 /> | |}<section end=uitkomst_per_kind_895623146 /> | ||
=== Medisch onderzoek === | === Medisch onderzoek === | ||
<section begin=medisch_onderzoek_895623146 /> | <section begin=medisch_onderzoek_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="2"|Irregulaire antistoffen? | ||
+ | |style="background-color: white;"|Nee | ||
|}<section end=medisch_onderzoek_895623146 /> | |}<section end=medisch_onderzoek_895623146 /> | ||
=== Postnatale fase === | === Postnatale fase === | ||
<section begin=postnatale_fase_895623146 /> | <section begin=postnatale_fase_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="4" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kindspecifieke gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Rangnummer kind | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voeding kind groep | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |rowspan="3"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="2"|Voeding kind datum | ||
+ | |style="background-color: white;"|2014-09-03 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Substantie voeding kind | ||
+ | |style="background-color: white;"|borstmelk (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | ||
|}<section end=postnatale_fase_895623146 /> | |}<section end=postnatale_fase_895623146 /> | ||
==Scenario 4. 1e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)== | ==Scenario 4. 1e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)== | ||
Regel 823: | Regel 1.783: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Burgerservicenummer | |colspan="2"|Burgerservicenummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|850810711 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lokale persoonsidentificatie | |colspan="2"|Lokale persoonsidentificatie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|* (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Geboortedatum | |colspan="2"|Geboortedatum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1987-08-06 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Adres - postcode | |colspan="2"|Adres - postcode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|4589 BA |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Etniciteit | |colspan="2"|Etniciteit | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lengte gemeten | |colspan="2"|Lengte gemeten | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|162 cm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Vrouwelijke genitale verminking? | |colspan="2"|Vrouwelijke genitale verminking? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Type vrouwelijke genitale verminking | |colspan="2"|Type vrouwelijke genitale verminking | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96') |
|}<section end=850810711 /> | |}<section end=850810711 /> | ||
=== Anamnese === | === Anamnese === | ||
<section begin=anamnese_850810711 /> | <section begin=anamnese_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Onder behandeling geweest? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Algemene anamnese | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Autoimmuun aandoening | ||
+ | |style="background-color: white;"|Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Urogenitale aandoening | ||
+ | |style="background-color: white;"|Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Diabetes mellitus? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Mdl aandoening | ||
+ | |style="background-color: white;"|Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Longaandoening | ||
+ | |style="background-color: white;"|Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type operatie | ||
+ | |style="background-color: white;"|Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type operatie | ||
+ | |style="background-color: white;"|Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Type operatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') |
|}<section end=anamnese_850810711 /> | |}<section end=anamnese_850810711 /> | ||
=== Zorgverlening === | === Zorgverlening === | ||
<section begin=zorgverlening_850810711 /> | <section begin=zorgverlening_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Zorgverlening |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="5" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Datum start zorgverantwoordelijkheid |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-08-07T00:00:00 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Datum einde zorgverantwoordelijkheid | ||
+ | |style="background-color: white;"|2014-09-15T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Conclusie risicostatus na intake | ||
+ | |style="background-color: white;"|3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Verwijsdetails | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="15"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verwijzing van | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorginstelling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgaanbieder identificatie nummer | ||
+ | |style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verwijzing naar | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="4"| |
− | |style="background-color: | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="4"|Zorginstelling | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Zorgaanbieder identificatie nummer |
− | |style="background-color: | + | |style="background-color: white;"|1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Redenen van verwijzing | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="1"| |
− | |style="background-color: | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="5"|Redenen van verwijzing | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="1"| |
− | |||
|}<section end=zorgverlening_850810711 /> | |}<section end=zorgverlening_850810711 /> | ||
=== Zorgverlenerzorginstelling === | === Zorgverlenerzorginstelling === | ||
Regel 898: | Regel 1.914: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
|}<section end=zorgverlenerzorginstelling_850810711 /> | |}<section end=zorgverlenerzorginstelling_850810711 /> | ||
=== Zwangerschap === | === Zwangerschap === | ||
Regel 913: | Regel 1.929: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Graviditeit | |colspan="2"|Graviditeit | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Pariteit voor deze zwangerschap | |colspan="2"|Pariteit voor deze zwangerschap | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|0 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Definitieve a terme datum | |colspan="2"|Definitieve a terme datum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-08-18 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Maternale sterfte? | |colspan="2"|Maternale sterfte? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Wijze einde zwangerschap | |colspan="2"|Wijze einde zwangerschap | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
|}<section end=zwangerschap_850810711 /> | |}<section end=zwangerschap_850810711 /> | ||
=== Bevalling === | === Bevalling === | ||
<section begin=bevalling_850810711 /> | <section begin=bevalling_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Aantal geboren kinderen |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Risicostatus voor baring | ||
+ | |style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Wijze waarop de baring begon | ||
+ | |style="background-color: white;"|spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Tijdstip begin actieve ontsluiting |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-08-03T21:09:00 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Medicatie nageboortetijdperk groep | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="3"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Medicatie nageboortetijdperk? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Soort medicatie nageboortetijdperk |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Placenta - geboorte placenta |
− | |style="background-color: white;"| | + | |style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Hoeveelheid bloedverlies |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1120 ml |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Conditie perineum postpartum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') |
|}<section end=bevalling_850810711 /> | |}<section end=bevalling_850810711 /> | ||
=== Uitkomst per kind === | === Uitkomst per kind === | ||
<section begin=uitkomst_per_kind_850810711 /> | <section begin=uitkomst_per_kind_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="7" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Baring | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |rowspan="58"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="6"|Werkelijke plaats baring type locatie | ||
+ | |style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Ziekenhuis baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ziekenhuisnummer lvrid | ||
+ | |style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Identificaties kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Bsn kind | ||
+ | |style="background-color: white;"|840736526 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Geslacht medische observatie | ||
+ | |style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Geboortedatum | ||
+ | |style="background-color: white;"|2014-08-04T23:35:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Rangnummer kind | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Perinatale sterfte groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Perinatale sterfte? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Kindspecifieke maternale gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="19"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Tijdstip breken vliezen | ||
+ | |style="background-color: white;"|2014-08-03T07:04:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kleur en consistentie vruchtwater | ||
+ | |style="background-color: white;"|bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Tijdstip actief meepersen | ||
+ | |style="background-color: white;"|2014-08-04T22:15:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Episiotomie? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Locatie episiotomie | ||
+ | |style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ruggeprik gewenst niet gekregen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Pijnbestrijding? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Pijnbestrijding | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Methode | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Methode | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Overig middel | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Middel | ||
+ | |style="background-color: white;"|Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Toediening | ||
+ | |style="background-color: white;"|Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Periode | ||
+ | |style="background-color: white;"|tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Sedatie? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Kindspecifieke uitkomstgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="21"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Type partus | ||
+ | |style="background-color: white;"|Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ligging bij geboorte | ||
+ | |style="background-color: white;"|Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Aanpakker kind - rol aanpakker kind | ||
+ | |style="background-color: white;"|co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Supervisor - rol supervisor | ||
+ | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Vaginale kunstverlossing groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Vaginale kunstverlossing | ||
+ | |style="background-color: white;"|Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Succes vaginale kunstverlossing? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Lichamelijk onderzoek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortegewicht | ||
+ | |style="background-color: white;"|4205 gram | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Congenitale afwijkingen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Problematiek kind? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kinderarts betrokken? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Betrokkenheid kinderarts | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Datum betrokkenheid | ||
+ | |style="background-color: white;"|2014-08-04T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Reden betrokkenheid | ||
+ | |style="background-color: white;"|Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Type betrokkenheid | ||
+ | |style="background-color: white;"|consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorginstelling lvrid | ||
+ | |style="background-color: white;"|0010 | ||
|}<section end=uitkomst_per_kind_850810711 /> | |}<section end=uitkomst_per_kind_850810711 /> | ||
=== Postnatale fase === | === Postnatale fase === | ||
<section begin=postnatale_fase_850810711 /> | <section begin=postnatale_fase_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="4" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Diagnoseinterventie postpartum | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Datum | ||
+ | |style="background-color: white;"|2014-08-08T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pathologie vrouw | ||
+ | |style="background-color: white;"|Embolism (disorder) (code = '414086009' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Diagnoseinterventie postpartum | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Datum | ||
+ | |style="background-color: white;"|2014-08-08T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pathologie vrouw | ||
+ | |style="background-color: white;"|Episiotomy infection (disorder) (code = '300927001' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kindspecifieke gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voeding kind groep | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="3"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Voeding kind datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-09-15 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Substantie voeding kind |
− | |style="background-color: white;"| | + | |style="background-color: white;"|kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
|}<section end=postnatale_fase_850810711 /> | |}<section end=postnatale_fase_850810711 /> | ||
==Scenario 4. 2e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)== | ==Scenario 4. 2e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)== | ||
Regel 1.000: | Regel 2.196: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Burgerservicenummer | |colspan="2"|Burgerservicenummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|850810711 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lokale persoonsidentificatie | |colspan="2"|Lokale persoonsidentificatie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|* (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Geboortedatum | |colspan="2"|Geboortedatum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1987-08-06 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Adres - postcode | |colspan="2"|Adres - postcode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|4589 BA |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Etniciteit | |colspan="2"|Etniciteit | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lengte gemeten | |colspan="2"|Lengte gemeten | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|162 cm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Vrouwelijke genitale verminking? | |colspan="2"|Vrouwelijke genitale verminking? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Type vrouwelijke genitale verminking | |colspan="2"|Type vrouwelijke genitale verminking | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96') |
|}<section end=850810711 /> | |}<section end=850810711 /> | ||
=== Anamnese === | === Anamnese === | ||
<section begin=anamnese_850810711 /> | <section begin=anamnese_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Onder behandeling geweest? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Algemene anamnese | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Autoimmuun aandoening | ||
+ | |style="background-color: white;"|Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Urogenitale aandoening | ||
+ | |style="background-color: white;"|Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Diabetes mellitus? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Mdl aandoening | ||
+ | |style="background-color: white;"|Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Longaandoening | ||
+ | |style="background-color: white;"|Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type operatie | ||
+ | |style="background-color: white;"|Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type operatie | ||
+ | |style="background-color: white;"|Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Type operatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') |
|}<section end=anamnese_850810711 /> | |}<section end=anamnese_850810711 /> | ||
=== Zorgverlening === | === Zorgverlening === | ||
<section begin=zorgverlening_850810711 /> | <section begin=zorgverlening_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Zorgverlening |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="5" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Datum start zorgverantwoordelijkheid |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-02-03T00:00:00 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Datum einde zorgverantwoordelijkheid | ||
+ | |style="background-color: white;"|2014-08-06T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Conclusie risicostatus na intake | ||
+ | |style="background-color: white;"|3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Verwijsdetails | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="15"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Datum verwijzing |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-08-06T00:00:00 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verwijzing van | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="4"| |
− | |style="background-color: | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="4"|Zorginstelling | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Zorgaanbieder identificatie nummer |
− | |style="background-color: | + | |style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verwijzing naar | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="4"| |
− | |style="background-color: | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="4"|Zorginstelling | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Zorgaanbieder identificatie nummer |
− | |style="background-color: | + | |style="background-color: white;"|1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Redenen van verwijzing | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="1"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Perinatale periode |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2e t/m 7e dag (code = '92' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') |
|}<section end=zorgverlening_850810711 /> | |}<section end=zorgverlening_850810711 /> | ||
=== Zorgverlenerzorginstelling === | === Zorgverlenerzorginstelling === | ||
Regel 1.087: | Regel 2.341: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
|}<section end=zorgverlenerzorginstelling_850810711 /> | |}<section end=zorgverlenerzorginstelling_850810711 /> | ||
=== Zwangerschap === | === Zwangerschap === | ||
<section begin=zwangerschap_850810711 /> | <section begin=zwangerschap_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Dossiernummer |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="3"|Graviditeit |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pariteit voor deze zwangerschap | ||
+ | |style="background-color: white;"|0 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|2014-08-18 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voornemens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie | ||
+ | |style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Prenatale controle | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum controle | ||
+ | |style="background-color: white;"|2014-05-07T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|149 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Leven voelen | ||
+ | |style="background-color: white;"|Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Rookgedrag | ||
+ | |style="background-color: white;"|niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Alcoholgebruik | ||
+ | |style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Drugsgebruik? | ||
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Gewicht gemeten |
− | |style="background-color: white;"| | + | |style="background-color: white;"|82 kg |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Diagnose | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="4"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-05-07T00:00:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Zwangerschapsduur |
− | |style="background-color: white;"| | + | |style="background-color: white;"|149 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Infectie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Maternale sterfte? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Wijze einde zwangerschap |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
|}<section end=zwangerschap_850810711 /> | |}<section end=zwangerschap_850810711 /> | ||
=== Bevalling === | === Bevalling === | ||
<section begin=bevalling_850810711 /> | <section begin=bevalling_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Diagnose bevalling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Niet vorderende ontsluiting? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Niet vorderende uitdrijving? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Aantal geboren kinderen | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Risicostatus voor baring | ||
+ | |style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Wijze waarop de baring begon |
− | |style="background-color: white;"| | + | |style="background-color: white;"|spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Tijdstip begin actieve ontsluiting |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-08-03T21:09:00 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Medicatie nageboortetijdperk groep | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="3"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Medicatie nageboortetijdperk? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Soort medicatie nageboortetijdperk |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Placenta - geboorte placenta |
− | |style="background-color: white;"| | + | |style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Hoeveelheid bloedverlies |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1120 ml |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Conditie perineum postpartum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') |
|}<section end=bevalling_850810711 /> | |}<section end=bevalling_850810711 /> | ||
=== Uitkomst per kind === | === Uitkomst per kind === | ||
<section begin=uitkomst_per_kind_850810711 /> | <section begin=uitkomst_per_kind_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="7" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="58"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Werkelijke plaats baring type locatie | ||
+ | |style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Ziekenhuis baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="5"|Ziekenhuisnummer lvrid |
− | |style="background-color: white;"| | + | |style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Identificaties kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Bsn kind | ||
+ | |style="background-color: white;"|840736526 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Geslacht medische observatie | ||
+ | |style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Geboortedatum | ||
+ | |style="background-color: white;"|2014-08-04T23:35:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Rangnummer kind | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Perinatale sterfte groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Perinatale sterfte? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Kindspecifieke maternale gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="19"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Tijdstip breken vliezen | ||
+ | |style="background-color: white;"|2014-08-03T07:04:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kleur en consistentie vruchtwater | ||
+ | |style="background-color: white;"|bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Tijdstip actief meepersen | ||
+ | |style="background-color: white;"|2014-08-04T22:15:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Episiotomie? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Locatie episiotomie | ||
+ | |style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ruggeprik gewenst niet gekregen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Pijnbestrijding? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Pijnbestrijding | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Methode | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Methode | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Overig middel | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Middel | ||
+ | |style="background-color: white;"|Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Toediening | ||
+ | |style="background-color: white;"|Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Periode | ||
+ | |style="background-color: white;"|tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Sedatie? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Kindspecifieke uitkomstgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="21"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Type partus | ||
+ | |style="background-color: white;"|Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ligging bij geboorte | ||
+ | |style="background-color: white;"|Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Aanpakker kind - rol aanpakker kind | ||
+ | |style="background-color: white;"|co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Supervisor - rol supervisor | ||
+ | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Vaginale kunstverlossing groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Vaginale kunstverlossing | ||
+ | |style="background-color: white;"|Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Succes vaginale kunstverlossing? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Lichamelijk onderzoek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortegewicht | ||
+ | |style="background-color: white;"|4205 gram | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Congenitale afwijkingen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Problematiek kind? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kinderarts betrokken? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Betrokkenheid kinderarts | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Datum betrokkenheid | ||
+ | |style="background-color: white;"|2014-08-04T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Reden betrokkenheid | ||
+ | |style="background-color: white;"|Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Type betrokkenheid | ||
+ | |style="background-color: white;"|consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorginstelling lvrid | ||
+ | |style="background-color: white;"|0010 | ||
|}<section end=uitkomst_per_kind_850810711 /> | |}<section end=uitkomst_per_kind_850810711 /> | ||
=== Medisch onderzoek === | === Medisch onderzoek === | ||
<section begin=medisch_onderzoek_850810711 /> | <section begin=medisch_onderzoek_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Irregulaire antistoffen? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|}<section end=medisch_onderzoek_850810711 /> | |}<section end=medisch_onderzoek_850810711 /> | ||
==Scenario 5. zorg volledig 2e lijn, vrouw overleden (voor vrouw met BSN: 912345676)== | ==Scenario 5. zorg volledig 2e lijn, vrouw overleden (voor vrouw met BSN: 912345676)== | ||
Regel 1.195: | Regel 2.651: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Burgerservicenummer | |colspan="2"|Burgerservicenummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|912345676 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lokale persoonsidentificatie | |colspan="2"|Lokale persoonsidentificatie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|* (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Geboortedatum | |colspan="2"|Geboortedatum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1993-03-04 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Adres - postcode | |colspan="2"|Adres - postcode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|9562 GF |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Etniciteit | |colspan="2"|Etniciteit | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Latijns Amerikaans (code = '14' in codeSystem '2.16.840.1.113883.2.4.4.13.28') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lengte gemeten | |colspan="2"|Lengte gemeten | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|186 cm |
|}<section end=912345676 /> | |}<section end=912345676 /> | ||
=== Anamnese === | === Anamnese === | ||
<section begin=anamnese_912345676 /> | <section begin=anamnese_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Onder behandeling geweest? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Algemene anamnese | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Cardiovasculaire aandoening | ||
+ | |style="background-color: white;"|Hypertensive disorder, systemic arterial (disorder) (code = '38341003' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Diabetes mellitus? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Neurologische aandoening | ||
+ | |style="background-color: white;"|Epilepsy (disorder) (code = '84757009' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Longaandoening | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Orthopedische afwijking | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type stollingsprobleem | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Psychiatrie? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|}<section end=anamnese_912345676 /> | |}<section end=anamnese_912345676 /> | ||
=== Zorgverlening === | === Zorgverlening === | ||
Regel 1.237: | Regel 2.715: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Datum start zorgverantwoordelijkheid | |colspan="2"|Datum start zorgverantwoordelijkheid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|2013-12-09T00:00:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Datum einde zorgverantwoordelijkheid | |colspan="2"|Datum einde zorgverantwoordelijkheid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-08-04T00:00:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale periode? | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Conclusie risicostatus na intake | |colspan="2"|Conclusie risicostatus na intake | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') |
|}<section end=zorgverlening_912345676 /> | |}<section end=zorgverlening_912345676 /> | ||
=== Zorgverlenerzorginstelling === | === Zorgverlenerzorginstelling === | ||
Regel 1.279: | Regel 2.757: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
|}<section end=zorgverlenerzorginstelling_912345676 /> | |}<section end=zorgverlenerzorginstelling_912345676 /> | ||
=== Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === | === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === | ||
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 /> | <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="5" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Wijze einde zwangerschap |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|2012-06-05 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Diagnose | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Infectie | ||
+ | |style="background-color: white;"|Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zwangerschapscholestase? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Afwijkende groei foetus | ||
+ | |style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Irregulaire antistoffen? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eerdere bevalling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="11"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Placenta - geboorte placenta | ||
+ | |style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Vorige uitkomst per kind - vorige baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Demografische gegevens - geboortedatum | ||
+ | |style="background-color: white;"|2012-06-09T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Kindspecifieke gegevens vorige uitkomsten | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Type partus |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Percentiel van het geboortegewicht |
− | |style="background-color: white;"| | + | |style="background-color: white;"|10 ≤ P < 50 (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.50') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Apgarscore na 5 min |
− | |style="background-color: white;"| | + | |style="background-color: white;"|10 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Congenitale afwijkingen? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 /> | |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 /> | ||
=== Zwangerschap === | === Zwangerschap === | ||
<section begin=zwangerschap_912345676 /> | <section begin=zwangerschap_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Dossiernummer |
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="3"|Graviditeit |
− | |style="background-color: white;"| | + | |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="3"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|2014-07-22 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voornemens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie | ||
+ | |style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Prenatale controle | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum controle | ||
+ | |style="background-color: white;"|2014-01-09T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|86 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Leven voelen | ||
+ | |style="background-color: white;"|Fetal movements absent (context-dependent category) (code = '289432001' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Rookgedrag | ||
+ | |style="background-color: white;"|gestopt tijdens huidige zwangerschap (code = '6' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Alcoholgebruik | ||
+ | |style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Drugsgebruik? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Gewicht gemeten | ||
+ | |style="background-color: white;"|89 kg | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Diagnose | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="5"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2014-01-09T00:00:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Zwangerschapsduur |
− | |style="background-color: white;"| | + | |style="background-color: white;"|86 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Afwijkende groei foetus |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Large-for-dates fetus (disorder) (code = '199616008' in codeSystem '2.16.840.1.113883.6.96') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Abruptio placentae? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Intrauteriene behandeling |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Selective destruction of fetus (procedure) (code = '265633004' in codeSystem '2.16.840.1.113883.6.96') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Maternale sterfte? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Wijze einde zwangerschap |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
|}<section end=zwangerschap_912345676 /> | |}<section end=zwangerschap_912345676 /> | ||
=== Bevalling === | === Bevalling === | ||
<section begin=bevalling_912345676 /> | <section begin=bevalling_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Partusnummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|000000 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Aantal geboren kinderen | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Risicostatus voor baring | ||
+ | |style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Interventies begin baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Interventie begin baring |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Indicatie interventie begin baring |
− | |style="background-color: white;"| | + | |style="background-color: white;"|acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Wijze waarop de baring begon |
− | |style="background-color: white;"| | + | |style="background-color: white;"|interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Medicatie nageboortetijdperk groep | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"|Medicatie nageboortetijdperk | + | |colspan="2"|Medicatie nageboortetijdperk? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Placenta - geboorte placenta |
− | |style="background-color: white;"| | + | |style="background-color: white;"|placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Hoeveelheid bloedverlies |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1500 ml |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Conditie perineum postpartum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') |
|}<section end=bevalling_912345676 /> | |}<section end=bevalling_912345676 /> | ||
=== Uitkomst per kind === | === Uitkomst per kind === | ||
<section begin=uitkomst_per_kind_912345676 /> | <section begin=uitkomst_per_kind_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Uitkomst per kind |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="6" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="58"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Werkelijke plaats baring type locatie | ||
+ | |style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Ziekenhuis baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ziekenhuisnummer lvrid | ||
+ | |style="background-color: white;"|0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Identificaties kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Bsn kind | ||
+ | |style="background-color: white;"|528741913 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslacht medische observatie | ||
+ | |style="background-color: white;"|twijfelachtig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortedatum | ||
+ | |style="background-color: white;"|2014-07-24T02:30:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Rangnummer kind | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Perinatale sterfte groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Perinatale sterfte? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Kindspecifieke maternale gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Kleur en consistentie vruchtwater | ||
+ | |style="background-color: white;"|meconium (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Episiotomie? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ruggeprik gewenst niet gekregen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Pijnbestrijding? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Pijnbestrijding | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Methode | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Methode | ||
+ | |style="background-color: white;"|General anesthesia (procedure) (code = '50697003' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Periode | ||
+ | |style="background-color: white;"|tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Sedatie? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Kindspecifieke uitkomstgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="28"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Type partus | ||
+ | |style="background-color: white;"|Emergency cesarian section (procedure) (code = '274130007' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ligging bij geboorte | ||
+ | |style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem '2.16.840.1.113883.5.1008') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Aanpakker kind - rol aanpakker kind | ||
+ | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Supervisor - rol supervisor | ||
+ | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Vaginale kunstverlossing groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Vaginale kunstverlossing | ||
+ | |style="background-color: white;"|Delivery by vacuum extraction (procedure) (code = '61586001' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Succes vaginale kunstverlossing? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Sectio caesarea group | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Beslismoment sectio caesarea | ||
+ | |style="background-color: white;"|tijdens uitdrijving besloten (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.5') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Indicatie secundaire sectio | ||
+ | |style="background-color: white;"|Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Lichamelijk onderzoek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Geboortegewicht | ||
+ | |style="background-color: white;"|3750 gram | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="4"|Congenitale afwijkingen? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Congenitale afwijkingen groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Specificatie congenitale afwijking groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="1"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Chromosomale afwijkingen? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Specificatie chromosomale afwijking groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Specificatie chromosomale afwijking | ||
+ | |style="background-color: white;"|Complete trisomy 21 syndrome (disorder) (code = '41040004' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problematiek kind? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problematiek kind | ||
+ | |style="background-color: white;"|Congenital hearing disorder (disorder) (code = '95827002' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Kinderarts betrokken? | ||
+ | |style="background-color: white;"|Nee | ||
|}<section end=uitkomst_per_kind_912345676 /> | |}<section end=uitkomst_per_kind_912345676 /> | ||
=== Medisch onderzoek === | === Medisch onderzoek === | ||
<section begin=medisch_onderzoek_912345676 /> | <section begin=medisch_onderzoek_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Irregulaire antistoffen? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Welke irregulaire antistoffen vrouw aanwezig | ||
+ | |style="background-color: white;"|Kell (code = '405844003' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=medisch_onderzoek_912345676 /> | |}<section end=medisch_onderzoek_912345676 /> | ||
=== Postnatale fase === | === Postnatale fase === | ||
<section begin=postnatale_fase_912345676 /> | <section begin=postnatale_fase_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="4" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Diagnoseinterventie postpartum | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Datum | ||
+ | |style="background-color: white;"|2014-07-24T00:00:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pathologie vrouw | ||
+ | |style="background-color: white;"|Postpartum deep phlebothrombosis (disorder) (code = '56272000' in codeSystem '2.16.840.1.113883.6.96') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kindspecifieke gegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |rowspan="5"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="4"|Voeding kind groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voeding kind datum | ||
+ | |style="background-color: white;"|2014-07-24 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Substantie voeding kind |
− | |style="background-color: white;"| | + | |style="background-color: white;"|kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
|}<section end=postnatale_fase_912345676 /> | |}<section end=postnatale_fase_912345676 /> |
Versie van 25 jan 2019 14:10
{{#customtitle:Kernset Geboortezorg 2.3 - inhoud kwalificatie}}
Deze pagina is nog in bewerking |
1 Addenda voor inhoudelijke gegevens Kernset Geboortezorg 2.3
1.1 Scenario 1. Zorg volledig 1e lijn, herpes, strippen, gezonde eenling (voor vrouw met BSN: 999910413)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 999910413 | |
Lokale persoonsidentificatie | 000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) | |
Geboortedatum | 1976-05-02 | |
Adres - postcode | 4563 AB | |
Etniciteit | Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 170 cm |
1.1.1 Anamnese
Anamnese | |||
Gegevenselement | Waarde | ||
Onder behandeling geweest? | Ja | ||
Algemene anamnese | |||
Cardiovasculaire aandoening | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
Oncologische aandoening | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
Infectieziekte | Herpes (code = '23513009' in codeSystem '2.16.840.1.113883.6.96') | ||
Type operatie | Orthopedisch (code = '112697007' in codeSystem 'Snomed CT') |
1.1.2 Zorgverlening
Zorgverlening | ||
Gegevenselement | Waarde | |
Datum start zorgverantwoordelijkheid | 2014-03-01T00:00:00 | |
Datum einde zorgverantwoordelijkheid | 2014-11-12T00:00:00 | |
Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Conclusie risicostatus na intake | 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') |
1.1.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | ||
Gegevenselement | Waarde | |
Zorginstelling lvrid | 1808 |
1.1.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||||
Gegevenselement | Waarde | ||||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||||
Definitieve a terme datum | 2011-12-01 | ||||
Irregulaire antistoffen? | Nee | ||||
Eerdere bevalling | |||||
Placenta - geboorte placenta | Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||||
Hoeveelheid bloedverlies | 550 ml | ||||
Vorige uitkomst per kind - vorige baring | |||||
Demografische gegevens - geboortedatum | 2011-12-08T00:00:00 | ||||
Kindspecifieke gegevens vorige uitkomsten | |||||
Type partus | Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT') | ||||
Percentiel van het geboortegewicht | 50 ≤ P < 90 (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.50') | ||||
Apgarscore na 5 min | 8 | ||||
Congenitale afwijkingen? | Nee |
1.1.5 Zwangerschap
Zwangerschap | |||
Gegevenselement | Waarde | ||
Dossiernummer | |||
Graviditeit | 2 | ||
Pariteit voor deze zwangerschap | 1 | ||
Definitieve a terme datum | 2014-10-09 | ||
Voornemens | |||
Voorgenomen plaats baring tijdens zwangerschap type locatie | Thuis (code = '169813005' in codeSystem '2.16.840.1.113883.6.96') | ||
Prenatale controle | |||
Datum controle | 2014-03-02T00:00:00 | ||
Zwangerschapsduur | 59 dagen | ||
Leven voelen | goed (code = '289431008' in codeSystem 'Snomed CT') | ||
Rookgedrag | niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
Drugsgebruik? | Nee | ||
Gewicht gemeten | 70 kg | ||
Diagnose | |||
Datum | 2014-03-02T00:00:00 | ||
Zwangerschapsduur | 59 dagen | ||
Infectie | Urineweg infectie (code = '307534009' in codeSystem 'Snomed CT') | ||
Maternale sterfte? | Nee | ||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.1.6 Bevalling
Bevalling | |||
Gegevenselement | Waarde | ||
Partusnummer | 000000 | ||
Aantal geboren kinderen | 1 | ||
Risicostatus voor baring | 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
Interventies begin baring | |||
Interventie begin baring | Strippen (code = '236960006' in codeSystem 'Snomed CT') | ||
Indicatie interventie begin baring | wens patiënt (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | ||
Wijze waarop de baring begon | Interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
Tijdstip begin actieve ontsluiting | 2014-10-08T14:30:00 | ||
Medicatie nageboortetijdperk groep | |||
Medicatie nageboortetijdperk? | Ja | ||
Soort medicatie nageboortetijdperk | Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') | ||
Placenta - geboorte placenta | Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
Hoeveelheid bloedverlies | 615 ml | ||
Conditie perineum postpartum | 1e graads perineumruptuur (code = '199916005' in codeSystem 'Snomed CT') |
1.1.7 Uitkomst per kind
Uitkomst per kind | |||||
Gegevenselement | Waarde | ||||
Baring | |||||
Werkelijke plaats baring type locatie | Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') | ||||
Demografische gegevens | |||||
Identificaties kind | |||||
Bsn kind | 999910383 | ||||
Geslacht medische observatie | vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||||
Geboortedatum | 2014-10-08T00:00:00 | ||||
Rangnummer kind | 1 | ||||
Perinatale sterfte groep | |||||
Perinatale sterfte? | Nee | ||||
Kindspecifieke maternale gegevens | |||||
Tijdstip breken vliezen | 2014-10-08T09:15:00 | ||||
Kleur en consistentie vruchtwater | Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||
Tijdstip actief meepersen | 2014-10-08T12:13:00 | ||||
Episiotomie? | Nee | ||||
Ruggeprik gewenst niet gekregen? | Nee | ||||
Pijnbestrijding? | Nee | ||||
Sedatie? | Nee | ||||
Kindspecifieke uitkomstgegevens | |||||
Type partus | Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT') | ||||
Ligging bij geboorte | Achterhoofd-achter (code = '37235006' in codeSystem 'Snomed CT') | ||||
Aanpakker kind - rol aanpakker kind | 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||||
Supervisor - rol supervisor | 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||||
Lichamelijk onderzoek kind | |||||
Geboortegewicht | 3450 gram | ||||
Congenitale afwijkingen? | Nee | ||||
Problematiek kind? | Nee | ||||
Kinderarts betrokken? | Nee |
1.1.8 Medisch onderzoek
Medisch onderzoek | |||
Gegevenselement | Waarde | ||
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
Irregulaire antistoffen? | Nee |
1.1.9 Postnatale fase
Postnatale fase | ||||
Gegevenselement | Waarde | |||
Kindspecifieke gegevens | ||||
Voeding kind groep | ||||
Voeding kind datum | 2014-10-12 | |||
Substantie voeding kind | borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | |||
Substantie voeding kind | kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
1.2 Scenario 2. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 961921821 | |
Lokale persoonsidentificatie | * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) | |
Geboortedatum | 1974-09-11 | |
Adres - postcode | 5689 CZ | |
Etniciteit | Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 184 cm |
1.2.1 Anamnese
Anamnese | ||
Gegevenselement | Waarde | |
Onder behandeling geweest? | Nee |
1.2.2 Zorgverlening
Zorgverlening | ||||||
Gegevenselement | Waarde | |||||
Datum start zorgverantwoordelijkheid | 2018-08-28 | |||||
Datum einde zorgverantwoordelijkheid | 2018-11-28 | |||||
Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||||
Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||||
Conclusie risicostatus na intake | 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | |||||
Verwijsdetails | ||||||
Datum verwijzing | 2014-05-06T00:00:00 | |||||
Verwijzing van | ||||||
Zorginstelling | ||||||
Zorgaanbieder identificatie nummer | 1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | |||||
Verwijzing naar | ||||||
Zorginstelling | ||||||
Specialisme | Gynaecoloog 2e lijn (code = '02' in codeSystem 'Specialisme, specifiek voor perinatologie.') | |||||
Redenen van verwijzing | ||||||
Van 1e naar 2e lijn | ||||||
Zwangerschap | ||||||
Hypertensieve aandoening | Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT') | |||||
Perinatale periode | voor 28e week (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') |
1.2.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | ||
Gegevenselement | Waarde | |
Zorginstelling lvrid | 1504 |
1.2.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||
Gegevenselement | Waarde | ||
Wijze einde zwangerschap | Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
Definitieve a terme datum | 2013-06-05 | ||
Diagnose | |||
Bloedverlies? | Ja | ||
Hyperemesis gravidarum? | Ja | ||
Irregulaire antistoffen? | Ja |
1.2.5 Zwangerschap
Zwangerschap | |||
Gegevenselement | Waarde | ||
Dossiernummer | |||
Graviditeit | 2 | ||
Pariteit voor deze zwangerschap | 0 | ||
Definitieve a terme datum | 2014-09-08 | ||
Voornemens | |||
Voorgenomen plaats baring tijdens zwangerschap type locatie | Nog niet bepaald (code = '05' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') | ||
Prenatale controle | |||
Datum controle | 2014-05-06T00:00:00 | ||
Zwangerschapsduur | 155 dagen | ||
Leven voelen | Weak fetal movements (finding) (code = '276372004' in codeSystem '2.16.840.1.113883.6.96') | ||
Rookgedrag | gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
Drugsgebruik? | Nee | ||
Gewicht gemeten | 85 kg | ||
Diagnose | |||
Datum | 2014-05-06T00:00:00 | ||
Zwangerschapsduur | 155 dagen | ||
Hypertensieve aandoening | Pregnancy-induced hypertension (disorder) (code = '48194001' in codeSystem '2.16.840.1.113883.6.96') | ||
Maternale sterfte? | Nee |
1.3 Scenario 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 961921821 | |
Lokale persoonsidentificatie | * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) | |
Geboortedatum | 1974-09-11 | |
Adres - postcode | 5689 CZ | |
Etniciteit | Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 184 cm |
1.3.1 Anamnese
Anamnese | ||
Gegevenselement | Waarde | |
Onder behandeling geweest? | Nee |
1.3.2 Zorgverlening
Zorgverlening | ||||||
Gegevenselement | Waarde | |||||
Datum start zorgverantwoordelijkheid | 2014-05-12T00:00:00 | |||||
Datum einde zorgverantwoordelijkheid | 2014-10-09T00:00:00 | |||||
Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||||
Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||||
Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||||
Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||||
Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||||
Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||||
Eindverantwoordelijk in welke perinatale periode? | follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||||
Verwijsdetails | ||||||
Verwijzing van | ||||||
Zorginstelling | ||||||
Zorgaanbieder identificatie nummer | 1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | |||||
Verwijzing naar | ||||||
Zorginstelling | ||||||
Zorgaanbieder identificatie nummer | 0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | |||||
Redenen van verwijzing | ||||||
Van 1e naar 2e lijn | ||||||
Zwangerschap | ||||||
Hypertensieve aandoening | Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT') |
1.3.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | ||
Gegevenselement | Waarde | |
Zorginstelling lvrid | 0003 |
1.3.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||
Gegevenselement | Waarde | ||
Wijze einde zwangerschap | Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
Definitieve a terme datum | 2013-06-05 | ||
Diagnose | |||
Gynaecologische aandoening | Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') | ||
Bloedverlies? | Ja | ||
Hyperemesis gravidarum? | Ja | ||
Irregulaire antistoffen? | Ja |
1.3.5 Zwangerschap
Zwangerschap | |||
Gegevenselement | Waarde | ||
Dossiernummer | |||
Graviditeit | 2 | ||
Pariteit voor deze zwangerschap | 0 | ||
Definitieve a terme datum | 2014-09-08 | ||
Voornemens | |||
Prenatale controle | |||
Datum controle | 2014-05-12T00:00:00 | ||
Zwangerschapsduur | 161 dagen | ||
Leven voelen | Reduced fetal movement (finding) (code = '276369006' in codeSystem '2.16.840.1.113883.6.96') | ||
Rookgedrag | gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
Drugsgebruik? | Nee | ||
Gewicht gemeten | 85 kg | ||
Diagnose | |||
Datum | 2014-05-12T00:00:00 | ||
Zwangerschapsduur | 161 dagen | ||
Gynaecologische aandoening | Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') | ||
Partiele mola? | Ja | ||
Hypertensieve aandoening | Pre-eclampsia (disorder) (code = '398254007' in codeSystem '2.16.840.1.113883.6.96') | ||
Maternale sterfte? | Nee | ||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.3.6 Bevalling
Bevalling | |||
Gegevenselement | Waarde | ||
Partusnummer | 000000 | ||
Aantal geboren kinderen | 1 | ||
Risicostatus voor baring | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
Interventies begin baring | |||
Interventie begin baring | Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96') | ||
Indicatie interventie begin baring | acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | ||
Wijze waarop de baring begon | interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
Tijdstip begin actieve ontsluiting | 2014-08-30T14:09:00 | ||
Medicatie nageboortetijdperk groep | |||
Medicatie nageboortetijdperk? | UNK | ||
Placenta - geboorte placenta | placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
Hoeveelheid bloedverlies | 980 ml | ||
Conditie perineum postpartum | Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') |
1.3.7 Uitkomst per kind
Uitkomst per kind | ||||||
Gegevenselement | Waarde | |||||
Baring | ||||||
Werkelijke plaats baring type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | |||||
Ziekenhuis baring | ||||||
Ziekenhuisnummer lvrid | 0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | |||||
Demografische gegevens | ||||||
Identificaties kind | ||||||
Bsn kind | 951847624 | |||||
Geslacht medische observatie | mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | |||||
Geboortedatum | 2014-09-01T02:34:00 | |||||
Rangnummer kind | 1 | |||||
Perinatale sterfte groep | ||||||
Perinatale sterfte? | Nee | |||||
Kindspecifieke maternale gegevens | ||||||
Tijdstip breken vliezen | 2014-08-30T23:04:00 | |||||
Kleur en consistentie vruchtwater | geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | |||||
Ruggeprik gewenst niet gekregen? | Nee | |||||
Pijnbestrijding? | Ja | |||||
Pijnbestrijding | ||||||
Methode | ||||||
Methode | Epidural anesthesia (procedure) (code = '18946005' in codeSystem '2.16.840.1.113883.6.96') | |||||
Periode | tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | |||||
Sedatie? | Ja | |||||
Kindspecifieke uitkomstgegevens | ||||||
Type partus | Cesarean section (procedure) (code = '11466000' in codeSystem 'SNOMED CT') | |||||
Ligging bij geboorte | Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | |||||
Aanpakker kind - rol aanpakker kind | gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | |||||
Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | |||||
Sectio caesarea group | ||||||
Indicatie primaire sectio | Suspected fetal distress (situation) (code = '444433005:246090004=130955003' in codeSystem '2.16.840.1.113883.6.96') | |||||
Indicatie primaire sectio | Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') | |||||
Lichamelijk onderzoek kind | ||||||
Geboortegewicht | 3620 gram | |||||
Congenitale afwijkingen? | Nee | |||||
Problematiek kind? | Nee | |||||
Kinderarts betrokken? | Ja | |||||
Betrokkenheid kinderarts | ||||||
Datum betrokkenheid | 2014-09-01T00:00:00 | |||||
Reden betrokkenheid | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | |||||
Type betrokkenheid | consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | |||||
Zorginstelling lvrid | 0003 |
1.3.8 Medisch onderzoek
Medisch onderzoek | |||
Gegevenselement | Waarde | ||
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
Irregulaire antistoffen? | Ja | ||
Welke irregulaire antistoffen vrouw aanwezig | Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96') |
1.3.9 Postnatale fase
Postnatale fase | ||||
Gegevenselement | Waarde | |||
Diagnoseinterventie postpartum | ||||
Datum | 2014-09-03T00:00:00 | |||
Pathologie vrouw | Urinary tract infectious disease (disorder) (code = '68566005' in codeSystem '2.16.840.1.113883.6.96') | |||
Kindspecifieke gegevens | ||||
Voeding kind groep | ||||
Voeding kind datum | 2014-10-07 | |||
Substantie voeding kind | kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
1.4 Scenario 3. zorg volledig in 2e lijn, meerling, 1 kind overleden (voor vrouw met BSN: 895623146)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 895623146 | |
Lokale persoonsidentificatie | 000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) | |
Geboortedatum | 1985-08-05 | |
Adres - postcode | 5421 JG | |
Etniciteit | Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 167 cm | |
Vrouwelijke genitale verminking? | Ja | |
Type vrouwelijke genitale verminking | Female genital mutilation type 2 (disorder) (code = '130621000119105' in codeSystem '2.16.840.1.113883.6.96') |
1.4.1 Anamnese
Anamnese | |||
Gegevenselement | Waarde | ||
Onder behandeling geweest? | Ja | ||
Algemene anamnese | |||
Cardiovasculaire aandoening | Cardiac arrhythmia (disorder) (code = '698247007' in codeSystem '2.16.840.1.113883.6.96') | ||
Schildklier aandoening | Hyperthyroidism (disorder) (code = '34486009' in codeSystem '2.16.840.1.113883.6.96') | ||
Anemie | Iron deficiency anemia (disorder) (code = '87522002' in codeSystem '2.16.840.1.113883.6.96') | ||
Bloedtransfusie? | Ja | ||
Type operatie | Operation on heart (procedure) (code = '64915003' in codeSystem '2.16.840.1.113883.6.96') |
1.4.2 Zorgverlening
Zorgverlening | ||
Gegevenselement | Waarde | |
Datum start zorgverantwoordelijkheid | 2014-03-10T00:00:00 | |
Datum einde zorgverantwoordelijkheid | 2014-11-03T00:00:00 | |
Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Conclusie risicostatus na intake | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') |
1.4.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | ||
Gegevenselement | Waarde | |
Zorginstelling lvrid | 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.4.4 Zwangerschap
Zwangerschap | |||
Gegevenselement | Waarde | ||
Dossiernummer | |||
Graviditeit | 1 | ||
Pariteit voor deze zwangerschap | 0 | ||
Definitieve a terme datum | 2014-09-22 | ||
Voornemens | |||
Voorgenomen plaats baring tijdens zwangerschap type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||
Prenatale controle | |||
Datum controle | 2014-05-21T00:00:00 | ||
Zwangerschapsduur | 156 dagen | ||
Leven voelen | Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96') | ||
Rookgedrag | niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
Drugsgebruik? | Nee | ||
Gewicht gemeten | 67 kg | ||
Diagnose | |||
Datum | 2014-05-21T00:00:00 | ||
Zwangerschapsduur | 156 dagen | ||
Bloedverlies? | Ja | ||
Infectie | Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | ||
Afwijkende groei foetus | Small for gestational age fetus (disorder) (code = '267258002' in codeSystem '2.16.840.1.113883.6.96') | ||
Abruptio placentae? | Ja | ||
Maternale sterfte? | Nee | ||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.4.5 Bevalling
Bevalling | |||
Gegevenselement | Waarde | ||
Partusnummer | 000000 | ||
Diagnose bevalling | |||
Pprom? | Ja | ||
Verdenking foetale nood? | Ja | ||
Aantal geboren kinderen | 2 | ||
Risicostatus voor baring | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
Wijze waarop de baring begon | spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
Tijdstip begin actieve ontsluiting | 2014-08-27T22:09:00 | ||
Medicatie nageboortetijdperk groep | |||
Medicatie nageboortetijdperk? | Nee | ||
Placenta - geboorte placenta | controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
Hoeveelheid bloedverlies | 1740 ml | ||
Conditie perineum postpartum | Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96') |
1.4.6 Uitkomst per kind
Uitkomst per kind | |||||||
Gegevenselement | Waarde | ||||||
Baring | |||||||
Werkelijke plaats baring type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Ziekenhuis baring | |||||||
Ziekenhuisnummer lvrid | 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||||
Demografische gegevens | |||||||
Identificaties kind | |||||||
Bsn kind | 847035116 | ||||||
Geslacht medische observatie | vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||||||
Geboortedatum | 2014-08-28T06:30:00 | ||||||
Rangnummer kind | 1 | ||||||
Perinatale sterfte groep | |||||||
Perinatale sterfte? | Nee | ||||||
Kindspecifieke maternale gegevens | |||||||
Tijdstip breken vliezen | 2014-08-27T22:09:00 | ||||||
Kleur en consistentie vruchtwater | kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
Tijdstip actief meepersen | 2014-08-27T23:49:00 | ||||||
Episiotomie? | Ja | ||||||
Locatie episiotomie | mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||||||
Ruggeprik gewenst niet gekregen? | Nee | ||||||
Pijnbestrijding? | Ja | ||||||
Pijnbestrijding | |||||||
Methode | |||||||
Methode | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||||||
Overig middel | |||||||
Middel | Administration of morphinomimetic analgesic (procedure) (code = '52685006:363701004=404642006' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Toediening | Administration of substance via intravenous route (procedure) (code = '431215000' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Periode | tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||||||
Sedatie? | Nee | ||||||
Kindspecifieke uitkomstgegevens | |||||||
Type partus | Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') | ||||||
Ligging bij geboorte | Face presentation (finding) (code = '21882006' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Aanpakker kind - rol aanpakker kind | arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||||||
Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||||||
Vaginale kunstverlossing groep | |||||||
Vaginale kunstverlossing | Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Succes vaginale kunstverlossing? | Ja | ||||||
Lichamelijk onderzoek kind | |||||||
Geboortegewicht | 2040 gram | ||||||
Congenitale afwijkingen? | Nee | ||||||
Problematiek kind? | Ja | ||||||
Problematiek kind | Birth trauma of fetus (disorder) (code = '56110009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Kinderarts betrokken? | Ja | ||||||
Betrokkenheid kinderarts | |||||||
Datum betrokkenheid | 2014-08-28T00:00:00 | ||||||
Reden betrokkenheid | Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Type betrokkenheid | consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
Zorginstelling lvrid | 9999 |
1.4.7 Uitkomst per kind
Uitkomst per kind | |||||||
Gegevenselement | Waarde | ||||||
Baring | |||||||
Werkelijke plaats baring type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Ziekenhuis baring | |||||||
Ziekenhuisnummer lvrid | 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||||
Demografische gegevens | |||||||
Identificaties kind | |||||||
Bsn kind | 847035128 | ||||||
Geslacht medische observatie | mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||||||
Geboortedatum | 2014-08-28T07:02:00 | ||||||
Rangnummer kind | 2 | ||||||
Perinatale sterfte groep | |||||||
Perinatale sterfte? | Ja | ||||||
Fase perinatale sterfte | Newborn death (event) (code = '276506001' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Datumtijd vaststelling perinatale sterfte | 2014-08-28T08:10:00 | ||||||
Kindspecifieke maternale gegevens | |||||||
Tijdstip breken vliezen | 2014-08-27T23:13:00 | ||||||
Kleur en consistentie vruchtwater | kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
Tijdstip actief meepersen | 2014-08-28T06:45:00 | ||||||
Episiotomie? | Ja | ||||||
Locatie episiotomie | mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||||||
Ruggeprik gewenst niet gekregen? | Nee | ||||||
Pijnbestrijding? | Ja | ||||||
Pijnbestrijding | |||||||
Methode | |||||||
Methode | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||||||
Overig middel | |||||||
Middel | Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Toediening | Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Periode | tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||||||
Sedatie? | Nee | ||||||
Kindspecifieke uitkomstgegevens | |||||||
Type partus | Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') | ||||||
Ligging bij geboorte | Complete breech presentation (finding) (code = '49168004' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Aanpakker kind - rol aanpakker kind | arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||||||
Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||||||
Vaginale kunstverlossing groep | |||||||
Vaginale kunstverlossing | Total breech extraction (procedure) (code = '416055001' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Succes vaginale kunstverlossing? | Ja | ||||||
Overige interventies | Maneuvers for delivery in shoulder dystocia (procedure) (code = '237008007' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Lichamelijk onderzoek kind | |||||||
Geboortegewicht | 1580 gram | ||||||
Congenitale afwijkingen? | Ja | ||||||
Congenitale afwijkingen groep | |||||||
Specificatie congenitale afwijking groep | |||||||
Specificatie congenitale afwijking | Spina bifida occulta (disorder) (code = '76916001' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Specificatie congenitale afwijking groep | |||||||
Specificatie congenitale afwijking | Multiple congenital cardiac defects (disorder) (code = '94702005' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Chromosomale afwijkingen? | Nee | ||||||
Problematiek kind? | Ja | ||||||
Problematiek kind | Subdural intracranial hemorrhage due to birth trauma (disorder) (code = '126941005' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Kinderarts betrokken? | Ja | ||||||
Betrokkenheid kinderarts | |||||||
Datum betrokkenheid | 2014-08-28T00:00:00 | ||||||
Reden betrokkenheid | Finding of neonatal condition (finding) (code = '364737004' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Type betrokkenheid | overdracht (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
Zorginstelling lvrid | 0001 |
1.4.8 Medisch onderzoek
Medisch onderzoek | |||
Gegevenselement | Waarde | ||
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
Irregulaire antistoffen? | Nee |
1.4.9 Postnatale fase
Postnatale fase | ||||
Gegevenselement | Waarde | |||
Kindspecifieke gegevens | ||||
Rangnummer kind | 1 | |||
Voeding kind groep | ||||
Voeding kind datum | 2014-09-03 | |||
Substantie voeding kind | borstmelk (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
1.5 Scenario 4. 1e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 850810711 | |
Lokale persoonsidentificatie | * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) | |
Geboortedatum | 1987-08-06 | |
Adres - postcode | 4589 BA | |
Etniciteit | Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 162 cm | |
Vrouwelijke genitale verminking? | Ja | |
Type vrouwelijke genitale verminking | Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96') |
1.5.1 Anamnese
Anamnese | |||
Gegevenselement | Waarde | ||
Onder behandeling geweest? | Ja | ||
Algemene anamnese | |||
Autoimmuun aandoening | Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96') | ||
Urogenitale aandoening | Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96') | ||
Diabetes mellitus? | Ja | ||
Mdl aandoening | Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96') | ||
Longaandoening | Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96') | ||
Type operatie | Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96') | ||
Type operatie | Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96') | ||
Type operatie | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') |
1.5.2 Zorgverlening
Zorgverlening | |||||
Gegevenselement | Waarde | ||||
Datum start zorgverantwoordelijkheid | 2014-08-07T00:00:00 | ||||
Datum einde zorgverantwoordelijkheid | 2014-09-15T00:00:00 | ||||
Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||||
Eindverantwoordelijk in welke perinatale periode? | follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||||
Conclusie risicostatus na intake | 3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | ||||
Verwijsdetails | |||||
Verwijzing van | |||||
Zorginstelling | |||||
Zorgaanbieder identificatie nummer | 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||
Verwijzing naar | |||||
Zorginstelling | |||||
Zorgaanbieder identificatie nummer | 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||
Redenen van verwijzing | |||||
Redenen van verwijzing | |||||
1.5.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | ||
Gegevenselement | Waarde | |
Zorginstelling lvrid | 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.5.4 Zwangerschap
Zwangerschap | ||
Gegevenselement | Waarde | |
Dossiernummer | ||
Graviditeit | 1 | |
Pariteit voor deze zwangerschap | 0 | |
Definitieve a terme datum | 2014-08-18 | |
Maternale sterfte? | Ja | |
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.5.5 Bevalling
Bevalling | |||
Gegevenselement | Waarde | ||
Aantal geboren kinderen | 1 | ||
Risicostatus voor baring | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
Wijze waarop de baring begon | spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
Tijdstip begin actieve ontsluiting | 2014-08-03T21:09:00 | ||
Medicatie nageboortetijdperk groep | |||
Medicatie nageboortetijdperk? | Ja | ||
Soort medicatie nageboortetijdperk | Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') | ||
Placenta - geboorte placenta | spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
Hoeveelheid bloedverlies | 1120 ml | ||
Conditie perineum postpartum | Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') |
1.5.6 Uitkomst per kind
Uitkomst per kind | |||||||
Gegevenselement | Waarde | ||||||
Baring | |||||||
Werkelijke plaats baring type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Ziekenhuis baring | |||||||
Ziekenhuisnummer lvrid | 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||||
Demografische gegevens | |||||||
Identificaties kind | |||||||
Bsn kind | 840736526 | ||||||
Geslacht medische observatie | vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||||||
Geboortedatum | 2014-08-04T23:35:00 | ||||||
Rangnummer kind | 1 | ||||||
Perinatale sterfte groep | |||||||
Perinatale sterfte? | Nee | ||||||
Kindspecifieke maternale gegevens | |||||||
Tijdstip breken vliezen | 2014-08-03T07:04:00 | ||||||
Kleur en consistentie vruchtwater | bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
Tijdstip actief meepersen | 2014-08-04T22:15:00 | ||||||
Episiotomie? | Ja | ||||||
Locatie episiotomie | mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||||||
Ruggeprik gewenst niet gekregen? | Nee | ||||||
Pijnbestrijding? | Ja | ||||||
Pijnbestrijding | |||||||
Methode | |||||||
Methode | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||||||
Overig middel | |||||||
Middel | Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Toediening | Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Periode | tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||||||
Sedatie? | Nee | ||||||
Kindspecifieke uitkomstgegevens | |||||||
Type partus | Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') | ||||||
Ligging bij geboorte | Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Aanpakker kind - rol aanpakker kind | co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||||||
Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||||||
Vaginale kunstverlossing groep | |||||||
Vaginale kunstverlossing | Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Succes vaginale kunstverlossing? | Ja | ||||||
Lichamelijk onderzoek kind | |||||||
Geboortegewicht | 4205 gram | ||||||
Congenitale afwijkingen? | Nee | ||||||
Problematiek kind? | Nee | ||||||
Kinderarts betrokken? | Ja | ||||||
Betrokkenheid kinderarts | |||||||
Datum betrokkenheid | 2014-08-04T00:00:00 | ||||||
Reden betrokkenheid | Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Type betrokkenheid | consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
Zorginstelling lvrid | 0010 |
1.5.7 Postnatale fase
Postnatale fase | ||||
Gegevenselement | Waarde | |||
Diagnoseinterventie postpartum | ||||
Datum | 2014-08-08T00:00:00 | |||
Pathologie vrouw | Embolism (disorder) (code = '414086009' in codeSystem '2.16.840.1.113883.6.96') | |||
Diagnoseinterventie postpartum | ||||
Datum | 2014-08-08T00:00:00 | |||
Pathologie vrouw | Episiotomy infection (disorder) (code = '300927001' in codeSystem '2.16.840.1.113883.6.96') | |||
Kindspecifieke gegevens | ||||
Voeding kind groep | ||||
Voeding kind datum | 2014-09-15 | |||
Substantie voeding kind | kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
1.6 Scenario 4. 2e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 850810711 | |
Lokale persoonsidentificatie | * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) | |
Geboortedatum | 1987-08-06 | |
Adres - postcode | 4589 BA | |
Etniciteit | Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 162 cm | |
Vrouwelijke genitale verminking? | Ja | |
Type vrouwelijke genitale verminking | Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96') |
1.6.1 Anamnese
Anamnese | |||
Gegevenselement | Waarde | ||
Onder behandeling geweest? | Ja | ||
Algemene anamnese | |||
Autoimmuun aandoening | Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96') | ||
Urogenitale aandoening | Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96') | ||
Diabetes mellitus? | Ja | ||
Mdl aandoening | Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96') | ||
Longaandoening | Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96') | ||
Type operatie | Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96') | ||
Type operatie | Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96') | ||
Type operatie | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') |
1.6.2 Zorgverlening
Zorgverlening | |||||
Gegevenselement | Waarde | ||||
Datum start zorgverantwoordelijkheid | 2014-02-03T00:00:00 | ||||
Datum einde zorgverantwoordelijkheid | 2014-08-06T00:00:00 | ||||
Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||||
Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||||
Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||||
Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||||
Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||||
Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||||
Conclusie risicostatus na intake | 3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | ||||
Verwijsdetails | |||||
Datum verwijzing | 2014-08-06T00:00:00 | ||||
Verwijzing van | |||||
Zorginstelling | |||||
Zorgaanbieder identificatie nummer | 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||
Verwijzing naar | |||||
Zorginstelling | |||||
Zorgaanbieder identificatie nummer | 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||
Redenen van verwijzing | |||||
Perinatale periode | 2e t/m 7e dag (code = '92' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') |
1.6.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | ||
Gegevenselement | Waarde | |
Zorginstelling lvrid | 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.6.4 Zwangerschap
Zwangerschap | |||
Gegevenselement | Waarde | ||
Dossiernummer | |||
Graviditeit | 1 | ||
Pariteit voor deze zwangerschap | 0 | ||
Definitieve a terme datum | 2014-08-18 | ||
Voornemens | |||
Voorgenomen plaats baring tijdens zwangerschap type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||
Prenatale controle | |||
Datum controle | 2014-05-07T00:00:00 | ||
Zwangerschapsduur | 149 dagen | ||
Leven voelen | Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96') | ||
Rookgedrag | niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
Drugsgebruik? | Nee | ||
Gewicht gemeten | 82 kg | ||
Diagnose | |||
Datum | 2014-05-07T00:00:00 | ||
Zwangerschapsduur | 149 dagen | ||
Infectie | Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | ||
Maternale sterfte? | Nee | ||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.6.5 Bevalling
Bevalling | |||
Gegevenselement | Waarde | ||
Diagnose bevalling | |||
Niet vorderende ontsluiting? | Ja | ||
Niet vorderende uitdrijving? | Ja | ||
Aantal geboren kinderen | 1 | ||
Risicostatus voor baring | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
Wijze waarop de baring begon | spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
Tijdstip begin actieve ontsluiting | 2014-08-03T21:09:00 | ||
Medicatie nageboortetijdperk groep | |||
Medicatie nageboortetijdperk? | Ja | ||
Soort medicatie nageboortetijdperk | Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') | ||
Placenta - geboorte placenta | spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
Hoeveelheid bloedverlies | 1120 ml | ||
Conditie perineum postpartum | Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') |
1.6.6 Uitkomst per kind
Uitkomst per kind | |||||||
Gegevenselement | Waarde | ||||||
Baring | |||||||
Werkelijke plaats baring type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Ziekenhuis baring | |||||||
Ziekenhuisnummer lvrid | 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||||
Demografische gegevens | |||||||
Identificaties kind | |||||||
Bsn kind | 840736526 | ||||||
Geslacht medische observatie | vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||||||
Geboortedatum | 2014-08-04T23:35:00 | ||||||
Rangnummer kind | 1 | ||||||
Perinatale sterfte groep | |||||||
Perinatale sterfte? | Nee | ||||||
Kindspecifieke maternale gegevens | |||||||
Tijdstip breken vliezen | 2014-08-03T07:04:00 | ||||||
Kleur en consistentie vruchtwater | bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
Tijdstip actief meepersen | 2014-08-04T22:15:00 | ||||||
Episiotomie? | Ja | ||||||
Locatie episiotomie | mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||||||
Ruggeprik gewenst niet gekregen? | Nee | ||||||
Pijnbestrijding? | Ja | ||||||
Pijnbestrijding | |||||||
Methode | |||||||
Methode | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||||||
Overig middel | |||||||
Middel | Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Toediening | Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Periode | tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||||||
Sedatie? | Nee | ||||||
Kindspecifieke uitkomstgegevens | |||||||
Type partus | Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') | ||||||
Ligging bij geboorte | Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Aanpakker kind - rol aanpakker kind | co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||||||
Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||||||
Vaginale kunstverlossing groep | |||||||
Vaginale kunstverlossing | Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Succes vaginale kunstverlossing? | Ja | ||||||
Lichamelijk onderzoek kind | |||||||
Geboortegewicht | 4205 gram | ||||||
Congenitale afwijkingen? | Nee | ||||||
Problematiek kind? | Nee | ||||||
Kinderarts betrokken? | Ja | ||||||
Betrokkenheid kinderarts | |||||||
Datum betrokkenheid | 2014-08-04T00:00:00 | ||||||
Reden betrokkenheid | Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Type betrokkenheid | consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
Zorginstelling lvrid | 0010 |
1.6.7 Medisch onderzoek
Medisch onderzoek | |||
Gegevenselement | Waarde | ||
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
Irregulaire antistoffen? | Nee |
1.7 Scenario 5. zorg volledig 2e lijn, vrouw overleden (voor vrouw met BSN: 912345676)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 912345676 | |
Lokale persoonsidentificatie | * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) | |
Geboortedatum | 1993-03-04 | |
Adres - postcode | 9562 GF | |
Etniciteit | Latijns Amerikaans (code = '14' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 186 cm |
1.7.1 Anamnese
Anamnese | |||
Gegevenselement | Waarde | ||
Onder behandeling geweest? | Ja | ||
Algemene anamnese | |||
Cardiovasculaire aandoening | Hypertensive disorder, systemic arterial (disorder) (code = '38341003' in codeSystem '2.16.840.1.113883.6.96') | ||
Diabetes mellitus? | Ja | ||
Neurologische aandoening | Epilepsy (disorder) (code = '84757009' in codeSystem '2.16.840.1.113883.6.96') | ||
Longaandoening | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
Orthopedische afwijking | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
Type stollingsprobleem | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
Psychiatrie? | Ja |
1.7.2 Zorgverlening
Zorgverlening | ||
Gegevenselement | Waarde | |
Datum start zorgverantwoordelijkheid | 2013-12-09T00:00:00 | |
Datum einde zorgverantwoordelijkheid | 2014-08-04T00:00:00 | |
Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Conclusie risicostatus na intake | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') |
1.7.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | ||
Gegevenselement | Waarde | |
Zorginstelling lvrid | 0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.7.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||||
Gegevenselement | Waarde | ||||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||||
Definitieve a terme datum | 2012-06-05 | ||||
Diagnose | |||||
Infectie | Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | ||||
Zwangerschapscholestase? | Ja | ||||
Afwijkende groei foetus | Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | ||||
Irregulaire antistoffen? | Ja | ||||
Eerdere bevalling | |||||
Placenta - geboorte placenta | spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||||
Vorige uitkomst per kind - vorige baring | |||||
Demografische gegevens - geboortedatum | 2012-06-09T00:00:00 | ||||
Kindspecifieke gegevens vorige uitkomsten | |||||
Type partus | Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') | ||||
Percentiel van het geboortegewicht | 10 ≤ P < 50 (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.50') | ||||
Apgarscore na 5 min | 10 | ||||
Congenitale afwijkingen? | Nee |
1.7.5 Zwangerschap
Zwangerschap | |||
Gegevenselement | Waarde | ||
Dossiernummer | |||
Graviditeit | 2 | ||
Pariteit voor deze zwangerschap | 1 | ||
Definitieve a terme datum | 2014-07-22 | ||
Voornemens | |||
Voorgenomen plaats baring tijdens zwangerschap type locatie | Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | ||
Prenatale controle | |||
Datum controle | 2014-01-09T00:00:00 | ||
Zwangerschapsduur | 86 dagen | ||
Leven voelen | Fetal movements absent (context-dependent category) (code = '289432001' in codeSystem '2.16.840.1.113883.6.96') | ||
Rookgedrag | gestopt tijdens huidige zwangerschap (code = '6' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
Drugsgebruik? | Ja | ||
Gewicht gemeten | 89 kg | ||
Diagnose | |||
Datum | 2014-01-09T00:00:00 | ||
Zwangerschapsduur | 86 dagen | ||
Afwijkende groei foetus | Large-for-dates fetus (disorder) (code = '199616008' in codeSystem '2.16.840.1.113883.6.96') | ||
Abruptio placentae? | Ja | ||
Intrauteriene behandeling | Selective destruction of fetus (procedure) (code = '265633004' in codeSystem '2.16.840.1.113883.6.96') | ||
Maternale sterfte? | Ja | ||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.7.6 Bevalling
Bevalling | |||
Gegevenselement | Waarde | ||
Partusnummer | 000000 | ||
Aantal geboren kinderen | 1 | ||
Risicostatus voor baring | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
Interventies begin baring | |||
Interventie begin baring | Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96') | ||
Indicatie interventie begin baring | acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | ||
Wijze waarop de baring begon | interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
Medicatie nageboortetijdperk groep | |||
Medicatie nageboortetijdperk? | Nee | ||
Placenta - geboorte placenta | placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
Hoeveelheid bloedverlies | 1500 ml | ||
Conditie perineum postpartum | Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') |
1.7.7 Uitkomst per kind
Uitkomst per kind | ||||||
Gegevenselement | Waarde | |||||
Baring | ||||||
Werkelijke plaats baring type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | |||||
Ziekenhuis baring | ||||||
Ziekenhuisnummer lvrid | 0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | |||||
Demografische gegevens | ||||||
Identificaties kind | ||||||
Bsn kind | 528741913 | |||||
Geslacht medische observatie | twijfelachtig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | |||||
Geboortedatum | 2014-07-24T02:30:00 | |||||
Rangnummer kind | 1 | |||||
Perinatale sterfte groep | ||||||
Perinatale sterfte? | Nee | |||||
Kindspecifieke maternale gegevens | ||||||
Kleur en consistentie vruchtwater | meconium (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | |||||
Episiotomie? | Nee | |||||
Ruggeprik gewenst niet gekregen? | Nee | |||||
Pijnbestrijding? | Ja | |||||
Pijnbestrijding | ||||||
Methode | ||||||
Methode | General anesthesia (procedure) (code = '50697003' in codeSystem '2.16.840.1.113883.6.96') | |||||
Periode | tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | |||||
Sedatie? | Ja | |||||
Kindspecifieke uitkomstgegevens | ||||||
Type partus | Emergency cesarian section (procedure) (code = '274130007' in codeSystem 'SNOMED CT') | |||||
Ligging bij geboorte | Onbekend (code = 'UNK' in codeSystem '2.16.840.1.113883.5.1008') | |||||
Aanpakker kind - rol aanpakker kind | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | |||||
Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | |||||
Vaginale kunstverlossing groep | ||||||
Vaginale kunstverlossing | Delivery by vacuum extraction (procedure) (code = '61586001' in codeSystem '2.16.840.1.113883.6.96') | |||||
Succes vaginale kunstverlossing? | Nee | |||||
Sectio caesarea group | ||||||
Beslismoment sectio caesarea | tijdens uitdrijving besloten (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.5') | |||||
Indicatie secundaire sectio | Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') | |||||
Lichamelijk onderzoek kind | ||||||
Geboortegewicht | 3750 gram | |||||
Congenitale afwijkingen? | Ja | |||||
Congenitale afwijkingen groep | ||||||
Specificatie congenitale afwijking groep | ||||||
Chromosomale afwijkingen? | Ja | |||||
Specificatie chromosomale afwijking groep | ||||||
Specificatie chromosomale afwijking | Complete trisomy 21 syndrome (disorder) (code = '41040004' in codeSystem '2.16.840.1.113883.6.96') | |||||
Problematiek kind? | Ja | |||||
Problematiek kind | Congenital hearing disorder (disorder) (code = '95827002' in codeSystem '2.16.840.1.113883.6.96') | |||||
Kinderarts betrokken? | Nee |
1.7.8 Medisch onderzoek
Medisch onderzoek | |||
Gegevenselement | Waarde | ||
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
Irregulaire antistoffen? | Ja | ||
Welke irregulaire antistoffen vrouw aanwezig | Kell (code = '405844003' in codeSystem '2.16.840.1.113883.6.96') |
1.7.9 Postnatale fase
Postnatale fase | ||||
Gegevenselement | Waarde | |||
Diagnoseinterventie postpartum | ||||
Datum | 2014-07-24T00:00:00 | |||
Pathologie vrouw | Postpartum deep phlebothrombosis (disorder) (code = '56272000' in codeSystem '2.16.840.1.113883.6.96') | |||
Kindspecifieke gegevens | ||||
Voeding kind groep | ||||
Voeding kind datum | 2014-07-24 | |||
Substantie voeding kind | kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |