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| (9 tussenliggende versies door dezelfde gebruiker niet weergegeven) |
| Regel 1: |
Regel 1: |
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| {{#customtitle:Kernset Geboortezorg 2.3 - inhoud kwalificatie}}
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| __NUMBEREDHEADINGS__
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| {{IssueBox|Deze pagina is nog in bewerking}}
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| [[Bestand:Nictiz_logo_PO_rechts_rgb.png |link=https://www.nictiz.nl/|rechts|Naar nictiz.nl]]
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|
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| =Addenda voor inhoudelijke gegevens Kernset Geboortezorg 2.3=
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| ==Scenario 1. Zorg volledig 1e lijn, herpes, strippen, gezonde eenling (voor vrouw met BSN: 999910413)==
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| <section begin=999910413 />
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| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw
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| |-style="background-color: #1F497D;; color: white; text-align:left;"
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| |colspan="2" width="25%"| Gegevenselement
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| || Waarde
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|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Burgerservicenummer
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| |style="background-color: white;"|999910413
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Lokale persoonsidentificatie
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| |style="background-color: white;"|000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Geboortedatum
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| |style="background-color: white;"|2 mei 1976
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Adres - postcode
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| |style="background-color: white;"|4563 AB
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Etniciteit
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| |style="background-color: white;"|Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Lengte gemeten
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| |style="background-color: white;"|170 cm
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| |}<section end=999910413 />
| |
| === Anamnese ===
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| <section begin=anamnese_999910413 />
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| {| class="wikitable" width="85%"
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| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese
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| |-style="background-color: #1F497D;; color: white; text-align:left;"
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| |colspan="3" width="25%"| Gegevenselement
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| || Waarde
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|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="3"|Onder behandeling geweest?
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| |style="background-color: white;"|Ja
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="4"|Algemene anamnese
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |rowspan="5"|
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Cardiovasculaire aandoening
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| |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Oncologische aandoening
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| |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Infectieziekte
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| |style="background-color: white;"|Herpes (code = '23513009' in codeSystem '2.16.840.1.113883.6.96')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Type operatie
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| |style="background-color: white;"|Orthopedisch (code = '112697007' in codeSystem 'Snomed CT')
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| |}<section end=anamnese_999910413 />
| |
| === Zorgverlening ===
| |
| <section begin=zorgverlening_999910413 />
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| {| class="wikitable" width="85%"
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| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlening
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| |-style="background-color: #1F497D;; color: white; text-align:left;"
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| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
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|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Datum start zorgverantwoordelijkheid
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| |style="background-color: white;"|1 mrt 2014 00:00
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Datum einde zorgverantwoordelijkheid
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| |style="background-color: white;"|12 nov 2014 00:00
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Eindverantwoordelijk in welke perinatale periode?
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| |style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Eindverantwoordelijk in welke perinatale periode?
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| |style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Eindverantwoordelijk in welke perinatale periode?
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| |style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Eindverantwoordelijk in welke perinatale periode?
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| |style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Eindverantwoordelijk in welke perinatale periode?
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| |style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Eindverantwoordelijk in welke perinatale periode?
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| |style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Eindverantwoordelijk in welke perinatale periode?
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| |style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Conclusie risicostatus na intake
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| |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 />
| |
| === Zorgverlenerzorginstelling ===
| |
| <section begin=zorgverlenerzorginstelling_999910413 />
| |
| {| class="wikitable" width="85%"
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| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling
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| |-style="background-color: #1F497D;; color: white; text-align:left;"
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| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Zorginstelling lvrid
| |
| |style="background-color: white;"|1808
| |
| |}<section end=zorgverlenerzorginstelling_999910413 />
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| === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
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| <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 />
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| {| class="wikitable" width="85%"
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| |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;"
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| |colspan="5" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="5"|Wijze einde zwangerschap
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| |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Definitieve a terme datum
| |
| |style="background-color: white;"|1 dec 2011
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="5"|Irregulaire antistoffen?
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| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="6"|Eerdere bevalling
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |rowspan="12"|
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="4"|Placenta - geboorte placenta
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| |style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="4"|Hoeveelheid bloedverlies
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| |style="background-color: white;"|550 ml
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="5"|Vorige uitkomst per kind - vorige baring
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |rowspan="8"|
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="3"|Demografische gegevens - geboortedatum
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| |style="background-color: white;"|8 dec 2011 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="4"|Kindspecifieke gegevens vorige uitkomsten
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |rowspan="5"|
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Type partus
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| |style="background-color: white;"|Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Percentiel van het geboortegewicht
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| |style="background-color: white;"|50 ≤ P < 90 (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.50')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Apgarscore na 5 min
| |
| |style="background-color: white;"|8
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Congenitale afwijkingen?
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| |style="background-color: white;"|Nee
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| |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 />
| |
| === Zwangerschap ===
| |
| <section begin=zwangerschap_999910413 />
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| {| class="wikitable" width="85%"
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| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap
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| |-style="background-color: #1F497D;; color: white; text-align:left;"
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| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="3"|Dossiernummer
| |
| |style="background-color: white;"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="3"|Graviditeit
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| |style="background-color: white;"|2
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="3"|Pariteit voor deze zwangerschap
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| |style="background-color: white;"|1
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="3"|Definitieve a terme datum
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| |style="background-color: white;"|9 okt 2014
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="4"|Voornemens
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |rowspan="2"|
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie
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| |style="background-color: white;"|Thuis (code = '169813005' in codeSystem '2.16.840.1.113883.6.96')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="4"|Prenatale controle
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |rowspan="8"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Datum controle
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| |style="background-color: white;"|2 mrt 2014 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Zwangerschapsduur
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| |style="background-color: white;"|59 dagen
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Leven voelen
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| |style="background-color: white;"|goed (code = '289431008' in codeSystem 'Snomed CT')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Rookgedrag
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| |style="background-color: white;"|niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Alcoholgebruik
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| |style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Drugsgebruik?
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| |style="background-color: white;"|Nee
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Gewicht gemeten
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| |style="background-color: white;"|70 kg
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="4"|Diagnose
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Datum
| |
| |style="background-color: white;"|2 mrt 2014 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Zwangerschapsduur
| |
| |style="background-color: white;"|59 dagen
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="2"|Infectie
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| |style="background-color: white;"|Urineweg infectie (code = '307534009' in codeSystem 'Snomed CT')
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| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="3"|Maternale sterfte?
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| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Wijze einde zwangerschap
| |
| |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
| |
| |}<section end=zwangerschap_999910413 />
| |
| === Bevalling ===
| |
| <section begin=bevalling_999910413 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
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| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
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| |colspan="3"|Partusnummer
| |
| |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;;"
| |
| |colspan="2"|Indicatie interventie begin baring
| |
| |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;;"
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| |colspan="3"|Wijze waarop de baring begon
| |
| |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="3"|Tijdstip begin actieve ontsluiting
| |
| |style="background-color: white;"|8 okt 2014 14:30
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Medicatie nageboortetijdperk groep
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Medicatie nageboortetijdperk?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Soort medicatie nageboortetijdperk
| |
| |style="background-color: white;"|Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|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="3"|Hoeveelheid bloedverlies
| |
| |style="background-color: white;"|615 ml
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Conditie perineum postpartum
| |
| |style="background-color: white;"|1e graads perineumruptuur (code = '199916005' in codeSystem 'Snomed CT')
| |
| |}<section end=bevalling_999910413 />
| |
| === Uitkomst per kind ===
| |
| <section begin=uitkomst_per_kind_999910413 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="5" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Baring
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="34"|
| |
| |-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;"|8 okt 2014 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;"|8 okt 2014 09:15
| |
| |-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;"|8 okt 2014 12:13
| |
| |-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 />
| |
| === Medisch onderzoek ===
| |
| <section begin=medisch_onderzoek_999910413 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || 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;;"
| |
| |colspan="2"|Irregulaire antistoffen?
| |
| |style="background-color: white;"|Nee
| |
| |}<section end=medisch_onderzoek_999910413 />
| |
| === Postnatale fase ===
| |
| <section begin=postnatale_fase_999910413 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || 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;"|12 okt 2014
| |
| |-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;;"
| |
| |colspan="2"|Substantie voeding kind
| |
| |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 />
| |
| ==Scenario 2. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)==
| |
| <section begin=961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Burgerservicenummer
| |
| |style="background-color: white;"|961921821
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Lokale persoonsidentificatie
| |
| |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;;"
| |
| |colspan="2"|Geboortedatum
| |
| |style="background-color: white;"|11 sep 1974
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Adres - postcode
| |
| |style="background-color: white;"|5689 CZ
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Etniciteit
| |
| |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;;"
| |
| |colspan="2"|Lengte gemeten
| |
| |style="background-color: white;"|184 cm
| |
| |}<section end=961921821 />
| |
| === Anamnese ===
| |
| <section begin=anamnese_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Anamnese
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Onder behandeling geweest?
| |
| |style="background-color: white;"|Nee
| |
| |}<section end=anamnese_961921821 />
| |
| === Zorgverlening ===
| |
| <section begin=zorgverlening_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Zorgverlening
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="6" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Datum start zorgverantwoordelijkheid
| |
| |style="background-color: white;"|28 aug 2018
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Datum einde zorgverantwoordelijkheid
| |
| |style="background-color: white;"|28 nov 2018
| |
| |-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;"|6 mei 2014 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;;"
| |
| |rowspan="6"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Van 1e naar 2e lijn
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Zwangerschap
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Hypertensieve aandoening
| |
| |style="background-color: white;"|Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Perinatale periode
| |
| |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 />
| |
| === Zorgverlenerzorginstelling ===
| |
| <section begin=zorgverlenerzorginstelling_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorginstelling lvrid
| |
| |style="background-color: white;"|1504
| |
| |}<section end=zorgverlenerzorginstelling_961921821 />
| |
| === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
| |
| <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Wijze einde zwangerschap
| |
| |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;"|5 jun 2013
| |
| |-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;;"
| |
| |colspan="2"|Bloedverlies?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Hyperemesis gravidarum?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Irregulaire antistoffen?
| |
| |style="background-color: white;"|Ja
| |
| |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
| |
| === Zwangerschap ===
| |
| <section begin=zwangerschap_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Dossiernummer
| |
| |style="background-color: white;"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Graviditeit
| |
| |style="background-color: white;"|2
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Pariteit voor deze zwangerschap
| |
| |style="background-color: white;"|0
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Definitieve a terme datum
| |
| |style="background-color: white;"|8 sep 2014
| |
| |-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;"|6 mei 2014 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;;"
| |
| |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="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Datum
| |
| |style="background-color: white;"|6 mei 2014 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"|Hypertensieve aandoening
| |
| |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;;"
| |
| |colspan="3"|Maternale sterfte?
| |
| |style="background-color: white;"|Nee
| |
| |}<section end=zwangerschap_961921821 />
| |
| ==Scenario 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)==
| |
| <section begin=961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Burgerservicenummer
| |
| |style="background-color: white;"|961921821
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Lokale persoonsidentificatie
| |
| |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;;"
| |
| |colspan="2"|Geboortedatum
| |
| |style="background-color: white;"|11 sep 1974
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Adres - postcode
| |
| |style="background-color: white;"|5689 CZ
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Etniciteit
| |
| |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;;"
| |
| |colspan="2"|Lengte gemeten
| |
| |style="background-color: white;"|184 cm
| |
| |}<section end=961921821 />
| |
| === Anamnese ===
| |
| <section begin=anamnese_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Anamnese
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Onder behandeling geweest?
| |
| |style="background-color: white;"|Nee
| |
| |}<section end=anamnese_961921821 />
| |
| === Zorgverlening ===
| |
| <section begin=zorgverlening_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Zorgverlening
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="6" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Datum start zorgverantwoordelijkheid
| |
| |style="background-color: white;"|12 mei 2014 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Datum einde zorgverantwoordelijkheid
| |
| |style="background-color: white;"|9 okt 2014 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;;"
| |
| |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"|Zorgaanbieder identificatie nummer
| |
| |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;;"
| |
| |rowspan="6"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Van 1e naar 2e lijn
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Zwangerschap
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Hypertensieve aandoening
| |
| |style="background-color: white;"|Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT')
| |
| |}<section end=zorgverlening_961921821 />
| |
| === Zorgverlenerzorginstelling ===
| |
| <section begin=zorgverlenerzorginstelling_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorginstelling lvrid
| |
| |style="background-color: white;"|0003
| |
| |}<section end=zorgverlenerzorginstelling_961921821 />
| |
| === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
| |
| <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Wijze einde zwangerschap
| |
| |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;"|5 jun 2013
| |
| |-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;;"
| |
| |colspan="2"|Bloedverlies?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Hyperemesis gravidarum?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Irregulaire antistoffen?
| |
| |style="background-color: white;"|Ja
| |
| |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
| |
| === Zwangerschap ===
| |
| <section begin=zwangerschap_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Dossiernummer
| |
| |style="background-color: white;"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Graviditeit
| |
| |style="background-color: white;"|2
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Pariteit voor deze zwangerschap
| |
| |style="background-color: white;"|0
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Definitieve a terme datum
| |
| |style="background-color: white;"|8 sep 2014
| |
| |-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;"|12 mei 2014 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;;"
| |
| |colspan="2"|Datum
| |
| |style="background-color: white;"|12 mei 2014 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"|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;;"
| |
| |colspan="2"|Partiele mola?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Hypertensieve aandoening
| |
| |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;;"
| |
| |colspan="3"|Maternale sterfte?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Wijze einde zwangerschap
| |
| |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
| |
| |}<section end=zwangerschap_961921821 />
| |
| === Bevalling ===
| |
| <section begin=bevalling_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Partusnummer
| |
| |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;;"
| |
| |colspan="2"|Interventie begin baring
| |
| |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;;"
| |
| |colspan="2"|Indicatie interventie begin baring
| |
| |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;;"
| |
| |colspan="3"|Wijze waarop de baring begon
| |
| |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="3"|Tijdstip begin actieve ontsluiting
| |
| |style="background-color: white;"|30 aug 2014 14:09
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Medicatie nageboortetijdperk groep
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Medicatie nageboortetijdperk?
| |
| |style="background-color: white;"|UNK
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Placenta - geboorte placenta
| |
| |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;;"
| |
| |colspan="3"|Hoeveelheid bloedverlies
| |
| |style="background-color: white;"|980 ml
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Conditie perineum postpartum
| |
| |style="background-color: white;"|Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96')
| |
| |}<section end=bevalling_961921821 />
| |
| === Uitkomst per kind ===
| |
| <section begin=uitkomst_per_kind_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="6" width="25%"| Gegevenselement
| |
| || 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;;"
| |
| |rowspan="2"|
| |
| |-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;"|1 sep 2014 02:34
| |
| |-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;"|30 aug 2014 23:04
| |
| |-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;"|1 sep 2014 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 />
| |
| === Medisch onderzoek ===
| |
| <section begin=medisch_onderzoek_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || 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;;"
| |
| |colspan="2"|Welke irregulaire antistoffen vrouw aanwezig
| |
| |style="background-color: white;"|Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96')
| |
| |}<section end=medisch_onderzoek_961921821 />
| |
| === Postnatale fase ===
| |
| <section begin=postnatale_fase_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || 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;"|3 sep 2014 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;"|7 okt 2014
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Substantie voeding kind
| |
| |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 />
| |
| ==Scenario 3. zorg volledig in 2e lijn, meerling, 1 kind overleden (voor vrouw met BSN: 895623146)==
| |
| <section begin=895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Burgerservicenummer
| |
| |style="background-color: white;"|895623146
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Lokale persoonsidentificatie
| |
| |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;;"
| |
| |colspan="2"|Geboortedatum
| |
| |style="background-color: white;"|5 aug 1985
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Adres - postcode
| |
| |style="background-color: white;"|5421 JG
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Etniciteit
| |
| |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;;"
| |
| |colspan="2"|Lengte gemeten
| |
| |style="background-color: white;"|167 cm
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Vrouwelijke genitale verminking?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Type vrouwelijke genitale verminking
| |
| |style="background-color: white;"|Female genital mutilation type 2 (disorder) (code = '130621000119105' in codeSystem '2.16.840.1.113883.6.96')
| |
| |}<section end=895623146 />
| |
| === Anamnese ===
| |
| <section begin=anamnese_895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Onder behandeling geweest?
| |
| |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;;"
| |
| |colspan="2"|Type operatie
| |
| |style="background-color: white;"|Operation on heart (procedure) (code = '64915003' in codeSystem '2.16.840.1.113883.6.96')
| |
| |}<section end=anamnese_895623146 />
| |
| === Zorgverlening ===
| |
| <section begin=zorgverlening_895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlening
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Datum start zorgverantwoordelijkheid
| |
| |style="background-color: white;"|10 mrt 2014 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Datum einde zorgverantwoordelijkheid
| |
| |style="background-color: white;"|3 nov 2014 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|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="2"|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="2"|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="2"|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="2"|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="2"|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="2"|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="2"|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="2"|Conclusie risicostatus na intake
| |
| |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 />
| |
| === Zorgverlenerzorginstelling ===
| |
| <section begin=zorgverlenerzorginstelling_895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorginstelling lvrid
| |
| |style="background-color: white;"|9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
| |
| |}<section end=zorgverlenerzorginstelling_895623146 />
| |
| === Zwangerschap ===
| |
| <section begin=zwangerschap_895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Dossiernummer
| |
| |style="background-color: white;"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Graviditeit
| |
| |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;"|22 sep 2014
| |
| |-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;"|21 mei 2014 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;"|21 mei 2014 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"|Bloedverlies?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|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="2"|Afwijkende groei foetus
| |
| |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;;"
| |
| |colspan="2"|Abruptio placentae?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Maternale sterfte?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Wijze einde zwangerschap
| |
| |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
| |
| |}<section end=zwangerschap_895623146 />
| |
| === Bevalling ===
| |
| <section begin=bevalling_895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Partusnummer
| |
| |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;;"
| |
| |colspan="3"|Aantal geboren kinderen
| |
| |style="background-color: white;"|2
| |
| |-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;;"
| |
| |colspan="3"|Tijdstip begin actieve ontsluiting
| |
| |style="background-color: white;"|27 aug 2014 22:09
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Medicatie nageboortetijdperk groep
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Medicatie nageboortetijdperk?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Placenta - geboorte placenta
| |
| |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;;"
| |
| |colspan="3"|Hoeveelheid bloedverlies
| |
| |style="background-color: white;"|1740 ml
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Conditie perineum postpartum
| |
| |style="background-color: white;"|Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96')
| |
| |}<section end=bevalling_895623146 />
| |
| === Uitkomst per kind ===
| |
| <section begin=uitkomst_per_kind_895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="7" width="25%"| Gegevenselement
| |
| || 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;"|28 aug 2014 06:30
| |
| |-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;"|27 aug 2014 22:09
| |
| |-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;"|27 aug 2014 23:49
| |
| |-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;;"
| |
| |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;"|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;"|28 aug 2014 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 />
| |
| === Uitkomst per kind ===
| |
| <section begin=uitkomst_per_kind_895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="7" width="25%"| Gegevenselement
| |
| || 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;"|28 aug 2014 07:02
| |
| |-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;"|28 aug 2014 08:10
| |
| |-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;"|27 aug 2014 23:13
| |
| |-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;"|28 aug 2014 06:45
| |
| |-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;;"
| |
| |rowspan="32"|
| |
| |-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;"|28 aug 2014 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 />
| |
| === Medisch onderzoek ===
| |
| <section begin=medisch_onderzoek_895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || 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;;"
| |
| |colspan="2"|Irregulaire antistoffen?
| |
| |style="background-color: white;"|Nee
| |
| |}<section end=medisch_onderzoek_895623146 />
| |
| === Postnatale fase ===
| |
| <section begin=postnatale_fase_895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || 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;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Voeding kind datum
| |
| |style="background-color: white;"|3 sep 2014
| |
| |-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 />
| |
| ==Scenario 4. 1e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)==
| |
| <section begin=850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Burgerservicenummer
| |
| |style="background-color: white;"|850810711
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Lokale persoonsidentificatie
| |
| |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;;"
| |
| |colspan="2"|Geboortedatum
| |
| |style="background-color: white;"|6 aug 1987
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Adres - postcode
| |
| |style="background-color: white;"|4589 BA
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Etniciteit
| |
| |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;;"
| |
| |colspan="2"|Lengte gemeten
| |
| |style="background-color: white;"|162 cm
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Vrouwelijke genitale verminking?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Type vrouwelijke genitale verminking
| |
| |style="background-color: white;"|Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96')
| |
| |}<section end=850810711 />
| |
| === Anamnese ===
| |
| <section begin=anamnese_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Onder behandeling geweest?
| |
| |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;;"
| |
| |colspan="2"|Type operatie
| |
| |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
| |
| |}<section end=anamnese_850810711 />
| |
| === Zorgverlening ===
| |
| <section begin=zorgverlening_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Zorgverlening
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="5" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Datum start zorgverantwoordelijkheid
| |
| |style="background-color: white;"|7 aug 2014 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Datum einde zorgverantwoordelijkheid
| |
| |style="background-color: white;"|15 sep 2014 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;;"
| |
| |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;"|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;;"
| |
| |rowspan="1"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Redenen van verwijzing
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="1"|
| |
| |}<section end=zorgverlening_850810711 />
| |
| === Zorgverlenerzorginstelling ===
| |
| <section begin=zorgverlenerzorginstelling_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorginstelling lvrid
| |
| |style="background-color: white;"|1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
| |
| |}<section end=zorgverlenerzorginstelling_850810711 />
| |
| === Zwangerschap ===
| |
| <section begin=zwangerschap_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zwangerschap
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Dossiernummer
| |
| |style="background-color: white;"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Graviditeit
| |
| |style="background-color: white;"|1
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Pariteit voor deze zwangerschap
| |
| |style="background-color: white;"|0
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Definitieve a terme datum
| |
| |style="background-color: white;"|18 aug 2014
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Maternale sterfte?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Wijze einde zwangerschap
| |
| |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
| |
| |}<section end=zwangerschap_850810711 />
| |
| === Bevalling ===
| |
| <section begin=bevalling_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-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="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;;"
| |
| |colspan="3"|Tijdstip begin actieve ontsluiting
| |
| |style="background-color: white;"|3 aug 2014 21:09
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Medicatie nageboortetijdperk groep
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Medicatie nageboortetijdperk?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Soort medicatie nageboortetijdperk
| |
| |style="background-color: white;"|Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|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="3"|Hoeveelheid bloedverlies
| |
| |style="background-color: white;"|1120 ml
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Conditie perineum postpartum
| |
| |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 />
| |
| === Uitkomst per kind ===
| |
| <section begin=uitkomst_per_kind_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="7" width="25%"| Gegevenselement
| |
| || 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;;"
| |
| |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;"|4 aug 2014 23:35
| |
| |-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;"|3 aug 2014 07:04
| |
| |-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;"|4 aug 2014 22:15
| |
| |-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;"|4 aug 2014 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 />
| |
| === Postnatale fase ===
| |
| <section begin=postnatale_fase_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || 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;"|8 aug 2014 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;"|8 aug 2014 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;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Voeding kind datum
| |
| |style="background-color: white;"|15 sep 2014
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Substantie voeding kind
| |
| |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 />
| |
| ==Scenario 4. 2e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)==
| |
| <section begin=850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Burgerservicenummer
| |
| |style="background-color: white;"|850810711
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Lokale persoonsidentificatie
| |
| |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;;"
| |
| |colspan="2"|Geboortedatum
| |
| |style="background-color: white;"|6 aug 1987
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Adres - postcode
| |
| |style="background-color: white;"|4589 BA
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Etniciteit
| |
| |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;;"
| |
| |colspan="2"|Lengte gemeten
| |
| |style="background-color: white;"|162 cm
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Vrouwelijke genitale verminking?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Type vrouwelijke genitale verminking
| |
| |style="background-color: white;"|Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96')
| |
| |}<section end=850810711 />
| |
| === Anamnese ===
| |
| <section begin=anamnese_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Onder behandeling geweest?
| |
| |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;;"
| |
| |colspan="2"|Type operatie
| |
| |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
| |
| |}<section end=anamnese_850810711 />
| |
| === Zorgverlening ===
| |
| <section begin=zorgverlening_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Zorgverlening
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="5" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Datum start zorgverantwoordelijkheid
| |
| |style="background-color: white;"|3 feb 2014 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Datum einde zorgverantwoordelijkheid
| |
| |style="background-color: white;"|6 aug 2014 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;;"
| |
| |colspan="4"|Datum verwijzing
| |
| |style="background-color: white;"|6 aug 2014 00:00
| |
| |-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;;"
| |
| |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;"|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;;"
| |
| |rowspan="1"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Perinatale periode
| |
| |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 />
| |
| === Zorgverlenerzorginstelling ===
| |
| <section begin=zorgverlenerzorginstelling_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorginstelling lvrid
| |
| |style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
| |
| |}<section end=zorgverlenerzorginstelling_850810711 />
| |
| === Zwangerschap ===
| |
| <section begin=zwangerschap_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Dossiernummer
| |
| |style="background-color: white;"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Graviditeit
| |
| |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;"|18 aug 2014
| |
| |-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;"|7 mei 2014 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;;"
| |
| |colspan="2"|Gewicht gemeten
| |
| |style="background-color: white;"|82 kg
| |
| |-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"|Datum
| |
| |style="background-color: white;"|7 mei 2014 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"|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="3"|Maternale sterfte?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Wijze einde zwangerschap
| |
| |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
| |
| |}<section end=zwangerschap_850810711 />
| |
| === Bevalling ===
| |
| <section begin=bevalling_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || 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;;"
| |
| |colspan="2"|Niet vorderende uitdrijving?
| |
| |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;;"
| |
| |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;;"
| |
| |colspan="3"|Tijdstip begin actieve ontsluiting
| |
| |style="background-color: white;"|3 aug 2014 21:09
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Medicatie nageboortetijdperk groep
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Medicatie nageboortetijdperk?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Soort medicatie nageboortetijdperk
| |
| |style="background-color: white;"|Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|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="3"|Hoeveelheid bloedverlies
| |
| |style="background-color: white;"|1120 ml
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Conditie perineum postpartum
| |
| |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 />
| |
| === Uitkomst per kind ===
| |
| <section begin=uitkomst_per_kind_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="7" width="25%"| Gegevenselement
| |
| || 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;;"
| |
| |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;"|4 aug 2014 23:35
| |
| |-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;"|3 aug 2014 07:04
| |
| |-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;"|4 aug 2014 22:15
| |
| |-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;"|4 aug 2014 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 />
| |
| === Medisch onderzoek ===
| |
| <section begin=medisch_onderzoek_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || 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;;"
| |
| |colspan="2"|Irregulaire antistoffen?
| |
| |style="background-color: white;"|Nee
| |
| |}<section end=medisch_onderzoek_850810711 />
| |
| ==Scenario 5. zorg volledig 2e lijn, vrouw overleden (voor vrouw met BSN: 912345676)==
| |
| <section begin=912345676 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Burgerservicenummer
| |
| |style="background-color: white;"|912345676
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Lokale persoonsidentificatie
| |
| |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;;"
| |
| |colspan="2"|Geboortedatum
| |
| |style="background-color: white;"|4 mrt 1993
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Adres - postcode
| |
| |style="background-color: white;"|9562 GF
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Etniciteit
| |
| |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;;"
| |
| |colspan="2"|Lengte gemeten
| |
| |style="background-color: white;"|186 cm
| |
| |}<section end=912345676 />
| |
| === Anamnese ===
| |
| <section begin=anamnese_912345676 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Onder behandeling geweest?
| |
| |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;;"
| |
| |colspan="2"|Psychiatrie?
| |
| |style="background-color: white;"|Ja
| |
| |}<section end=anamnese_912345676 />
| |
| === Zorgverlening ===
| |
| <section begin=zorgverlening_912345676 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlening
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Datum start zorgverantwoordelijkheid
| |
| |style="background-color: white;"|9 dec 2013 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Datum einde zorgverantwoordelijkheid
| |
| |style="background-color: white;"|4 aug 2014 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|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="2"|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="2"|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="2"|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="2"|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="2"|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="2"|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="2"|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="2"|Conclusie risicostatus na intake
| |
| |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 />
| |
| === Zorgverlenerzorginstelling ===
| |
| <section begin=zorgverlenerzorginstelling_912345676 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorginstelling lvrid
| |
| |style="background-color: white;"|0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
| |
| |}<section end=zorgverlenerzorginstelling_912345676 />
| |
| === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
| |
| <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="5" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Wijze einde zwangerschap
| |
| |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;"|5 jun 2012
| |
| |-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;"|9 jun 2012 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;"|Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Percentiel van het geboortegewicht
| |
| |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;;"
| |
| |colspan="2"|Apgarscore na 5 min
| |
| |style="background-color: white;"|10
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Congenitale afwijkingen?
| |
| |style="background-color: white;"|Nee
| |
| |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 />
| |
| === Zwangerschap ===
| |
| <section begin=zwangerschap_912345676 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Dossiernummer
| |
| |style="background-color: white;"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Graviditeit
| |
| |style="background-color: white;"|2
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Pariteit voor deze zwangerschap
| |
| |style="background-color: white;"|1
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Definitieve a terme datum
| |
| |style="background-color: white;"|22 jul 2014
| |
| |-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;"|9 jan 2014 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;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Datum
| |
| |style="background-color: white;"|9 jan 2014 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"|Afwijkende groei foetus
| |
| |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;;"
| |
| |colspan="2"|Abruptio placentae?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Intrauteriene behandeling
| |
| |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;;"
| |
| |colspan="3"|Maternale sterfte?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Wijze einde zwangerschap
| |
| |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
| |
| |}<section end=zwangerschap_912345676 />
| |
| === Bevalling ===
| |
| <section begin=bevalling_912345676 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Partusnummer
| |
| |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;;"
| |
| |colspan="2"|Interventie begin baring
| |
| |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;;"
| |
| |colspan="2"|Indicatie interventie begin baring
| |
| |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;;"
| |
| |colspan="3"|Wijze waarop de baring begon
| |
| |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;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Medicatie nageboortetijdperk?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Placenta - geboorte placenta
| |
| |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;;"
| |
| |colspan="3"|Hoeveelheid bloedverlies
| |
| |style="background-color: white;"|1500 ml
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Conditie perineum postpartum
| |
| |style="background-color: white;"|Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96')
| |
| |}<section end=bevalling_912345676 />
| |
| === Uitkomst per kind ===
| |
| <section begin=uitkomst_per_kind_912345676 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="6" width="25%"| Gegevenselement
| |
| || 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;"|24 jul 2014 02:30
| |
| |-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;;"
| |
| |colspan="4"|Congenitale afwijkingen?
| |
| |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 />
| |
| === Medisch onderzoek ===
| |
| <section begin=medisch_onderzoek_912345676 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || 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;;"
| |
| |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 />
| |
| === Postnatale fase ===
| |
| <section begin=postnatale_fase_912345676 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || 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;"|24 jul 2014 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;;"
| |
| |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;"|24 jul 2014
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Substantie voeding kind
| |
| |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 />
| |
| [[Categorie:Kwalificatie]]
| |
