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| Regel 1: | Regel 1: | ||
{{DISPLAYTITLE:Kernset Aanleverbericht 2.2 - inhoud kwalificatie}} | |||
__NUMBEREDHEADINGS__ | __NUMBEREDHEADINGS__ | ||
| Regel 4: | Regel 5: | ||
[[Bestand:Nictiz_logo_PO_rechts_rgb.png |link=https://www.nictiz.nl/|rechts|Naar nictiz.nl]] | [[Bestand:Nictiz_logo_PO_rechts_rgb.png |link=https://www.nictiz.nl/|rechts|Naar nictiz.nl]] | ||
=Addenda voor inhoudelijke gegevens= | =Addenda voor inhoudelijke gegevens Kernset Aanleverbericht 2.2= | ||
==Scenario 1. Zorg volledig 1e lijn, herpes, strippen, gezonde eenling (voor vrouw met BSN: 999910413)== | ==Scenario 1. Zorg volledig 1e lijn, herpes, strippen, gezonde eenling (voor vrouw met BSN: 999910413)== | ||
<section begin=999910413 /> | <section begin=999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="2" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Burgerservicenummer | ||
|style="background-color: white;"|999910413 | |style="background-color: white;"|999910413 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Lokale persoonsidentificatie | ||
|style="background-color: white;"|000000 | |style="background-color: white;"|000000 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Geboortedatum | ||
|style="background-color: white;"|2 mei 1976 | |style="background-color: white;"|2 mei 1976 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="2"|Adres - postcode | ||
|style="background-color: white;"|4563 AB | |style="background-color: white;"|4563 AB | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Etniciteit | ||
|style="background-color: white;"|Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |style="background-color: white;"|Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="2"|Lengte gemeten | ||
|style="background-color: white;"|170 cm | |||
|}<section end=999910413 /> | |||
=== Anamnese === | |||
<section begin=anamnese_999910413 /> | |||
{| 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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Onder behandeling | |colspan="3"|Onder behandeling geweest? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Algemene anamnese | |colspan="4"|Algemene anamnese | ||
| Regel 44: | Regel 49: | ||
|rowspan="9"| | |rowspan="9"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Cardiovasculaire | |colspan="2"|Cardiovasculaire aandoening? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Cardiovasculaire aandoening | |colspan="2"|Cardiovasculaire aandoening | ||
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Oncologische | |colspan="2"|Oncologische aandoening? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Oncologische aandoening | |colspan="2"|Oncologische aandoening | ||
|style="background-color: white;"|other (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | |style="background-color: white;"|other (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Infectieziekte? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Infectieziekte | |colspan="2"|Infectieziekte | ||
|style="background-color: white;"|Herpesvirus infection (disorder) (code = '23513009' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Herpesvirus infection (disorder) (code = '23513009' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Operatie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Type operatie | |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="background-color: white;"|Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=anamnese_999910413 /> | |||
=== Zorgverlening === | |||
|}<section end= | |||
=== | |||
<section begin=zorgverlening_999910413 /> | <section begin=zorgverlening_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlening | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="2" width="25%"| Gegevenselement | |colspan="2" width="25%"| Gegevenselement | ||
| Regel 86: | Regel 88: | ||
|style="background-color: white;"|12 nov 2014 | |style="background-color: white;"|12 nov 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 110: | Regel 112: | ||
|style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Is er sprake van overdracht | |colspan="2"|Is er sprake van overdracht aan? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|}<section end=zorgverlening_999910413 /> | |}<section end=zorgverlening_999910413 /> | ||
=== | === Zorgverlenerzorginstelling === | ||
<section begin=zorgverlenerzorginstelling_999910413 /> | <section begin=zorgverlenerzorginstelling_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="2" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
|style="background-color: white;"|1808 | |style="background-color: white;"|1808 | ||
|}<section end=zorgverlenerzorginstelling_999910413 /> | |}<section end=zorgverlenerzorginstelling_999910413 /> | ||
=== | === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === | ||
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 /> | <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Wijze einde zwangerschap | ||
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Definitieve a terme datum | ||
|style="background-color: white;"|1 dec 2011 | |style="background-color: white;"|1 dec 2011 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Irregulaire antistoffen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|Eerdere bevalling | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="12"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| | |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="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Hoeveelheid bloedverlies | ||
|style="background-color: white;"|550 ml | |style="background-color: white;"|550 ml | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Vorige uitkomst per kind - vorige baring | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="8"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Demografische gegevens - geboortedatum | |||
|style="background-color: white;"|8 dec 2011 | |||
|colspan=" | |||
|style="background-color: white;"|8 dec 2011 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Kindspecifieke gegevens vorige uitkomsten | |colspan="4"|Kindspecifieke gegevens vorige uitkomsten | ||
| Regel 189: | Regel 175: | ||
|style="background-color: white;"|8 | |style="background-color: white;"|8 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Congenitale | |colspan="2"|Congenitale afwijkingen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 /> | |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 /> | ||
=== | === Zwangerschap === | ||
<section begin=zwangerschap_999910413 /> | <section begin=zwangerschap_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
| Regel 236: | Regel 222: | ||
|style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Drugsgebruik? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Gewicht gemeten | |colspan="2"|Gewicht gemeten | ||
| Regel 255: | Regel 241: | ||
|style="background-color: white;"|Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Maternale | |colspan="3"|Maternale sterfte? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Wijze einde zwangerschap | |colspan="3"|Wijze einde zwangerschap | ||
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
|}<section end=zwangerschap_999910413 /> | |}<section end=zwangerschap_999910413 /> | ||
=== | === Bevalling === | ||
<section begin=bevalling_999910413 /> | <section begin=bevalling_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
| Regel 271: | Regel 257: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Partusnummer | |colspan="3"|Partusnummer | ||
|style="background-color: white;"|000000 | |style="background-color: white;"|000000 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Aantal geboren kinderen | |colspan="3"|Aantal geboren kinderen | ||
| Regel 295: | Regel 281: | ||
|style="background-color: white;"|8 okt 2014 | |style="background-color: white;"|8 okt 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Bijstimulatie | |colspan="3"|Bijstimulatie toegediend? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Medicatie nageboortetijdperk groep | |colspan="4"|Medicatie nageboortetijdperk groep | ||
| Regel 302: | Regel 288: | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Medicatie | |colspan="2"|Medicatie nageboortetijdperk? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Soort medicatie nageboortetijdperk | |colspan="2"|Soort medicatie nageboortetijdperk | ||
|style="background-color: white;"|Oxytocin (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') | |style="background-color: white;"|Oxytocin (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="3"|Placenta - geboorte placenta | ||
|style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | |style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 321: | Regel 303: | ||
|style="background-color: white;"|First degree perineal tear during delivery - delivered (disorder) (code = '199916005' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|First degree perineal tear during delivery - delivered (disorder) (code = '199916005' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=bevalling_999910413 /> | |}<section end=bevalling_999910413 /> | ||
=== | === Uitkomst per kind === | ||
<section begin=uitkomst_per_kind_999910413 /> | <section begin=uitkomst_per_kind_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Uitkomst per kind | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="4" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Baring | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="23"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Demografische gegevens - geboortedatum | |||
|colspan="3"| | |||
|style="background-color: white;"|8 okt 2014 | |style="background-color: white;"|8 okt 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Kindspecifieke maternale gegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="8"| | |rowspan="8"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Tijdstip breken vliezen | ||
|style="background-color: white;"|8 okt 2014 | |style="background-color: white;"|8 okt 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Kleur en consistentie vruchtwater | ||
|style="background-color: white;"|kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Tijdstip actief meepersen | ||
|style="background-color: white;"|8 okt 2014 | |style="background-color: white;"|8 okt 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Episiotomie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Ruggeprik gewenst niet gekregen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Pijnbestrijding? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Sedatie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Kindspecifieke uitkomstgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="10"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Type partus | ||
|style="background-color: white;"|Delivery normal (finding) (code = '48782003' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Delivery normal (finding) (code = '48782003' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Apgarscore na 5 min | ||
|style="background-color: white;"|9 | |style="background-color: white;"|9 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Ligging bij geboorte | ||
|style="background-color: white;"|Occipitoposterior position (finding) (code = '37235006' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Occipitoposterior position (finding) (code = '37235006' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="2"|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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lichamelijk onderzoek kind - geboortegewicht | |||
|colspan="2 | |||
|style="background-color: white;"|3450 gram | |style="background-color: white;"|3450 gram | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Congenitale afwijkingen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Problematiek kind? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Kinderarts betrokken? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|}<section end=uitkomst_per_kind_999910413 /> | |}<section end=uitkomst_per_kind_999910413 /> | ||
=== | === Medisch onderzoek === | ||
<section begin=medisch_onderzoek_999910413 /> | <section begin=medisch_onderzoek_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Irregulaire | |colspan="2"|Irregulaire antistoffen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|}<section end=medisch_onderzoek_999910413 /> | |}<section end=medisch_onderzoek_999910413 /> | ||
=== | === Postnatale fase === | ||
<section begin=postnatale_fase_999910413 /> | <section begin=postnatale_fase_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="4" width="25%"| Gegevenselement | |colspan="4" width="25%"| Gegevenselement | ||
| Regel 485: | Regel 423: | ||
<section begin=961921821 /> | <section begin=961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="2" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Burgerservicenummer | ||
|style="background-color: white;"|961921821 | |style="background-color: white;"|961921821 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Lokale persoonsidentificatie | ||
|style="background-color: white;"|* | |style="background-color: white;"|* | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Geboortedatum | ||
|style="background-color: white;"|11 sep 1974 | |style="background-color: white;"|11 sep 1974 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Adres - postcode | ||
|style="background-color: white;"|5689 CZ | |style="background-color: white;"|5689 CZ | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Etniciteit | ||
|style="background-color: white;"|Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |style="background-color: white;"|Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Lengte gemeten | ||
|style="background-color: white;"|184 cm | |style="background-color: white;"|184 cm | ||
|}<section end=961921821 /> | |}<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 /> | <section begin=zorgverlening_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zorgverlening | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="4" width="25%"| Gegevenselement | |colspan="4" width="25%"| Gegevenselement | ||
| Regel 535: | Regel 474: | ||
|style="background-color: white;"|6 mei 2014 | |style="background-color: white;"|6 mei 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Eindverantwoordelijk in welke perinatale | |colspan="4"|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="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Eindverantwoordelijk in welke perinatale | |colspan="4"|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="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 544: | Regel 483: | ||
|style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Is er sprake van overdracht | |colspan="4"|Is er sprake van overdracht aan? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Overdrachtdetails | |colspan="5"|Overdrachtdetails | ||
| Regel 567: | Regel 506: | ||
|style="background-color: white;"|Zwangerschapshypertensie, systolische RR >140 mm Hg (code = '4284' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.1') | |style="background-color: white;"|Zwangerschapshypertensie, systolische RR >140 mm Hg (code = '4284' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.1') | ||
|}<section end=zorgverlening_961921821 /> | |}<section end=zorgverlening_961921821 /> | ||
=== | === Zorgverlenerzorginstelling === | ||
<section begin=zorgverlenerzorginstelling_961921821 /> | <section begin=zorgverlenerzorginstelling_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="2" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
|style="background-color: white;"|1504 | |style="background-color: white;"|1504 | ||
|}<section end=zorgverlenerzorginstelling_961921821 /> | |}<section end=zorgverlenerzorginstelling_961921821 /> | ||
=== | === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === | ||
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
| Regel 602: | Regel 537: | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Bloedverlies? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Hyperemesis | |colspan="2"|Hyperemesis gravidarum? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Irregulaire | |colspan="3"|Irregulaire antistoffen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | ||
=== | === Zwangerschap === | ||
<section begin=zwangerschap_961921821 /> | <section begin=zwangerschap_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
| Regel 655: | Regel 590: | ||
|style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Drugsgebruik? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Gewicht gemeten | |colspan="2"|Gewicht gemeten | ||
| Regel 674: | Regel 609: | ||
|style="background-color: white;"|Pregnancy-induced hypertension (disorder) (code = '48194001' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Pregnancy-induced hypertension (disorder) (code = '48194001' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Maternale | |colspan="3"|Maternale sterfte? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|}<section end=zwangerschap_961921821 /> | |}<section end=zwangerschap_961921821 /> | ||
==Scenario 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)== | ==Scenario 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)== | ||
<section begin=961921821 /> | <section begin=961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="2" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Burgerservicenummer | ||
|style="background-color: white;"|961921821 | |style="background-color: white;"|961921821 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Lokale persoonsidentificatie | ||
|style="background-color: white;"|* | |style="background-color: white;"|* | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Geboortedatum | ||
|style="background-color: white;"|11 sep 1974 | |style="background-color: white;"|11 sep 1974 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Adres - postcode | ||
|style="background-color: white;"|5689 CZ | |style="background-color: white;"|5689 CZ | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Etniciteit | ||
|style="background-color: white;"|Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |style="background-color: white;"|Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Lengte gemeten | ||
|style="background-color: white;"|184 cm | |style="background-color: white;"|184 cm | ||
|}<section end=961921821 /> | |}<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 /> | <section begin=zorgverlening_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zorgverlening | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="4" width="25%"| Gegevenselement | |colspan="4" width="25%"| Gegevenselement | ||
| Regel 730: | Regel 666: | ||
|style="background-color: white;"|9 okt 2014 | |style="background-color: white;"|9 okt 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Eindverantwoordelijk in welke perinatale | |colspan="4"|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="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Eindverantwoordelijk in welke perinatale | |colspan="4"|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="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Eindverantwoordelijk in welke perinatale | |colspan="4"|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="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Eindverantwoordelijk in welke perinatale | |colspan="4"|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="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Eindverantwoordelijk in welke perinatale | |colspan="4"|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="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Eindverantwoordelijk in welke perinatale | |colspan="4"|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="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Eindverantwoordelijk in welke perinatale | |colspan="4"|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="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 760: | Regel 696: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Overname van zorginstelling id | |colspan="2"|Overname van zorginstelling id | ||
|style="background-color: white;"|1504 | |style="background-color: white;"|1504 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Redenen van overname | |colspan="4"|Redenen van overname | ||
| Regel 769: | Regel 705: | ||
|style="background-color: white;"|Pre-eclampsie tijdens zwangerschap (code = '4291' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.1') | |style="background-color: white;"|Pre-eclampsie tijdens zwangerschap (code = '4291' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.1') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Is er sprake van overdracht | |colspan="4"|Is er sprake van overdracht aan? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|}<section end=zorgverlening_961921821 /> | |}<section end=zorgverlening_961921821 /> | ||
=== | === Zorgverlenerzorginstelling === | ||
<section begin=zorgverlenerzorginstelling_961921821 /> | <section begin=zorgverlenerzorginstelling_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="2" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
|style="background-color: white;"|0003 | |style="background-color: white;"|0003 | ||
|}<section end=zorgverlenerzorginstelling_961921821 /> | |}<section end=zorgverlenerzorginstelling_961921821 /> | ||
=== | === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === | ||
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
| Regel 810: | Regel 742: | ||
|style="background-color: white;"|Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Bloedverlies? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Hyperemesis | |colspan="2"|Hyperemesis gravidarum? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Irregulaire | |colspan="3"|Irregulaire antistoffen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | ||
=== | === Zwangerschap === | ||
<section begin=zwangerschap_961921821 /> | <section begin=zwangerschap_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
| Regel 860: | Regel 792: | ||
|style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Drugsgebruik? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Gewicht gemeten | |colspan="2"|Gewicht gemeten | ||
| Regel 879: | Regel 811: | ||
|style="background-color: white;"|Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Partiele | |colspan="2"|Partiele mola? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Hypertensieve aandoening | |colspan="2"|Hypertensieve aandoening | ||
|style="background-color: white;"|Pre-eclampsia (disorder) (code = '398254007' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Pre-eclampsia (disorder) (code = '398254007' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Maternale | |colspan="3"|Maternale sterfte? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Wijze einde zwangerschap | |colspan="3"|Wijze einde zwangerschap | ||
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
|}<section end=zwangerschap_961921821 /> | |}<section end=zwangerschap_961921821 /> | ||
=== | === Bevalling === | ||
<section begin=bevalling_961921821 /> | <section begin=bevalling_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
| Regel 901: | Regel 833: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Partusnummer | |colspan="3"|Partusnummer | ||
|style="background-color: white;"|000000 | |style="background-color: white;"|000000 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Aantal geboren kinderen | |colspan="3"|Aantal geboren kinderen | ||
| Regel 925: | Regel 857: | ||
|style="background-color: white;"|30 aug 2014 | |style="background-color: white;"|30 aug 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Bijstimulatie | |colspan="3"|Bijstimulatie toegediend? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Medicatie nageboortetijdperk groep | |colspan="4"|Medicatie nageboortetijdperk groep | ||
| Regel 932: | Regel 864: | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Medicatie | |colspan="2"|Medicatie nageboortetijdperk? | ||
|style="background-color: white;"|UNK | |style="background-color: white;"|UNK | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Placenta - geboorte placenta | ||
|style="background-color: white;"|placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | |style="background-color: white;"|placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 948: | Regel 876: | ||
|style="background-color: white;"|Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=bevalling_961921821 /> | |}<section end=bevalling_961921821 /> | ||
=== | === Uitkomst per kind === | ||
<section begin=uitkomst_per_kind_961921821 /> | <section begin=uitkomst_per_kind_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Uitkomst per kind | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="6" width="25%"| Gegevenselement | |colspan="6" width="25%"| Gegevenselement | ||
| Regel 959: | Regel 887: | ||
|colspan="7"|Baring | |colspan="7"|Baring | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="40"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Werkelijke plaats baring type locatie | |colspan="5"|Werkelijke plaats baring type locatie | ||
| Regel 969: | Regel 897: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Ziekenhuisnummer lvrid | |colspan="4"|Ziekenhuisnummer lvrid | ||
|style="background-color: white;"|0003 | |style="background-color: white;"|0003 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="5"|Demografische gegevens - geboortedatum | ||
|style="background-color: white;"|1 sep 2014 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|Kindspecifieke maternale gegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="12"| | |||
|rowspan="12"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Tijdstip breken vliezen | |colspan="4"|Tijdstip breken vliezen | ||
| Regel 1.008: | Regel 912: | ||
|style="background-color: white;"|geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | |style="background-color: white;"|geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Ruggeprik gewenst niet | |colspan="4"|Ruggeprik gewenst niet gekregen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| | |colspan="4"|Pijnbestrijding? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Pijnbestrijding | |colspan="5"|Pijnbestrijding | ||
| Regel 1.028: | Regel 932: | ||
|style="background-color: white;"|tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| | |colspan="4"|Sedatie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Kindspecifieke uitkomstgegevens | |colspan="6"|Kindspecifieke uitkomstgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="20"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Type partus | |colspan="4"|Type partus | ||
| Regel 1.043: | Regel 947: | ||
|colspan="4"|Ligging bij geboorte | |colspan="4"|Ligging bij geboorte | ||
|style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | |style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.067: | Regel 963: | ||
|colspan="3"|Indicatie sectio caesarea | |colspan="3"|Indicatie sectio caesarea | ||
|style="background-color: white;"|Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Lichamelijk onderzoek kind - geboortegewicht | ||
|style="background-color: white;"|3620 gram | |style="background-color: white;"|3620 gram | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Congenitale | |colspan="4"|Congenitale afwijkingen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Problematiek | |colspan="4"|Problematiek kind? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Kinderarts | |colspan="4"|Kinderarts betrokken? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Betrokkenheid kinderarts | |colspan="5"|Betrokkenheid kinderarts | ||
| Regel 1.098: | Regel 990: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Zorginstelling lvrid | |colspan="3"|Zorginstelling lvrid | ||
|style="background-color: white;"|0003 | |style="background-color: white;"|0003 | ||
|}<section end=uitkomst_per_kind_961921821 /> | |}<section end=uitkomst_per_kind_961921821 /> | ||
=== | === Medisch onderzoek === | ||
<section begin=medisch_onderzoek_961921821 /> | <section begin=medisch_onderzoek_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Irregulaire | |colspan="2"|Irregulaire antistoffen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Welke irregulaire antistoffen vrouw aanwezig | |colspan="2"|Welke irregulaire antistoffen vrouw aanwezig | ||
|style="background-color: white;"|Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=medisch_onderzoek_961921821 /> | |}<section end=medisch_onderzoek_961921821 /> | ||
=== | === Postnatale fase === | ||
<section begin=postnatale_fase_961921821 /> | <section begin=postnatale_fase_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="4" width="25%"| Gegevenselement | |colspan="4" width="25%"| Gegevenselement | ||
| Regel 1.143: | Regel 1.027: | ||
|style="background-color: white;"|3 sep 2014 | |style="background-color: white;"|3 sep 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Pathologie | |colspan="3"|Pathologie vrouw? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Pathologie vrouw | |colspan="3"|Pathologie vrouw | ||
| Regel 1.166: | Regel 1.050: | ||
<section begin=895623146 /> | <section begin=895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="2" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Burgerservicenummer | ||
|style="background-color: white;"|895623146 | |style="background-color: white;"|895623146 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Lokale persoonsidentificatie | ||
|style="background-color: white;"|000000 | |style="background-color: white;"|000000 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Geboortedatum | ||
|style="background-color: white;"|5 aug 1985 | |style="background-color: white;"|5 aug 1985 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="2"|Adres - postcode | ||
|style="background-color: white;"|5421 JG | |style="background-color: white;"|5421 JG | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Etniciteit | ||
|style="background-color: white;"|Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |style="background-color: white;"|Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="2"|Lengte gemeten | ||
|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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Onder behandeling | |colspan="3"|Onder behandeling geweest? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Algemene anamnese | |colspan="4"|Algemene anamnese | ||
| Regel 1.202: | Regel 1.096: | ||
|rowspan="10"| | |rowspan="10"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Cardiovasculaire | |colspan="2"|Cardiovasculaire aandoening? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Cardiovasculaire aandoening | |colspan="2"|Cardiovasculaire aandoening | ||
|style="background-color: white;"|Cardiac arrhythmia (disorder) (code = '698247007' in codeSystem '2.16.840.1.113883.6.96') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Schildklier | |colspan="2"|Schildklier aandoening? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Schildklier aandoening | |colspan="2"|Schildklier aandoening | ||
|style="background-color: white;"|Hyperthyroidism (disorder) (code = '34486009' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Hyperthyroidism (disorder) (code = '34486009' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Anemie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Anemie | |colspan="2"|Anemie | ||
|style="background-color: white;"|Iron deficiency anemia (disorder) (code = '87522002' in codeSystem '2.16.840.1.113883.6.96') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Bloedtransfusie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Operatie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Type operatie | |colspan="2"|Type operatie | ||
|style="background-color: white;"|Operation on heart (procedure) (code = '64915003' in codeSystem '2.16.840.1.113883.6.96') | |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 end= | |||
=== | |||
<section begin=zorgverlening_895623146 /> | <section begin=zorgverlening_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlening | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="2" width="25%"| Gegevenselement | |colspan="2" width="25%"| Gegevenselement | ||
| Regel 1.253: | Regel 1.138: | ||
|style="background-color: white;"|3 nov 2014 | |style="background-color: white;"|3 nov 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.280: | Regel 1.165: | ||
|style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | |style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Is er sprake van overdracht | |colspan="2"|Is er sprake van overdracht aan? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|}<section end=zorgverlening_895623146 /> | |}<section end=zorgverlening_895623146 /> | ||
=== | === Zorgverlenerzorginstelling === | ||
<section begin=zorgverlenerzorginstelling_895623146 /> | <section begin=zorgverlenerzorginstelling_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="2" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
|style="background-color: white;"|9999 | |style="background-color: white;"|9999 | ||
|}<section end=zorgverlenerzorginstelling_895623146 /> | |}<section end=zorgverlenerzorginstelling_895623146 /> | ||
=== | === Zwangerschap === | ||
<section begin=zwangerschap_895623146 /> | <section begin=zwangerschap_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
| Regel 1.343: | Regel 1.224: | ||
|style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Drugsgebruik? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Gewicht gemeten | |colspan="2"|Gewicht gemeten | ||
| Regel 1.359: | Regel 1.240: | ||
|style="background-color: white;"|156 dagen | |style="background-color: white;"|156 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Bloedverlies? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Infectie | |colspan="2"|Infectie | ||
| Regel 1.368: | Regel 1.249: | ||
|style="background-color: white;"|Small for gestational age fetus (disorder) (code = '267258002' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Small for gestational age fetus (disorder) (code = '267258002' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Abruptio | |colspan="2"|Abruptio placentae? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Maternale | |colspan="3"|Maternale sterfte? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Wijze einde zwangerschap | |colspan="3"|Wijze einde zwangerschap | ||
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
|}<section end=zwangerschap_895623146 /> | |}<section end=zwangerschap_895623146 /> | ||
=== | === Bevalling === | ||
<section begin=bevalling_895623146 /> | <section begin=bevalling_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
| Regel 1.387: | Regel 1.268: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Partusnummer | |colspan="3"|Partusnummer | ||
|style="background-color: white;"|000000 | |style="background-color: white;"|000000 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Diagnose bevalling | |colspan="4"|Diagnose bevalling | ||
| Regel 1.393: | Regel 1.274: | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Pprom? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Verdenking foetale | |colspan="2"|Verdenking foetale nood? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Aantal geboren kinderen | |colspan="3"|Aantal geboren kinderen | ||
| Regel 1.411: | Regel 1.292: | ||
|style="background-color: white;"|27 aug 2014 | |style="background-color: white;"|27 aug 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Bijstimulatie | |colspan="3"|Bijstimulatie toegediend? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Medicatie nageboortetijdperk groep | |colspan="4"|Medicatie nageboortetijdperk groep | ||
| Regel 1.418: | Regel 1.299: | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Medicatie | |colspan="2"|Medicatie nageboortetijdperk? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Placenta - geboorte placenta | ||
|style="background-color: white;"|controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | |style="background-color: white;"|controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.434: | Regel 1.311: | ||
|style="background-color: white;"|Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=bevalling_895623146 /> | |}<section end=bevalling_895623146 /> | ||
=== | === Uitkomst per kind === | ||
<section begin=uitkomst_per_kind_895623146 /> | <section begin=uitkomst_per_kind_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="7" width="25%"| Gegevenselement | |colspan="7" width="25%"| Gegevenselement | ||
| Regel 1.445: | Regel 1.322: | ||
|colspan="8"|Baring | |colspan="8"|Baring | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="48"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Werkelijke plaats baring type locatie | |colspan="6"|Werkelijke plaats baring type locatie | ||
| Regel 1.455: | Regel 1.332: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Ziekenhuisnummer lvrid | |colspan="5"|Ziekenhuisnummer lvrid | ||
|style="background-color: white;"|9999 | |style="background-color: white;"|9999 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="6"|Demografische gegevens - geboortedatum | |||
|style="background-color: white;"|28 aug 2014 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Kindspecifieke maternale gegevens | |||
|colspan="7"|Kindspecifieke maternale gegevens | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="19"| | |rowspan="19"| | ||
| Regel 1.497: | Regel 1.350: | ||
|style="background-color: white;"|27 aug 2014 | |style="background-color: white;"|27 aug 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|Episiotomie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Locatie episiotomie | |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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Ruggeprik gewenst niet | |colspan="5"|Ruggeprik gewenst niet gekregen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|Pijnbestrijding? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Pijnbestrijding | |colspan="6"|Pijnbestrijding | ||
| Regel 1.533: | Regel 1.386: | ||
|style="background-color: white;"|tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|Sedatie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Kindspecifieke uitkomstgegevens | |colspan="7"|Kindspecifieke uitkomstgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="21"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Type partus | |colspan="5"|Type partus | ||
| Regel 1.548: | Regel 1.401: | ||
|colspan="5"|Ligging bij geboorte | |colspan="5"|Ligging bij geboorte | ||
|style="background-color: white;"|Face presentation (finding) (code = '21882006' in codeSystem '2.16.840.1.113883.6.96') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.570: | Regel 1.415: | ||
|style="background-color: white;"|Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Succes vaginale | |colspan="4"|Succes vaginale kunstverlossing? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Lichamelijk onderzoek kind - geboortegewicht | ||
|style="background-color: white;"|2040 gram | |style="background-color: white;"|2040 gram | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Congenitale | |colspan="5"|Congenitale afwijkingen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Problematiek | |colspan="5"|Problematiek kind? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Problematiek kind | |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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Kinderarts | |colspan="5"|Kinderarts betrokken? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Betrokkenheid kinderarts | |colspan="6"|Betrokkenheid kinderarts | ||
| Regel 1.606: | Regel 1.447: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorginstelling lvrid | |colspan="4"|Zorginstelling lvrid | ||
|style="background-color: white;"|9999 | |style="background-color: white;"|9999 | ||
|}<section end=uitkomst_per_kind_895623146 /> | |}<section end=uitkomst_per_kind_895623146 /> | ||
=== | === Uitkomst per kind === | ||
<section begin=uitkomst_per_kind_895623146 /> | <section begin=uitkomst_per_kind_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="7" width="25%"| Gegevenselement | |colspan="7" width="25%"| Gegevenselement | ||
| Regel 1.619: | Regel 1.460: | ||
|colspan="8"|Baring | |colspan="8"|Baring | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="58"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Werkelijke plaats baring type locatie | |colspan="6"|Werkelijke plaats baring type locatie | ||
| Regel 1.629: | Regel 1.470: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Ziekenhuisnummer lvrid | |colspan="5"|Ziekenhuisnummer lvrid | ||
|style="background-color: white;"|9999 | |style="background-color: white;"|9999 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="6"|Demografische gegevens - geboortedatum | ||
|style="background-color: white;"|28 aug 2014 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="7"|Kindspecifieke maternale gegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="19"| | |||
|rowspan="19"| | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Tijdstip breken vliezen | |colspan="5"|Tijdstip breken vliezen | ||
| Regel 1.677: | Regel 1.488: | ||
|style="background-color: white;"|28 aug 2014 | |style="background-color: white;"|28 aug 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|Episiotomie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Locatie episiotomie | |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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Ruggeprik gewenst niet | |colspan="5"|Ruggeprik gewenst niet gekregen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|Pijnbestrijding? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Pijnbestrijding | |colspan="6"|Pijnbestrijding | ||
| Regel 1.713: | Regel 1.524: | ||
|style="background-color: white;"|tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|Sedatie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Kindspecifieke uitkomstgegevens | |colspan="7"|Kindspecifieke uitkomstgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="31"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Type partus | |colspan="5"|Type partus | ||
| Regel 1.728: | Regel 1.539: | ||
|colspan="5"|Ligging bij geboorte | |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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.750: | Regel 1.553: | ||
|style="background-color: white;"|Total breech extraction (procedure) (code = '416055001' in codeSystem '2.16.840.1.113883.6.96') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Succes vaginale | |colspan="4"|Succes vaginale kunstverlossing? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Overige interventies | |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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Lichamelijk onderzoek kind - geboortegewicht | ||
|style="background-color: white;"|1580 gram | |style="background-color: white;"|1580 gram | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Congenitale | |colspan="5"|Congenitale afwijkingen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Congenitale afwijkingen groep | |colspan="6"|Congenitale afwijkingen groep | ||
| Regel 1.784: | Regel 1.583: | ||
|style="background-color: white;"|Multiple congenital cardiac defects (disorder) (code = '94702005' in codeSystem '2.16.840.1.113883.6.96') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Chromosomale | |colspan="4"|Chromosomale afwijkingen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Problematiek | |colspan="5"|Problematiek kind? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Problematiek kind | |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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Kinderarts | |colspan="5"|Kinderarts betrokken? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Betrokkenheid kinderarts | |colspan="6"|Betrokkenheid kinderarts | ||
| Regel 1.810: | Regel 1.609: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorginstelling lvrid | |colspan="4"|Zorginstelling lvrid | ||
|style="background-color: white;"|0001 | |style="background-color: white;"|0001 | ||
|}<section end=uitkomst_per_kind_895623146 /> | |}<section end=uitkomst_per_kind_895623146 /> | ||
=== | === Medisch onderzoek === | ||
<section begin=medisch_onderzoek_895623146 /> | <section begin=medisch_onderzoek_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Irregulaire antistoffen? | |||
|style="background-color: white;"|Nee | |||
|}<section end=medisch_onderzoek_895623146 /> | |||
=== Postnatale fase === | |||
|colspan="2"|Irregulaire | |||
|style="background-color: white;"| | |||
|}<section end=medisch_onderzoek_895623146 /> | |||
=== | |||
<section begin=postnatale_fase_895623146 /> | <section begin=postnatale_fase_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="4" width="25%"| Gegevenselement | |colspan="4" width="25%"| Gegevenselement | ||
| Regel 1.862: | Regel 1.653: | ||
<section begin=850810711 /> | <section begin=850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="2" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Burgerservicenummer | ||
|style="background-color: white;"|850810711 | |style="background-color: white;"|850810711 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Lokale persoonsidentificatie | ||
|style="background-color: white;"|* | |style="background-color: white;"|* | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Geboortedatum | ||
|style="background-color: white;"|6 aug 1987 | |style="background-color: white;"|6 aug 1987 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="2"|Adres - postcode | ||
|style="background-color: white;"|4589 BA | |style="background-color: white;"|4589 BA | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Etniciteit | ||
|style="background-color: white;"|Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |style="background-color: white;"|Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="2"|Lengte gemeten | ||
|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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Onder behandeling | |colspan="2"|Type vrouwelijke genitale verminking | ||
|style="background-color: white;"| | |style="background-color: white;"|Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=850810711 /> | |||
=== 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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Algemene anamnese | |colspan="4"|Algemene anamnese | ||
| Regel 1.898: | Regel 1.699: | ||
|rowspan="14"| | |rowspan="14"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Autoimmuun | |colspan="2"|Autoimmuun aandoening? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Autoimmuun aandoening | |colspan="2"|Autoimmuun aandoening | ||
|style="background-color: white;"|Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Urogenitale | |colspan="2"|Urogenitale aandoening? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Urogenitale aandoening | |colspan="2"|Urogenitale aandoening | ||
|style="background-color: white;"|Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Diabetes | |colspan="2"|Diabetes mellitus? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Mdl | |colspan="2"|Mdl aandoening? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Mdl aandoening | |colspan="2"|Mdl aandoening | ||
|style="background-color: white;"|Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Longaandoening? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Longaandoening | |colspan="2"|Longaandoening | ||
|style="background-color: white;"|Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Operatie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Type operatie | |colspan="2"|Type operatie | ||
| Regel 1.936: | Regel 1.737: | ||
|colspan="2"|Type operatie | |colspan="2"|Type operatie | ||
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
|}<section end=anamnese_850810711 /> | |||
=== Zorgverlening === | |||
|}<section end= | |||
=== | |||
<section begin=zorgverlening_850810711 /> | <section begin=zorgverlening_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zorgverlening | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="4" width="25%"| Gegevenselement | |colspan="4" width="25%"| Gegevenselement | ||
| Regel 1.961: | Regel 1.753: | ||
|style="background-color: white;"|15 sep 2014 | |style="background-color: white;"|15 sep 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Eindverantwoordelijk in welke perinatale | |colspan="4"|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="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Eindverantwoordelijk in welke perinatale | |colspan="4"|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="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 1.979: | Regel 1.771: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Overname van zorginstelling id | |colspan="2"|Overname van zorginstelling id | ||
|style="background-color: white;"|0010 | |style="background-color: white;"|0010 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Redenen van overname | |colspan="4"|Redenen van overname | ||
| Regel 1.991: | Regel 1.783: | ||
|style="background-color: white;"|Overige niet medische indicaties vrouw en kind (code = '8499' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.1') | |style="background-color: white;"|Overige niet medische indicaties vrouw en kind (code = '8499' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.1') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Is er sprake van overdracht | |colspan="4"|Is er sprake van overdracht aan? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|}<section end=zorgverlening_850810711 /> | |}<section end=zorgverlening_850810711 /> | ||
=== | === Zorgverlenerzorginstelling === | ||
<section begin=zorgverlenerzorginstelling_850810711 /> | <section begin=zorgverlenerzorginstelling_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="2" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
|style="background-color: white;"|1410 | |style="background-color: white;"|1410 | ||
|}<section end=zorgverlenerzorginstelling_850810711 /> | |}<section end=zorgverlenerzorginstelling_850810711 /> | ||
=== | === Zwangerschap === | ||
<section begin=zwangerschap_850810711 /> | <section begin=zwangerschap_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zwangerschap | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="2" width="25%"| Gegevenselement | |colspan="2" width="25%"| Gegevenselement | ||
| Regel 2.028: | Regel 1.816: | ||
|style="background-color: white;"|18 aug 2014 | |style="background-color: white;"|18 aug 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Maternale | |colspan="2"|Maternale sterfte? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Wijze einde zwangerschap | |colspan="2"|Wijze einde zwangerschap | ||
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
|}<section end=zwangerschap_850810711 /> | |}<section end=zwangerschap_850810711 /> | ||
=== | === Bevalling === | ||
<section begin=bevalling_850810711 /> | <section begin=bevalling_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
| Regel 2.055: | Regel 1.843: | ||
|style="background-color: white;"|3 aug 2014 | |style="background-color: white;"|3 aug 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Bijstimulatie | |colspan="3"|Bijstimulatie toegediend? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Medicatie nageboortetijdperk groep | |colspan="4"|Medicatie nageboortetijdperk groep | ||
| Regel 2.062: | Regel 1.850: | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Medicatie | |colspan="2"|Medicatie nageboortetijdperk? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Soort medicatie nageboortetijdperk | |colspan="2"|Soort medicatie nageboortetijdperk | ||
|style="background-color: white;"|Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') | |style="background-color: white;"|Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="3"|Placenta - geboorte placenta | ||
|style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | |style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 2.081: | Regel 1.865: | ||
|style="background-color: white;"|Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=bevalling_850810711 /> | |}<section end=bevalling_850810711 /> | ||
=== | === Uitkomst per kind === | ||
<section begin=uitkomst_per_kind_850810711 /> | <section begin=uitkomst_per_kind_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="7" width="25%"| Gegevenselement | |colspan="7" width="25%"| Gegevenselement | ||
| Regel 2.092: | Regel 1.876: | ||
|colspan="8"|Baring | |colspan="8"|Baring | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="47"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Werkelijke plaats baring type locatie | |colspan="6"|Werkelijke plaats baring type locatie | ||
| Regel 2.102: | Regel 1.886: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Ziekenhuisnummer lvrid | |colspan="5"|Ziekenhuisnummer lvrid | ||
|style="background-color: white;"|0010 | |style="background-color: white;"|0010 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Demografische gegevens - geboortedatum | |||
|colspan="6"| | |||
|style="background-color: white;"|4 aug 2014 | |style="background-color: white;"|4 aug 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Kindspecifieke maternale gegevens | |colspan="7"|Kindspecifieke maternale gegevens | ||
| Regel 2.144: | Regel 1.904: | ||
|style="background-color: white;"|4 aug 2014 | |style="background-color: white;"|4 aug 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|Episiotomie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Locatie episiotomie | |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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Ruggeprik gewenst niet | |colspan="5"|Ruggeprik gewenst niet gekregen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|Pijnbestrijding? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Pijnbestrijding | |colspan="6"|Pijnbestrijding | ||
| Regel 2.180: | Regel 1.940: | ||
|style="background-color: white;"|tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|Sedatie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Kindspecifieke uitkomstgegevens | |colspan="7"|Kindspecifieke uitkomstgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="20"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Type partus | |colspan="5"|Type partus | ||
| Regel 2.195: | Regel 1.955: | ||
|colspan="5"|Ligging bij geboorte | |colspan="5"|Ligging bij geboorte | ||
|style="background-color: white;"|Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 2.217: | Regel 1.969: | ||
|style="background-color: white;"|Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Succes vaginale | |colspan="4"|Succes vaginale kunstverlossing? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Lichamelijk onderzoek kind - geboortegewicht | ||
|style="background-color: white;"|4205 gram | |style="background-color: white;"|4205 gram | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Congenitale | |colspan="5"|Congenitale afwijkingen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Problematiek | |colspan="5"|Problematiek kind? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Kinderarts | |colspan="5"|Kinderarts betrokken? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Betrokkenheid kinderarts | |colspan="6"|Betrokkenheid kinderarts | ||
| Regel 2.250: | Regel 1.998: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorginstelling lvrid | |colspan="4"|Zorginstelling lvrid | ||
|style="background-color: white;"|0010 | |style="background-color: white;"|0010 | ||
|}<section end=uitkomst_per_kind_850810711 /> | |}<section end=uitkomst_per_kind_850810711 /> | ||
=== | === Postnatale fase === | ||
<section begin=postnatale_fase_850810711 /> | <section begin=postnatale_fase_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="4" width="25%"| Gegevenselement | |colspan="4" width="25%"| Gegevenselement | ||
| Regel 2.268: | Regel 2.016: | ||
|style="background-color: white;"|8 aug 2014 | |style="background-color: white;"|8 aug 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Pathologie | |colspan="3"|Pathologie vrouw? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Pathologie vrouw | |colspan="3"|Pathologie vrouw | ||
| Regel 2.281: | Regel 2.029: | ||
|style="background-color: white;"|8 aug 2014 | |style="background-color: white;"|8 aug 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Pathologie | |colspan="3"|Pathologie vrouw? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Pathologie vrouw | |colspan="3"|Pathologie vrouw | ||
| Regel 2.304: | Regel 2.052: | ||
<section begin=850810711 /> | <section begin=850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="2" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Burgerservicenummer | ||
|style="background-color: white;"|850810711 | |style="background-color: white;"|850810711 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Lokale persoonsidentificatie | ||
|style="background-color: white;"|* | |style="background-color: white;"|* | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Geboortedatum | ||
|style="background-color: white;"|6 aug 1987 | |style="background-color: white;"|6 aug 1987 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Adres - postcode | ||
|style="background-color: white;"|4589 BA | |style="background-color: white;"|4589 BA | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Etniciteit | ||
|style="background-color: white;"|Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |style="background-color: white;"|Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="2"|Lengte gemeten | ||
|style="background-color: white;"|162 cm | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Onder behandeling | |colspan="2"|Vrouwelijke genitale verminking? | ||
|style="background-color: white;"| | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Algemene anamnese | |colspan="4"|Algemene anamnese | ||
| Regel 2.340: | Regel 2.098: | ||
|rowspan="14"| | |rowspan="14"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Autoimmuun | |colspan="2"|Autoimmuun aandoening? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Autoimmuun aandoening | |colspan="2"|Autoimmuun aandoening | ||
|style="background-color: white;"|Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Urogenitale | |colspan="2"|Urogenitale aandoening? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Urogenitale aandoening | |colspan="2"|Urogenitale aandoening | ||
|style="background-color: white;"|Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Diabetes | |colspan="2"|Diabetes mellitus? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Mdl | |colspan="2"|Mdl aandoening? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Mdl aandoening | |colspan="2"|Mdl aandoening | ||
|style="background-color: white;"|Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Longaandoening? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Longaandoening | |colspan="2"|Longaandoening | ||
|style="background-color: white;"|Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Operatie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Type operatie | |colspan="2"|Type operatie | ||
| Regel 2.378: | Regel 2.136: | ||
|colspan="2"|Type operatie | |colspan="2"|Type operatie | ||
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
|}<section end=anamnese_850810711 /> | |||
=== Zorgverlening === | |||
|}<section end= | |||
=== | |||
<section begin=zorgverlening_850810711 /> | <section begin=zorgverlening_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zorgverlening | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="4" width="25%"| Gegevenselement | |colspan="4" width="25%"| Gegevenselement | ||
| Regel 2.403: | Regel 2.152: | ||
|style="background-color: white;"|6 aug 2014 | |style="background-color: white;"|6 aug 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Eindverantwoordelijk in welke perinatale | |colspan="4"|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="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Eindverantwoordelijk in welke perinatale | |colspan="4"|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="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Eindverantwoordelijk in welke perinatale | |colspan="4"|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="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Eindverantwoordelijk in welke perinatale | |colspan="4"|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="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Eindverantwoordelijk in welke perinatale | |colspan="4"|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="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Eindverantwoordelijk in welke perinatale | |colspan="4"|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="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 2.424: | Regel 2.173: | ||
|style="background-color: white;"|3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Is er sprake van overdracht | |colspan="4"|Is er sprake van overdracht aan? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Overdrachtdetails | |colspan="5"|Overdrachtdetails | ||
| Regel 2.435: | Regel 2.184: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Overdracht aan zorginstelling id | |colspan="3"|Overdracht aan zorginstelling id | ||
|style="background-color: white;"|1410 | |style="background-color: white;"|1410 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Perinatale periode van overdracht | |colspan="3"|Perinatale periode van overdracht | ||
| Regel 2.447: | Regel 2.196: | ||
|style="background-color: white;"|anders (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | |style="background-color: white;"|anders (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
|}<section end=zorgverlening_850810711 /> | |}<section end=zorgverlening_850810711 /> | ||
=== | === Zorgverlenerzorginstelling === | ||
<section begin=zorgverlenerzorginstelling_850810711 /> | <section begin=zorgverlenerzorginstelling_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="2" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
|style="background-color: white;"|0010 | |style="background-color: white;"|0010 | ||
|}<section end=zorgverlenerzorginstelling_850810711 /> | |}<section end=zorgverlenerzorginstelling_850810711 /> | ||
=== | === Zwangerschap === | ||
<section begin=zwangerschap_850810711 /> | <section begin=zwangerschap_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
| Regel 2.507: | Regel 2.252: | ||
|style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Drugsgebruik? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Gewicht gemeten | |colspan="2"|Gewicht gemeten | ||
| Regel 2.526: | Regel 2.271: | ||
|style="background-color: white;"|Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Maternale | |colspan="3"|Maternale sterfte? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Wijze einde zwangerschap | |colspan="3"|Wijze einde zwangerschap | ||
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
|}<section end=zwangerschap_850810711 /> | |}<section end=zwangerschap_850810711 /> | ||
=== | === Bevalling === | ||
<section begin=bevalling_850810711 /> | <section begin=bevalling_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
| Regel 2.545: | Regel 2.290: | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Niet vorderende | |colspan="2"|Niet vorderende ontsluiting? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Niet vorderende | |colspan="2"|Niet vorderende uitdrijving? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Aantal geboren kinderen | |colspan="3"|Aantal geboren kinderen | ||
| Regel 2.563: | Regel 2.308: | ||
|style="background-color: white;"|3 aug 2014 | |style="background-color: white;"|3 aug 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Bijstimulatie | |colspan="3"|Bijstimulatie toegediend? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Medicatie nageboortetijdperk groep | |colspan="4"|Medicatie nageboortetijdperk groep | ||
| Regel 2.570: | Regel 2.315: | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Medicatie | |colspan="2"|Medicatie nageboortetijdperk? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Soort medicatie nageboortetijdperk | |colspan="2"|Soort medicatie nageboortetijdperk | ||
|style="background-color: white;"|Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') | |style="background-color: white;"|Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Placenta - geboorte placenta | ||
|style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | |style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 2.589: | Regel 2.330: | ||
|style="background-color: white;"|Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=bevalling_850810711 /> | |}<section end=bevalling_850810711 /> | ||
=== | === Uitkomst per kind === | ||
<section begin=uitkomst_per_kind_850810711 /> | <section begin=uitkomst_per_kind_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="7" width="25%"| Gegevenselement | |colspan="7" width="25%"| Gegevenselement | ||
| Regel 2.600: | Regel 2.341: | ||
|colspan="8"|Baring | |colspan="8"|Baring | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="47"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Werkelijke plaats baring type locatie | |colspan="6"|Werkelijke plaats baring type locatie | ||
| Regel 2.610: | Regel 2.351: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Ziekenhuisnummer lvrid | |colspan="5"|Ziekenhuisnummer lvrid | ||
|style="background-color: white;"|0010 | |style="background-color: white;"|0010 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="6"|Demografische gegevens - geboortedatum | ||
|style="background-color: white;"|4 aug 2014 | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="7"|Kindspecifieke maternale gegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="19"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Tijdstip breken vliezen | ||
|style="background-color: white;"| | |style="background-color: white;"|3 aug 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Kleur en consistentie vruchtwater | |||
|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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 2.652: | Regel 2.369: | ||
|style="background-color: white;"|4 aug 2014 | |style="background-color: white;"|4 aug 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|Episiotomie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Locatie episiotomie | |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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Ruggeprik gewenst niet | |colspan="5"|Ruggeprik gewenst niet gekregen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|Pijnbestrijding? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Pijnbestrijding | |colspan="6"|Pijnbestrijding | ||
| Regel 2.688: | Regel 2.405: | ||
|style="background-color: white;"|tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"| | |colspan="5"|Sedatie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Kindspecifieke uitkomstgegevens | |colspan="7"|Kindspecifieke uitkomstgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="20"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Type partus | |colspan="5"|Type partus | ||
| Regel 2.703: | Regel 2.420: | ||
|colspan="5"|Ligging bij geboorte | |colspan="5"|Ligging bij geboorte | ||
|style="background-color: white;"|Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 2.725: | Regel 2.434: | ||
|style="background-color: white;"|Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Succes vaginale | |colspan="4"|Succes vaginale kunstverlossing? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Lichamelijk onderzoek kind - geboortegewicht | ||
|style="background-color: white;"|4205 gram | |style="background-color: white;"|4205 gram | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Congenitale | |colspan="5"|Congenitale afwijkingen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Problematiek | |colspan="5"|Problematiek kind? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Kinderarts | |colspan="5"|Kinderarts betrokken? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Betrokkenheid kinderarts | |colspan="6"|Betrokkenheid kinderarts | ||
| Regel 2.758: | Regel 2.463: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorginstelling lvrid | |colspan="4"|Zorginstelling lvrid | ||
|style="background-color: white;"|0010 | |style="background-color: white;"|0010 | ||
|}<section end=uitkomst_per_kind_850810711 /> | |}<section end=uitkomst_per_kind_850810711 /> | ||
=== | === Medisch onderzoek === | ||
<section begin=medisch_onderzoek_850810711 /> | <section begin=medisch_onderzoek_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Irregulaire antistoffen? | |||
|style="background-color: white;"|Nee | |||
|}<section end=medisch_onderzoek_850810711 /> | |||
|colspan="2"|Irregulaire | |||
|style="background-color: white;"| | |||
|}<section end=medisch_onderzoek_850810711 /> | |||
==Scenario 5. zorg volledig 2e lijn, vrouw overleden (voor vrouw met BSN: 912345676)== | ==Scenario 5. zorg volledig 2e lijn, vrouw overleden (voor vrouw met BSN: 912345676)== | ||
<section begin=912345676 /> | <section begin=912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="2" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Burgerservicenummer | ||
|style="background-color: white;"|912345676 | |style="background-color: white;"|912345676 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Lokale persoonsidentificatie | ||
|style="background-color: white;"|* | |style="background-color: white;"|* | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Geboortedatum | ||
|style="background-color: white;"|4 mrt 1993 | |style="background-color: white;"|4 mrt 1993 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="2"|Adres - postcode | ||
|style="background-color: white;"|9562 GF | |style="background-color: white;"|9562 GF | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="2"|Etniciteit | ||
|style="background-color: white;"|Latijns Amerikaans (code = '14' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |style="background-color: white;"|Latijns Amerikaans (code = '14' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="2"|Lengte gemeten | ||
|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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Onder behandeling | |colspan="3"|Onder behandeling geweest? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Algemene anamnese | |colspan="4"|Algemene anamnese | ||
| Regel 2.823: | Regel 2.524: | ||
|rowspan="13"| | |rowspan="13"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Cardiovasculaire | |colspan="2"|Cardiovasculaire aandoening? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Cardiovasculaire aandoening | |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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Diabetes | |colspan="2"|Diabetes mellitus? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Neurologische | |colspan="2"|Neurologische aandoening? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Neurologische aandoening | |colspan="2"|Neurologische aandoening | ||
|style="background-color: white;"|Epilepsy (disorder) (code = '84757009' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Epilepsy (disorder) (code = '84757009' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Longaandoening? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Longaandoening | |colspan="2"|Longaandoening | ||
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Orthopedische | |colspan="2"|Orthopedische afwijking? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Orthopedische afwijking | |colspan="2"|Orthopedische afwijking | ||
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Stollingsprobleem? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Type stollingsprobleem | |colspan="2"|Type stollingsprobleem | ||
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Psychiatrie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|}<section end=anamnese_912345676 /> | |||
=== Zorgverlening === | |||
|}<section end= | |||
=== | |||
<section begin=zorgverlening_912345676 /> | <section begin=zorgverlening_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlening | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="2" width="25%"| Gegevenselement | |colspan="2" width="25%"| Gegevenselement | ||
| Regel 2.877: | Regel 2.575: | ||
|style="background-color: white;"|4 aug 2014 | |style="background-color: white;"|4 aug 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Eindverantwoordelijk in welke perinatale | |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="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 2.904: | Regel 2.602: | ||
|style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | |style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Is er sprake van overdracht | |colspan="2"|Is er sprake van overdracht aan? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|}<section end=zorgverlening_912345676 /> | |}<section end=zorgverlening_912345676 /> | ||
=== | === Zorgverlenerzorginstelling === | ||
<section begin=zorgverlenerzorginstelling_912345676 /> | <section begin=zorgverlenerzorginstelling_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="2" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
|style="background-color: white;"|0179 | |style="background-color: white;"|0179 | ||
|}<section end=zorgverlenerzorginstelling_912345676 /> | |}<section end=zorgverlenerzorginstelling_912345676 /> | ||
=== | === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === | ||
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 /> | <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Wijze einde zwangerschap | ||
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Definitieve a terme datum | ||
|style="background-color: white;"|5 jun 2012 | |style="background-color: white;"|5 jun 2012 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="6"|Diagnose | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Infectie | ||
|style="background-color: white;"|Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Zwangerschapscholestase? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Afwijkende groei foetus | ||
|style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | |style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Irregulaire antistoffen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"| | |colspan="6"|Eerdere bevalling | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="11"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| | |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="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Vorige uitkomst per kind - vorige baring | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="8"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |colspan="3"|Demografische gegevens - geboortedatum | ||
|style="background-color: white;"|9 jun 2012 | |style="background-color: white;"|9 jun 2012 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 2.993: | Regel 2.675: | ||
|style="background-color: white;"|10 | |style="background-color: white;"|10 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Congenitale | |colspan="2"|Congenitale afwijkingen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 /> | |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 /> | ||
=== | === Zwangerschap === | ||
<section begin=zwangerschap_912345676 /> | <section begin=zwangerschap_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
| Regel 3.040: | Regel 2.722: | ||
|style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Drugsgebruik? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Gewicht gemeten | |colspan="2"|Gewicht gemeten | ||
| Regel 3.059: | Regel 2.741: | ||
|style="background-color: white;"|Large-for-dates fetus (disorder) (code = '199616008' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Large-for-dates fetus (disorder) (code = '199616008' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Abruptio | |colspan="2"|Abruptio placentae? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Intrauteriene behandeling | |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="background-color: white;"|Selective destruction of fetus (procedure) (code = '265633004' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Maternale | |colspan="3"|Maternale sterfte? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Wijze einde zwangerschap | |colspan="3"|Wijze einde zwangerschap | ||
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
|}<section end=zwangerschap_912345676 /> | |}<section end=zwangerschap_912345676 /> | ||
=== | === Bevalling === | ||
<section begin=bevalling_912345676 /> | <section begin=bevalling_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
| Regel 3.081: | Regel 2.763: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Partusnummer | |colspan="3"|Partusnummer | ||
|style="background-color: white;"|000000 | |style="background-color: white;"|000000 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Aantal geboren kinderen | |colspan="3"|Aantal geboren kinderen | ||
| Regel 3.102: | Regel 2.784: | ||
|style="background-color: white;"|acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | |style="background-color: white;"|acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Bijstimulatie | |colspan="3"|Bijstimulatie toegediend? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Medicatie nageboortetijdperk groep | |colspan="4"|Medicatie nageboortetijdperk groep | ||
| Regel 3.109: | Regel 2.791: | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Medicatie | |colspan="2"|Medicatie nageboortetijdperk? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Placenta - geboorte placenta | ||
|style="background-color: white;"|placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | |style="background-color: white;"|placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 3.125: | Regel 2.803: | ||
|style="background-color: white;"|Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=bevalling_912345676 /> | |}<section end=bevalling_912345676 /> | ||
=== | === Uitkomst per kind === | ||
<section begin=uitkomst_per_kind_912345676 /> | <section begin=uitkomst_per_kind_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Uitkomst per kind | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="6" width="25%"| Gegevenselement | |colspan="6" width="25%"| Gegevenselement | ||
| Regel 3.136: | Regel 2.814: | ||
|colspan="7"|Baring | |colspan="7"|Baring | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="47"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Werkelijke plaats baring type locatie | |colspan="5"|Werkelijke plaats baring type locatie | ||
| Regel 3.146: | Regel 2.824: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Ziekenhuisnummer lvrid | |colspan="4"|Ziekenhuisnummer lvrid | ||
|style="background-color: white;"|0179 | |style="background-color: white;"|0179 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Demografische gegevens - geboortedatum | |||
|colspan=" | |||
|style="background-color: white;"|24 jul 2014 | |style="background-color: white;"|24 jul 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Kindspecifieke maternale gegevens | |colspan="6"|Kindspecifieke maternale gegevens | ||
| Regel 3.182: | Regel 2.836: | ||
|style="background-color: white;"|meconium (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| | |colspan="4"|Episiotomie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Ruggeprik gewenst niet | |colspan="4"|Ruggeprik gewenst niet gekregen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| | |colspan="4"|Pijnbestrijding? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Pijnbestrijding | |colspan="5"|Pijnbestrijding | ||
| Regel 3.205: | Regel 2.859: | ||
|style="background-color: white;"|tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"| | |colspan="4"|Sedatie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Kindspecifieke uitkomstgegevens | |colspan="6"|Kindspecifieke uitkomstgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan=" | |rowspan="27"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Type partus | |colspan="4"|Type partus | ||
| Regel 3.220: | Regel 2.874: | ||
|colspan="4"|Ligging bij geboorte | |colspan="4"|Ligging bij geboorte | ||
|style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem '2.16.840.1.113883.5.1008') | |style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem '2.16.840.1.113883.5.1008') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-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="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;;" | |-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="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| Regel 3.242: | Regel 2.888: | ||
|style="background-color: white;"|Delivery by vacuum extraction (procedure) (code = '61586001' in codeSystem '2.16.840.1.113883.6.96') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Succes vaginale | |colspan="3"|Succes vaginale kunstverlossing? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Sectio caesarea group | |colspan="5"|Sectio caesarea group | ||
| Regel 3.254: | Regel 2.900: | ||
|colspan="3"|Indicatie sectio caesarea | |colspan="3"|Indicatie sectio caesarea | ||
|style="background-color: white;"|Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Lichamelijk onderzoek kind - geboortegewicht | ||
|style="background-color: white;"|3750 gram | |style="background-color: white;"|3750 gram | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Congenitale | |colspan="4"|Congenitale afwijkingen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Congenitale afwijkingen groep | |colspan="5"|Congenitale afwijkingen groep | ||
| Regel 3.273: | Regel 2.915: | ||
|rowspan="1"| | |rowspan="1"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Chromosomale | |colspan="3"|Chromosomale afwijkingen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Specificatie chromosomale afwijking groep | |colspan="4"|Specificatie chromosomale afwijking groep | ||
| Regel 3.283: | Regel 2.925: | ||
|style="background-color: white;"|Complete trisomy 21 syndrome (disorder) (code = '41040004' in codeSystem '2.16.840.1.113883.6.96') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Problematiek | |colspan="4"|Problematiek kind? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Problematiek kind | |colspan="4"|Problematiek kind | ||
|style="background-color: white;"|Congenital hearing disorder (disorder) (code = '95827002' in codeSystem '2.16.840.1.113883.6.96') | |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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Kinderarts | |colspan="4"|Kinderarts betrokken? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|}<section end=uitkomst_per_kind_912345676 /> | |}<section end=uitkomst_per_kind_912345676 /> | ||
=== | === Medisch onderzoek === | ||
<section begin=medisch_onderzoek_912345676 /> | <section begin=medisch_onderzoek_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Irregulaire | |colspan="2"|Irregulaire antistoffen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Welke irregulaire antistoffen vrouw aanwezig | |colspan="2"|Welke irregulaire antistoffen vrouw aanwezig | ||
|style="background-color: white;"|Kell (code = '405844003' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Kell (code = '405844003' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=medisch_onderzoek_912345676 /> | |}<section end=medisch_onderzoek_912345676 /> | ||
=== | === Postnatale fase === | ||
<section begin=postnatale_fase_912345676 /> | <section begin=postnatale_fase_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="4" width="25%"| Gegevenselement | |colspan="4" width="25%"| Gegevenselement | ||
| Regel 3.335: | Regel 2.969: | ||
|style="background-color: white;"|24 jul 2014 | |style="background-color: white;"|24 jul 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Pathologie | |colspan="3"|Pathologie vrouw? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Pathologie vrouw | |colspan="3"|Pathologie vrouw | ||
| Regel 3.355: | Regel 2.989: | ||
|style="background-color: white;"|kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | |style="background-color: white;"|kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | ||
|}<section end=postnatale_fase_912345676 /> | |}<section end=postnatale_fase_912345676 /> | ||
[[Categorie:Kwalificatie]] | |||
Huidige versie van 20 jul 2020 om 00:59
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Addenda voor inhoudelijke gegevens Kernset Aanleverbericht 2.2
Scenario 1. Zorg volledig 1e lijn, herpes, strippen, gezonde eenling (voor vrouw met BSN: 999910413)
| Vrouw | ||
| Gegevenselement | Waarde | |
| Burgerservicenummer | 999910413 | |
| Lokale persoonsidentificatie | 000000 | |
| Geboortedatum | 2 mei 1976 | |
| Adres - postcode | 4563 AB | |
| Etniciteit | Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
| Lengte gemeten | 170 cm | |
Anamnese
| Anamnese | |||
| Gegevenselement | Waarde | ||
| Onder behandeling geweest? | Ja | ||
| Algemene anamnese | |||
| Cardiovasculaire aandoening? | Ja | ||
| Cardiovasculaire aandoening | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
| Oncologische aandoening? | Ja | ||
| Oncologische aandoening | other (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
| Infectieziekte? | Ja | ||
| Infectieziekte | Herpesvirus infection (disorder) (code = '23513009' in codeSystem '2.16.840.1.113883.6.96') | ||
| Operatie? | Ja | ||
| Type operatie | Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96') | ||
Zorgverlening
| Zorgverlening | ||
| Gegevenselement | Waarde | |
| Datum start zorgverantwoordelijkheid | 1 mrt 2014 | |
| Datum einde zorgverantwoordelijkheid | 12 nov 2014 | |
| Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Conclusie risicostatus na intake | 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | |
| Is er sprake van overdracht aan? | Nee | |
Zorgverlenerzorginstelling
| Zorgverlenerzorginstelling | ||
| Gegevenselement | Waarde | |
| Zorginstelling lvrid | 1808 | |
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
| Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||||
| Gegevenselement | Waarde | ||||
| Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||||
| Definitieve a terme datum | 1 dec 2011 | ||||
| Irregulaire antistoffen? | Nee | ||||
| Eerdere bevalling | |||||
| Placenta - geboorte placenta | spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||||
| Hoeveelheid bloedverlies | 550 ml | ||||
| Vorige uitkomst per kind - vorige baring | |||||
| Demografische gegevens - geboortedatum | 8 dec 2011 | ||||
| Kindspecifieke gegevens vorige uitkomsten | |||||
| Type partus | Delivery normal (finding) (code = '48782003' in codeSystem '2.16.840.1.113883.6.96') | ||||
| Percentiel van het geboortegewicht | 50 ≤ P < 90 (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.50') | ||||
| Apgarscore na 5 min | 8 | ||||
| Congenitale afwijkingen? | Nee | ||||
Zwangerschap
| Zwangerschap | |||
| Gegevenselement | Waarde | ||
| Graviditeit | 2 | ||
| Pariteit voor deze zwangerschap | 1 | ||
| Definitieve a terme datum | 9 okt 2014 | ||
| Voornemens | |||
| Voorgenomen plaats baring tijdens zwangerschap type locatie | Home birth (finding) (code = '169813005' in codeSystem '2.16.840.1.113883.6.96') | ||
| Prenatale controle | |||
| Datum controle | 2 mrt 2014 | ||
| Zwangerschapsduur | 59 dagen | ||
| Leven voelen | Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96') | ||
| Rookgedrag | niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
| Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
| Drugsgebruik? | Nee | ||
| Gewicht gemeten | 70 kg | ||
| Diagnose | |||
| Datum | 2 mrt 2014 | ||
| Zwangerschapsduur | 59 dagen | ||
| Infectie | Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | ||
| Maternale sterfte? | Nee | ||
| Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
Bevalling
| Bevalling | |||
| Gegevenselement | Waarde | ||
| Partusnummer | 000000 | ||
| Aantal geboren kinderen | 1 | ||
| Risicostatus voor baring | 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
| Wijze waarop de baring begon | interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
| Interventies begin baring groep | |||
| Interventie begin baring | Sweeping of membrane (procedure) (code = '236960006' in codeSystem '2.16.840.1.113883.6.96') | ||
| Indicatie interventie begin baring | wens patiënt (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | ||
| Tijdstip begin actieve ontsluiting | 8 okt 2014 | ||
| Bijstimulatie toegediend? | Nee | ||
| Medicatie nageboortetijdperk groep | |||
| Medicatie nageboortetijdperk? | Ja | ||
| Soort medicatie nageboortetijdperk | Oxytocin (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') | ||
| Placenta - geboorte placenta | spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
| Hoeveelheid bloedverlies | 615 ml | ||
| Conditie perineum postpartum | First degree perineal tear during delivery - delivered (disorder) (code = '199916005' in codeSystem '2.16.840.1.113883.6.96') | ||
Uitkomst per kind
| Uitkomst per kind | ||||
| Gegevenselement | Waarde | |||
| Baring | ||||
| Werkelijke plaats baring type locatie | Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') | |||
| Demografische gegevens - geboortedatum | 8 okt 2014 | |||
| Kindspecifieke maternale gegevens | ||||
| Tijdstip breken vliezen | 8 okt 2014 | |||
| Kleur en consistentie vruchtwater | kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | |||
| Tijdstip actief meepersen | 8 okt 2014 | |||
| Episiotomie? | Nee | |||
| Ruggeprik gewenst niet gekregen? | Nee | |||
| Pijnbestrijding? | Nee | |||
| Sedatie? | Nee | |||
| Kindspecifieke uitkomstgegevens | ||||
| Type partus | Delivery normal (finding) (code = '48782003' in codeSystem '2.16.840.1.113883.6.96') | |||
| Apgarscore na 5 min | 9 | |||
| Ligging bij geboorte | Occipitoposterior position (finding) (code = '37235006' in codeSystem '2.16.840.1.113883.6.96') | |||
| Aanpakker kind - rol aanpakker kind | 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | |||
| Supervisor - rol supervisor | 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | |||
| Lichamelijk onderzoek kind - geboortegewicht | 3450 gram | |||
| Congenitale afwijkingen? | Nee | |||
| Problematiek kind? | Nee | |||
| Kinderarts betrokken? | Nee | |||
Medisch onderzoek
| Medisch onderzoek | |||
| Gegevenselement | Waarde | ||
| Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
| Irregulaire antistoffen? | Nee | ||
Postnatale fase
| Postnatale fase | ||||
| Gegevenselement | Waarde | |||
| Kindspecifieke gegevens | ||||
| Voeding kind groep | ||||
| Voeding kind datum | 12 okt 2014 | |||
| Substantie voeding kind | borstmelk (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | |||
| Substantie voeding kind | kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | |||
Scenario 2. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)
| Vrouw | ||
| Gegevenselement | Waarde | |
| Burgerservicenummer | 961921821 | |
| Lokale persoonsidentificatie | * | |
| Geboortedatum | 11 sep 1974 | |
| Adres - postcode | 5689 CZ | |
| Etniciteit | Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
| Lengte gemeten | 184 cm | |
Anamnese
| Anamnese | ||
| Gegevenselement | Waarde | |
| Onder behandeling geweest? | Nee | |
Zorgverlening
| Zorgverlening | ||||
| Gegevenselement | Waarde | |||
| Datum start zorgverantwoordelijkheid | 3 feb 2014 | |||
| Datum einde zorgverantwoordelijkheid | 6 mei 2014 | |||
| Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
| Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
| Conclusie risicostatus na intake | 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | |||
| Is er sprake van overdracht aan? | Ja | |||
| Overdrachtdetails | ||||
| Datum van overdracht | 6 mei 2014 | |||
| Overdracht aan zorginstelling specialisme | Gynaecoloog / obstetricus (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | |||
| Perinatale periode van overdracht | voor 28e week (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') | |||
| Redenen van overdracht aan | ||||
| Reden overdracht aan lijst prn | Zwangerschapshypertensie, systolische RR >140 mm Hg (code = '4284' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.1') | |||
Zorgverlenerzorginstelling
| Zorgverlenerzorginstelling | ||
| Gegevenselement | Waarde | |
| Zorginstelling lvrid | 1504 | |
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
| Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||
| Gegevenselement | Waarde | ||
| Wijze einde zwangerschap | Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
| Definitieve a terme datum | 5 jun 2013 | ||
| Diagnose | |||
| Bloedverlies? | Ja | ||
| Hyperemesis gravidarum? | Ja | ||
| Irregulaire antistoffen? | Ja | ||
Zwangerschap
| Zwangerschap | |||
| Gegevenselement | Waarde | ||
| Graviditeit | 2 | ||
| Pariteit voor deze zwangerschap | 0 | ||
| Definitieve a terme datum | 8 sep 2014 | ||
| Voornemens | |||
| Voorgenomen plaats baring tijdens zwangerschap type locatie | Nog niet bepaald (code = '05' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') | ||
| Prenatale controle | |||
| Datum controle | 6 mei 2014 | ||
| Zwangerschapsduur | 155 dagen | ||
| Leven voelen | Weak fetal movements (finding) (code = '276372004' in codeSystem '2.16.840.1.113883.6.96') | ||
| Rookgedrag | gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
| Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
| Drugsgebruik? | Nee | ||
| Gewicht gemeten | 85 kg | ||
| Diagnose | |||
| Datum | 6 mei 2014 | ||
| Zwangerschapsduur | 155 dagen | ||
| Hypertensieve aandoening | Pregnancy-induced hypertension (disorder) (code = '48194001' in codeSystem '2.16.840.1.113883.6.96') | ||
| Maternale sterfte? | Nee | ||
Scenario 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)
| Vrouw | ||
| Gegevenselement | Waarde | |
| Burgerservicenummer | 961921821 | |
| Lokale persoonsidentificatie | * | |
| Geboortedatum | 11 sep 1974 | |
| Adres - postcode | 5689 CZ | |
| Etniciteit | Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
| Lengte gemeten | 184 cm | |
Anamnese
| Anamnese | ||
| Gegevenselement | Waarde | |
| Onder behandeling geweest? | Nee | |
Zorgverlening
| Zorgverlening | ||||
| Gegevenselement | Waarde | |||
| Datum start zorgverantwoordelijkheid | 12 mei 2014 | |||
| Datum einde zorgverantwoordelijkheid | 9 okt 2014 | |||
| Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
| Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
| Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
| Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
| Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
| Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
| Eindverantwoordelijk in welke perinatale periode? | follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
| Zorgverzoekdetails | ||||
| Overname van zorginstelling | ||||
| Overname van zorginstelling id | 1504 | |||
| Redenen van overname | ||||
| Reden van overname lijst prn | Pre-eclampsie tijdens zwangerschap (code = '4291' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.1') | |||
| Is er sprake van overdracht aan? | Nee | |||
Zorgverlenerzorginstelling
| Zorgverlenerzorginstelling | ||
| Gegevenselement | Waarde | |
| Zorginstelling lvrid | 0003 | |
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
| Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||
| Gegevenselement | Waarde | ||
| Wijze einde zwangerschap | Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
| Definitieve a terme datum | 5 jun 2013 | ||
| Diagnose | |||
| Gynaecologische aandoening | Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') | ||
| Bloedverlies? | Ja | ||
| Hyperemesis gravidarum? | Ja | ||
| Irregulaire antistoffen? | Ja | ||
Zwangerschap
| Zwangerschap | |||
| Gegevenselement | Waarde | ||
| Graviditeit | 2 | ||
| Pariteit voor deze zwangerschap | 0 | ||
| Definitieve a terme datum | 8 sep 2014 | ||
| Voornemens | |||
| Prenatale controle | |||
| Datum controle | 12 mei 2014 | ||
| Zwangerschapsduur | 161 dagen | ||
| Leven voelen | Reduced fetal movement (finding) (code = '276369006' in codeSystem '2.16.840.1.113883.6.96') | ||
| Rookgedrag | gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
| Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
| Drugsgebruik? | Nee | ||
| Gewicht gemeten | 85 kg | ||
| Diagnose | |||
| Datum | 12 mei 2014 | ||
| Zwangerschapsduur | 161 dagen | ||
| Gynaecologische aandoening | Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') | ||
| Partiele mola? | Ja | ||
| Hypertensieve aandoening | Pre-eclampsia (disorder) (code = '398254007' in codeSystem '2.16.840.1.113883.6.96') | ||
| Maternale sterfte? | Nee | ||
| Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
Bevalling
| Bevalling | |||
| Gegevenselement | Waarde | ||
| Partusnummer | 000000 | ||
| Aantal geboren kinderen | 1 | ||
| Risicostatus voor baring | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
| Wijze waarop de baring begon | interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
| Interventies begin baring groep | |||
| Interventie begin baring | Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96') | ||
| Indicatie interventie begin baring | acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | ||
| Tijdstip begin actieve ontsluiting | 30 aug 2014 | ||
| Bijstimulatie toegediend? | Nee | ||
| Medicatie nageboortetijdperk groep | |||
| Medicatie nageboortetijdperk? | UNK | ||
| Placenta - geboorte placenta | placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
| Hoeveelheid bloedverlies | 980 ml | ||
| Conditie perineum postpartum | Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') | ||
Uitkomst per kind
| Uitkomst per kind | ||||||
| Gegevenselement | Waarde | |||||
| Baring | ||||||
| Werkelijke plaats baring type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | |||||
| Ziekenhuis baring | ||||||
| Ziekenhuisnummer lvrid | 0003 | |||||
| Demografische gegevens - geboortedatum | 1 sep 2014 | |||||
| Kindspecifieke maternale gegevens | ||||||
| Tijdstip breken vliezen | 30 aug 2014 | |||||
| Kleur en consistentie vruchtwater | geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | |||||
| Ruggeprik gewenst niet gekregen? | Nee | |||||
| Pijnbestrijding? | Ja | |||||
| Pijnbestrijding | ||||||
| Methode | ||||||
| Methode | Epidural anesthesia (procedure) (code = '18946005' in codeSystem '2.16.840.1.113883.6.96') | |||||
| Periode | tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | |||||
| Sedatie? | Ja | |||||
| Kindspecifieke uitkomstgegevens | ||||||
| Type partus | Cesarean delivery - delivered (finding) (code = '200146002' in codeSystem '2.16.840.1.113883.6.96') | |||||
| Apgarscore na 5 min | 10 | |||||
| Ligging bij geboorte | Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | |||||
| Aanpakker kind - rol aanpakker kind | gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | |||||
| Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | |||||
| Sectio caesarea group | ||||||
| Indicatie sectio caesarea | Suspected fetal distress (situation) (code = '444433005:246090004=130955003' in codeSystem '2.16.840.1.113883.6.96') | |||||
| Indicatie sectio caesarea | Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') | |||||
| Lichamelijk onderzoek kind - geboortegewicht | 3620 gram | |||||
| Congenitale afwijkingen? | Nee | |||||
| Problematiek kind? | Nee | |||||
| Kinderarts betrokken? | Ja | |||||
| Betrokkenheid kinderarts | ||||||
| Datum betrokkenheid | 1 sep 2014 | |||||
| Reden betrokkenheid | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | |||||
| Type betrokkenheid | consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | |||||
| Zorginstelling lvrid | 0003 | |||||
Medisch onderzoek
| Medisch onderzoek | |||
| Gegevenselement | Waarde | ||
| Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
| Irregulaire antistoffen? | Ja | ||
| Welke irregulaire antistoffen vrouw aanwezig | Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96') | ||
Postnatale fase
| Postnatale fase | ||||
| Gegevenselement | Waarde | |||
| Diagnose postpartum | ||||
| Datum | 3 sep 2014 | |||
| Pathologie vrouw? | Ja | |||
| Pathologie vrouw | Urinary tract infectious disease (disorder) (code = '68566005' in codeSystem '2.16.840.1.113883.6.96') | |||
| Kindspecifieke kraamzorggegevens | ||||
| Voeding kind groep | ||||
| Voeding kind datum | 7 okt 2014 | |||
| Substantie voeding kind | kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | |||
Scenario 3. zorg volledig in 2e lijn, meerling, 1 kind overleden (voor vrouw met BSN: 895623146)
| Vrouw | ||
| Gegevenselement | Waarde | |
| Burgerservicenummer | 895623146 | |
| Lokale persoonsidentificatie | 000000 | |
| Geboortedatum | 5 aug 1985 | |
| Adres - postcode | 5421 JG | |
| Etniciteit | Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
| Lengte gemeten | 167 cm | |
| Vrouwelijke genitale verminking? | Ja | |
| Type vrouwelijke genitale verminking | Female genital mutilation type 2 (disorder) (code = '130621000119105' in codeSystem '2.16.840.1.113883.6.96') | |
Anamnese
| Anamnese | |||
| Gegevenselement | Waarde | ||
| Onder behandeling geweest? | Ja | ||
| Algemene anamnese | |||
| Cardiovasculaire aandoening? | Ja | ||
| Cardiovasculaire aandoening | Cardiac arrhythmia (disorder) (code = '698247007' in codeSystem '2.16.840.1.113883.6.96') | ||
| Schildklier aandoening? | Ja | ||
| Schildklier aandoening | Hyperthyroidism (disorder) (code = '34486009' in codeSystem '2.16.840.1.113883.6.96') | ||
| Anemie? | Ja | ||
| Anemie | Iron deficiency anemia (disorder) (code = '87522002' in codeSystem '2.16.840.1.113883.6.96') | ||
| Bloedtransfusie? | Ja | ||
| Operatie? | Ja | ||
| Type operatie | Operation on heart (procedure) (code = '64915003' in codeSystem '2.16.840.1.113883.6.96') | ||
Zorgverlening
| Zorgverlening | ||
| Gegevenselement | Waarde | |
| Datum start zorgverantwoordelijkheid | 10 mrt 2014 | |
| Datum einde zorgverantwoordelijkheid | 3 nov 2014 | |
| Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Conclusie risicostatus na intake | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | |
| Is er sprake van overdracht aan? | Nee | |
Zorgverlenerzorginstelling
| Zorgverlenerzorginstelling | ||
| Gegevenselement | Waarde | |
| Zorginstelling lvrid | 9999 | |
Zwangerschap
| Zwangerschap | |||
| Gegevenselement | Waarde | ||
| Graviditeit | 1 | ||
| Pariteit voor deze zwangerschap | 0 | ||
| Definitieve a terme datum | 22 sep 2014 | ||
| Voornemens | |||
| Voorgenomen plaats baring tijdens zwangerschap type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||
| Prenatale controle | |||
| Datum controle | 21 mei 2014 | ||
| Zwangerschapsduur | 156 dagen | ||
| Leven voelen | Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96') | ||
| Rookgedrag | niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
| Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
| Drugsgebruik? | Nee | ||
| Gewicht gemeten | 67 kg | ||
| Diagnose | |||
| Datum | 21 mei 2014 | ||
| Zwangerschapsduur | 156 dagen | ||
| Bloedverlies? | Ja | ||
| Infectie | Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | ||
| Afwijkende groei foetus | Small for gestational age fetus (disorder) (code = '267258002' in codeSystem '2.16.840.1.113883.6.96') | ||
| Abruptio placentae? | Ja | ||
| Maternale sterfte? | Nee | ||
| Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
Bevalling
| Bevalling | |||
| Gegevenselement | Waarde | ||
| Partusnummer | 000000 | ||
| Diagnose bevalling | |||
| Pprom? | Ja | ||
| Verdenking foetale nood? | Ja | ||
| Aantal geboren kinderen | 2 | ||
| Risicostatus voor baring | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
| Wijze waarop de baring begon | spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
| Tijdstip begin actieve ontsluiting | 27 aug 2014 | ||
| Bijstimulatie toegediend? | Ja | ||
| Medicatie nageboortetijdperk groep | |||
| Medicatie nageboortetijdperk? | Nee | ||
| Placenta - geboorte placenta | controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
| Hoeveelheid bloedverlies | 1740 ml | ||
| Conditie perineum postpartum | Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96') | ||
Uitkomst per kind
| Uitkomst per kind | |||||||
| Gegevenselement | Waarde | ||||||
| Baring | |||||||
| Werkelijke plaats baring type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Ziekenhuis baring | |||||||
| Ziekenhuisnummer lvrid | 9999 | ||||||
| Demografische gegevens - geboortedatum | 28 aug 2014 | ||||||
| Kindspecifieke maternale gegevens | |||||||
| Tijdstip breken vliezen | 27 aug 2014 | ||||||
| Kleur en consistentie vruchtwater | kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
| Tijdstip actief meepersen | 27 aug 2014 | ||||||
| Episiotomie? | Ja | ||||||
| Locatie episiotomie | mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||||||
| Ruggeprik gewenst niet gekregen? | Nee | ||||||
| Pijnbestrijding? | Ja | ||||||
| Pijnbestrijding | |||||||
| Methode | |||||||
| Methode | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||||||
| Overig middel | |||||||
| Middel | Administration of morphinomimetic analgesic (procedure) (code = '52685006:363701004=404642006' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Toediening | Administration of substance via intravenous route (procedure) (code = '431215000' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Periode | tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||||||
| Sedatie? | Nee | ||||||
| Kindspecifieke uitkomstgegevens | |||||||
| Type partus | Assisted delivery of fetus (finding) (code = '8561000146109' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Apgarscore na 5 min | 7 | ||||||
| Ligging bij geboorte | Face presentation (finding) (code = '21882006' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Aanpakker kind - rol aanpakker kind | arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||||||
| Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||||||
| Vaginale kunstverlossing groep | |||||||
| Vaginale kunstverlossing | Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Succes vaginale kunstverlossing? | Ja | ||||||
| Lichamelijk onderzoek kind - geboortegewicht | 2040 gram | ||||||
| Congenitale afwijkingen? | Nee | ||||||
| Problematiek kind? | Ja | ||||||
| Problematiek kind | Birth trauma of fetus (disorder) (code = '56110009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Kinderarts betrokken? | Ja | ||||||
| Betrokkenheid kinderarts | |||||||
| Datum betrokkenheid | 28 aug 2014 | ||||||
| Reden betrokkenheid | Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Type betrokkenheid | consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
| Zorginstelling lvrid | 9999 | ||||||
Uitkomst per kind
| Uitkomst per kind | |||||||
| Gegevenselement | Waarde | ||||||
| Baring | |||||||
| Werkelijke plaats baring type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Ziekenhuis baring | |||||||
| Ziekenhuisnummer lvrid | 9999 | ||||||
| Demografische gegevens - geboortedatum | 28 aug 2014 | ||||||
| Kindspecifieke maternale gegevens | |||||||
| Tijdstip breken vliezen | 27 aug 2014 | ||||||
| Kleur en consistentie vruchtwater | kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
| Tijdstip actief meepersen | 28 aug 2014 | ||||||
| Episiotomie? | Ja | ||||||
| Locatie episiotomie | mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||||||
| Ruggeprik gewenst niet gekregen? | Nee | ||||||
| Pijnbestrijding? | Ja | ||||||
| Pijnbestrijding | |||||||
| Methode | |||||||
| Methode | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||||||
| Overig middel | |||||||
| Middel | Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Toediening | Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Periode | tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||||||
| Sedatie? | Nee | ||||||
| Kindspecifieke uitkomstgegevens | |||||||
| Type partus | Assisted delivery of fetus (finding) (code = '8561000146109' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Apgarscore na 5 min | 4 | ||||||
| Ligging bij geboorte | Complete breech presentation (finding) (code = '49168004' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Aanpakker kind - rol aanpakker kind | arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||||||
| Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||||||
| Vaginale kunstverlossing groep | |||||||
| Vaginale kunstverlossing | Total breech extraction (procedure) (code = '416055001' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Succes vaginale kunstverlossing? | Ja | ||||||
| Overige interventies | Maneuvers for delivery in shoulder dystocia (procedure) (code = '237008007' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Lichamelijk onderzoek kind - geboortegewicht | 1580 gram | ||||||
| Congenitale afwijkingen? | Ja | ||||||
| Congenitale afwijkingen groep | |||||||
| Specificatie congenitale afwijking groep | |||||||
| Specificatie congenitale afwijking | Spina bifida occulta (disorder) (code = '76916001' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Specificatie congenitale afwijking groep | |||||||
| Specificatie congenitale afwijking | Multiple congenital cardiac defects (disorder) (code = '94702005' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Chromosomale afwijkingen? | Nee | ||||||
| Problematiek kind? | Ja | ||||||
| Problematiek kind | Subdural intracranial hemorrhage due to birth trauma (disorder) (code = '126941005' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Kinderarts betrokken? | Ja | ||||||
| Betrokkenheid kinderarts | |||||||
| Datum betrokkenheid | 28 aug 2014 | ||||||
| Reden betrokkenheid | Finding of neonatal condition (finding) (code = '364737004' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Type betrokkenheid | overdracht (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
| Zorginstelling lvrid | 0001 | ||||||
Medisch onderzoek
| Medisch onderzoek | |||
| Gegevenselement | Waarde | ||
| Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
| Irregulaire antistoffen? | Nee | ||
Postnatale fase
| Postnatale fase | ||||
| Gegevenselement | Waarde | |||
| Kindspecifieke gegevens | ||||
| Voeding kind groep | ||||
| Voeding kind datum | 3 sep 2014 | |||
| Substantie voeding kind | borstmelk (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | |||
Scenario 4. 1e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)
| Vrouw | ||
| Gegevenselement | Waarde | |
| Burgerservicenummer | 850810711 | |
| Lokale persoonsidentificatie | * | |
| Geboortedatum | 6 aug 1987 | |
| Adres - postcode | 4589 BA | |
| Etniciteit | Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
| Lengte gemeten | 162 cm | |
| Vrouwelijke genitale verminking? | Ja | |
| Type vrouwelijke genitale verminking | Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96') | |
Anamnese
| Anamnese | |||
| Gegevenselement | Waarde | ||
| Onder behandeling geweest? | Ja | ||
| Algemene anamnese | |||
| Autoimmuun aandoening? | Ja | ||
| Autoimmuun aandoening | Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96') | ||
| Urogenitale aandoening? | Ja | ||
| Urogenitale aandoening | Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96') | ||
| Diabetes mellitus? | Ja | ||
| Mdl aandoening? | Ja | ||
| Mdl aandoening | Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96') | ||
| Longaandoening? | Ja | ||
| Longaandoening | Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96') | ||
| Operatie? | Ja | ||
| Type operatie | Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96') | ||
| Type operatie | Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96') | ||
| Type operatie | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
Zorgverlening
| Zorgverlening | ||||
| Gegevenselement | Waarde | |||
| Datum start zorgverantwoordelijkheid | 7 aug 2014 | |||
| Datum einde zorgverantwoordelijkheid | 15 sep 2014 | |||
| Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
| Eindverantwoordelijk in welke perinatale periode? | follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
| Conclusie risicostatus na intake | 3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | |||
| Zorgverzoekdetails | ||||
| Overname van zorginstelling | ||||
| Overname van zorginstelling id | 0010 | |||
| Redenen van overname | ||||
| Reden van overname lijst prn | Uitbesteding zorg 2e lijn overige redenen (code = '8240' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.1') | |||
| Reden van overname lijst prn | Overige niet medische indicaties vrouw en kind (code = '8499' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.1') | |||
| Is er sprake van overdracht aan? | Nee | |||
Zorgverlenerzorginstelling
| Zorgverlenerzorginstelling | ||
| Gegevenselement | Waarde | |
| Zorginstelling lvrid | 1410 | |
Zwangerschap
| Zwangerschap | ||
| Gegevenselement | Waarde | |
| Graviditeit | 1 | |
| Pariteit voor deze zwangerschap | 0 | |
| Definitieve a terme datum | 18 aug 2014 | |
| Maternale sterfte? | Ja | |
| Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |
Bevalling
| Bevalling | |||
| Gegevenselement | Waarde | ||
| Aantal geboren kinderen | 1 | ||
| Risicostatus voor baring | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
| Wijze waarop de baring begon | spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
| Tijdstip begin actieve ontsluiting | 3 aug 2014 | ||
| Bijstimulatie toegediend? | Nee | ||
| Medicatie nageboortetijdperk groep | |||
| Medicatie nageboortetijdperk? | Ja | ||
| Soort medicatie nageboortetijdperk | Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') | ||
| Placenta - geboorte placenta | spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
| Hoeveelheid bloedverlies | 1120 ml | ||
| Conditie perineum postpartum | Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') | ||
Uitkomst per kind
| Uitkomst per kind | |||||||
| Gegevenselement | Waarde | ||||||
| Baring | |||||||
| Werkelijke plaats baring type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Ziekenhuis baring | |||||||
| Ziekenhuisnummer lvrid | 0010 | ||||||
| Demografische gegevens - geboortedatum | 4 aug 2014 | ||||||
| Kindspecifieke maternale gegevens | |||||||
| Tijdstip breken vliezen | 3 aug 2014 | ||||||
| Kleur en consistentie vruchtwater | bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
| Tijdstip actief meepersen | 4 aug 2014 | ||||||
| Episiotomie? | Ja | ||||||
| Locatie episiotomie | mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||||||
| Ruggeprik gewenst niet gekregen? | Nee | ||||||
| Pijnbestrijding? | Ja | ||||||
| Pijnbestrijding | |||||||
| Methode | |||||||
| Methode | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||||||
| Overig middel | |||||||
| Middel | Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Toediening | Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Periode | tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||||||
| Sedatie? | Nee | ||||||
| Kindspecifieke uitkomstgegevens | |||||||
| Type partus | Assisted delivery of fetus (finding) (code = '8561000146109' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Apgarscore na 5 min | 9 | ||||||
| Ligging bij geboorte | Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Aanpakker kind - rol aanpakker kind | co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||||||
| Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||||||
| Vaginale kunstverlossing groep | |||||||
| Vaginale kunstverlossing | Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Succes vaginale kunstverlossing? | Ja | ||||||
| Lichamelijk onderzoek kind - geboortegewicht | 4205 gram | ||||||
| Congenitale afwijkingen? | Nee | ||||||
| Problematiek kind? | Nee | ||||||
| Kinderarts betrokken? | Ja | ||||||
| Betrokkenheid kinderarts | |||||||
| Datum betrokkenheid | 4 aug 2014 | ||||||
| Reden betrokkenheid | Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Type betrokkenheid | consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
| Zorginstelling lvrid | 0010 | ||||||
Postnatale fase
| Postnatale fase | ||||
| Gegevenselement | Waarde | |||
| Diagnose postpartum | ||||
| Datum | 8 aug 2014 | |||
| Pathologie vrouw? | Ja | |||
| Pathologie vrouw | Embolism (disorder) (code = '414086009' in codeSystem '2.16.840.1.113883.6.96') | |||
| Diagnose postpartum | ||||
| Datum | 8 aug 2014 | |||
| Pathologie vrouw? | Ja | |||
| Pathologie vrouw | Episiotomy infection (disorder) (code = '300927001' in codeSystem '2.16.840.1.113883.6.96') | |||
| Kindspecifieke gegevens | ||||
| Voeding kind groep | ||||
| Voeding kind datum | 15 sep 2014 | |||
| Substantie voeding kind | kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | |||
Scenario 4. 2e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)
| Vrouw | ||
| Gegevenselement | Waarde | |
| Burgerservicenummer | 850810711 | |
| Lokale persoonsidentificatie | * | |
| Geboortedatum | 6 aug 1987 | |
| Adres - postcode | 4589 BA | |
| Etniciteit | Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
| Lengte gemeten | 162 cm | |
| Vrouwelijke genitale verminking? | Ja | |
| Type vrouwelijke genitale verminking | Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96') | |
Anamnese
| Anamnese | |||
| Gegevenselement | Waarde | ||
| Onder behandeling geweest? | Ja | ||
| Algemene anamnese | |||
| Autoimmuun aandoening? | Ja | ||
| Autoimmuun aandoening | Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96') | ||
| Urogenitale aandoening? | Ja | ||
| Urogenitale aandoening | Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96') | ||
| Diabetes mellitus? | Ja | ||
| Mdl aandoening? | Ja | ||
| Mdl aandoening | Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96') | ||
| Longaandoening? | Ja | ||
| Longaandoening | Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96') | ||
| Operatie? | Ja | ||
| Type operatie | Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96') | ||
| Type operatie | Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96') | ||
| Type operatie | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
Zorgverlening
| Zorgverlening | ||||
| Gegevenselement | Waarde | |||
| Datum start zorgverantwoordelijkheid | 3 feb 2014 | |||
| Datum einde zorgverantwoordelijkheid | 6 aug 2014 | |||
| Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
| Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
| Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
| Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
| Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
| Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
| Conclusie risicostatus na intake | 3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | |||
| Is er sprake van overdracht aan? | Ja | |||
| Overdrachtdetails | ||||
| Datum van overdracht | 6 aug 2014 | |||
| Overdracht aan zorginstelling id | 1410 | |||
| Perinatale periode van overdracht | 2e t/m 7e dag (code = '92' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') | |||
| Redenen van overdracht aan | ||||
| Reden overdracht aan lijst prn | anders (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | |||
Zorgverlenerzorginstelling
| Zorgverlenerzorginstelling | ||
| Gegevenselement | Waarde | |
| Zorginstelling lvrid | 0010 | |
Zwangerschap
| Zwangerschap | |||
| Gegevenselement | Waarde | ||
| Graviditeit | 1 | ||
| Pariteit voor deze zwangerschap | 0 | ||
| Definitieve a terme datum | 18 aug 2014 | ||
| Voornemens | |||
| Voorgenomen plaats baring tijdens zwangerschap type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||
| Prenatale controle | |||
| Datum controle | 7 mei 2014 | ||
| Zwangerschapsduur | 149 dagen | ||
| Leven voelen | Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96') | ||
| Rookgedrag | niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
| Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
| Drugsgebruik? | Nee | ||
| Gewicht gemeten | 82 kg | ||
| Diagnose | |||
| Datum | 7 mei 2014 | ||
| Zwangerschapsduur | 149 dagen | ||
| Infectie | Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | ||
| Maternale sterfte? | Nee | ||
| Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
Bevalling
| Bevalling | |||
| Gegevenselement | Waarde | ||
| Diagnose bevalling | |||
| Niet vorderende ontsluiting? | Ja | ||
| Niet vorderende uitdrijving? | Ja | ||
| Aantal geboren kinderen | 1 | ||
| Risicostatus voor baring | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
| Wijze waarop de baring begon | spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
| Tijdstip begin actieve ontsluiting | 3 aug 2014 | ||
| Bijstimulatie toegediend? | Nee | ||
| Medicatie nageboortetijdperk groep | |||
| Medicatie nageboortetijdperk? | Ja | ||
| Soort medicatie nageboortetijdperk | Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') | ||
| Placenta - geboorte placenta | spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
| Hoeveelheid bloedverlies | 1120 ml | ||
| Conditie perineum postpartum | Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') | ||
Uitkomst per kind
| Uitkomst per kind | |||||||
| Gegevenselement | Waarde | ||||||
| Baring | |||||||
| Werkelijke plaats baring type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Ziekenhuis baring | |||||||
| Ziekenhuisnummer lvrid | 0010 | ||||||
| Demografische gegevens - geboortedatum | 4 aug 2014 | ||||||
| Kindspecifieke maternale gegevens | |||||||
| Tijdstip breken vliezen | 3 aug 2014 | ||||||
| Kleur en consistentie vruchtwater | bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
| Tijdstip actief meepersen | 4 aug 2014 | ||||||
| Episiotomie? | Ja | ||||||
| Locatie episiotomie | mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||||||
| Ruggeprik gewenst niet gekregen? | Nee | ||||||
| Pijnbestrijding? | Ja | ||||||
| Pijnbestrijding | |||||||
| Methode | |||||||
| Methode | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||||||
| Overig middel | |||||||
| Middel | Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Toediening | Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Periode | tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||||||
| Sedatie? | Nee | ||||||
| Kindspecifieke uitkomstgegevens | |||||||
| Type partus | Assisted delivery of fetus (finding) (code = '8561000146109' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Apgarscore na 5 min | 9 | ||||||
| Ligging bij geboorte | Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Aanpakker kind - rol aanpakker kind | co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||||||
| Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||||||
| Vaginale kunstverlossing groep | |||||||
| Vaginale kunstverlossing | Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Succes vaginale kunstverlossing? | Ja | ||||||
| Lichamelijk onderzoek kind - geboortegewicht | 4205 gram | ||||||
| Congenitale afwijkingen? | Nee | ||||||
| Problematiek kind? | Nee | ||||||
| Kinderarts betrokken? | Ja | ||||||
| Betrokkenheid kinderarts | |||||||
| Datum betrokkenheid | 4 aug 2014 | ||||||
| Reden betrokkenheid | Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Type betrokkenheid | consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
| Zorginstelling lvrid | 0010 | ||||||
Medisch onderzoek
| Medisch onderzoek | |||
| Gegevenselement | Waarde | ||
| Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
| Irregulaire antistoffen? | Nee | ||
Scenario 5. zorg volledig 2e lijn, vrouw overleden (voor vrouw met BSN: 912345676)
| Vrouw | ||
| Gegevenselement | Waarde | |
| Burgerservicenummer | 912345676 | |
| Lokale persoonsidentificatie | * | |
| Geboortedatum | 4 mrt 1993 | |
| Adres - postcode | 9562 GF | |
| Etniciteit | Latijns Amerikaans (code = '14' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
| Lengte gemeten | 186 cm | |
Anamnese
| Anamnese | |||
| Gegevenselement | Waarde | ||
| Onder behandeling geweest? | Ja | ||
| Algemene anamnese | |||
| Cardiovasculaire aandoening? | Ja | ||
| Cardiovasculaire aandoening | Hypertensive disorder, systemic arterial (disorder) (code = '38341003' in codeSystem '2.16.840.1.113883.6.96') | ||
| Diabetes mellitus? | Ja | ||
| Neurologische aandoening? | Ja | ||
| Neurologische aandoening | Epilepsy (disorder) (code = '84757009' in codeSystem '2.16.840.1.113883.6.96') | ||
| Longaandoening? | Ja | ||
| Longaandoening | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
| Orthopedische afwijking? | Ja | ||
| Orthopedische afwijking | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
| Stollingsprobleem? | Ja | ||
| Type stollingsprobleem | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
| Psychiatrie? | Ja | ||
Zorgverlening
| Zorgverlening | ||
| Gegevenselement | Waarde | |
| Datum start zorgverantwoordelijkheid | 9 dec 2013 | |
| Datum einde zorgverantwoordelijkheid | 4 aug 2014 | |
| Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Eindverantwoordelijk in welke perinatale periode? | follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
| Conclusie risicostatus na intake | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | |
| Is er sprake van overdracht aan? | Nee | |
Zorgverlenerzorginstelling
| Zorgverlenerzorginstelling | ||
| Gegevenselement | Waarde | |
| Zorginstelling lvrid | 0179 | |
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
| Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||||
| Gegevenselement | Waarde | ||||
| Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||||
| Definitieve a terme datum | 5 jun 2012 | ||||
| Diagnose | |||||
| Infectie | Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | ||||
| Zwangerschapscholestase? | Ja | ||||
| Afwijkende groei foetus | Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | ||||
| Irregulaire antistoffen? | Ja | ||||
| Eerdere bevalling | |||||
| Placenta - geboorte placenta | spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||||
| Vorige uitkomst per kind - vorige baring | |||||
| Demografische gegevens - geboortedatum | 9 jun 2012 | ||||
| Kindspecifieke gegevens vorige uitkomsten | |||||
| Type partus | Assisted delivery of fetus (finding) (code = '8561000146109' in codeSystem '2.16.840.1.113883.6.96') | ||||
| Percentiel van het geboortegewicht | 10 ≤ P < 50 (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.50') | ||||
| Apgarscore na 5 min | 10 | ||||
| Congenitale afwijkingen? | Nee | ||||
Zwangerschap
| Zwangerschap | |||
| Gegevenselement | Waarde | ||
| Graviditeit | 2 | ||
| Pariteit voor deze zwangerschap | 1 | ||
| Definitieve a terme datum | 22 jul 2014 | ||
| Voornemens | |||
| Voorgenomen plaats baring tijdens zwangerschap type locatie | Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | ||
| Prenatale controle | |||
| Datum controle | 9 jan 2014 | ||
| Zwangerschapsduur | 86 dagen | ||
| Leven voelen | Fetal movements absent (context-dependent category) (code = '289432001' in codeSystem '2.16.840.1.113883.6.96') | ||
| Rookgedrag | gestopt tijdens huidige zwangerschap (code = '6' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
| Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
| Drugsgebruik? | Ja | ||
| Gewicht gemeten | 89 kg | ||
| Diagnose | |||
| Datum | 9 jan 2014 | ||
| Zwangerschapsduur | 86 dagen | ||
| Afwijkende groei foetus | Large-for-dates fetus (disorder) (code = '199616008' in codeSystem '2.16.840.1.113883.6.96') | ||
| Abruptio placentae? | Ja | ||
| Intrauteriene behandeling | Selective destruction of fetus (procedure) (code = '265633004' in codeSystem '2.16.840.1.113883.6.96') | ||
| Maternale sterfte? | Ja | ||
| Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
Bevalling
| Bevalling | |||
| Gegevenselement | Waarde | ||
| Partusnummer | 000000 | ||
| Aantal geboren kinderen | 1 | ||
| Risicostatus voor baring | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
| Wijze waarop de baring begon | interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
| Interventies begin baring groep | |||
| Interventie begin baring | Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96') | ||
| Indicatie interventie begin baring | acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | ||
| Bijstimulatie toegediend? | Nee | ||
| Medicatie nageboortetijdperk groep | |||
| Medicatie nageboortetijdperk? | Nee | ||
| Placenta - geboorte placenta | placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
| Hoeveelheid bloedverlies | 1500 ml | ||
| Conditie perineum postpartum | Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') | ||
Uitkomst per kind
| Uitkomst per kind | ||||||
| Gegevenselement | Waarde | |||||
| Baring | ||||||
| Werkelijke plaats baring type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | |||||
| Ziekenhuis baring | ||||||
| Ziekenhuisnummer lvrid | 0179 | |||||
| Demografische gegevens - geboortedatum | 24 jul 2014 | |||||
| Kindspecifieke maternale gegevens | ||||||
| Kleur en consistentie vruchtwater | meconium (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | |||||
| Episiotomie? | Nee | |||||
| Ruggeprik gewenst niet gekregen? | Nee | |||||
| Pijnbestrijding? | Ja | |||||
| Pijnbestrijding | ||||||
| Methode | ||||||
| Methode | General anesthesia (procedure) (code = '50697003' in codeSystem '2.16.840.1.113883.6.96') | |||||
| Periode | tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | |||||
| Sedatie? | Ja | |||||
| Kindspecifieke uitkomstgegevens | ||||||
| Type partus | Delivery by emergency cesarean section (finding) (code = '200149009' in codeSystem '2.16.840.1.113883.6.96') | |||||
| Apgarscore na 5 min | 9 | |||||
| Ligging bij geboorte | Onbekend (code = 'UNK' in codeSystem '2.16.840.1.113883.5.1008') | |||||
| Aanpakker kind - rol aanpakker kind | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | |||||
| Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | |||||
| Vaginale kunstverlossing groep | ||||||
| Vaginale kunstverlossing | Delivery by vacuum extraction (procedure) (code = '61586001' in codeSystem '2.16.840.1.113883.6.96') | |||||
| Succes vaginale kunstverlossing? | Nee | |||||
| Sectio caesarea group | ||||||
| Beslismoment sectio caesarea | tijdens uitdrijving besloten (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.5') | |||||
| Indicatie sectio caesarea | Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') | |||||
| Lichamelijk onderzoek kind - geboortegewicht | 3750 gram | |||||
| Congenitale afwijkingen? | Ja | |||||
| Congenitale afwijkingen groep | ||||||
| Specificatie congenitale afwijking groep | ||||||
| Chromosomale afwijkingen? | Ja | |||||
| Specificatie chromosomale afwijking groep | ||||||
| Specificatie chromosomale afwijking | Complete trisomy 21 syndrome (disorder) (code = '41040004' in codeSystem '2.16.840.1.113883.6.96') | |||||
| Problematiek kind? | Ja | |||||
| Problematiek kind | Congenital hearing disorder (disorder) (code = '95827002' in codeSystem '2.16.840.1.113883.6.96') | |||||
| Kinderarts betrokken? | Nee | |||||
Medisch onderzoek
| Medisch onderzoek | |||
| Gegevenselement | Waarde | ||
| Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
| Irregulaire antistoffen? | Ja | ||
| Welke irregulaire antistoffen vrouw aanwezig | Kell (code = '405844003' in codeSystem '2.16.840.1.113883.6.96') | ||
Postnatale fase
| Postnatale fase | ||||
| Gegevenselement | Waarde | |||
| Diagnose postpartum | ||||
| Datum | 24 jul 2014 | |||
| Pathologie vrouw? | Ja | |||
| Pathologie vrouw | Postpartum deep phlebothrombosis (disorder) (code = '56272000' in codeSystem '2.16.840.1.113883.6.96') | |||
| Kindspecifieke gegevens | ||||
| Voeding kind groep | ||||
| Voeding kind datum | 24 jul 2014 | |||
| Substantie voeding kind | kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | |||