Gbz:Vdraft Sandbox-prio1-vrg: verschil tussen versies
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Regel 1: | Regel 1: | ||
<noinclude> | <noinclude> | ||
− | {{ | + | {{DISPLAYTITLE:Kernset Geboortezorg 2.3 - inhoud kwalificatie}} |
__NUMBEREDHEADINGS__ | __NUMBEREDHEADINGS__ | ||
− | |||
− | =Addenda voor inhoudelijke gegevens | + | =Addenda voor inhoudelijke gegevens Kernset Geboortezorg 2.3=</noinclude> |
− | ==Scenario | + | ==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 (in identificerend systeem: BSN) | |style="background-color: white;"|999910413 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Lokale persoonsidentificatie | ||
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Geboortedatum | ||
+ | |style="background-color: white;"|2 mei in het jaar: (jaar van T) - 39 jaar | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Adres - postcode | ||
+ | |style="background-color: white;"|4563 AB | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Etniciteit | ||
+ | |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;;" | ||
+ | |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;;" | ||
+ | |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=" | + | |colspan="4"|Algemene anamnese |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Cardiovasculaire aandoening |
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Oncologische aandoening | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Infectieziekte | ||
+ | |style="background-color: white;"|Herpes (code = '23513009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type operatie | ||
+ | |style="background-color: white;"|Orthopedisch (code = '112697007' in codeSystem 'SNOMED CT') | ||
+ | |}<section end=anamnese_999910413 /> | ||
+ | === Zorgverlening === | ||
+ | <section begin=zorgverlening_999910413 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlening | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum start zorgverantwoordelijkheid | ||
+ | |style="background-color: white;"|T - 306 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum einde zorgverantwoordelijkheid | ||
+ | |style="background-color: white;"|T - 50 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Conclusie risicostatus na intake |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') |
− | |}<section end= | + | |}<section end=zorgverlening_999910413 /> |
=== Zorgverlenerzorginstelling === | === Zorgverlenerzorginstelling === | ||
<section begin=zorgverlenerzorginstelling_999910413 /> | <section begin=zorgverlenerzorginstelling_999910413 /> | ||
Regel 42: | Regel 109: | ||
|colspan="4"|Zorginstelling | |colspan="4"|Zorginstelling | ||
|-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"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1808 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
+ | |}<section end=zorgverlenerzorginstelling_999910413 /> | ||
+ | === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === | ||
+ | <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="5" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="5"|Wijze einde zwangerschap |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|T - 1127 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Irregulaire antistoffen? | ||
+ | |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="3"| | + | |rowspan="12"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Placenta - geboorte placenta | ||
+ | |style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Hoeveelheid bloedverlies | ||
+ | |style="background-color: white;"|550 ml | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Vorige uitkomst per kind - vorige baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Geboortedatum | ||
+ | |style="background-color: white;"|T - 1120 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Kindspecifieke gegevens vorige uitkomsten | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type partus | ||
+ | |style="background-color: white;"|Spontaan (code = '177184002' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Percentiel van het geboortegewicht | ||
+ | |style="background-color: white;"|p50 tot p90 (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.50') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Apgarscore na 5 min |
− | |style="background-color: white;"| | + | |style="background-color: white;"|8 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Congenitale afwijkingen? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
− | |}<section end= | + | |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 /> |
=== Zwangerschap === | === Zwangerschap === | ||
<section begin=zwangerschap_999910413 /> | <section begin=zwangerschap_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="3"|Dossiernummer |
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Graviditeit | ||
+ | |style="background-color: white;"|2 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pariteit voor deze zwangerschap | ||
|style="background-color: white;"|1 | |style="background-color: white;"|1 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="3"|Definitieve a terme datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 84 dagen |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voornemens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie | ||
+ | |style="background-color: white;"|Thuis (code = '169813005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Prenatale controle | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum controle | ||
+ | |style="background-color: white;"|T - 305 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|59 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Leven voelen | ||
+ | |style="background-color: white;"|goed (code = '289431008' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Rookgedrag | ||
+ | |style="background-color: white;"|niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Alcoholgebruik | ||
+ | |style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Drugsgebruik? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Gewicht gemeten | ||
+ | |style="background-color: white;"|70 kg | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Diagnose | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum | ||
+ | |style="background-color: white;"|T - 305 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|59 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Infectie | ||
+ | |style="background-color: white;"|Urineweg infectie (code = '307534009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Maternale sterfte? | ||
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Wijze einde zwangerschap |
|style="background-color: white;"|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 === | === Bevalling === | ||
<section begin=bevalling_999910413 /> | <section begin=bevalling_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"|Tijdstip begin actieve ontsluiting | + | |colspan="3"|Partusnummer |
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Aantal geboren kinderen | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Risicostatus voor baring | ||
+ | |style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Interventies begin baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Interventie begin baring | ||
+ | |style="background-color: white;"|Strippen (code = '236960006' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Indicatie interventie begin baring | ||
+ | |style="background-color: white;"|wens patiënt (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Wijze waarop de baring begon | ||
+ | |style="background-color: white;"|Interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Tijdstip begin actieve ontsluiting | ||
+ | |style="background-color: white;"|T - 86 dagen om 14:30 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Medicatie nageboortetijdperk groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Medicatie nageboortetijdperk? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Soort medicatie nageboortetijdperk | ||
+ | |style="background-color: white;"|Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Placenta - geboorte placenta | ||
+ | |style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Hoeveelheid bloedverlies |
− | |style="background-color: white;"| | + | |style="background-color: white;"|615 ml |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Conditie perineum postpartum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1e graads perineumruptuur (code = '199916005' in codeSystem 'SNOMED CT') |
|}<section end=bevalling_999910413 /> | |}<section end=bevalling_999910413 /> | ||
=== Uitkomst per kind === | === Uitkomst per kind === | ||
Regel 110: | Regel 301: | ||
|colspan="6"|Baring | |colspan="6"|Baring | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="34"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Werkelijke plaats baring type locatie | ||
+ | |style="background-color: white;"|Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Demografische gegevens | |colspan="5"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Identificaties kind | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Bsn kind | ||
+ | |style="background-color: white;"|999910383 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Geslacht medische observatie | ||
+ | |style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Geboortedatum | |colspan="3"|Geboortedatum | ||
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|T - 85 dagen |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Rangnummer kind | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Perinatale sterfte groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Perinatale sterfte? | ||
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Kindspecifieke maternale gegevens | |colspan="5"|Kindspecifieke maternale gegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="8"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Tijdstip breken vliezen | ||
+ | |style="background-color: white;"|T - 85 dagen om 09:15 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Kleur en consistentie vruchtwater | ||
+ | |style="background-color: white;"|Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Tijdstip actief meepersen | |colspan="3"|Tijdstip actief meepersen | ||
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|T - 85 dagen om 12:13 uur |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Episiotomie? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Ruggeprik gewenst niet gekregen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pijnbestrijding? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Sedatie? | ||
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Kindspecifieke uitkomstgegevens | |colspan="5"|Kindspecifieke uitkomstgegevens | ||
|-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="3"|Type partus | |colspan="3"|Type partus | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Spontaan (code = '177184002' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Ligging bij geboorte | ||
+ | |style="background-color: white;"|Achterhoofd-achter (code = '37235006' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Aanpakker kind - rol aanpakker kind | ||
+ | |style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Supervisor - rol supervisor |
− | |style="background-color: white;"| | + | |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="4"| | + | |colspan="4"|Lichamelijk onderzoek kind |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Geboortegewicht |
− | |style="background-color: white;"| | + | |style="background-color: white;"|3450 gram |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Congenitale afwijkingen? |
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|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="3"|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= | + | <section begin=medisch_onderzoek_999910413 /> |
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Irregulaire antistoffen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |}<section end=medisch_onderzoek_999910413 /> | ||
+ | === Postnatale fase === | ||
+ | <section begin=postnatale_fase_999910413 /> | ||
{| class="wikitable" width="85%" | {| 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 | ||
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kindspecifieke gegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Burgerservicenummer | + | |rowspan="7"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="3"|Rangnummer kind | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voeding kind groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voeding kind datum | ||
+ | |style="background-color: white;"|T - 81 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Substantie voeding kind | ||
+ | |style="background-color: white;"|borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Substantie voeding kind | ||
+ | |style="background-color: white;"|kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | ||
+ | |}<section end=postnatale_fase_999910413 /> | ||
+ | ==Scenario 2. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling. (voor vrouw met BSN: 961921821)== | ||
+ | <section begin=961921821 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Burgerservicenummer | ||
+ | |style="background-color: white;"|961921821 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Lokale persoonsidentificatie | ||
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Geboortedatum | ||
+ | |style="background-color: white;"|11 sep in het jaar: (jaar van T) - 41 jaar | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Adres - postcode | ||
+ | |style="background-color: white;"|5689 CZ | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Etniciteit | ||
+ | |style="background-color: white;"|Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Lengte gemeten | ||
+ | |style="background-color: white;"|184 cm | ||
+ | |}<section end=961921821 /> | ||
+ | === Anamnese === | ||
+ | <section begin=anamnese_961921821 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Anamnese | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Onder behandeling geweest? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |}<section end=anamnese_961921821 /> | ||
+ | === Zorgverlening === | ||
+ | <section begin=zorgverlening_961921821 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Zorgverlening | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="6" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Datum start zorgverantwoordelijkheid | ||
+ | |style="background-color: white;"|T - 332 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Datum einde zorgverantwoordelijkheid | ||
+ | |style="background-color: white;"|T - 240 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Conclusie risicostatus na intake | ||
+ | |style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Verwijsdetails | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="21"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Datum verwijzing | ||
+ | |style="background-color: white;"|T - 240 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Verwijzing van | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zorginstelling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Zorgaanbieder identificatie nummer | ||
+ | |style="background-color: white;"|1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Verwijzing naar |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="5"|Zorginstelling |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Specialisme | ||
+ | |style="background-color: white;"|gynaecoloog 2e lijn (code = '02' in codeSystem '2.16.840.1.113883.2.4.4.15.1') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Type verwijzing | ||
+ | |style="background-color: white;"|Consult (code = '11429006' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Redenen van verwijzing | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Van 1e naar 2e lijn | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="4"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zwangerschap | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Hypertensieve aandoening |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Perinatale periode |
− | |style="background-color: white;"| | + | |style="background-color: white;"|voor 28e week (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') |
− | |}<section end= | + | |}<section end=zorgverlening_961921821 /> |
=== Zorgverlenerzorginstelling === | === Zorgverlenerzorginstelling === | ||
− | <section begin= | + | <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="4" | Zorgverlenerzorginstelling | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zorgverlenerzorginstelling | ||
Regel 190: | Regel 559: | ||
|colspan="4"|Zorginstelling | |colspan="4"|Zorginstelling | ||
|-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"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
+ | |}<section end=zorgverlenerzorginstelling_961921821 /> | ||
+ | === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === | ||
+ | <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="3"|Wijze einde zwangerschap |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|T - 575 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Diagnose |
|-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"| | + | |colspan="2"|Bloedverlies? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Hyperemesis gravidarum? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
− | |}<section end= | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="3"|Irregulaire antistoffen? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | ||
=== Zwangerschap === | === Zwangerschap === | ||
− | <section begin= | + | <section begin=zwangerschap_961921821 /> |
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Dossiernummer | ||
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Graviditeit | ||
+ | |style="background-color: white;"|2 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pariteit voor deze zwangerschap | ||
+ | |style="background-color: white;"|0 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|T - 115 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voornemens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie | ||
+ | |style="background-color: white;"|Nog niet bepaald (code = '05' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Prenatale controle | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum controle | ||
+ | |style="background-color: white;"|T - 240 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|155 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Leven voelen | ||
+ | |style="background-color: white;"|weinig (code = '276372004' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Rookgedrag | ||
+ | |style="background-color: white;"|gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Alcoholgebruik | ||
+ | |style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Drugsgebruik? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Gewicht gemeten | ||
+ | |style="background-color: white;"|85 kg | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Diagnose | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum | ||
+ | |style="background-color: white;"|T - 240 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|155 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Hypertensieve aandoening | ||
+ | |style="background-color: white;"|Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Maternale sterfte? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |}<section end=zwangerschap_961921821 /> | ||
+ | ==Scenario 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling. (voor vrouw met BSN: 961921821)== | ||
+ | <section begin=961921821 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Burgerservicenummer | ||
+ | |style="background-color: white;"|961921821 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Lokale persoonsidentificatie | ||
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Geboortedatum | ||
+ | |style="background-color: white;"|11 sep in het jaar: (jaar van T) - 41 jaar | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Adres - postcode | ||
+ | |style="background-color: white;"|5689 CZ | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Etniciteit | ||
+ | |style="background-color: white;"|Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Lengte gemeten | ||
+ | |style="background-color: white;"|184 cm | ||
+ | |}<section end=961921821 /> | ||
+ | === Anamnese === | ||
+ | <section begin=anamnese_961921821 /> | ||
{| class="wikitable" width="85%" | {| 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" | Anamnese |
|-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 217: | Regel 697: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"|Graviditeit | + | |colspan="2"|Onder behandeling geweest? |
+ | |style="background-color: white;"|Nee | ||
+ | |}<section end=anamnese_961921821 /> | ||
+ | === Zorgverlening === | ||
+ | <section begin=zorgverlening_961921821 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Zorgverlening | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="6" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Datum start zorgverantwoordelijkheid | ||
+ | |style="background-color: white;"|T - 234 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Datum einde zorgverantwoordelijkheid | ||
+ | |style="background-color: white;"|T - 84 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Verwijsdetails | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="18"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Verwijzing van | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zorginstelling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Zorgaanbieder identificatie nummer | ||
+ | |style="background-color: white;"|1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Verwijzing naar | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zorginstelling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Zorgaanbieder identificatie nummer | ||
+ | |style="background-color: white;"|0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Redenen van verwijzing | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Van 1e naar 2e lijn | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zwangerschap | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Hypertensieve aandoening | ||
+ | |style="background-color: white;"|Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT') | ||
+ | |}<section end=zorgverlening_961921821 /> | ||
+ | === Zorgverlenerzorginstelling === | ||
+ | <section begin=zorgverlenerzorginstelling_961921821 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zorgverlenerzorginstelling | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorginstelling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorginstelling lvrid | ||
+ | |style="background-color: white;"|0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |}<section end=zorgverlenerzorginstelling_961921821 /> | ||
+ | === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === | ||
+ | <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Wijze einde zwangerschap | ||
+ | |style="background-color: white;"|Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|T - 575 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Diagnose | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Gynaecologische aandoening | ||
+ | |style="background-color: white;"|Uterus anomalie (code = '37849005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Bloedverlies? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Hyperemesis gravidarum? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Irregulaire antistoffen? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | ||
+ | === Zwangerschap === | ||
+ | <section begin=zwangerschap_961921821 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Dossiernummer | ||
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Graviditeit | ||
|style="background-color: white;"|2 | |style="background-color: white;"|2 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Pariteit voor deze zwangerschap |
+ | |style="background-color: white;"|0 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|T - 115 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voornemens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie | ||
+ | |style="background-color: white;"|Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Prenatale controle | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum controle | ||
+ | |style="background-color: white;"|T - 234 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|161 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Leven voelen | ||
+ | |style="background-color: white;"|verminderd (code = '276369006' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Rookgedrag | ||
+ | |style="background-color: white;"|gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Alcoholgebruik | ||
+ | |style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Drugsgebruik? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Gewicht gemeten | ||
+ | |style="background-color: white;"|85 kg | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Diagnose | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum | ||
+ | |style="background-color: white;"|T - 234 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|161 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Gynaecologische aandoening | ||
+ | |style="background-color: white;"|Uterus anomalie (code = '37849005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Partiele mola? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Hypertensieve aandoening | ||
+ | |style="background-color: white;"|Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Maternale sterfte? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Wijze einde zwangerschap | ||
+ | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
+ | |}<section end=zwangerschap_961921821 /> | ||
+ | === Bevalling === | ||
+ | <section begin=bevalling_961921821 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Partusnummer | ||
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Aantal geboren kinderen | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Risicostatus voor baring | ||
+ | |style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Interventies begin baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Interventie begin baring | ||
+ | |style="background-color: white;"|Primaire sectio caesarea (code = '80771000146107' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Indicatie interventie begin baring | ||
+ | |style="background-color: white;"|acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Wijze waarop de baring begon | ||
+ | |style="background-color: white;"|Interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Tijdstip begin actieve ontsluiting | ||
+ | |style="background-color: white;"|T - 124 dagen om 14:09 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Medicatie nageboortetijdperk groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Medicatie nageboortetijdperk? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Soort medicatie nageboortetijdperk | ||
+ | |style="background-color: white;"|Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Placenta - geboorte placenta | ||
+ | |style="background-color: white;"|Placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Hoeveelheid bloedverlies | ||
+ | |style="background-color: white;"|980 ml | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Conditie perineum postpartum | ||
+ | |style="background-color: white;"|Gaaf (code = '289854007' in codeSystem 'SNOMED CT') | ||
+ | |}<section end=bevalling_961921821 /> | ||
+ | === Uitkomst per kind === | ||
+ | <section begin=uitkomst_per_kind_961921821 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Uitkomst per kind | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="6" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="51"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Werkelijke plaats baring type locatie | ||
+ | |style="background-color: white;"|Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Ziekenhuis baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ziekenhuisnummer lvrid | ||
+ | |style="background-color: white;"|0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Identificaties kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Bsn kind | ||
+ | |style="background-color: white;"|951847624 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslacht medische observatie | ||
+ | |style="background-color: white;"|mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortedatum | ||
+ | |style="background-color: white;"|T - 122 dagen om 02:34 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Rangnummer kind | ||
|style="background-color: white;"|1 | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Perinatale sterfte groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Perinatale sterfte? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Kindspecifieke maternale gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Tijdstip breken vliezen | ||
+ | |style="background-color: white;"|T - 124 dagen om 23:04 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Kleur en consistentie vruchtwater | ||
+ | |style="background-color: white;"|geen informatie (code = 'NI' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ruggeprik gewenst niet gekregen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Pijnbestrijding? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Pijnbestrijding | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |rowspan="5"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="4"|Methode | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Methode | ||
+ | |style="background-color: white;"|Epidurale analgesie (code = '18946005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Periode | ||
+ | |style="background-color: white;"|tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Sedatie? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Kindspecifieke uitkomstgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="21"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Type partus | ||
+ | |style="background-color: white;"|Sectio Caesarea (code = '11466000' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ligging bij geboorte | ||
+ | |style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Aanpakker kind - rol aanpakker kind | ||
+ | |style="background-color: white;"|gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Supervisor - rol supervisor | ||
+ | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem 'UZI Rolcodes') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Sectio caesarea group | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Indicatie primaire sectio | ||
+ | |style="background-color: white;"|verdenking foetale nood (code = '444433005:246090004=130955003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Indicatie primaire sectio | ||
+ | |style="background-color: white;"|maternale conditie (code = '418138009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Lichamelijk onderzoek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Geboortegewicht | ||
+ | |style="background-color: white;"|3620 gram | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Congenitale afwijkingen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problematiek kind? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Kinderarts betrokken? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Betrokkenheid kinderarts | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Datum betrokkenheid | ||
+ | |style="background-color: white;"|T - 122 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Reden betrokkenheid | ||
+ | |style="background-color: white;"|overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Type betrokkenheid | ||
+ | |style="background-color: white;"|Consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Zorginstelling lvrid | ||
+ | |style="background-color: white;"|0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |}<section end=uitkomst_per_kind_961921821 /> | ||
+ | === Medisch onderzoek === | ||
+ | <section begin=medisch_onderzoek_961921821 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Irregulaire antistoffen? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Welke irregulaire antistoffen vrouw aanwezig |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Rhesus D (code = '112162009' in codeSystem 'SNOMED CT') |
− | |}<section end= | + | |}<section end=medisch_onderzoek_961921821 /> |
− | == | + | === Postnatale fase === |
− | <section begin= | + | <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 | ||
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Diagnoseinterventie postnataal | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 120 dagen |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pathologie vrouw | ||
+ | |style="background-color: white;"|Urineweginfectie (code = '68566005' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Kindspecifieke gegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="6"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Rangnummer kind | ||
+ | |style="background-color: white;"|1 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Voeding kind groep |
|-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"| | + | |colspan="2"|Voeding kind datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 86 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Substantie voeding kind |
− | |style="background-color: white;"| | + | |style="background-color: white;"|kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
− | |}<section end= | + | |}<section end=postnatale_fase_961921821 /> |
+ | ==Scenario 3. zorg volledig in 2e lijn, meerling, 1 kind overleden. (voor vrouw met BSN: 895623146)== | ||
+ | <section begin=895623146 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Burgerservicenummer | ||
+ | |style="background-color: white;"|895623146 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Lokale persoonsidentificatie | ||
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Geboortedatum | ||
+ | |style="background-color: white;"|5 aug in het jaar: (jaar van T) - 30 jaar | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Adres - postcode | ||
+ | |style="background-color: white;"|5421 JG | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Etniciteit | ||
+ | |style="background-color: white;"|Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Lengte gemeten | ||
+ | |style="background-color: white;"|167 cm | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Vrouwelijke genitale verminking? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type vrouwelijke genitale verminking | ||
+ | |style="background-color: white;"|Type 2 (code = '130621000119105' in codeSystem 'SNOMED CT') | ||
+ | |}<section end=895623146 /> | ||
+ | === Anamnese === | ||
+ | <section begin=anamnese_895623146 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Onder behandeling geweest? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Algemene anamnese | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Cardiovasculaire aandoening | ||
+ | |style="background-color: white;"|Hartritmestoornis (code = '698247007' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Schildklier aandoening | ||
+ | |style="background-color: white;"|Hyperthyreoidie (code = '34486009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Anemie | ||
+ | |style="background-color: white;"|IJzergebrek (code = '87522002' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Bloedtransfusie? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type operatie | ||
+ | |style="background-color: white;"|Hart (code = '64915003' in codeSystem 'SNOMED CT') | ||
+ | |}<section end=anamnese_895623146 /> | ||
+ | === Zorgverlening === | ||
+ | <section begin=zorgverlening_895623146 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlening | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum start zorgverantwoordelijkheid | ||
+ | |style="background-color: white;"|T - 297 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum einde zorgverantwoordelijkheid | ||
+ | |style="background-color: white;"|T - 59 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Conclusie risicostatus na intake | ||
+ | |style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | ||
+ | |}<section end=zorgverlening_895623146 /> | ||
=== Zorgverlenerzorginstelling === | === Zorgverlenerzorginstelling === | ||
− | <section begin= | + | <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="4" | Zorgverlenerzorginstelling | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zorgverlenerzorginstelling | ||
Regel 265: | Regel 1.267: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorginstelling | |colspan="4"|Zorginstelling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorginstelling lvrid | ||
+ | |style="background-color: white;"|9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |}<section end=zorgverlenerzorginstelling_895623146 /> | ||
+ | === Zwangerschap === | ||
+ | <section begin=zwangerschap_895623146 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Dossiernummer | ||
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Graviditeit | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pariteit voor deze zwangerschap | ||
+ | |style="background-color: white;"|0 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|T - 101 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voornemens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie | ||
+ | |style="background-color: white;"|Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Prenatale controle | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum controle | ||
+ | |style="background-color: white;"|T - 225 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|156 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Leven voelen | ||
+ | |style="background-color: white;"|goed (code = '289431008' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Rookgedrag | ||
+ | |style="background-color: white;"|niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Alcoholgebruik | ||
+ | |style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Drugsgebruik? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Gewicht gemeten | ||
+ | |style="background-color: white;"|67 kg | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Diagnose | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum | ||
+ | |style="background-color: white;"|T - 225 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|156 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Bloedverlies? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Infectie | ||
+ | |style="background-color: white;"|Urineweg infectie (code = '307534009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Afwijkende groei foetus | ||
+ | |style="background-color: white;"|Dysmaturiteit (code = '267258002' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Abruptio placentae? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Maternale sterfte? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Wijze einde zwangerschap | ||
+ | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
+ | |}<section end=zwangerschap_895623146 /> | ||
+ | === Bevalling === | ||
+ | <section begin=bevalling_895623146 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Partusnummer | ||
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Diagnose bevalling | ||
|-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"|Zorginstelling lvrid | + | |colspan="2"|Pprom? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Verdenking foetale nood? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Aantal geboren kinderen | ||
+ | |style="background-color: white;"|2 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Risicostatus voor baring | ||
+ | |style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Wijze waarop de baring begon | ||
+ | |style="background-color: white;"|Spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Tijdstip begin actieve ontsluiting | ||
+ | |style="background-color: white;"|T - 127 dagen om 22:09 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Medicatie nageboortetijdperk groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Medicatie nageboortetijdperk? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Placenta - geboorte placenta | ||
+ | |style="background-color: white;"|Controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Hoeveelheid bloedverlies | ||
+ | |style="background-color: white;"|1740 ml | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Conditie perineum postpartum | ||
+ | |style="background-color: white;"|Episiotomiewond (code = '609344008' in codeSystem 'SNOMED CT') | ||
+ | |}<section end=bevalling_895623146 /> | ||
+ | === Uitkomst per kind === | ||
+ | <section begin=uitkomst_per_kind_895623146 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="7" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="59"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Werkelijke plaats baring type locatie | ||
+ | |style="background-color: white;"|Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Ziekenhuis baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ziekenhuisnummer lvrid | ||
+ | |style="background-color: white;"|9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Identificaties kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Bsn kind | ||
+ | |style="background-color: white;"|847035116 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Geslacht medische observatie | ||
+ | |style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Geboortedatum | ||
+ | |style="background-color: white;"|T - 126 dagen om 06:30 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Rangnummer kind | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Perinatale sterfte groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Perinatale sterfte? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Kindspecifieke maternale gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="19"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Tijdstip breken vliezen | ||
+ | |style="background-color: white;"|T - 127 dagen om 22:09 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kleur en consistentie vruchtwater | ||
+ | |style="background-color: white;"|Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Tijdstip actief meepersen | ||
+ | |style="background-color: white;"|T - 127 dagen om 23:49 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Episiotomie? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Locatie episiotomie | ||
+ | |style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ruggeprik gewenst niet gekregen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Pijnbestrijding? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Pijnbestrijding | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Methode | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Methode | ||
+ | |style="background-color: white;"|Overig middel (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Overig middel | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Middel | ||
+ | |style="background-color: white;"|Morfinometica (code = '52685006:363701004=404642006' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Toediening | ||
+ | |style="background-color: white;"|Intraveneus (code = '431215000' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Periode | ||
+ | |style="background-color: white;"|tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Sedatie? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Kindspecifieke uitkomstgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="22"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Type partus | ||
+ | |style="background-color: white;"|Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ligging bij geboorte | ||
+ | |style="background-color: white;"|Aangezicht (code = '21882006' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Aanpakker kind - rol aanpakker kind | ||
+ | |style="background-color: white;"|arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Supervisor - rol supervisor | ||
+ | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem 'UZI Rolcodes') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Vaginale kunstverlossing groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Vaginale kunstverlossing | ||
+ | |style="background-color: white;"|Forceps (code = '302383004' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Succes vaginale kunstverlossing? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Lichamelijk onderzoek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortegewicht | ||
+ | |style="background-color: white;"|2040 gram | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Congenitale afwijkingen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Problematiek kind? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Problematiek kind | ||
+ | |style="background-color: white;"|Geboortetrauma (code = '56110009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kinderarts betrokken? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Betrokkenheid kinderarts | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Datum betrokkenheid | ||
+ | |style="background-color: white;"|T - 126 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Reden betrokkenheid | ||
+ | |style="background-color: white;"|kunstverlossing (code = '8571000146103' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Type betrokkenheid | ||
+ | |style="background-color: white;"|Consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorginstelling lvrid | ||
+ | |style="background-color: white;"|9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |}<section end=uitkomst_per_kind_895623146 /> | ||
+ | === Uitkomst per kind === | ||
+ | <section begin=uitkomst_per_kind_895623146 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="7" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="71"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Werkelijke plaats baring type locatie | ||
+ | |style="background-color: white;"|Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Ziekenhuis baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ziekenhuisnummer lvrid | ||
+ | |style="background-color: white;"|9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Identificaties kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Bsn kind | ||
+ | |style="background-color: white;"|847035128 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Geslacht medische observatie | ||
+ | |style="background-color: white;"|mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Geboortedatum | ||
+ | |style="background-color: white;"|T - 126 dagen om 07:02 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Rangnummer kind | ||
+ | |style="background-color: white;"|2 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Perinatale sterfte groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Perinatale sterfte? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Fase perinatale sterfte | ||
+ | |style="background-color: white;"|Postpartum (code = '276506001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Datumtijd vaststelling perinatale sterfte | ||
+ | |style="background-color: white;"|T - 126 dagen om 08:10 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Kindspecifieke maternale gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="19"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Tijdstip breken vliezen | ||
+ | |style="background-color: white;"|T - 127 dagen om 23:13 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kleur en consistentie vruchtwater | ||
+ | |style="background-color: white;"|Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Tijdstip actief meepersen | ||
+ | |style="background-color: white;"|T - 126 dagen om 06:45 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Episiotomie? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Locatie episiotomie | ||
+ | |style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ruggeprik gewenst niet gekregen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Pijnbestrijding? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Pijnbestrijding | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Methode | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Methode | ||
+ | |style="background-color: white;"|Overig middel (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Overig middel | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Middel | ||
+ | |style="background-color: white;"|Entonox (code = '426060003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Toediening | ||
+ | |style="background-color: white;"|Inhalatie (code = '241717009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Periode | ||
+ | |style="background-color: white;"|tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Sedatie? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Kindspecifieke uitkomstgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="32"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Type partus | ||
+ | |style="background-color: white;"|Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ligging bij geboorte | ||
+ | |style="background-color: white;"|Volkomen stuit (code = '49168004' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Aanpakker kind - rol aanpakker kind | ||
+ | |style="background-color: white;"|arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Supervisor - rol supervisor | ||
+ | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem 'UZI Rolcodes') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Vaginale kunstverlossing groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Vaginale kunstverlossing | ||
+ | |style="background-color: white;"|Stuitextractie (code = '416055001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Succes vaginale kunstverlossing? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Overige interventies | ||
+ | |style="background-color: white;"|Opheffen schouderdystocie (code = '237008007' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Lichamelijk onderzoek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortegewicht | ||
+ | |style="background-color: white;"|1580 gram | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Congenitale afwijkingen? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Congenitale afwijkingen groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Specificatie congenitale afwijking groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Specificatie congenitale afwijking | ||
+ | |style="background-color: white;"|spina bifida occulta (code = '76916001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Specificatie congenitale afwijking groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Specificatie congenitale afwijking | ||
+ | |style="background-color: white;"|gecompliceerd vitium (code = '94702005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Chromosomale afwijkingen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Problematiek kind? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Problematiek kind | ||
+ | |style="background-color: white;"|Subdurale bloeding (code = '126941005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kinderarts betrokken? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Betrokkenheid kinderarts | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Datum betrokkenheid | ||
+ | |style="background-color: white;"|T - 126 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Reden betrokkenheid | ||
+ | |style="background-color: white;"|overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Type betrokkenheid | ||
+ | |style="background-color: white;"|Overdracht (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorginstelling lvrid | ||
+ | |style="background-color: white;"|0001 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |}<section end=uitkomst_per_kind_895623146 /> | ||
+ | === Medisch onderzoek === | ||
+ | <section begin=medisch_onderzoek_895623146 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Irregulaire antistoffen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |}<section end=medisch_onderzoek_895623146 /> | ||
+ | === Postnatale fase === | ||
+ | <section begin=postnatale_fase_895623146 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kindspecifieke gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Rangnummer kind |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Voeding kind groep |
|-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"| | + | |colspan="2"|Voeding kind datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 120 dagen |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Substantie voeding kind | ||
+ | |style="background-color: white;"|borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | ||
+ | |}<section end=postnatale_fase_895623146 /> | ||
+ | ==Scenario 4. 1e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden. (voor vrouw met BSN: 850810711)== | ||
+ | <section begin=850810711 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Burgerservicenummer | ||
+ | |style="background-color: white;"|850810711 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Lokale persoonsidentificatie | ||
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Geboortedatum | ||
+ | |style="background-color: white;"|6 aug in het jaar: (jaar van T) - 28 jaar | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Adres - postcode | ||
+ | |style="background-color: white;"|4589 BA | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Etniciteit | ||
+ | |style="background-color: white;"|Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Lengte gemeten | ||
+ | |style="background-color: white;"|162 cm | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Vrouwelijke genitale verminking? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type vrouwelijke genitale verminking | ||
+ | |style="background-color: white;"|Type 1 (code = '130631000119108' in codeSystem 'SNOMED CT') | ||
+ | |}<section end=850810711 /> | ||
+ | === Anamnese === | ||
+ | <section begin=anamnese_850810711 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Onder behandeling geweest? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Algemene anamnese | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Autoimmuun aandoening | ||
+ | |style="background-color: white;"|Reuma (code = '396332003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Urogenitale aandoening | ||
+ | |style="background-color: white;"|Bacteriurie (code = '61373006' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Diabetes mellitus? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Mdl aandoening | ||
+ | |style="background-color: white;"|Chronische leveraandoeningen (code = '328383001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Longaandoening | ||
+ | |style="background-color: white;"|Astma (code = '195967001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type operatie | ||
+ | |style="background-color: white;"|Orthopedisch (code = '112697007' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type operatie | ||
+ | |style="background-color: white;"|Appendectomie (code = '80146002' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type operatie | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
+ | |}<section end=anamnese_850810711 /> | ||
+ | === Zorgverlening === | ||
+ | <section begin=zorgverlening_850810711 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Zorgverlening | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="5" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Datum start zorgverantwoordelijkheid | ||
+ | |style="background-color: white;"|T - 147 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Datum einde zorgverantwoordelijkheid | ||
+ | |style="background-color: white;"|T - 108 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Conclusie risicostatus na intake | ||
+ | |style="background-color: white;"|3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Verwijsdetails | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="14"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verwijzing van | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorginstelling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgaanbieder identificatie nummer | ||
+ | |style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verwijzing naar | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorginstelling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Zorgaanbieder identificatie nummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
− | |}<section end= | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="5"|Redenen van verwijzing | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Van 2e naar 1e lijn | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
+ | |}<section end=zorgverlening_850810711 /> | ||
+ | === Zorgverlenerzorginstelling === | ||
+ | <section begin=zorgverlenerzorginstelling_850810711 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zorgverlenerzorginstelling | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorginstelling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorginstelling lvrid | ||
+ | |style="background-color: white;"|1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |}<section end=zorgverlenerzorginstelling_850810711 /> | ||
=== Zwangerschap === | === Zwangerschap === | ||
− | <section begin= | + | <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" | Zwangerschap | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zwangerschap | ||
Regel 292: | Regel 1.956: | ||
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Dossiernummer | ||
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Graviditeit | |colspan="2"|Graviditeit | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Pariteit voor deze zwangerschap | |colspan="2"|Pariteit voor deze zwangerschap | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|0 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|T - 136 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Maternale sterfte? | ||
+ | |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 /> | ||
+ | === Bevalling === | ||
+ | <section begin=bevalling_850810711 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Aantal geboren kinderen | ||
+ | |style="background-color: white;"|1 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"|Datum einde zwangerschap | + | |colspan="3"|Risicostatus voor baring |
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') |
− | |}<section end= | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="3"|Wijze waarop de baring begon | ||
+ | |style="background-color: white;"|Spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Tijdstip begin actieve ontsluiting | ||
+ | |style="background-color: white;"|T - 151 dagen om 21:09 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Medicatie nageboortetijdperk groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Medicatie nageboortetijdperk? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Soort medicatie nageboortetijdperk | ||
+ | |style="background-color: white;"|Prostaglandine (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Placenta - geboorte placenta | ||
+ | |style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Hoeveelheid bloedverlies | ||
+ | |style="background-color: white;"|1120 ml | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Conditie perineum postpartum | ||
+ | |style="background-color: white;"|3e graads ruptuur (code = '199930000' in codeSystem 'SNOMED CT') | ||
+ | |}<section end=bevalling_850810711 /> | ||
+ | === Uitkomst per kind === | ||
+ | <section begin=uitkomst_per_kind_850810711 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="7" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="58"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Werkelijke plaats baring type locatie | ||
+ | |style="background-color: white;"|Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Ziekenhuis baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ziekenhuisnummer lvrid | ||
+ | |style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Identificaties kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Bsn kind | ||
+ | |style="background-color: white;"|840736526 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Geslacht medische observatie | ||
+ | |style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Geboortedatum | ||
+ | |style="background-color: white;"|T - 150 dagen om 23:35 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Rangnummer kind | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Perinatale sterfte groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Perinatale sterfte? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Kindspecifieke maternale gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="19"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Tijdstip breken vliezen | ||
+ | |style="background-color: white;"|T - 151 dagen om 07:04 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kleur en consistentie vruchtwater | ||
+ | |style="background-color: white;"|Bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Tijdstip actief meepersen | ||
+ | |style="background-color: white;"|T - 150 dagen om 22:15 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Episiotomie? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Locatie episiotomie | ||
+ | |style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ruggeprik gewenst niet gekregen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Pijnbestrijding? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Pijnbestrijding | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Methode | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Methode | ||
+ | |style="background-color: white;"|Overig middel (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Overig middel | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Middel | ||
+ | |style="background-color: white;"|Entonox (code = '426060003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Toediening | ||
+ | |style="background-color: white;"|Inhalatie (code = '241717009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Periode | ||
+ | |style="background-color: white;"|tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Sedatie? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Kindspecifieke uitkomstgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="21"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Type partus | ||
+ | |style="background-color: white;"|Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ligging bij geboorte | ||
+ | |style="background-color: white;"|Kruin (code = '249079005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Aanpakker kind - rol aanpakker kind | ||
+ | |style="background-color: white;"|co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Supervisor - rol supervisor | ||
+ | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem 'UZI Rolcodes') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Vaginale kunstverlossing groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Vaginale kunstverlossing | ||
+ | |style="background-color: white;"|Forceps (code = '302383004' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Succes vaginale kunstverlossing? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Lichamelijk onderzoek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortegewicht | ||
+ | |style="background-color: white;"|4205 gram | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Congenitale afwijkingen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Problematiek kind? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kinderarts betrokken? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Betrokkenheid kinderarts | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Datum betrokkenheid | ||
+ | |style="background-color: white;"|T - 150 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Reden betrokkenheid | ||
+ | |style="background-color: white;"|kunstverlossing (code = '8571000146103' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Type betrokkenheid | ||
+ | |style="background-color: white;"|Consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorginstelling lvrid | ||
+ | |style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |}<section end=uitkomst_per_kind_850810711 /> | ||
+ | === Postnatale fase === | ||
+ | <section begin=postnatale_fase_850810711 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Diagnoseinterventie postnataal | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Datum | ||
+ | |style="background-color: white;"|T - 146 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pathologie vrouw | ||
+ | |style="background-color: white;"|Embolie (code = '414086009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Diagnoseinterventie postnataal | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Datum | ||
+ | |style="background-color: white;"|T - 146 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pathologie vrouw | ||
+ | |style="background-color: white;"|Ontstoken episiotomie (code = '300927001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kindspecifieke gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voeding kind groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voeding kind datum | ||
+ | |style="background-color: white;"|T - 108 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Substantie voeding kind | ||
+ | |style="background-color: white;"|kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | ||
+ | |}<section end=postnatale_fase_850810711 /> | ||
+ | ==Scenario 4. 2e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)== | ||
+ | <section begin=850810711 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Burgerservicenummer | ||
+ | |style="background-color: white;"|850810711 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Lokale persoonsidentificatie | ||
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Geboortedatum | ||
+ | |style="background-color: white;"|6 aug in het jaar: (jaar van T) - 28 jaar | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Adres - postcode | ||
+ | |style="background-color: white;"|4589 BA | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Etniciteit | ||
+ | |style="background-color: white;"|Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Lengte gemeten | ||
+ | |style="background-color: white;"|162 cm | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Vrouwelijke genitale verminking? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type vrouwelijke genitale verminking | ||
+ | |style="background-color: white;"|Type 1 (code = '130631000119108' in codeSystem 'SNOMED CT') | ||
+ | |}<section end=850810711 /> | ||
+ | === Anamnese === | ||
+ | <section begin=anamnese_850810711 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Onder behandeling geweest? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Algemene anamnese | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Autoimmuun aandoening | ||
+ | |style="background-color: white;"|Reuma (code = '396332003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Urogenitale aandoening | ||
+ | |style="background-color: white;"|Bacteriurie (code = '61373006' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Diabetes mellitus? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Mdl aandoening | ||
+ | |style="background-color: white;"|Chronische leveraandoeningen (code = '328383001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Longaandoening | ||
+ | |style="background-color: white;"|Astma (code = '195967001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type operatie | ||
+ | |style="background-color: white;"|Orthopedisch (code = '112697007' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type operatie | ||
+ | |style="background-color: white;"|Appendectomie (code = '80146002' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type operatie | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
+ | |}<section end=anamnese_850810711 /> | ||
+ | === Zorgverlening === | ||
+ | <section begin=zorgverlening_850810711 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Zorgverlening | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="5" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Datum start zorgverantwoordelijkheid | ||
+ | |style="background-color: white;"|T - 332 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Datum einde zorgverantwoordelijkheid | ||
+ | |style="background-color: white;"|T - 148 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Conclusie risicostatus na intake | ||
+ | |style="background-color: white;"|3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Verwijsdetails | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="16"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Datum verwijzing | ||
+ | |style="background-color: white;"|T - 148 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verwijzing van | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorginstelling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgaanbieder identificatie nummer | ||
+ | |style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verwijzing naar | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorginstelling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgaanbieder identificatie nummer | ||
+ | |style="background-color: white;"|1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Redenen van verwijzing | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Van 2e naar 1e lijn | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Perinatale periode | ||
+ | |style="background-color: white;"|2e t/m 7e dag (code = '92' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') | ||
+ | |}<section end=zorgverlening_850810711 /> | ||
+ | === Zorgverlenerzorginstelling === | ||
+ | <section begin=zorgverlenerzorginstelling_850810711 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zorgverlenerzorginstelling | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorginstelling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorginstelling lvrid | ||
+ | |style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |}<section end=zorgverlenerzorginstelling_850810711 /> | ||
+ | === Zwangerschap === | ||
+ | <section begin=zwangerschap_850810711 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Dossiernummer | ||
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Graviditeit | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pariteit voor deze zwangerschap | ||
+ | |style="background-color: white;"|0 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|T - 136 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voornemens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie | ||
+ | |style="background-color: white;"|Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Prenatale controle | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum controle | ||
+ | |style="background-color: white;"|T - 239 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|177 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Leven voelen | ||
+ | |style="background-color: white;"|goed (code = '289431008' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Rookgedrag | ||
+ | |style="background-color: white;"|niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Alcoholgebruik | ||
+ | |style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Drugsgebruik? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Gewicht gemeten | ||
+ | |style="background-color: white;"|82 kg | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Diagnose | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum | ||
+ | |style="background-color: white;"|T - 239 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|177 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Infectie | ||
+ | |style="background-color: white;"|Urineweg infectie (code = '307534009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Maternale sterfte? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Wijze einde zwangerschap | ||
+ | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
+ | |}<section end=zwangerschap_850810711 /> | ||
=== Bevalling === | === Bevalling === | ||
− | <section begin= | + | <section begin=bevalling_850810711 /> |
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Diagnose bevalling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Niet vorderende ontsluiting? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Niet vorderende uitdrijving? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Aantal geboren kinderen | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Risicostatus voor baring | ||
+ | |style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Wijze waarop de baring begon | ||
+ | |style="background-color: white;"|Spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Tijdstip begin actieve ontsluiting | ||
+ | |style="background-color: white;"|T - 151 dagen om 21:09 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Medicatie nageboortetijdperk groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Medicatie nageboortetijdperk? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Soort medicatie nageboortetijdperk | ||
+ | |style="background-color: white;"|Prostaglandine (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Placenta - geboorte placenta | ||
+ | |style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Hoeveelheid bloedverlies | ||
+ | |style="background-color: white;"|1120 ml | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Conditie perineum postpartum | ||
+ | |style="background-color: white;"|3e graads ruptuur (code = '199930000' in codeSystem 'SNOMED CT') | ||
+ | |}<section end=bevalling_850810711 /> | ||
+ | === Uitkomst per kind === | ||
+ | <section begin=uitkomst_per_kind_850810711 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="7" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="58"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Werkelijke plaats baring type locatie | ||
+ | |style="background-color: white;"|Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Ziekenhuis baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ziekenhuisnummer lvrid | ||
+ | |style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Identificaties kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Bsn kind | ||
+ | |style="background-color: white;"|840736526 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Geslacht medische observatie | ||
+ | |style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Geboortedatum | ||
+ | |style="background-color: white;"|T - 150 dagen om 23:35 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Rangnummer kind | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Perinatale sterfte groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Perinatale sterfte? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Kindspecifieke maternale gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="19"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Tijdstip breken vliezen | ||
+ | |style="background-color: white;"|T - 151 dagen om 07:04 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kleur en consistentie vruchtwater | ||
+ | |style="background-color: white;"|Bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Tijdstip actief meepersen | ||
+ | |style="background-color: white;"|T - 150 dagen om 22:15 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Episiotomie? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Locatie episiotomie | ||
+ | |style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ruggeprik gewenst niet gekregen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Pijnbestrijding? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Pijnbestrijding | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Methode | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Methode | ||
+ | |style="background-color: white;"|Overig middel (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Overig middel | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Middel | ||
+ | |style="background-color: white;"|Entonox (code = '426060003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Toediening | ||
+ | |style="background-color: white;"|Inhalatie (code = '241717009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Periode | ||
+ | |style="background-color: white;"|tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Sedatie? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Kindspecifieke uitkomstgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="21"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Type partus | ||
+ | |style="background-color: white;"|Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ligging bij geboorte | ||
+ | |style="background-color: white;"|Kruin (code = '249079005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Aanpakker kind - rol aanpakker kind | ||
+ | |style="background-color: white;"|co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Supervisor - rol supervisor | ||
+ | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem 'UZI Rolcodes') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Vaginale kunstverlossing groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Vaginale kunstverlossing | ||
+ | |style="background-color: white;"|Forceps (code = '302383004' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Succes vaginale kunstverlossing? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Lichamelijk onderzoek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortegewicht | ||
+ | |style="background-color: white;"|4205 gram | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Congenitale afwijkingen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Problematiek kind? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kinderarts betrokken? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Betrokkenheid kinderarts | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Datum betrokkenheid | ||
+ | |style="background-color: white;"|T - 150 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Reden betrokkenheid | ||
+ | |style="background-color: white;"|kunstverlossing (code = '8571000146103' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Type betrokkenheid | ||
+ | |style="background-color: white;"|Consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorginstelling lvrid | ||
+ | |style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |}<section end=uitkomst_per_kind_850810711 /> | ||
+ | === Medisch onderzoek === | ||
+ | <section begin=medisch_onderzoek_850810711 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Irregulaire antistoffen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |}<section end=medisch_onderzoek_850810711 /> | ||
+ | ==Scenario 5. zorg volledig 2e lijn, vrouw overleden. (voor vrouw met BSN: 912345676)== | ||
+ | <section begin=912345676 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Burgerservicenummer | ||
+ | |style="background-color: white;"|912345676 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Lokale persoonsidentificatie | ||
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Geboortedatum | ||
+ | |style="background-color: white;"|4 maa in het jaar: (jaar van T) - 22 jaar | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Adres - postcode | ||
+ | |style="background-color: white;"|9562 GF | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Etniciteit | ||
+ | |style="background-color: white;"|Latijns Amerikaans (code = '14' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Lengte gemeten | ||
+ | |style="background-color: white;"|186 cm | ||
+ | |}<section end=912345676 /> | ||
+ | === Anamnese === | ||
+ | <section begin=anamnese_912345676 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Onder behandeling geweest? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Algemene anamnese | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Cardiovasculaire aandoening | ||
+ | |style="background-color: white;"|Hypertensie (code = '38341003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Diabetes mellitus? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Neurologische aandoening | ||
+ | |style="background-color: white;"|Epilepsie (code = '84757009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Longaandoening | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Orthopedische afwijking | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type stollingsprobleem | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Psychiatrie? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |}<section end=anamnese_912345676 /> | ||
+ | === Zorgverlening === | ||
+ | <section begin=zorgverlening_912345676 /> | ||
{| class="wikitable" width="85%" | {| 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 314: | Regel 2.753: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Datum start zorgverantwoordelijkheid |
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|T - 388 dagen |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum einde zorgverantwoordelijkheid | ||
+ | |style="background-color: white;"|T - 150 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Conclusie risicostatus na intake | ||
+ | |style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | ||
+ | |}<section end=zorgverlening_912345676 /> | ||
+ | === Zorgverlenerzorginstelling === | ||
+ | <section begin=zorgverlenerzorginstelling_912345676 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zorgverlenerzorginstelling | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorginstelling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorginstelling lvrid | ||
+ | |style="background-color: white;"|0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |}<section end=zorgverlenerzorginstelling_912345676 /> | ||
+ | === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === | ||
+ | <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="5" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Wijze einde zwangerschap | ||
+ | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|T - 940 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Diagnose | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Infectie | ||
+ | |style="background-color: white;"|Urineweg infectie (code = '307534009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zwangerschapscholestase? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Afwijkende groei foetus | ||
+ | |style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Irregulaire antistoffen? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Eerdere bevalling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="11"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Placenta - geboorte placenta | ||
+ | |style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Vorige uitkomst per kind - vorige baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Geboortedatum | ||
+ | |style="background-color: white;"|T - 936 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Kindspecifieke gegevens vorige uitkomsten | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type partus | ||
+ | |style="background-color: white;"|Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Percentiel van het geboortegewicht | ||
+ | |style="background-color: white;"|p10 tot p50 (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.50') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Apgarscore na 5 min | ||
+ | |style="background-color: white;"|10 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Congenitale afwijkingen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 /> | ||
+ | === Zwangerschap === | ||
+ | <section begin=zwangerschap_912345676 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Dossiernummer | ||
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Graviditeit | ||
+ | |style="background-color: white;"|2 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pariteit voor deze zwangerschap | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|T - 163 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voornemens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie | ||
+ | |style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Prenatale controle | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum controle | ||
+ | |style="background-color: white;"|T - 357 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|86 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Leven voelen | ||
+ | |style="background-color: white;"|geen (code = '289432001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Rookgedrag | ||
+ | |style="background-color: white;"|gestopt tijdens huidige zwangerschap (code = '6' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Alcoholgebruik | ||
+ | |style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Drugsgebruik? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Gewicht gemeten | ||
+ | |style="background-color: white;"|89 kg | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Diagnose | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum | ||
+ | |style="background-color: white;"|T - 357 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|86 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Afwijkende groei foetus | ||
+ | |style="background-color: white;"|Macrosomie (code = '199616008' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Abruptio placentae? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Intrauteriene behandeling | ||
+ | |style="background-color: white;"|Selectieve foeticide (code = '265633004' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Maternale sterfte? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Wijze einde zwangerschap | ||
+ | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
+ | |}<section end=zwangerschap_912345676 /> | ||
+ | === Bevalling === | ||
+ | <section begin=bevalling_912345676 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Partusnummer | ||
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Aantal geboren kinderen |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="3"|Risicostatus voor baring |
− | |style="background-color: | + | |style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Interventies begin baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"|Conditie perineum postpartum | + | |colspan="2"|Interventie begin baring |
+ | |style="background-color: white;"|Primaire sectio caesarea (code = '80771000146107' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Indicatie interventie begin baring | ||
+ | |style="background-color: white;"|acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Wijze waarop de baring begon | ||
+ | |style="background-color: white;"|Interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Medicatie nageboortetijdperk groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Medicatie nageboortetijdperk? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Placenta - geboorte placenta | ||
+ | |style="background-color: white;"|Placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Hoeveelheid bloedverlies | ||
+ | |style="background-color: white;"|1500 ml | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Conditie perineum postpartum | ||
|style="background-color: white;"|Gaaf (code = '289854007' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Gaaf (code = '289854007' in codeSystem 'SNOMED CT') | ||
− | |}<section end= | + | |}<section end=bevalling_912345676 /> |
=== Uitkomst per kind === | === Uitkomst per kind === | ||
− | <section begin= | + | <section begin=uitkomst_per_kind_912345676 /> |
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Uitkomst per kind |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="6" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="7"|Baring |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="56"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Werkelijke plaats baring type locatie | ||
+ | |style="background-color: white;"|Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Ziekenhuis baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ziekenhuisnummer lvrid | ||
+ | |style="background-color: white;"|0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Identificaties kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Bsn kind | ||
+ | |style="background-color: white;"|528741913 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslacht medische observatie | ||
+ | |style="background-color: white;"|niet conclusief (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortedatum | ||
+ | |style="background-color: white;"|T - 161 dagen om 02:30 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Rangnummer kind | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Perinatale sterfte groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Perinatale sterfte? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Kindspecifieke maternale gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Kleur en consistentie vruchtwater | ||
+ | |style="background-color: white;"|Meconium (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Episiotomie? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ruggeprik gewenst niet gekregen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Pijnbestrijding? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Pijnbestrijding | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Methode | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Methode | ||
+ | |style="background-color: white;"|Algehele anesthesie (code = '50697003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Periode | ||
+ | |style="background-color: white;"|tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Sedatie? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Kindspecifieke uitkomstgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="26"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Type partus | ||
+ | |style="background-color: white;"|Secundair (code = '274130007' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ligging bij geboorte | ||
+ | |style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Aanpakker kind - rol aanpakker kind | ||
+ | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem 'UZI Rolcodes') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Supervisor - rol supervisor | ||
+ | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem 'UZI Rolcodes') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Vaginale kunstverlossing groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Vaginale kunstverlossing | ||
+ | |style="background-color: white;"|Vacuüm (code = '61586001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Succes vaginale kunstverlossing? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Sectio caesarea group | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Beslismoment sectio caesarea | ||
+ | |style="background-color: white;"|Tijdens uitdrijving besloten (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.5') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Indicatie secundaire sectio | ||
+ | |style="background-color: white;"|maternale conditie (code = '418138009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Lichamelijk onderzoek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Geboortegewicht | ||
+ | |style="background-color: white;"|3750 gram | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Congenitale afwijkingen? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Congenitale afwijkingen groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Chromosomale afwijkingen? |
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Specificatie chromosomale afwijking groep |
|-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="3"|Geboortedatum | + | |colspan="2"|Specificatie chromosomale afwijking |
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|trisomie 21 (code = '41040004' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problematiek kind? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problematiek kind | ||
+ | |style="background-color: white;"|Gehoor (code = '95827002' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Kinderarts betrokken? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |}<section end=uitkomst_per_kind_912345676 /> | ||
+ | === Medisch onderzoek === | ||
+ | <section begin=medisch_onderzoek_912345676 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Irregulaire antistoffen? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Welke irregulaire antistoffen vrouw aanwezig | ||
+ | |style="background-color: white;"|Kell (code = '405844003' in codeSystem 'SNOMED CT') | ||
+ | |}<section end=medisch_onderzoek_912345676 /> | ||
+ | === Postnatale fase === | ||
+ | <section begin=postnatale_fase_912345676 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Diagnoseinterventie postnataal | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Datum | ||
+ | |style="background-color: white;"|T - 161 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pathologie vrouw | ||
+ | |style="background-color: white;"|Trombose diep veneuze postpartum (code = '56272000' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kindspecifieke gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voeding kind groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voeding kind datum | ||
+ | |style="background-color: white;"|T - 161 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Substantie voeding kind | ||
+ | |style="background-color: white;"|kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | ||
+ | |}<section end=postnatale_fase_912345676 /> | ||
+ | ==Scenario 6. 2de lijn met comorbiditeit. (voor vrouw met BSN: 100202020)== | ||
+ | <section begin=100202020 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Burgerservicenummer | ||
+ | |style="background-color: white;"|100202020 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Lokale persoonsidentificatie | ||
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Geboortedatum | ||
+ | |style="background-color: white;"|1 jan in het jaar: (jaar van T) - 31 jaar | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Adres - postcode | ||
+ | |style="background-color: white;"|1234 AB | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Etniciteit | ||
+ | |style="background-color: white;"|Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Lengte gemeten | ||
+ | |style="background-color: white;"|172 cm | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Vrouwelijke genitale verminking? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |}<section end=100202020 /> | ||
+ | === Anamnese === | ||
+ | <section begin=anamnese_100202020 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Onder behandeling geweest? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Algemene anamnese | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="18"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Autoimmuun aandoening | ||
+ | |style="background-color: white;"|Reuma (code = '396332003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Cardiovasculaire aandoening | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Overig, niet nader omschreven | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Urogenitale aandoening | ||
+ | |style="background-color: white;"|Pyelonefritis (code = '45816000' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Oncologische aandoening | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Overig, niet nader omschreven | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Schildklier aandoening | ||
+ | |style="background-color: white;"|Hypothyreoidie (code = '40930008' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Diabetes mellitus? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Neurologische aandoening | ||
+ | |style="background-color: white;"|Hernia nuclei pulposi (code = '84857004' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Neurologische aandoening | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Overig, niet nader omschreven | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Mdl aandoening | ||
+ | |style="background-color: white;"|M. Crohn (code = '34000006' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Anemie | ||
+ | |style="background-color: white;"|IJzergebrek (code = '87522002' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Longaandoening | ||
+ | |style="background-color: white;"|Astma (code = '195967001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Orthopedische afwijking | ||
+ | |style="background-color: white;"|Trauma bekken (code = '282771003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Bloedtransfusie? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type operatie | ||
+ | |style="background-color: white;"|Sectio (code = '11466000' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Type operatie | ||
+ | |style="background-color: white;"|Rug (code = '129152004:260686004=129284003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Psychiatrie? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Overige aandoening? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |}<section end=anamnese_100202020 /> | ||
+ | === Zorgverlening === | ||
+ | <section begin=zorgverlening_100202020 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlening | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum start zorgverantwoordelijkheid | ||
+ | |style="background-color: white;"|T - 306 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum einde zorgverantwoordelijkheid | ||
+ | |style="background-color: white;"|T - 78 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | ||
+ | |style="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Conclusie risicostatus na intake | ||
+ | |style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | ||
+ | |}<section end=zorgverlening_100202020 /> | ||
+ | === Zorgverlenerzorginstelling === | ||
+ | <section begin=zorgverlenerzorginstelling_100202020 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zorgverlenerzorginstelling | ||
+ | |-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=" | + | |colspan="4"|Zorginstelling |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="2"|Zorginstelling agbid |
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|12345678 (in identificerend systeem: AGB-Z) |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorginstelling lvrid | ||
+ | |style="background-color: white;"|0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |}<section end=zorgverlenerzorginstelling_100202020 /> | ||
+ | === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === | ||
+ | <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_100202020 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="6" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Wijze einde zwangerschap | ||
+ | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|T - 1064 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Diagnose | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Bloedverlies? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Cervixinsufficientie? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Infectie | ||
+ | |style="background-color: white;"|Intra-uterien (code = '301775005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Hyperemesis gravidarum? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Hypertensieve aandoening | ||
+ | |style="background-color: white;"|Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zwangerschapscholestase? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Diabetes gravidarum met insuline? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Afwijkende groei foetus | ||
+ | |style="background-color: white;"|Macrosomie (code = '199616008' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Dreigende partus immaturus? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Dreigende partus prematurus? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Abruptio placentae? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Irregulaire antistoffen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Eerdere bevalling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="15"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Placenta - geboorte placenta | ||
+ | |style="background-color: white;"|Placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Hoeveelheid bloedverlies | ||
+ | |style="background-color: white;"|895 ml | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Vorige uitkomst per kind - vorige baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="11"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Geboortedatum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 1112 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Kindspecifieke | + | |colspan="5"|Kindspecifieke gegevens vorige uitkomsten |
|-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"|Type partus | |colspan="3"|Type partus | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Secundair (code = '274130007' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Percentiel van het geboortegewicht | ||
+ | |style="background-color: white;"|p2,3 tot p10 (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.50') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Apgarscore na 5 min | ||
+ | |style="background-color: white;"|8 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Congenitale afwijkingen? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Congenitale afwijkingen groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Chromosomale afwijkingen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_100202020 /> | ||
+ | === Zwangerschap === | ||
+ | <section begin=zwangerschap_100202020 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zwangerschap | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Dossiernummer | ||
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Graviditeit | ||
+ | |style="background-color: white;"|2 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Pariteit voor deze zwangerschap | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Definitieve a terme datum | ||
+ | |style="background-color: white;"|T - 91 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Voornemens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Voorgenomen plaats baring tijdens zwangerschap type locatie | ||
+ | |style="background-color: white;"|Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Prenatale controle | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Datum controle | ||
+ | |style="background-color: white;"|T - 306 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Zwangerschapsduur | |colspan="3"|Zwangerschapsduur | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|65 dagen |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Leven voelen | ||
+ | |style="background-color: white;"|geen (code = '289432001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Rookgedrag | ||
+ | |style="background-color: white;"|gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Alcoholgebruik | ||
+ | |style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Drugsgebruik? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Gewicht gemeten | ||
+ | |style="background-color: white;"|68 kg | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Lichamelijk onderzoek kind | + | |colspan="5"|Diagnose |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="18"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Datum | ||
+ | |style="background-color: white;"|T - 306 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|65 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Gynaecologische aandoening | ||
+ | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Overig, niet nader gespecificeerd | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Bloedverlies? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Partiele mola? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Cervixinsufficientie? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Hyperemesis gravidarum? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Zwangerschapscholestase? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Diabetes gravidarum met insuline? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Afwijkende groei foetus | ||
+ | |style="background-color: white;"|Dysmaturiteit (code = '267258002' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Dreigende partus immaturus? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Dreigende partus prematurus? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Abruptio placentae? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Navelstrengprolaps? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Intrauteriene vruchtdood | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Vermoeden intrauteriene vruchtdood? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Maternale sterfte? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Wijze einde zwangerschap | ||
+ | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
+ | |}<section end=zwangerschap_100202020 /> | ||
+ | === Bevalling === | ||
+ | <section begin=bevalling_100202020 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Bevalling | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Partusnummer | ||
+ | |style="background-color: white;"|* [waarde moet gegenereerd worden in het zendende systeem] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Diagnose bevalling | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Pprom? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Prom? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Koorts? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Niet vorderende ontsluiting? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Niet vorderende uitdrijving? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verdenking foetale nood? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Intrauteriene vruchtdood | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Vermoeden intrauteriene vruchtdood? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Vastzittende placenta? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Fluxus postpartum? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Aantal geboren kinderen | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Risicostatus voor baring | ||
+ | |style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Interventies begin baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Interventie begin baring | ||
+ | |style="background-color: white;"|Primen prostaglandine (code = '236966000' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Indicatie interventie begin baring | ||
+ | |style="background-color: white;"|niet levensbedreigend (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Wijze waarop de baring begon | ||
+ | |style="background-color: white;"|Spontane weeën (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Tijdstip begin actieve ontsluiting | ||
+ | |style="background-color: white;"|T - 78 dagen om 03:45 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Medicatie nageboortetijdperk groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Medicatie nageboortetijdperk? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Soort medicatie nageboortetijdperk | ||
+ | |style="background-color: white;"|Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Placenta - geboorte placenta | ||
+ | |style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Hoeveelheid bloedverlies | ||
+ | |style="background-color: white;"|1050 ml | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Conditie perineum postpartum | ||
+ | |style="background-color: white;"|1e graads perineumruptuur (code = '199916005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Conditie perineum postpartum | ||
+ | |style="background-color: white;"|Episiotomiewond (code = '609344008' in codeSystem 'SNOMED CT') | ||
+ | |}<section end=bevalling_100202020 /> | ||
+ | === Uitkomst per kind === | ||
+ | <section begin=uitkomst_per_kind_100202020 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="7" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="8"|Baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="67"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Werkelijke plaats baring type locatie | ||
+ | |style="background-color: white;"|Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Ziekenhuis baring | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ziekenhuisnummer lvrid | ||
+ | |style="background-color: white;"|0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Identificaties kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Bsn kind | ||
+ | |style="background-color: white;"|847035116 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Geslacht medische observatie | ||
+ | |style="background-color: white;"|mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Geboortedatum | ||
+ | |style="background-color: white;"|T - 78 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Rangnummer kind | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Perinatale sterfte groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Perinatale sterfte? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Kindspecifieke maternale gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="20"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Bijstimulatie toegediend? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Tijdstip breken vliezen | ||
+ | |style="background-color: white;"|T - 78 dagen om 04:30 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kleur en consistentie vruchtwater | ||
+ | |style="background-color: white;"|Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Tijdstip actief meepersen | ||
+ | |style="background-color: white;"|T - 78 dagen om 05:00 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Episiotomie? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Locatie episiotomie | ||
+ | |style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ruggeprik gewenst niet gekregen? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Pijnbestrijding? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Pijnbestrijding | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Methode | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Methode | ||
+ | |style="background-color: white;"|Overig middel (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Overig middel | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Middel | ||
+ | |style="background-color: white;"|Entonox (code = '426060003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Toediening | ||
+ | |style="background-color: white;"|Inhalatie (code = '241717009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Periode | ||
+ | |style="background-color: white;"|tijdens ontsluitingsperiode > 3 cm (code = 'OntMt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Sedatie? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Kindspecifieke uitkomstgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="29"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Type partus | ||
+ | |style="background-color: white;"|Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ligging bij geboorte | ||
+ | |style="background-color: white;"|Achterhoofd-voor (code = '70028003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Aanpakker kind - rol aanpakker kind | ||
+ | |style="background-color: white;"|klinisch verloskundige (code = '25' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Supervisor - rol supervisor | ||
+ | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem 'UZI Rolcodes') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Vaginale kunstverlossing groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Vaginale kunstverlossing | ||
+ | |style="background-color: white;"|Vacuüm (code = '61586001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Succes vaginale kunstverlossing? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Lichamelijk onderzoek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Apgarscore na 5 min | ||
+ | |style="background-color: white;"|9 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortegewicht | ||
+ | |style="background-color: white;"|3550 gram | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Congenitale afwijkingen? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Congenitale afwijkingen groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Specificatie congenitale afwijking groep | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Specificatie congenitale afwijking | ||
+ | |style="background-color: white;"|overige congenitale huidafwijking (code = '74' in codeSystem '2.16.840.1.113883.2.4.4.13.8') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Chromosomale afwijkingen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Problematiek kind? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Problematiek kind | ||
+ | |style="background-color: white;"|Geboortetrauma (code = '56110009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kinderarts betrokken? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Betrokkenheid kinderarts | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Datum betrokkenheid | ||
+ | |style="background-color: white;"|T - 78 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Reden betrokkenheid | ||
+ | |style="background-color: white;"|kunstverlossing (code = '8571000146103' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Type betrokkenheid | ||
+ | |style="background-color: white;"|Consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorginstelling lvrid | ||
+ | |style="background-color: white;"|0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
+ | |}<section end=uitkomst_per_kind_100202020 /> | ||
+ | === Medisch onderzoek === | ||
+ | <section begin=medisch_onderzoek_100202020 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Irregulaire antistoffen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |}<section end=medisch_onderzoek_100202020 /> | ||
+ | === Postnatale fase === | ||
+ | <section begin=postnatale_fase_100202020 /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Kindspecifieke gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Rangnummer kind | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Voeding kind groep | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-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"| | + | |colspan="2"|Voeding kind datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 78 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Substantie voeding kind |
− | |style="background-color: white;"| | + | |style="background-color: white;"|borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
− | |}<section end= | + | |}<section end=postnatale_fase_100202020 /> |
[[Categorie:Kwalificatie]] | [[Categorie:Kwalificatie]] |
Huidige versie van 17 feb 2021 om 17:03
1 Addenda voor inhoudelijke gegevens Kernset Geboortezorg 2.3
1.1 Scenario 1. Zorg volledig 1e lijn, herpes, strippen, gezonde eenling. (voor vrouw met BSN: 999910413)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 999910413 (in identificerend systeem: BSN) | |
Lokale persoonsidentificatie | * [waarde moet gegenereerd worden in het zendende systeem] | |
Geboortedatum | 2 mei in het jaar: (jaar van T) - 39 jaar | |
Adres - postcode | 4563 AB | |
Etniciteit | Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 170 cm |
1.1.1 Anamnese
Anamnese | |||
Gegevenselement | Waarde | ||
Onder behandeling geweest? | Ja | ||
Algemene anamnese | |||
Cardiovasculaire aandoening | Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
Oncologische aandoening | Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
Infectieziekte | Herpes (code = '23513009' in codeSystem 'SNOMED CT') | ||
Type operatie | Orthopedisch (code = '112697007' in codeSystem 'SNOMED CT') |
1.1.2 Zorgverlening
Zorgverlening | ||
Gegevenselement | Waarde | |
Datum start zorgverantwoordelijkheid | T - 306 dagen | |
Datum einde zorgverantwoordelijkheid | T - 50 dagen | |
Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Conclusie risicostatus na intake | 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') |
1.1.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | |||
Gegevenselement | Waarde | ||
Zorginstelling | |||
Zorginstelling lvrid | 1808 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.1.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||||
Gegevenselement | Waarde | ||||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||||
Definitieve a terme datum | T - 1127 dagen | ||||
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 | |||||
Geboortedatum | T - 1120 dagen | ||||
Kindspecifieke gegevens vorige uitkomsten | |||||
Type partus | Spontaan (code = '177184002' in codeSystem 'SNOMED CT') | ||||
Percentiel van het geboortegewicht | p50 tot p90 (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.50') | ||||
Apgarscore na 5 min | 8 | ||||
Congenitale afwijkingen? | Nee |
1.1.5 Zwangerschap
Zwangerschap | |||
Gegevenselement | Waarde | ||
Dossiernummer | * [waarde moet gegenereerd worden in het zendende systeem] | ||
Graviditeit | 2 | ||
Pariteit voor deze zwangerschap | 1 | ||
Definitieve a terme datum | T - 84 dagen | ||
Voornemens | |||
Voorgenomen plaats baring tijdens zwangerschap type locatie | Thuis (code = '169813005' in codeSystem 'SNOMED CT') | ||
Prenatale controle | |||
Datum controle | T - 305 dagen | ||
Zwangerschapsduur | 59 dagen | ||
Leven voelen | goed (code = '289431008' in codeSystem 'SNOMED CT') | ||
Rookgedrag | niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
Drugsgebruik? | Nee | ||
Gewicht gemeten | 70 kg | ||
Diagnose | |||
Datum | T - 305 dagen | ||
Zwangerschapsduur | 59 dagen | ||
Infectie | Urineweg infectie (code = '307534009' in codeSystem 'SNOMED CT') | ||
Maternale sterfte? | Nee | ||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.1.6 Bevalling
Bevalling | |||
Gegevenselement | Waarde | ||
Partusnummer | * [waarde moet gegenereerd worden in het zendende systeem] | ||
Aantal geboren kinderen | 1 | ||
Risicostatus voor baring | 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
Interventies begin baring | |||
Interventie begin baring | Strippen (code = '236960006' in codeSystem 'SNOMED CT') | ||
Indicatie interventie begin baring | wens patiënt (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | ||
Wijze waarop de baring begon | Interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
Tijdstip begin actieve ontsluiting | T - 86 dagen om 14:30 uur | ||
Medicatie nageboortetijdperk groep | |||
Medicatie nageboortetijdperk? | Ja | ||
Soort medicatie nageboortetijdperk | Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') | ||
Placenta - geboorte placenta | Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
Hoeveelheid bloedverlies | 615 ml | ||
Conditie perineum postpartum | 1e graads perineumruptuur (code = '199916005' in codeSystem 'SNOMED CT') |
1.1.7 Uitkomst per kind
Uitkomst per kind | |||||
Gegevenselement | Waarde | ||||
Baring | |||||
Werkelijke plaats baring type locatie | Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') | ||||
Demografische gegevens | |||||
Identificaties kind | |||||
Bsn kind | 999910383 (in identificerend systeem: BSN) | ||||
Geslacht medische observatie | vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||||
Geboortedatum | T - 85 dagen | ||||
Rangnummer kind | 1 | ||||
Perinatale sterfte groep | |||||
Perinatale sterfte? | Nee | ||||
Kindspecifieke maternale gegevens | |||||
Tijdstip breken vliezen | T - 85 dagen om 09:15 uur | ||||
Kleur en consistentie vruchtwater | Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||
Tijdstip actief meepersen | T - 85 dagen om 12:13 uur | ||||
Episiotomie? | Nee | ||||
Ruggeprik gewenst niet gekregen? | Nee | ||||
Pijnbestrijding? | Nee | ||||
Sedatie? | Nee | ||||
Kindspecifieke uitkomstgegevens | |||||
Type partus | Spontaan (code = '177184002' in codeSystem 'SNOMED CT') | ||||
Ligging bij geboorte | Achterhoofd-achter (code = '37235006' in codeSystem 'SNOMED CT') | ||||
Aanpakker kind - rol aanpakker kind | 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||||
Supervisor - rol supervisor | 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||||
Lichamelijk onderzoek kind | |||||
Geboortegewicht | 3450 gram | ||||
Congenitale afwijkingen? | Nee | ||||
Problematiek kind? | Nee | ||||
Kinderarts betrokken? | Nee |
1.1.8 Medisch onderzoek
Medisch onderzoek | |||
Gegevenselement | Waarde | ||
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
Irregulaire antistoffen? | Nee |
1.1.9 Postnatale fase
Postnatale fase | ||||
Gegevenselement | Waarde | |||
Kindspecifieke gegevens | ||||
Rangnummer kind | 1 | |||
Voeding kind groep | ||||
Voeding kind datum | T - 81 dagen | |||
Substantie voeding kind | borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | |||
Substantie voeding kind | kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
1.2 Scenario 2. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling. (voor vrouw met BSN: 961921821)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 961921821 (in identificerend systeem: BSN) | |
Lokale persoonsidentificatie | * [waarde moet gegenereerd worden in het zendende systeem] | |
Geboortedatum | 11 sep in het jaar: (jaar van T) - 41 jaar | |
Adres - postcode | 5689 CZ | |
Etniciteit | Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 184 cm |
1.2.1 Anamnese
Anamnese | ||
Gegevenselement | Waarde | |
Onder behandeling geweest? | Nee |
1.2.2 Zorgverlening
Zorgverlening | ||||||
Gegevenselement | Waarde | |||||
Datum start zorgverantwoordelijkheid | T - 332 dagen | |||||
Datum einde zorgverantwoordelijkheid | T - 240 dagen | |||||
Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||||
Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||||
Conclusie risicostatus na intake | 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | |||||
Verwijsdetails | ||||||
Datum verwijzing | T - 240 dagen | |||||
Verwijzing van | ||||||
Zorginstelling | ||||||
Zorgaanbieder identificatie nummer | 1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | |||||
Verwijzing naar | ||||||
Zorginstelling | ||||||
Specialisme | gynaecoloog 2e lijn (code = '02' in codeSystem '2.16.840.1.113883.2.4.4.15.1') | |||||
Type verwijzing | Consult (code = '11429006' in codeSystem 'SNOMED CT') | |||||
Redenen van verwijzing | ||||||
Van 1e naar 2e lijn | ||||||
Zwangerschap | ||||||
Hypertensieve aandoening | Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT') | |||||
Perinatale periode | voor 28e week (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') |
1.2.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | |||
Gegevenselement | Waarde | ||
Zorginstelling | |||
Zorginstelling lvrid | 1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.2.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||
Gegevenselement | Waarde | ||
Wijze einde zwangerschap | Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
Definitieve a terme datum | T - 575 dagen | ||
Diagnose | |||
Bloedverlies? | Ja | ||
Hyperemesis gravidarum? | Ja | ||
Irregulaire antistoffen? | Ja |
1.2.5 Zwangerschap
Zwangerschap | |||
Gegevenselement | Waarde | ||
Dossiernummer | * [waarde moet gegenereerd worden in het zendende systeem] | ||
Graviditeit | 2 | ||
Pariteit voor deze zwangerschap | 0 | ||
Definitieve a terme datum | T - 115 dagen | ||
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 | T - 240 dagen | ||
Zwangerschapsduur | 155 dagen | ||
Leven voelen | weinig (code = '276372004' in codeSystem 'SNOMED CT') | ||
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 | T - 240 dagen | ||
Zwangerschapsduur | 155 dagen | ||
Hypertensieve aandoening | Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT') | ||
Maternale sterfte? | Nee |
1.3 Scenario 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling. (voor vrouw met BSN: 961921821)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 961921821 (in identificerend systeem: BSN) | |
Lokale persoonsidentificatie | * [waarde moet gegenereerd worden in het zendende systeem] | |
Geboortedatum | 11 sep in het jaar: (jaar van T) - 41 jaar | |
Adres - postcode | 5689 CZ | |
Etniciteit | Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 184 cm |
1.3.1 Anamnese
Anamnese | ||
Gegevenselement | Waarde | |
Onder behandeling geweest? | Nee |
1.3.2 Zorgverlening
Zorgverlening | ||||||
Gegevenselement | Waarde | |||||
Datum start zorgverantwoordelijkheid | T - 234 dagen | |||||
Datum einde zorgverantwoordelijkheid | T - 84 dagen | |||||
Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||||
Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||||
Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||||
Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||||
Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||||
Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||||
Eindverantwoordelijk in welke perinatale periode? | follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||||
Verwijsdetails | ||||||
Verwijzing van | ||||||
Zorginstelling | ||||||
Zorgaanbieder identificatie nummer | 1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | |||||
Verwijzing naar | ||||||
Zorginstelling | ||||||
Zorgaanbieder identificatie nummer | 0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | |||||
Redenen van verwijzing | ||||||
Van 1e naar 2e lijn | ||||||
Zwangerschap | ||||||
Hypertensieve aandoening | Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT') |
1.3.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | |||
Gegevenselement | Waarde | ||
Zorginstelling | |||
Zorginstelling lvrid | 0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.3.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||
Gegevenselement | Waarde | ||
Wijze einde zwangerschap | Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
Definitieve a terme datum | T - 575 dagen | ||
Diagnose | |||
Gynaecologische aandoening | Uterus anomalie (code = '37849005' in codeSystem 'SNOMED CT') | ||
Bloedverlies? | Ja | ||
Hyperemesis gravidarum? | Ja | ||
Irregulaire antistoffen? | Ja |
1.3.5 Zwangerschap
Zwangerschap | |||
Gegevenselement | Waarde | ||
Dossiernummer | * [waarde moet gegenereerd worden in het zendende systeem] | ||
Graviditeit | 2 | ||
Pariteit voor deze zwangerschap | 0 | ||
Definitieve a terme datum | T - 115 dagen | ||
Voornemens | |||
Voorgenomen plaats baring tijdens zwangerschap type locatie | Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||
Prenatale controle | |||
Datum controle | T - 234 dagen | ||
Zwangerschapsduur | 161 dagen | ||
Leven voelen | verminderd (code = '276369006' in codeSystem 'SNOMED CT') | ||
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 | T - 234 dagen | ||
Zwangerschapsduur | 161 dagen | ||
Gynaecologische aandoening | Uterus anomalie (code = '37849005' in codeSystem 'SNOMED CT') | ||
Partiele mola? | Ja | ||
Hypertensieve aandoening | Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT') | ||
Maternale sterfte? | Nee | ||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.3.6 Bevalling
Bevalling | |||
Gegevenselement | Waarde | ||
Partusnummer | * [waarde moet gegenereerd worden in het zendende systeem] | ||
Aantal geboren kinderen | 1 | ||
Risicostatus voor baring | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
Interventies begin baring | |||
Interventie begin baring | Primaire sectio caesarea (code = '80771000146107' in codeSystem 'SNOMED CT') | ||
Indicatie interventie begin baring | acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | ||
Wijze waarop de baring begon | Interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
Tijdstip begin actieve ontsluiting | T - 124 dagen om 14:09 uur | ||
Medicatie nageboortetijdperk groep | |||
Medicatie nageboortetijdperk? | Ja | ||
Soort medicatie nageboortetijdperk | Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') | ||
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 | Gaaf (code = '289854007' in codeSystem 'SNOMED CT') |
1.3.7 Uitkomst per kind
Uitkomst per kind | ||||||
Gegevenselement | Waarde | |||||
Baring | ||||||
Werkelijke plaats baring type locatie | Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | |||||
Ziekenhuis baring | ||||||
Ziekenhuisnummer lvrid | 0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | |||||
Demografische gegevens | ||||||
Identificaties kind | ||||||
Bsn kind | 951847624 (in identificerend systeem: BSN) | |||||
Geslacht medische observatie | mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | |||||
Geboortedatum | T - 122 dagen om 02:34 uur | |||||
Rangnummer kind | 1 | |||||
Perinatale sterfte groep | ||||||
Perinatale sterfte? | Nee | |||||
Kindspecifieke maternale gegevens | ||||||
Tijdstip breken vliezen | T - 124 dagen om 23:04 uur | |||||
Kleur en consistentie vruchtwater | geen informatie (code = 'NI' in codeSystem 'HL7 NullFlavor') | |||||
Ruggeprik gewenst niet gekregen? | Nee | |||||
Pijnbestrijding? | Ja | |||||
Pijnbestrijding | ||||||
Methode | ||||||
Methode | Epidurale analgesie (code = '18946005' in codeSystem 'SNOMED CT') | |||||
Periode | tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | |||||
Sedatie? | Ja | |||||
Kindspecifieke uitkomstgegevens | ||||||
Type partus | Sectio Caesarea (code = '11466000' in codeSystem 'SNOMED CT') | |||||
Ligging bij geboorte | Geen informatie (code = 'NI' in codeSystem 'HL7 NullFlavor') | |||||
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 'UZI Rolcodes') | |||||
Sectio caesarea group | ||||||
Indicatie primaire sectio | verdenking foetale nood (code = '444433005:246090004=130955003' in codeSystem 'SNOMED CT') | |||||
Indicatie primaire sectio | maternale conditie (code = '418138009' in codeSystem 'SNOMED CT') | |||||
Lichamelijk onderzoek kind | ||||||
Geboortegewicht | 3620 gram | |||||
Congenitale afwijkingen? | Nee | |||||
Problematiek kind? | Nee | |||||
Kinderarts betrokken? | Ja | |||||
Betrokkenheid kinderarts | ||||||
Datum betrokkenheid | T - 122 dagen | |||||
Reden betrokkenheid | overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | |||||
Type betrokkenheid | Consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | |||||
Zorginstelling lvrid | 0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.3.8 Medisch onderzoek
Medisch onderzoek | |||
Gegevenselement | Waarde | ||
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
Irregulaire antistoffen? | Ja | ||
Welke irregulaire antistoffen vrouw aanwezig | Rhesus D (code = '112162009' in codeSystem 'SNOMED CT') |
1.3.9 Postnatale fase
Postnatale fase | ||||
Gegevenselement | Waarde | |||
Diagnoseinterventie postnataal | ||||
Datum | T - 120 dagen | |||
Pathologie vrouw | Urineweginfectie (code = '68566005' in codeSystem 'SNOMED CT') | |||
Kindspecifieke gegevens | ||||
Rangnummer kind | 1 | |||
Voeding kind groep | ||||
Voeding kind datum | T - 86 dagen | |||
Substantie voeding kind | kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
1.4 Scenario 3. zorg volledig in 2e lijn, meerling, 1 kind overleden. (voor vrouw met BSN: 895623146)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 895623146 (in identificerend systeem: BSN) | |
Lokale persoonsidentificatie | * [waarde moet gegenereerd worden in het zendende systeem] | |
Geboortedatum | 5 aug in het jaar: (jaar van T) - 30 jaar | |
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 | Type 2 (code = '130621000119105' in codeSystem 'SNOMED CT') |
1.4.1 Anamnese
Anamnese | |||
Gegevenselement | Waarde | ||
Onder behandeling geweest? | Ja | ||
Algemene anamnese | |||
Cardiovasculaire aandoening | Hartritmestoornis (code = '698247007' in codeSystem 'SNOMED CT') | ||
Schildklier aandoening | Hyperthyreoidie (code = '34486009' in codeSystem 'SNOMED CT') | ||
Anemie | IJzergebrek (code = '87522002' in codeSystem 'SNOMED CT') | ||
Bloedtransfusie? | Ja | ||
Type operatie | Hart (code = '64915003' in codeSystem 'SNOMED CT') |
1.4.2 Zorgverlening
Zorgverlening | ||
Gegevenselement | Waarde | |
Datum start zorgverantwoordelijkheid | T - 297 dagen | |
Datum einde zorgverantwoordelijkheid | T - 59 dagen | |
Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Conclusie risicostatus na intake | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') |
1.4.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | |||
Gegevenselement | Waarde | ||
Zorginstelling | |||
Zorginstelling lvrid | 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.4.4 Zwangerschap
Zwangerschap | |||
Gegevenselement | Waarde | ||
Dossiernummer | * [waarde moet gegenereerd worden in het zendende systeem] | ||
Graviditeit | 1 | ||
Pariteit voor deze zwangerschap | 0 | ||
Definitieve a terme datum | T - 101 dagen | ||
Voornemens | |||
Voorgenomen plaats baring tijdens zwangerschap type locatie | Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||
Prenatale controle | |||
Datum controle | T - 225 dagen | ||
Zwangerschapsduur | 156 dagen | ||
Leven voelen | goed (code = '289431008' in codeSystem 'SNOMED CT') | ||
Rookgedrag | niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
Drugsgebruik? | Nee | ||
Gewicht gemeten | 67 kg | ||
Diagnose | |||
Datum | T - 225 dagen | ||
Zwangerschapsduur | 156 dagen | ||
Bloedverlies? | Ja | ||
Infectie | Urineweg infectie (code = '307534009' in codeSystem 'SNOMED CT') | ||
Afwijkende groei foetus | Dysmaturiteit (code = '267258002' in codeSystem 'SNOMED CT') | ||
Abruptio placentae? | Ja | ||
Maternale sterfte? | Nee | ||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.4.5 Bevalling
Bevalling | |||
Gegevenselement | Waarde | ||
Partusnummer | * [waarde moet gegenereerd worden in het zendende systeem] | ||
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 | T - 127 dagen om 22:09 uur | ||
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 | Episiotomiewond (code = '609344008' in codeSystem 'SNOMED CT') |
1.4.6 Uitkomst per kind
Uitkomst per kind | |||||||
Gegevenselement | Waarde | ||||||
Baring | |||||||
Werkelijke plaats baring type locatie | Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||||||
Ziekenhuis baring | |||||||
Ziekenhuisnummer lvrid | 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||||
Demografische gegevens | |||||||
Identificaties kind | |||||||
Bsn kind | 847035116 (in identificerend systeem: BSN) | ||||||
Geslacht medische observatie | vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||||||
Geboortedatum | T - 126 dagen om 06:30 uur | ||||||
Rangnummer kind | 1 | ||||||
Perinatale sterfte groep | |||||||
Perinatale sterfte? | Nee | ||||||
Kindspecifieke maternale gegevens | |||||||
Tijdstip breken vliezen | T - 127 dagen om 22:09 uur | ||||||
Kleur en consistentie vruchtwater | Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
Tijdstip actief meepersen | T - 127 dagen om 23:49 uur | ||||||
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 middel (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||||||
Overig middel | |||||||
Middel | Morfinometica (code = '52685006:363701004=404642006' in codeSystem 'SNOMED CT') | ||||||
Toediening | Intraveneus (code = '431215000' in codeSystem 'SNOMED CT') | ||||||
Periode | tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||||||
Sedatie? | Nee | ||||||
Kindspecifieke uitkomstgegevens | |||||||
Type partus | Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | ||||||
Ligging bij geboorte | Aangezicht (code = '21882006' in codeSystem 'SNOMED CT') | ||||||
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 'UZI Rolcodes') | ||||||
Vaginale kunstverlossing groep | |||||||
Vaginale kunstverlossing | Forceps (code = '302383004' in codeSystem 'SNOMED CT') | ||||||
Succes vaginale kunstverlossing? | Ja | ||||||
Lichamelijk onderzoek kind | |||||||
Geboortegewicht | 2040 gram | ||||||
Congenitale afwijkingen? | Nee | ||||||
Problematiek kind? | Ja | ||||||
Problematiek kind | Geboortetrauma (code = '56110009' in codeSystem 'SNOMED CT') | ||||||
Kinderarts betrokken? | Ja | ||||||
Betrokkenheid kinderarts | |||||||
Datum betrokkenheid | T - 126 dagen | ||||||
Reden betrokkenheid | kunstverlossing (code = '8571000146103' in codeSystem 'SNOMED CT') | ||||||
Type betrokkenheid | Consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
Zorginstelling lvrid | 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.4.7 Uitkomst per kind
Uitkomst per kind | |||||||
Gegevenselement | Waarde | ||||||
Baring | |||||||
Werkelijke plaats baring type locatie | Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||||||
Ziekenhuis baring | |||||||
Ziekenhuisnummer lvrid | 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||||
Demografische gegevens | |||||||
Identificaties kind | |||||||
Bsn kind | 847035128 (in identificerend systeem: BSN) | ||||||
Geslacht medische observatie | mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||||||
Geboortedatum | T - 126 dagen om 07:02 uur | ||||||
Rangnummer kind | 2 | ||||||
Perinatale sterfte groep | |||||||
Perinatale sterfte? | Ja | ||||||
Fase perinatale sterfte | Postpartum (code = '276506001' in codeSystem 'SNOMED CT') | ||||||
Datumtijd vaststelling perinatale sterfte | T - 126 dagen om 08:10 uur | ||||||
Kindspecifieke maternale gegevens | |||||||
Tijdstip breken vliezen | T - 127 dagen om 23:13 uur | ||||||
Kleur en consistentie vruchtwater | Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
Tijdstip actief meepersen | T - 126 dagen om 06:45 uur | ||||||
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 middel (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||||||
Overig middel | |||||||
Middel | Entonox (code = '426060003' in codeSystem 'SNOMED CT') | ||||||
Toediening | Inhalatie (code = '241717009' in codeSystem 'SNOMED CT') | ||||||
Periode | tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||||||
Sedatie? | Nee | ||||||
Kindspecifieke uitkomstgegevens | |||||||
Type partus | Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | ||||||
Ligging bij geboorte | Volkomen stuit (code = '49168004' in codeSystem 'SNOMED CT') | ||||||
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 'UZI Rolcodes') | ||||||
Vaginale kunstverlossing groep | |||||||
Vaginale kunstverlossing | Stuitextractie (code = '416055001' in codeSystem 'SNOMED CT') | ||||||
Succes vaginale kunstverlossing? | Ja | ||||||
Overige interventies | Opheffen schouderdystocie (code = '237008007' in codeSystem 'SNOMED CT') | ||||||
Lichamelijk onderzoek kind | |||||||
Geboortegewicht | 1580 gram | ||||||
Congenitale afwijkingen? | Ja | ||||||
Congenitale afwijkingen groep | |||||||
Specificatie congenitale afwijking groep | |||||||
Specificatie congenitale afwijking | spina bifida occulta (code = '76916001' in codeSystem 'SNOMED CT') | ||||||
Specificatie congenitale afwijking groep | |||||||
Specificatie congenitale afwijking | gecompliceerd vitium (code = '94702005' in codeSystem 'SNOMED CT') | ||||||
Chromosomale afwijkingen? | Nee | ||||||
Problematiek kind? | Ja | ||||||
Problematiek kind | Subdurale bloeding (code = '126941005' in codeSystem 'SNOMED CT') | ||||||
Kinderarts betrokken? | Ja | ||||||
Betrokkenheid kinderarts | |||||||
Datum betrokkenheid | T - 126 dagen | ||||||
Reden betrokkenheid | overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||||||
Type betrokkenheid | Overdracht (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
Zorginstelling lvrid | 0001 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.4.8 Medisch onderzoek
Medisch onderzoek | |||
Gegevenselement | Waarde | ||
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
Irregulaire antistoffen? | Nee |
1.4.9 Postnatale fase
Postnatale fase | ||||
Gegevenselement | Waarde | |||
Kindspecifieke gegevens | ||||
Rangnummer kind | 1 | |||
Voeding kind groep | ||||
Voeding kind datum | T - 120 dagen | |||
Substantie voeding kind | borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
1.5 Scenario 4. 1e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden. (voor vrouw met BSN: 850810711)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 850810711 (in identificerend systeem: BSN) | |
Lokale persoonsidentificatie | * [waarde moet gegenereerd worden in het zendende systeem] | |
Geboortedatum | 6 aug in het jaar: (jaar van T) - 28 jaar | |
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 | Type 1 (code = '130631000119108' in codeSystem 'SNOMED CT') |
1.5.1 Anamnese
Anamnese | |||
Gegevenselement | Waarde | ||
Onder behandeling geweest? | Ja | ||
Algemene anamnese | |||
Autoimmuun aandoening | Reuma (code = '396332003' in codeSystem 'SNOMED CT') | ||
Urogenitale aandoening | Bacteriurie (code = '61373006' in codeSystem 'SNOMED CT') | ||
Diabetes mellitus? | Ja | ||
Mdl aandoening | Chronische leveraandoeningen (code = '328383001' in codeSystem 'SNOMED CT') | ||
Longaandoening | Astma (code = '195967001' in codeSystem 'SNOMED CT') | ||
Type operatie | Orthopedisch (code = '112697007' in codeSystem 'SNOMED CT') | ||
Type operatie | Appendectomie (code = '80146002' in codeSystem 'SNOMED CT') | ||
Type operatie | Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') |
1.5.2 Zorgverlening
Zorgverlening | |||||
Gegevenselement | Waarde | ||||
Datum start zorgverantwoordelijkheid | T - 147 dagen | ||||
Datum einde zorgverantwoordelijkheid | T - 108 dagen | ||||
Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||||
Eindverantwoordelijk in welke perinatale periode? | follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||||
Conclusie risicostatus na intake | 3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | ||||
Verwijsdetails | |||||
Verwijzing van | |||||
Zorginstelling | |||||
Zorgaanbieder identificatie nummer | 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||
Verwijzing naar | |||||
Zorginstelling | |||||
Zorgaanbieder identificatie nummer | 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||
Redenen van verwijzing | |||||
Van 2e naar 1e lijn | Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') |
1.5.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | |||
Gegevenselement | Waarde | ||
Zorginstelling | |||
Zorginstelling lvrid | 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.5.4 Zwangerschap
Zwangerschap | ||
Gegevenselement | Waarde | |
Dossiernummer | * [waarde moet gegenereerd worden in het zendende systeem] | |
Graviditeit | 1 | |
Pariteit voor deze zwangerschap | 0 | |
Definitieve a terme datum | T - 136 dagen | |
Maternale sterfte? | Ja | |
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.5.5 Bevalling
Bevalling | |||
Gegevenselement | Waarde | ||
Aantal geboren kinderen | 1 | ||
Risicostatus voor baring | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
Wijze waarop de baring begon | Spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
Tijdstip begin actieve ontsluiting | T - 151 dagen om 21:09 uur | ||
Medicatie nageboortetijdperk groep | |||
Medicatie nageboortetijdperk? | Ja | ||
Soort medicatie nageboortetijdperk | Prostaglandine (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 | 3e graads ruptuur (code = '199930000' in codeSystem 'SNOMED CT') |
1.5.6 Uitkomst per kind
Uitkomst per kind | |||||||
Gegevenselement | Waarde | ||||||
Baring | |||||||
Werkelijke plaats baring type locatie | Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||||||
Ziekenhuis baring | |||||||
Ziekenhuisnummer lvrid | 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||||
Demografische gegevens | |||||||
Identificaties kind | |||||||
Bsn kind | 840736526 (in identificerend systeem: BSN) | ||||||
Geslacht medische observatie | vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||||||
Geboortedatum | T - 150 dagen om 23:35 uur | ||||||
Rangnummer kind | 1 | ||||||
Perinatale sterfte groep | |||||||
Perinatale sterfte? | Nee | ||||||
Kindspecifieke maternale gegevens | |||||||
Tijdstip breken vliezen | T - 151 dagen om 07:04 uur | ||||||
Kleur en consistentie vruchtwater | Bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
Tijdstip actief meepersen | T - 150 dagen om 22:15 uur | ||||||
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 middel (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||||||
Overig middel | |||||||
Middel | Entonox (code = '426060003' in codeSystem 'SNOMED CT') | ||||||
Toediening | Inhalatie (code = '241717009' in codeSystem 'SNOMED CT') | ||||||
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 | Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | ||||||
Ligging bij geboorte | Kruin (code = '249079005' in codeSystem 'SNOMED CT') | ||||||
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 'UZI Rolcodes') | ||||||
Vaginale kunstverlossing groep | |||||||
Vaginale kunstverlossing | Forceps (code = '302383004' in codeSystem 'SNOMED CT') | ||||||
Succes vaginale kunstverlossing? | Ja | ||||||
Lichamelijk onderzoek kind | |||||||
Geboortegewicht | 4205 gram | ||||||
Congenitale afwijkingen? | Nee | ||||||
Problematiek kind? | Nee | ||||||
Kinderarts betrokken? | Ja | ||||||
Betrokkenheid kinderarts | |||||||
Datum betrokkenheid | T - 150 dagen | ||||||
Reden betrokkenheid | kunstverlossing (code = '8571000146103' in codeSystem 'SNOMED CT') | ||||||
Type betrokkenheid | Consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
Zorginstelling lvrid | 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.5.7 Postnatale fase
Postnatale fase | ||||
Gegevenselement | Waarde | |||
Diagnoseinterventie postnataal | ||||
Datum | T - 146 dagen | |||
Pathologie vrouw | Embolie (code = '414086009' in codeSystem 'SNOMED CT') | |||
Diagnoseinterventie postnataal | ||||
Datum | T - 146 dagen | |||
Pathologie vrouw | Ontstoken episiotomie (code = '300927001' in codeSystem 'SNOMED CT') | |||
Kindspecifieke gegevens | ||||
Voeding kind groep | ||||
Voeding kind datum | T - 108 dagen | |||
Substantie voeding kind | kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
1.6 Scenario 4. 2e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 850810711 (in identificerend systeem: BSN) | |
Lokale persoonsidentificatie | * [waarde moet gegenereerd worden in het zendende systeem] | |
Geboortedatum | 6 aug in het jaar: (jaar van T) - 28 jaar | |
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 | Type 1 (code = '130631000119108' in codeSystem 'SNOMED CT') |
1.6.1 Anamnese
Anamnese | |||
Gegevenselement | Waarde | ||
Onder behandeling geweest? | Ja | ||
Algemene anamnese | |||
Autoimmuun aandoening | Reuma (code = '396332003' in codeSystem 'SNOMED CT') | ||
Urogenitale aandoening | Bacteriurie (code = '61373006' in codeSystem 'SNOMED CT') | ||
Diabetes mellitus? | Ja | ||
Mdl aandoening | Chronische leveraandoeningen (code = '328383001' in codeSystem 'SNOMED CT') | ||
Longaandoening | Astma (code = '195967001' in codeSystem 'SNOMED CT') | ||
Type operatie | Orthopedisch (code = '112697007' in codeSystem 'SNOMED CT') | ||
Type operatie | Appendectomie (code = '80146002' in codeSystem 'SNOMED CT') | ||
Type operatie | Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') |
1.6.2 Zorgverlening
Zorgverlening | |||||
Gegevenselement | Waarde | ||||
Datum start zorgverantwoordelijkheid | T - 332 dagen | ||||
Datum einde zorgverantwoordelijkheid | T - 148 dagen | ||||
Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||||
Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||||
Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||||
Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||||
Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||||
Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||||
Conclusie risicostatus na intake | 3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | ||||
Verwijsdetails | |||||
Datum verwijzing | T - 148 dagen | ||||
Verwijzing van | |||||
Zorginstelling | |||||
Zorgaanbieder identificatie nummer | 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||
Verwijzing naar | |||||
Zorginstelling | |||||
Zorgaanbieder identificatie nummer | 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||
Redenen van verwijzing | |||||
Van 2e naar 1e lijn | Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||||
Perinatale periode | 2e t/m 7e dag (code = '92' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') |
1.6.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | |||
Gegevenselement | Waarde | ||
Zorginstelling | |||
Zorginstelling lvrid | 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.6.4 Zwangerschap
Zwangerschap | |||
Gegevenselement | Waarde | ||
Dossiernummer | * [waarde moet gegenereerd worden in het zendende systeem] | ||
Graviditeit | 1 | ||
Pariteit voor deze zwangerschap | 0 | ||
Definitieve a terme datum | T - 136 dagen | ||
Voornemens | |||
Voorgenomen plaats baring tijdens zwangerschap type locatie | Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||
Prenatale controle | |||
Datum controle | T - 239 dagen | ||
Zwangerschapsduur | 177 dagen | ||
Leven voelen | goed (code = '289431008' in codeSystem 'SNOMED CT') | ||
Rookgedrag | niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
Drugsgebruik? | Nee | ||
Gewicht gemeten | 82 kg | ||
Diagnose | |||
Datum | T - 239 dagen | ||
Zwangerschapsduur | 177 dagen | ||
Infectie | Urineweg infectie (code = '307534009' in codeSystem 'SNOMED CT') | ||
Maternale sterfte? | Nee | ||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.6.5 Bevalling
Bevalling | |||
Gegevenselement | Waarde | ||
Diagnose bevalling | |||
Niet vorderende ontsluiting? | Ja | ||
Niet vorderende uitdrijving? | Ja | ||
Aantal geboren kinderen | 1 | ||
Risicostatus voor baring | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
Wijze waarop de baring begon | Spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
Tijdstip begin actieve ontsluiting | T - 151 dagen om 21:09 uur | ||
Medicatie nageboortetijdperk groep | |||
Medicatie nageboortetijdperk? | Ja | ||
Soort medicatie nageboortetijdperk | Prostaglandine (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 | 3e graads ruptuur (code = '199930000' in codeSystem 'SNOMED CT') |
1.6.6 Uitkomst per kind
Uitkomst per kind | |||||||
Gegevenselement | Waarde | ||||||
Baring | |||||||
Werkelijke plaats baring type locatie | Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||||||
Ziekenhuis baring | |||||||
Ziekenhuisnummer lvrid | 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||||
Demografische gegevens | |||||||
Identificaties kind | |||||||
Bsn kind | 840736526 (in identificerend systeem: BSN) | ||||||
Geslacht medische observatie | vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||||||
Geboortedatum | T - 150 dagen om 23:35 uur | ||||||
Rangnummer kind | 1 | ||||||
Perinatale sterfte groep | |||||||
Perinatale sterfte? | Nee | ||||||
Kindspecifieke maternale gegevens | |||||||
Tijdstip breken vliezen | T - 151 dagen om 07:04 uur | ||||||
Kleur en consistentie vruchtwater | Bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
Tijdstip actief meepersen | T - 150 dagen om 22:15 uur | ||||||
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 middel (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||||||
Overig middel | |||||||
Middel | Entonox (code = '426060003' in codeSystem 'SNOMED CT') | ||||||
Toediening | Inhalatie (code = '241717009' in codeSystem 'SNOMED CT') | ||||||
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 | Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | ||||||
Ligging bij geboorte | Kruin (code = '249079005' in codeSystem 'SNOMED CT') | ||||||
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 'UZI Rolcodes') | ||||||
Vaginale kunstverlossing groep | |||||||
Vaginale kunstverlossing | Forceps (code = '302383004' in codeSystem 'SNOMED CT') | ||||||
Succes vaginale kunstverlossing? | Ja | ||||||
Lichamelijk onderzoek kind | |||||||
Geboortegewicht | 4205 gram | ||||||
Congenitale afwijkingen? | Nee | ||||||
Problematiek kind? | Nee | ||||||
Kinderarts betrokken? | Ja | ||||||
Betrokkenheid kinderarts | |||||||
Datum betrokkenheid | T - 150 dagen | ||||||
Reden betrokkenheid | kunstverlossing (code = '8571000146103' in codeSystem 'SNOMED CT') | ||||||
Type betrokkenheid | Consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
Zorginstelling lvrid | 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.6.7 Medisch onderzoek
Medisch onderzoek | |||
Gegevenselement | Waarde | ||
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
Irregulaire antistoffen? | Nee |
1.7 Scenario 5. zorg volledig 2e lijn, vrouw overleden. (voor vrouw met BSN: 912345676)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 912345676 (in identificerend systeem: BSN) | |
Lokale persoonsidentificatie | * [waarde moet gegenereerd worden in het zendende systeem] | |
Geboortedatum | 4 maa in het jaar: (jaar van T) - 22 jaar | |
Adres - postcode | 9562 GF | |
Etniciteit | Latijns Amerikaans (code = '14' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 186 cm |
1.7.1 Anamnese
Anamnese | |||
Gegevenselement | Waarde | ||
Onder behandeling geweest? | Ja | ||
Algemene anamnese | |||
Cardiovasculaire aandoening | Hypertensie (code = '38341003' in codeSystem 'SNOMED CT') | ||
Diabetes mellitus? | Ja | ||
Neurologische aandoening | Epilepsie (code = '84757009' in codeSystem 'SNOMED CT') | ||
Longaandoening | Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
Orthopedische afwijking | Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
Type stollingsprobleem | Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
Psychiatrie? | Ja |
1.7.2 Zorgverlening
Zorgverlening | ||
Gegevenselement | Waarde | |
Datum start zorgverantwoordelijkheid | T - 388 dagen | |
Datum einde zorgverantwoordelijkheid | T - 150 dagen | |
Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Conclusie risicostatus na intake | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') |
1.7.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | |||
Gegevenselement | Waarde | ||
Zorginstelling | |||
Zorginstelling lvrid | 0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.7.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||||
Gegevenselement | Waarde | ||||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||||
Definitieve a terme datum | T - 940 dagen | ||||
Diagnose | |||||
Infectie | Urineweg infectie (code = '307534009' in codeSystem 'SNOMED CT') | ||||
Zwangerschapscholestase? | Ja | ||||
Afwijkende groei foetus | Geen informatie (code = 'NI' in codeSystem 'HL7 NullFlavor') | ||||
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 | |||||
Geboortedatum | T - 936 dagen | ||||
Kindspecifieke gegevens vorige uitkomsten | |||||
Type partus | Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | ||||
Percentiel van het geboortegewicht | p10 tot p50 (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.50') | ||||
Apgarscore na 5 min | 10 | ||||
Congenitale afwijkingen? | Nee |
1.7.5 Zwangerschap
Zwangerschap | |||
Gegevenselement | Waarde | ||
Dossiernummer | * [waarde moet gegenereerd worden in het zendende systeem] | ||
Graviditeit | 2 | ||
Pariteit voor deze zwangerschap | 1 | ||
Definitieve a terme datum | T - 163 dagen | ||
Voornemens | |||
Voorgenomen plaats baring tijdens zwangerschap type locatie | Geen informatie (code = 'NI' in codeSystem 'HL7 NullFlavor') | ||
Prenatale controle | |||
Datum controle | T - 357 dagen | ||
Zwangerschapsduur | 86 dagen | ||
Leven voelen | geen (code = '289432001' in codeSystem 'SNOMED CT') | ||
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 | T - 357 dagen | ||
Zwangerschapsduur | 86 dagen | ||
Afwijkende groei foetus | Macrosomie (code = '199616008' in codeSystem 'SNOMED CT') | ||
Abruptio placentae? | Ja | ||
Intrauteriene behandeling | Selectieve foeticide (code = '265633004' in codeSystem 'SNOMED CT') | ||
Maternale sterfte? | Ja | ||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.7.6 Bevalling
Bevalling | |||
Gegevenselement | Waarde | ||
Partusnummer | * [waarde moet gegenereerd worden in het zendende systeem] | ||
Aantal geboren kinderen | 1 | ||
Risicostatus voor baring | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
Interventies begin baring | |||
Interventie begin baring | Primaire sectio caesarea (code = '80771000146107' in codeSystem 'SNOMED CT') | ||
Indicatie interventie begin baring | acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | ||
Wijze waarop de baring begon | Interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
Medicatie nageboortetijdperk groep | |||
Medicatie nageboortetijdperk? | Nee | ||
Placenta - geboorte placenta | Placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
Hoeveelheid bloedverlies | 1500 ml | ||
Conditie perineum postpartum | Gaaf (code = '289854007' in codeSystem 'SNOMED CT') |
1.7.7 Uitkomst per kind
Uitkomst per kind | ||||||
Gegevenselement | Waarde | |||||
Baring | ||||||
Werkelijke plaats baring type locatie | Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | |||||
Ziekenhuis baring | ||||||
Ziekenhuisnummer lvrid | 0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | |||||
Demografische gegevens | ||||||
Identificaties kind | ||||||
Bsn kind | 528741913 (in identificerend systeem: BSN) | |||||
Geslacht medische observatie | niet conclusief (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | |||||
Geboortedatum | T - 161 dagen om 02:30 uur | |||||
Rangnummer kind | 1 | |||||
Perinatale sterfte groep | ||||||
Perinatale sterfte? | Nee | |||||
Kindspecifieke maternale gegevens | ||||||
Kleur en consistentie vruchtwater | Meconium (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | |||||
Episiotomie? | Nee | |||||
Ruggeprik gewenst niet gekregen? | Nee | |||||
Pijnbestrijding? | Ja | |||||
Pijnbestrijding | ||||||
Methode | ||||||
Methode | Algehele anesthesie (code = '50697003' in codeSystem 'SNOMED CT') | |||||
Periode | tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | |||||
Sedatie? | Ja | |||||
Kindspecifieke uitkomstgegevens | ||||||
Type partus | Secundair (code = '274130007' in codeSystem 'SNOMED CT') | |||||
Ligging bij geboorte | Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor') | |||||
Aanpakker kind - rol aanpakker kind | gynaecoloog (code = '01.046' in codeSystem 'UZI Rolcodes') | |||||
Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem 'UZI Rolcodes') | |||||
Vaginale kunstverlossing groep | ||||||
Vaginale kunstverlossing | Vacuüm (code = '61586001' in codeSystem 'SNOMED CT') | |||||
Succes vaginale kunstverlossing? | Nee | |||||
Sectio caesarea group | ||||||
Beslismoment sectio caesarea | Tijdens uitdrijving besloten (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.5') | |||||
Indicatie secundaire sectio | maternale conditie (code = '418138009' in codeSystem 'SNOMED CT') | |||||
Lichamelijk onderzoek kind | ||||||
Geboortegewicht | 3750 gram | |||||
Congenitale afwijkingen? | Ja | |||||
Congenitale afwijkingen groep | ||||||
Chromosomale afwijkingen? | Ja | |||||
Specificatie chromosomale afwijking groep | ||||||
Specificatie chromosomale afwijking | trisomie 21 (code = '41040004' in codeSystem 'SNOMED CT') | |||||
Problematiek kind? | Ja | |||||
Problematiek kind | Gehoor (code = '95827002' in codeSystem 'SNOMED CT') | |||||
Kinderarts betrokken? | Nee |
1.7.8 Medisch onderzoek
Medisch onderzoek | |||
Gegevenselement | Waarde | ||
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
Irregulaire antistoffen? | Ja | ||
Welke irregulaire antistoffen vrouw aanwezig | Kell (code = '405844003' in codeSystem 'SNOMED CT') |
1.7.9 Postnatale fase
Postnatale fase | ||||
Gegevenselement | Waarde | |||
Diagnoseinterventie postnataal | ||||
Datum | T - 161 dagen | |||
Pathologie vrouw | Trombose diep veneuze postpartum (code = '56272000' in codeSystem 'SNOMED CT') | |||
Kindspecifieke gegevens | ||||
Voeding kind groep | ||||
Voeding kind datum | T - 161 dagen | |||
Substantie voeding kind | kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
1.8 Scenario 6. 2de lijn met comorbiditeit. (voor vrouw met BSN: 100202020)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 100202020 (in identificerend systeem: BSN) | |
Lokale persoonsidentificatie | * [waarde moet gegenereerd worden in het zendende systeem] | |
Geboortedatum | 1 jan in het jaar: (jaar van T) - 31 jaar | |
Adres - postcode | 1234 AB | |
Etniciteit | Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 172 cm | |
Vrouwelijke genitale verminking? | Nee |
1.8.1 Anamnese
Anamnese | |||
Gegevenselement | Waarde | ||
Onder behandeling geweest? | Ja | ||
Algemene anamnese | |||
Autoimmuun aandoening | Reuma (code = '396332003' in codeSystem 'SNOMED CT') | ||
Cardiovasculaire aandoening | Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Overig, niet nader omschreven | ||
Urogenitale aandoening | Pyelonefritis (code = '45816000' in codeSystem 'SNOMED CT') | ||
Oncologische aandoening | Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Overig, niet nader omschreven | ||
Schildklier aandoening | Hypothyreoidie (code = '40930008' in codeSystem 'SNOMED CT') | ||
Diabetes mellitus? | Nee | ||
Neurologische aandoening | Hernia nuclei pulposi (code = '84857004' in codeSystem 'SNOMED CT') | ||
Neurologische aandoening | Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Overig, niet nader omschreven | ||
Mdl aandoening | M. Crohn (code = '34000006' in codeSystem 'SNOMED CT') | ||
Anemie | IJzergebrek (code = '87522002' in codeSystem 'SNOMED CT') | ||
Longaandoening | Astma (code = '195967001' in codeSystem 'SNOMED CT') | ||
Orthopedische afwijking | Trauma bekken (code = '282771003' in codeSystem 'SNOMED CT') | ||
Bloedtransfusie? | Nee | ||
Type operatie | Sectio (code = '11466000' in codeSystem 'SNOMED CT') | ||
Type operatie | Rug (code = '129152004:260686004=129284003' in codeSystem 'SNOMED CT') | ||
Psychiatrie? | Nee | ||
Overige aandoening? | Nee |
1.8.2 Zorgverlening
Zorgverlening | ||
Gegevenselement | Waarde | |
Datum start zorgverantwoordelijkheid | T - 306 dagen | |
Datum einde zorgverantwoordelijkheid | T - 78 dagen | |
Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Conclusie risicostatus na intake | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') |
1.8.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | |||
Gegevenselement | Waarde | ||
Zorginstelling | |||
Zorginstelling agbid | 12345678 (in identificerend systeem: AGB-Z) | ||
Zorginstelling lvrid | 0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.8.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | ||||||
Gegevenselement | Waarde | |||||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |||||
Definitieve a terme datum | T - 1064 dagen | |||||
Diagnose | ||||||
Bloedverlies? | Ja | |||||
Cervixinsufficientie? | Nee | |||||
Infectie | Intra-uterien (code = '301775005' in codeSystem 'SNOMED CT') | |||||
Hyperemesis gravidarum? | Nee | |||||
Hypertensieve aandoening | Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT') | |||||
Zwangerschapscholestase? | Nee | |||||
Diabetes gravidarum met insuline? | Nee | |||||
Afwijkende groei foetus | Macrosomie (code = '199616008' in codeSystem 'SNOMED CT') | |||||
Dreigende partus immaturus? | Nee | |||||
Dreigende partus prematurus? | Nee | |||||
Abruptio placentae? | Ja | |||||
Irregulaire antistoffen? | Nee | |||||
Eerdere bevalling | ||||||
Placenta - geboorte placenta | Placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | |||||
Hoeveelheid bloedverlies | 895 ml | |||||
Vorige uitkomst per kind - vorige baring | ||||||
Geboortedatum | T - 1112 dagen | |||||
Kindspecifieke gegevens vorige uitkomsten | ||||||
Type partus | Secundair (code = '274130007' in codeSystem 'SNOMED CT') | |||||
Percentiel van het geboortegewicht | p2,3 tot p10 (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.50') | |||||
Apgarscore na 5 min | 8 | |||||
Congenitale afwijkingen? | Ja | |||||
Congenitale afwijkingen groep | ||||||
Chromosomale afwijkingen? | Nee |
1.8.5 Zwangerschap
Zwangerschap | ||||
Gegevenselement | Waarde | |||
Dossiernummer | * [waarde moet gegenereerd worden in het zendende systeem] | |||
Graviditeit | 2 | |||
Pariteit voor deze zwangerschap | 1 | |||
Definitieve a terme datum | T - 91 dagen | |||
Voornemens | ||||
Voorgenomen plaats baring tijdens zwangerschap type locatie | Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | |||
Prenatale controle | ||||
Datum controle | T - 306 dagen | |||
Zwangerschapsduur | 65 dagen | |||
Leven voelen | geen (code = '289432001' in codeSystem 'SNOMED CT') | |||
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 | 68 kg | |||
Diagnose | ||||
Datum | T - 306 dagen | |||
Zwangerschapsduur | 65 dagen | |||
Gynaecologische aandoening | Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Overig, niet nader gespecificeerd | |||
Bloedverlies? | Nee | |||
Partiele mola? | Nee | |||
Cervixinsufficientie? | Nee | |||
Hyperemesis gravidarum? | Nee | |||
Zwangerschapscholestase? | Nee | |||
Diabetes gravidarum met insuline? | Nee | |||
Afwijkende groei foetus | Dysmaturiteit (code = '267258002' in codeSystem 'SNOMED CT') | |||
Dreigende partus immaturus? | Nee | |||
Dreigende partus prematurus? | Nee | |||
Abruptio placentae? | Nee | |||
Navelstrengprolaps? | Nee | |||
Intrauteriene vruchtdood | ||||
Vermoeden intrauteriene vruchtdood? | Nee | |||
Maternale sterfte? | Nee | |||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.8.6 Bevalling
Bevalling | ||||
Gegevenselement | Waarde | |||
Partusnummer | * [waarde moet gegenereerd worden in het zendende systeem] | |||
Diagnose bevalling | ||||
Pprom? | Nee | |||
Prom? | Nee | |||
Koorts? | Nee | |||
Niet vorderende ontsluiting? | Nee | |||
Niet vorderende uitdrijving? | Nee | |||
Verdenking foetale nood? | Nee | |||
Intrauteriene vruchtdood | ||||
Vermoeden intrauteriene vruchtdood? | Nee | |||
Vastzittende placenta? | Nee | |||
Fluxus postpartum? | 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') | |||
Interventies begin baring | ||||
Interventie begin baring | Primen prostaglandine (code = '236966000' in codeSystem 'SNOMED CT') | |||
Indicatie interventie begin baring | niet levensbedreigend (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | |||
Wijze waarop de baring begon | Spontane weeën (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | |||
Tijdstip begin actieve ontsluiting | T - 78 dagen om 03:45 uur | |||
Medicatie nageboortetijdperk groep | ||||
Medicatie nageboortetijdperk? | Ja | |||
Soort medicatie nageboortetijdperk | Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') | |||
Placenta - geboorte placenta | Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | |||
Hoeveelheid bloedverlies | 1050 ml | |||
Conditie perineum postpartum | 1e graads perineumruptuur (code = '199916005' in codeSystem 'SNOMED CT') | |||
Conditie perineum postpartum | Episiotomiewond (code = '609344008' in codeSystem 'SNOMED CT') |
1.8.7 Uitkomst per kind
Uitkomst per kind | |||||||
Gegevenselement | Waarde | ||||||
Baring | |||||||
Werkelijke plaats baring type locatie | Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||||||
Ziekenhuis baring | |||||||
Ziekenhuisnummer lvrid | 0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||||
Demografische gegevens | |||||||
Identificaties kind | |||||||
Bsn kind | 847035116 (in identificerend systeem: BSN) | ||||||
Geslacht medische observatie | mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||||||
Geboortedatum | T - 78 dagen | ||||||
Rangnummer kind | 1 | ||||||
Perinatale sterfte groep | |||||||
Perinatale sterfte? | Nee | ||||||
Kindspecifieke maternale gegevens | |||||||
Bijstimulatie toegediend? | Ja | ||||||
Tijdstip breken vliezen | T - 78 dagen om 04:30 uur | ||||||
Kleur en consistentie vruchtwater | Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
Tijdstip actief meepersen | T - 78 dagen om 05:00 uur | ||||||
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? | Ja | ||||||
Pijnbestrijding? | Ja | ||||||
Pijnbestrijding | |||||||
Methode | |||||||
Methode | Overig middel (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||||||
Overig middel | |||||||
Middel | Entonox (code = '426060003' in codeSystem 'SNOMED CT') | ||||||
Toediening | Inhalatie (code = '241717009' in codeSystem 'SNOMED CT') | ||||||
Periode | tijdens ontsluitingsperiode > 3 cm (code = 'OntMt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||||||
Sedatie? | Ja | ||||||
Kindspecifieke uitkomstgegevens | |||||||
Type partus | Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | ||||||
Ligging bij geboorte | Achterhoofd-voor (code = '70028003' in codeSystem 'SNOMED CT') | ||||||
Aanpakker kind - rol aanpakker kind | klinisch verloskundige (code = '25' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||||||
Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem 'UZI Rolcodes') | ||||||
Vaginale kunstverlossing groep | |||||||
Vaginale kunstverlossing | Vacuüm (code = '61586001' in codeSystem 'SNOMED CT') | ||||||
Succes vaginale kunstverlossing? | Ja | ||||||
Lichamelijk onderzoek kind | |||||||
Apgarscore na 5 min | 9 | ||||||
Geboortegewicht | 3550 gram | ||||||
Congenitale afwijkingen? | Ja | ||||||
Congenitale afwijkingen groep | |||||||
Specificatie congenitale afwijking groep | |||||||
Specificatie congenitale afwijking | overige congenitale huidafwijking (code = '74' in codeSystem '2.16.840.1.113883.2.4.4.13.8') | ||||||
Chromosomale afwijkingen? | Nee | ||||||
Problematiek kind? | Ja | ||||||
Problematiek kind | Geboortetrauma (code = '56110009' in codeSystem 'SNOMED CT') | ||||||
Kinderarts betrokken? | Ja | ||||||
Betrokkenheid kinderarts | |||||||
Datum betrokkenheid | T - 78 dagen | ||||||
Reden betrokkenheid | kunstverlossing (code = '8571000146103' in codeSystem 'SNOMED CT') | ||||||
Type betrokkenheid | Consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
Zorginstelling lvrid | 0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.8.8 Medisch onderzoek
Medisch onderzoek | |||
Gegevenselement | Waarde | ||
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
Irregulaire antistoffen? | Nee |
1.8.9 Postnatale fase
Postnatale fase | ||||
Gegevenselement | Waarde | |||
Kindspecifieke gegevens | ||||
Rangnummer kind | 1 | |||
Voeding kind groep | ||||
Voeding kind datum | T - 78 dagen | |||
Substantie voeding kind | borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |