mp:Vdraft Sandbox: verschil tussen versies

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<noinclude>
 +
{{DISPLAYTITLE:Kernset Neonatologie 3.0 - inhoud kwalificatie}}
 
__NUMBEREDHEADINGS__
 
__NUMBEREDHEADINGS__
{{DISPLAYTITLE:e-overdracht: addendum inhoudelijke gegevens}}
 
  
=Addenda voor inhoudelijke gegevens=
+
=Addenda voor inhoudelijke gegevens Kernset Neonatologie 3.0=</noinclude>
<section begin=eovd-saa-tst-1.1-alle_zibs />
+
==Scenario Testscenario 1: uitgebreide problematiek ==
==Scenario Aanmeldbericht==
+
       
 +
=== Documentgegevens ===
  
=== Administratieve gegevens===
+
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Documentgegevens
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Identificatie
 +
|style="background-color: white;"|0000 (in identificerend systeem: abc123)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Document datum
 +
|style="background-color: white;"|T - 1 dag
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Set identificatie
 +
|style="background-color: white;"|0000 (in identificerend systeem: abc123)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Versienummer
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Software naam
 +
|style="background-color: white;"|InformatieSysteemX
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Verificatie zorgverlener
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Geverifieerd door zorgverlener?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Verificatie datum
 +
|style="background-color: white;"|T - 0 dagen
 +
|}
 +
=== Zorgaanbieder ===
  
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Administratieve gegevens
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgaanbieder
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="6" width="30%"| Gegevenselement
+
|colspan="2" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="6"|Datum overplaatsing
+
|colspan="2"|Zorgaanbieder identificatienummer
|style="background-color: white;"|T + 1 dag
+
|style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2)
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="7"|Persoonsgegevens
+
|colspan="2"|Zorgaanbieder identificatienummer
 +
|style="background-color: white;"|0000 (in identificerend systeem: AGB-Z)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="47"|
+
|colspan="2"|Zorgaanbieder identificatienummer
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|style="background-color: white;"|0000 (in identificerend systeem: URA)
|colspan="6"|Patient
+
|}
 +
=== Zorgverlener ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Zorgverlener
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 +
|colspan="4" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="18"|
+
|colspan="4"|Zorgverlener identificatienummer
 +
|style="background-color: white;"|0000 (in identificerend systeem: 2.16.528.1.1007.5.1)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Naamgegevens
 
|colspan="5"|Naamgegevens
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="6"|
+
|rowspan="12"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Voornamen
 
|colspan="3"|Voornamen
|style="background-color: white;"|Erik
+
|style="background-color: white;"|Hans Peter
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Initialen
 
|colspan="3"|Initialen
|style="background-color: white;"|E
+
|style="background-color: white;"|HP
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Roepnaam
 +
|style="background-color: white;"|Hans
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Naamgebruik
 +
|style="background-color: white;"|Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="4"|Geslachtsnaam
 
|colspan="4"|Geslachtsnaam
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voorvoegsels
 +
|style="background-color: white;"|van den
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Achternaam
 +
|style="background-color: white;"|Akker
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Geslachtsnaam partner
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-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"|Achternaam
+
|colspan="2"|Achternaam partner
|style="background-color: white;"|XXX_Altenborg
+
|style="background-color: white;"|Pieterse
 +
|}
 +
=== Vrouw ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Vrouw
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="4" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Demografische gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Patient
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Identificatienummer
 +
|style="background-color: white;"|000000000 (in identificerend systeem: BSN)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Geboortedatum
 +
|style="background-color: white;"|T - 27 jaar
 +
|}
 +
=== Zwangerschapsgegevens ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Zwangerschapsgegevens
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="4" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Graviditeit
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Pariteit voor deze zwangerschap
 +
|style="background-color: white;"|0
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Complicaties tijdens zwangerschap
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Complicaties zwangerschap?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Adresgegevens
+
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|koorts (code = '386661006' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Verificatie status
 +
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Magnesiumsulfaat
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="6"|
+
|colspan="3"|Antenatale steroiden gegeven?
 +
|style="background-color: white;"|Nee
 +
|}
 +
=== Kind ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Kind
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="6" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Demografische gegevens
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Straat
+
|rowspan="14"|
|style="background-color: white;"|Knolweg
+
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="6"|Patient
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Huisnummer
+
|rowspan="12"|
|style="background-color: white;"|1000
+
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="5"|Adresgegevens
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Postcode
+
|rowspan="4"|
|style="background-color: white;"|9999XA
+
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="4"|Adresgegevens
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Woonplaats
+
|rowspan="2"|
|style="background-color: white;"|Stitswerd
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Adres soort
+
|colspan="2"|Postcode
|style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse')
+
|style="background-color: white;"|1234 AB
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Identificatienummer
 
|colspan="4"|Identificatienummer
|style="background-color: white;"|999911612 (in identificerend systeem: BSN)
+
|style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Geboortedatum
 
|colspan="4"|Geboortedatum
|style="background-color: white;"|14 aug 1964
+
|style="background-color: white;"|T - 90 dagen om 12:13 uur
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Geslacht
 
|colspan="4"|Geslacht
|style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender')
+
|style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Meerling indicator
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Rangnummer kind
 +
|style="background-color: white;"|2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Overlijdens indicator
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Bevallingsgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Zwangerschapsduur
 +
|style="background-color: white;"|179 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Aantal geboren kinderen
 +
|style="background-color: white;"|2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Type partus
 +
|style="background-color: white;"|Primair (code = '177141003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Locatie partus
 +
|style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Zorgaanbieder
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Zorgaanbieder identificatienummer
 +
|style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Organisatie naam
 +
|style="background-color: white;"|UMC Papendorp
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="6"|Betaler
+
|colspan="7"|Ondersteuning opvang
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="7"|
 
|rowspan="7"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Verzekeraar
+
|colspan="6"|Verrichting
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Verrichting type
 +
|style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Verrichting
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Verrichting type
 +
|style="background-color: white;"|endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Opname gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="37"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Opname
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Opname datum
 +
|style="background-color: white;"|T - 90 dagen om 13:30 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ic opname?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Heropname?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Herkomst kind
 +
|style="background-color: white;"|In-hospital admission from obstetrical ward (procedure) (code = '59151000146103' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Opname indicatie
 +
|style="background-color: white;"|Finding of length of gestation (finding) (code = '366323009' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ontslag datum
 +
|style="background-color: white;"|T - 31 dagen om 12 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Onderzoek
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="27"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Lichaamslengte
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Lengte waarde
 +
|style="background-color: white;"|31 cm
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Lengte datum tijd
 +
|style="background-color: white;"|T - 90 dagen om 13:20 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Lichaamsgewicht
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Gewicht waarde
 +
|style="background-color: white;"|710 g
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Gewicht datum tijd
 +
|style="background-color: white;"|T - 90 dagen om 13:21 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Lichaamstemperatuur
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="5"|
 
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Temperatuur waarde
 +
|style="background-color: white;"|37.4 graden celsius
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Temperatuur datum tijd
 +
|style="background-color: white;"|T - 90 dagen om 13:22 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Toelichting
 +
|style="background-color: white;"|abc
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Temperatuur type
 +
|style="background-color: white;"|Rectale temperatuur (code = '307047009' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Verzekering
+
|colspan="5"|Schedelomvang
 
|-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"|Eind datum tijd
+
|colspan="3"|Schedelomvang waarde
|style="background-color: white;"|T + 1 jaar
+
|style="background-color: white;"|22.5 cm
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Schedelomvang datum tijd
 +
|style="background-color: white;"|T - 90 dagen om 13:23 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Apgar score na 1 min
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Apgar score totaal
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Apgar score na 5 min
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Apgar score totaal
 +
|style="background-color: white;"|5
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Nsp h arterieel
 +
|style="background-color: white;"|7.05 ph
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Be
 +
|style="background-color: white;"|-12.0 mmol/l
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Problematiek kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="100"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Geboortetrauma
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Ademhalingsondersteuning
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="13"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ademhalingsondersteuning?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verrichting
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verrichting start datum
 +
|style="background-color: white;"|T - 90 dagen om 13:35 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verrichting eind datum
 +
|style="background-color: white;"|T - 33 dagen om 12 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verrichting type
 +
|style="background-color: white;"|Oxygen therapy using high flow oxygen nasal cannula (procedure) (code = '57485005:424226004=426854004' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verrichting
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verrichting start datum
 +
|style="background-color: white;"|T - 33 dagen om 12 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verrichting eind datum
 +
|style="background-color: white;"|T - 31 dagen om 10 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verrichting type
 +
|style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|O2 op dag 28?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Respiratoir
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="14"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|Respiratory distress syndrome in the newborn (disorder) (code = '46775006' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verificatie status
 +
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Aanvang
 +
|style="background-color: white;"|Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Medicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Stimulatie ademhaling
 +
|style="background-color: white;"|COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Surfactant
 +
|style="background-color: white;"|NATUURLIJKE FOSFOLIPIDEN - LONGSURFACTANTS (code = 'R07AA02' in codeSystem 'ATC-NL')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Medicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Stimulatie ademhaling
 +
|style="background-color: white;"|DOXAPRAM (code = 'R07AB01' in codeSystem 'ATC-NL')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Circulatoir
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|Patent ductus arteriosus (disorder) (code = '83330001' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verificatie status
 +
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verrichting
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verrichting type
 +
|style="background-color: white;"|Drug therapy for patent ductus arteriosus (procedure) (code = '58801000146104' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Infectieus
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="13"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|Suspected sepsis (situation) (code = '9331000146100' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem begin datum
 +
|style="background-color: white;"|T - 89 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem eind datum
 +
|style="background-color: white;"|T - 86 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verificatie status
 +
|style="background-color: white;"|Werk (code = '415684004' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Aanvang
 +
|style="background-color: white;"|Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Microorganisme sepsis meningitis
 +
|style="background-color: white;"|Other, specify (code = 'OTH' in codeSystem 'HL7 NullFlavor'): abc
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Lijnsepsis?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Onset
 +
|style="background-color: white;"|vroege neonatale periode (kwalificatiewaarde) (code = '303114002' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Antibiotica eerste 3 dagen?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Gastrointestinaal
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verrichting
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verrichting type
 +
|style="background-color: white;"|Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Hematologisch
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verrichting
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verrichting type
 +
|style="background-color: white;"|Transfusion for anemia (procedure) (code = '59071000146107' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Metabool en endocrien
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="12"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|<span id="hyperbilirubemie" title="Intern ID = hyperbilirubemie">Probleem hyperbilirubemie</span>
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verificatie status
 +
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verrichting
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Indicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem
 +
|style="background-color: white;"|Zie [[#hyperbilirubemie|Probleem: hyperbilirubemie]]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verrichting type
 +
|style="background-color: white;"|Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Neurologisch
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Zintuigen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="11"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|Retinopathy of prematurity stage 2 - intraretinal ridge (disorder) (code = '408848001' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verificatie status
 +
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Rop screening verricht?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Rop screening afgesloten?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Aabr verricht?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Aabr afwijkend?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Bera verricht?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Congenitale aandoeningen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Ontslagoverplaatsing
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="15"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Nog opgenomen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Bestemming kind
 +
|style="background-color: white;"|Discharge to other hospital (procedure) (code = '115851000146108' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Lichamelijk onderzoek
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="10"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Lichaamsgewicht
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Gewicht waarde
 +
|style="background-color: white;"|1740 gram
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Gewicht datum tijd
 +
|style="background-color: white;"|T - 31 dagen om 09 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Schedelomvang
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Schedelomvang meetmethode
 +
|style="background-color: white;"|Meten van schedelomvang m.b.v. meetlint (code = '31551000146109' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Schedelomvang waarde
 +
|style="background-color: white;"|30 cm
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Schedelomvang datum tijd
 +
|style="background-color: white;"|T - 31 dagen om 09:01 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Voeding kind
 +
|style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Mortaliteit
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Overlijden lt12 uur na opname nicu?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Overleden op verloskamer?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Staken icbehandeling?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Follow up
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Na ontslag
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|O2 op dag 28?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Gradatie bpd
 +
|style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Zintuigen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Problemen aanwezig?
 +
|style="background-color: white;"|NullFlavor: UNK
 +
|}
 +
==Scenario Testscenario 2: geb.trauma + neurologisch + anat afw  + overlijden ==
 +
       
 +
=== Documentgegevens ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Documentgegevens
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Identificatie
 +
|style="background-color: white;"|0000 (in identificerend systeem: abc123)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Document datum
 +
|style="background-color: white;"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Set identificatie
 +
|style="background-color: white;"|0000 (in identificerend systeem: abc123)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Versienummer
 +
|style="background-color: white;"|2
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Verzekeringssoort
+
|colspan="3"|Software naam
|style="background-color: white;"|Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1')
+
|style="background-color: white;"|XIS
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="6"|Contactpersoon
+
|colspan="4"|Verificatie zorgverlener
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Geverifieerd door zorgverlener?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="18"|
+
|colspan="2"|Verificatie datum
 +
|style="background-color: white;"|
 +
|}
 +
=== Zorgaanbieder ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgaanbieder
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorgaanbieder identificatienummer
 +
|style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2)
 +
|}
 +
=== Zorgverlener ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Zorgverlener
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="4" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Zorgverlener identificatienummer
 +
|style="background-color: white;"|0000 (in identificerend systeem: UZI Personen)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Naamgegevens
 
|colspan="5"|Naamgegevens
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="7"|
+
|rowspan="8"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Voornamen
 
|colspan="3"|Voornamen
|style="background-color: white;"|Johanna
+
|style="background-color: white;"|Hans Paul
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Initialen
 
|colspan="3"|Initialen
|style="background-color: white;"|J
+
|style="background-color: white;"|H.P.
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Roepnaam
 
|colspan="3"|Roepnaam
|style="background-color: white;"|Hanna
+
|style="background-color: white;"|Hans
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Naamgebruik
 +
|style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="4"|Geslachtsnaam
 
|colspan="4"|Geslachtsnaam
Regel 112: Regel 756:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Achternaam
 
|colspan="2"|Achternaam
|style="background-color: white;"|Bakker
+
|style="background-color: white;"|Pieterse
 +
|}
 +
=== Vrouw ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Vrouw
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="4" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Demografische gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Patient
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Identificatienummer
 +
|style="background-color: white;"|(in identificerend systeem: BSN)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Geboortedatum
 +
|style="background-color: white;"|T - 26 jaar
 +
|}
 +
=== Zwangerschapsgegevens ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Zwangerschapsgegevens
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="4" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Graviditeit
 +
|style="background-color: white;"|3
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Pariteit voor deze zwangerschap
 +
|style="background-color: white;"|2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Complicaties tijdens zwangerschap
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Complicaties zwangerschap?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|hypertensieve aandoening (aandoening) (code = '38341003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Verificatie status
 +
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Magnesiumsulfaat
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Antenatale steroiden gegeven?
 +
|style="background-color: white;"|NullFlavor: NA
 +
|}
 +
=== Kind ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Kind
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="6" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Demografische gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Contactgegevens
+
|colspan="6"|Patient
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="7"|
 
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Identificatienummer
 +
|style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geboortedatum
 +
|style="background-color: white;"|T - 10 dagen om 10:44 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geslacht
 +
|style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Meerling indicator
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Overlijdens indicator
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Datum overlijden
 +
|style="background-color: white;"|T - 10 dagen om 21 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Bevallingsgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Zwangerschapsduur
 +
|style="background-color: white;"|254 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Aantal geboren kinderen
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Type partus
 +
|style="background-color: white;"|Primair (code = '177141003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Locatie partus
 +
|style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Telefoonnummers
+
|colspan="6"|Zorgaanbieder
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Zorgaanbieder identificatienummer
 +
|style="background-color: white;"|234 (in identificerend systeem: AGB-Z)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Organisatie naam
 +
|style="background-color: white;"|UMC Papendorp
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Ondersteuning opvang
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Verrichting
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-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"|Telefoonnummer
+
|colspan="4"|Verrichting type
|style="background-color: white;"|+31645678912
+
|style="background-color: white;"|endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Opname gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="28"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Email adressen
+
|colspan="6"|Opname
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Opname datum
 +
|style="background-color: white;"|T - 10 dagen om 11:15 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ic opname?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Heropname?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Herkomst kind
 +
|style="background-color: white;"|In-hospital admission from obstetrical ward (procedure) (code = '59151000146103' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Opname indicatie
 +
|style="background-color: white;"|Perinatal asphyxia (disorder) (code = '281578009' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Opname indicatie
 +
|style="background-color: white;"|Infant in poor condition at birth (finding) (code = '276707008' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Opname indicatie
 +
|style="background-color: white;"|Congenital disease (disorder) (code = '66091009' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ontslag datum
 +
|style="background-color: white;"|T - 10 dagen om 21 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Onderzoek
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="16"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Lichaamsgewicht
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Gewicht waarde
 +
|style="background-color: white;"|3870 g
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Gewicht datum tijd
 +
|style="background-color: white;"|T - 10 dagen om 11:01 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Lichaamstemperatuur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Temperatuur waarde
 +
|style="background-color: white;"|36.1 graden celsius
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Temperatuur datum tijd
 +
|style="background-color: white;"|T - 10 dagen om 11:02 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Temperatuur type
 +
|style="background-color: white;"|Rectale temperatuur (code = '307047009' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Apgar score na 1 min
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-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"|Email adres
+
|colspan="3"|Apgar score totaal
|style="background-color: white;"|jbakker@123net.nl
+
|style="background-color: white;"|0
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Apgar score na 5 min
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="4"|Relatie
+
|rowspan="2"|
|style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Apgar score totaal
 +
|style="background-color: white;"|2
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="7"|Sturende organisatie
+
|colspan="7"|Problematiek kind
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="16"|
+
|rowspan="71"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="6"|Zorgaanbieder
+
|colspan="6"|Geboortetrauma
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="14"|
+
|rowspan="6"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="4"|Zorgaanbieder identificatienummer
+
|colspan="4"|Problemen aanwezig?
|style="background-color: white;"|06590457 (in identificerend systeem: AGB-Z)
+
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Probleem
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="4"|Organisatie naam
+
|rowspan="3"|
|style="background-color: white;"|AB-zkh
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="4"|Organisatie locatie
+
|colspan="3"|Probleem naam
|style="background-color: white;"|Noord
+
|style="background-color: white;"|Spinal cord injury due to birth trauma (disorder) (code = '698500002' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="4"|Afdeling specialisme
+
|colspan="3"|Verificatie status
|style="background-color: white;"|Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')
+
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Contactgegevens
+
|colspan="6"|Ademhalingsondersteuning
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="7"|
 
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ademhalingsondersteuning?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Telefoonnummers
+
|colspan="5"|Verrichting
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verrichting start datum
 +
|style="background-color: white;"|T - 10 dagen om 11:16 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verrichting type
 +
|style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|O2 op dag 28?
 +
|style="background-color: white;"|NullFlavor: NA
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Respiratoir
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Circulatoir
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|Neonatal hypotension (disorder) (code = '276519002' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verificatie status
 +
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Infectieus
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Gastrointestinaal
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-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"|Telefoonnummer
+
|colspan="4"|Problemen aanwezig?
|style="background-color: white;"|+31182435770
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Email adressen
+
|colspan="6"|Hematologisch
 
|-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"|Email adres
+
|colspan="4"|Problemen aanwezig?
|style="background-color: white;"|neurologie@ABZ.nl
+
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Metabool en endocrien
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="4"|Organisatie type
+
|colspan="4"|Problemen aanwezig?
|style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060')
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="7"|Ontvangende organisatie
+
|colspan="6"|Neurologisch
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="20"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|<span id="neonatal_encephalopathy" title="Intern ID = neonatal_encephalopathy">Probleem neonatal_encephalopathy</span>
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|Neonatal encephalopathy (disorder) (code = '95628005' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Ernst encefalopathie
 +
|style="background-color: white;"|Ernstig (code = '24484000' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verificatie status
 +
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|asfyxie bij geboorte (code = '413654009' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verificatie status
 +
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|Intraventricular (nontraumatic) hemorrhage, grade 2, of fetus and newborn (disorder) (code = '206396002' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verrichting
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-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="6"|Zorgaanbieder
+
|colspan="4"|Indicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem
 +
|style="background-color: white;"|Zie [[#neonatal_encephalopathy|Probleem: neonatal_encephalopathy]]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verrichting type
 +
|style="background-color: white;"|echografische beeldvorming van hoofd (verrichting) (code = '241449005' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Zintuigen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|NullFlavor: UNK
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Congenitale aandoeningen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Aangeboren anatomische afwijkingen majorsyndromen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|Overige congenitale afwijkingen zenuwstelsel (code = '09' in codeSystem '2.16.840.1.113883.2.4.4.13.8')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Verificatie status
 +
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Ontslagoverplaatsing
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Nog opgenomen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Voeding kind
 +
|style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Mortaliteit
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Overlijden lt12 uur na opname nicu?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Overleden op verloskamer?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Oorzaak overlijden
 +
|style="background-color: white;"|multiorgaanfalen (aandoening) (code = '57653000' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Staken icbehandeling?
 +
|style="background-color: white;"|Ja
 +
|}
 +
==Scenario Testscenario 3: stofwisselingsziekte  ==
 +
       
 +
=== Documentgegevens ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Documentgegevens
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Identificatie
 +
|style="background-color: white;"|0000 (in identificerend systeem: abc123)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Document datum
 +
|style="background-color: white;"|T - 0 dagen om 17 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Set identificatie
 +
|style="background-color: white;"|0000 (in identificerend systeem: abc123)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Versienummer
 +
|style="background-color: white;"|3
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Software naam
 +
|style="background-color: white;"|XIS
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Verificatie zorgverlener
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-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="4"|Afdeling specialisme
+
|colspan="2"|Geverifieerd door zorgverlener?
|style="background-color: white;"|Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="4"|Organisatie type
+
|colspan="2"|Verificatie datum
|style="background-color: white;"|Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060')
+
|style="background-color: white;"|
 
|}
 
|}
=== Algemene patienten context===
+
=== Zorgaanbieder ===
  
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Algemene patienten context
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgaanbieder
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="4" width="30%"| Gegevenselement
+
|colspan="2" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorgaanbieder identificatienummer
 +
|style="background-color: white;"|0000 (in identificerend systeem: AGB-Z)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorgaanbieder identificatienummer
 +
|style="background-color: white;"|(in identificerend systeem: URA)
 +
|}
 +
=== Zorgverlener ===
 +
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Zorgverlener
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="4" width="25%"| Gegevenselement
 +
|| Waarde
 +
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Zorgverlener identificatienummer
 +
|style="background-color: white;"|0000 (in identificerend systeem: AGB-Z)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Juridische situatie
+
|colspan="5"|Naamgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Voornamen
 +
|style="background-color: white;"|Hans Peter
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Initialen
 +
|style="background-color: white;"|HP
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="5"|
+
|colspan="3"|Roepnaam
 +
|style="background-color: white;"|Hans
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Naamgebruik
 +
|style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|<span id="tst-1.1-juridischesituatie-01" title="Intern ID = tst-1.1-juridischesituatie-01">Juridische situatie tst-1.1-juridischesituatie-01</span>
+
|colspan="4"|Geslachtsnaam
 
|-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"|Vertegenwoordiging
+
|colspan="2"|Voorvoegsels
|style="background-color: white;"|Onder curatele stelling (code = '9' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.23.3')
+
|style="background-color: white;"|van de
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Achternaam
 +
|style="background-color: white;"|Velde
 +
|}
 +
=== Zwangerschapsgegevens ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Zwangerschapsgegevens
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Graviditeit
 +
|style="background-color: white;"|4
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Datum aanvang
+
|colspan="3"|Pariteit voor deze zwangerschap
|style="background-color: white;"|T - 1 jaar
+
|style="background-color: white;"|2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Complicaties tijdens zwangerschap
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Complicaties zwangerschap?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Antenatale steroiden gegeven?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Antenatale steroiden
 +
|style="background-color: white;"|Complete steroid therapy for fetal lung maturation (procedure) (code = '255594003434601000124108' in codeSystem 'SNOMED CT')
 
|}
 
|}
=== Medische context===
+
=== Kind ===
  
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Medische context
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Kind
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="4" width="30%"| Gegevenselement
+
|colspan="6" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Medische diagnose
+
|colspan="7"|Demografische gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Patient
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="18"|
+
|colspan="4"|Identificatienummer
 +
|style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geboortedatum
 +
|style="background-color: white;"|T - 76 dagen om 06:55 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geslacht
 +
|style="background-color: white;"|Ongedifferentieerd (code = 'UN' in codeSystem 'HL7 AdministrativeGender')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Overlijdens indicator
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Bevallingsgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Zwangerschapsduur
 +
|style="background-color: white;"|215 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Aantal geboren kinderen
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Type partus
 +
|style="background-color: white;"|Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Locatie partus
 +
|style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Opname gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="29"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Opname
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Opname datum
 +
|style="background-color: white;"|T - 0 dagen om 09:15 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ic opname?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Heropname?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Herkomst kind
 +
|style="background-color: white;"|Hospital admission from home or birth center (procedure) (code = '59141000146101' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Opname indicatie
 +
|style="background-color: white;"|Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): vaccinatie onder observatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ontslag datum
 +
|style="background-color: white;"|T - 0 dagen om 16 uur
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Probleem
+
|colspan="6"|Onderzoek
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="4"|
+
|rowspan="19"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Lichaamslengte
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Probleem naam
+
|rowspan="3"|
|style="background-color: white;"|ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT')
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Probleem status
+
|colspan="3"|Lengte waarde
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|43 cm
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Toelichting
+
|colspan="3"|Lengte datum tijd
|style="background-color: white;"|niet bekend met neurologische klachten
+
|style="background-color: white;"|T - 0 dagen om 09:30 uur
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Probleem
+
|colspan="5"|Lichaamsgewicht
 
|-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"|Probleem naam
+
|colspan="3"|Gewicht waarde
|style="background-color: white;"|neoplasma van colon (code = '126838000')
+
|style="background-color: white;"|1800 g
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Probleem status
+
|colspan="3"|Gewicht datum tijd
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|T - 0 dagen om 09:30 uur
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Probleem
+
|colspan="5"|Lichaamstemperatuur
 
|-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"|Probleem naam
+
|colspan="3"|Temperatuur waarde
|style="background-color: white;"|oksel (code = '238600001' in codeSystem 'SNOMED Clinical Terms')
+
|style="background-color: white;"|37.1
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Probleem status
+
|colspan="3"|Temperatuur datum tijd
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|T - 0 dagen om 09:30 uur
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Probleem
+
|colspan="5"|Schedelomvang
 
|-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"|Probleem naam
+
|colspan="3"|Schedelomvang waarde
|style="background-color: white;"|inverse psoriasis (code = '238600001')
+
|style="background-color: white;"|31 centimeter
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Schedelomvang datum tijd
 +
|style="background-color: white;"|T - 0 dagen om 09:32 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Nsp h arterieel
 +
|style="background-color: white;"|7.35 ph
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Be
 +
|style="background-color: white;"|0.0 mmol/l
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Problematiek kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="10"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Congenitale aandoeningen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Probleem status
+
|colspan="4"|Problemen aanwezig?
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Voorgeschiedenis
+
|colspan="5"|Stofwisselingsziekten
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="5"|
 
|rowspan="5"|
Regel 278: Regel 1.420:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Probleem naam
 
|colspan="2"|Probleem naam
|style="background-color: white;"|diabetes mellitus (code = '73211009')
+
|style="background-color: white;"|stoornis van mineraalstofwisseling (aandoening) (code = '45744005' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Probleem status
+
|colspan="2"|Verificatie status
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|Differentiaal (code = '410590009' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Let op
+
|colspan="7"|Ontslagoverplaatsing
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="7"|
+
|colspan="5"|Nog opgenomen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Bestemming kind
 +
|style="background-color: white;"|Discharge to home (procedure) (code = '306689006' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Voeding kind
 +
|style="background-color: white;"|moedermelk (substantie) (code = '226789007' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ondersteuning bij ontslag naar huis
 +
|style="background-color: white;"|monitoren met cardiotachometer (regime/therapie) (code = '63818009' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Alert
+
|colspan="7"|Mortaliteit
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="2"|
+
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Overlijden lt12 uur na opname nicu?
 +
|style="background-color: white;"|NullFlavor: NA
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Overleden op verloskamer?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Staken icbehandeling?
 +
|style="background-color: white;"|NullFlavor: NA
 +
|}
 +
==Scenario Testscenario 4: gastro + chirurgie ==
 +
       
 +
=== Documentgegevens ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Documentgegevens
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Identificatie
 +
|style="background-color: white;"|0000
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Document datum
 +
|style="background-color: white;"|T - 10 dagen om 10 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Set identificatie
 +
|style="background-color: white;"|0000
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Versienummer
 +
|style="background-color: white;"|1
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Alert naam
+
|colspan="3"|Software naam
|style="background-color: white;"|Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|InformatieSysteemX
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Alert
+
|colspan="4"|Verificatie zorgverlener
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="2"|
+
|colspan="2"|Geverifieerd door zorgverlener?
 +
|style="background-color: white;"|NullFlavor: NI
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Verificatie datum
 +
|style="background-color: white;"|
 +
|}
 +
=== Zorgaanbieder ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgaanbieder
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Alert naam
+
|colspan="2"|Zorgaanbieder identificatienummer
|style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie
+
|style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2)
 +
|}
 +
=== Vrouw ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Vrouw
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="4" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Vrijheidsbeperking
+
|colspan="5"|Demografische gegevens
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="9"|
+
|rowspan="5"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Vrijheidsbeperkende interventie
+
|colspan="4"|Patient
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="7"|
+
|rowspan="3"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Wilsbekwaam
+
|colspan="2"|Identificatienummer
|style="background-color: white;"|Ja
+
|style="background-color: white;"|(in identificerend systeem: BSN)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Juridische situatie
+
|colspan="2"|Geboortedatum
|style="background-color: white;"|Zie [[#tst-1.1-juridischesituatie-01|Juridische situatie: tst-1.1-juridischesituatie-01]]
+
|style="background-color: white;"|
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|}
|colspan="2"|Soort interventie
+
=== Zwangerschapsgegevens ===
|style="background-color: white;"|geforceerd toedienen van voeding bij patiënt (code = '37041007' in codeSystem 'SNOMED CT')
+
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
{| class="wikitable" width="85%"
|colspan="2"|Reden van toepassen
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zwangerschapsgegevens
|style="background-color: white;"|bevorderen van fysieke gezondheid (code = '121581000146106' in codeSystem 'SNOMED CT')
+
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Instemming
+
|colspan="2"|Graviditeit
|style="background-color: white;"|Instemming patiënt (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.6.1')
+
|style="background-color: white;"|1
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Begin
+
|colspan="2"|Pariteit voor deze zwangerschap
|style="background-color: white;"|T - 50 dagen
+
|style="background-color: white;"|0
 
|}
 
|}
=== Verpleegkundige context zorgplan===
+
=== Kind ===
  
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Verpleegkundige context zorgplan
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Kind
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="6" width="30%"| Gegevenselement
+
|colspan="6" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="7"|Actuele patientproblemen
+
|colspan="7"|Demografische gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Patient
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Identificatienummer
 +
|style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geboortedatum
 +
|style="background-color: white;"|T - 87 dagen om 13 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geslacht
 +
|style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Meerling indicator
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="64"|
+
|colspan="4"|Rangnummer kind
 +
|style="background-color: white;"|2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Overlijdens indicator
 +
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="6"|Patientprobleem
+
|colspan="7"|Bevallingsgegevens
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="15"|
+
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Zwangerschapsduur
 +
|style="background-color: white;"|236 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Aantal geboren kinderen
 +
|style="background-color: white;"|2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Type partus
 +
|style="background-color: white;"|Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Locatie partus
 +
|style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|<span id="tst-1.1-patientprobleem-01" title="Intern ID = tst-1.1-patientprobleem-01">Probleem tst-1.1-patientprobleem-01</span>
+
|colspan="7"|Ondersteuning opvang
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="4"|
 
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Verrichting
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Verrichting type
 +
|style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Opname gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="23"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Opname
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="11"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Opname datum
 +
|style="background-color: white;"|T - 80 dagen om 09 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ic opname?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Heropname?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Probleem naam
+
|colspan="4"|Herkomst kind
|style="background-color: white;"|probleem met zichzelf wassen (code = '288552005' in codeSystem 'Referentieset Nationale kernset patientproblemen')
+
|style="background-color: white;"|Hospital admission, transfer from other hospital or health care facility (procedure) (code = '4563007' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Zorgaanbieder
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Zorgaanbieder identificatienummer
 +
|style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Organisatie naam
 +
|style="background-color: white;"|AZ Papendorp
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Opname indicatie
 +
|style="background-color: white;"|Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): abc
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ontslag datum
 +
|style="background-color: white;"|T - 11 dagen om 16 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Onderzoek
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Lichaamslengte
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Probleem status
+
|colspan="3"|Lengte waarde
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|43 cm
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Toelichting
+
|colspan="3"|Lengte datum tijd
|style="background-color: white;"|meneer kan niet buigen
+
|style="background-color: white;"|T - 80 dagen om 09:30 uur
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Verpleegkundige interventie
+
|colspan="5"|Lichaamsgewicht
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="8"|
+
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Gewicht waarde
 +
|style="background-color: white;"|1530 g
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Gewicht datum tijd
 +
|style="background-color: white;"|T - 80 dagen om 09:30 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Problematiek kind
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Interventie
+
|rowspan="104"|
|style="background-color: white;"|ondersteunen bij wassen en/of persoonlijke hygiëne (code = '386420003' in codeSystem 'SNOMED Clinical Terms')
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Indicatie
+
|colspan="6"|Geboortetrauma
 
|-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"|Probleem
+
|colspan="4"|Problemen aanwezig?
|style="background-color: white;"|Zie [[#tst-1.1-patientprobleem-01|Probleem: tst-1.1-patientprobleem-01]]
+
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Ademhalingsondersteuning
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ademhalingsondersteuning?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Uitvoerder
+
|colspan="5"|Verrichting
 
|-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"|Zorgverlener
+
|colspan="3"|Verrichting type
|style="background-color: white;"|Ja
+
|style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|O2 op dag 28?
 +
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="6"|Patientprobleem
+
|colspan="6"|Respiratoir
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="11"|
+
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|<span id="tst-1.1-patientprobleem-02" title="Intern ID = tst-1.1-patientprobleem-02">Probleem tst-1.1-patientprobleem-02</span>
+
|colspan="5"|Probleem
 
|-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"|Probleem naam
 
|colspan="3"|Probleem naam
|style="background-color: white;"|probleem met zichzelf kleden (code = '284972002' in codeSystem 'Referentieset Nationale kernset patientproblemen')
+
|style="background-color: white;"|Bronchopulmonary dysplasia of newborn (disorder) (code = '67569000' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Probleem status
+
|colspan="3"|Verificatie status
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Verpleegkundige interventie
+
|colspan="5"|Medicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Stimulatie ademhaling
 +
|style="background-color: white;"|COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Circulatoir
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-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="3"|Interventie
+
|colspan="4"|Problemen aanwezig?
|style="background-color: white;"|ondersteunen bij aankleden (code = '313332003' in codeSystem 'SNOMED Clinical Terms')
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Indicatie
+
|colspan="5"|Probleem
 
|-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"|Probleem
+
|colspan="3"|Probleem naam
|style="background-color: white;"|Zie [[#tst-1.1-patientprobleem-02|Probleem: tst-1.1-patientprobleem-02]]
+
|style="background-color: white;"|Neonatal hypotension (disorder) (code = '276519002' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Infectieus
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|neonatale sepsis (aandoening) (code = '206376005' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Microorganisme sepsis meningitis
 +
|style="background-color: white;"|Listeria monocytogenes (organism) (code = '36094007' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Lijnsepsis?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Onset
 +
|style="background-color: white;"|late neonatale periode (kwalificatiewaarde) (code = '303115001' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Antibiotica eerste 3 dagen?
 +
|style="background-color: white;"|NullFlavor: NA
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Infuus
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Infuuskatheter
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Medisch hulpmiddel
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Begin datum
 +
|style="background-color: white;"|T - 80 dagen om 10 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Einddatum
 +
|style="background-color: white;"|T - 17 dagen om 09 uur
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="6"|Patientprobleem
+
|colspan="6"|Gastrointestinaal
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="22"|
+
|rowspan="18"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|<span id="tst-1.1-patientprobleem-03" title="Intern ID = tst-1.1-patientprobleem-03">Probleem tst-1.1-patientprobleem-03</span>
+
|colspan="5"|<span id="enterocolitis" title="Intern ID = enterocolitis">Probleem enterocolitis</span>
 
|-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"|Probleem naam
 
|colspan="3"|Probleem naam
|style="background-color: white;"|decubitus (code = '399912005' in codeSystem 'Referentieset Nationale kernset patientproblemen')
+
|style="background-color: white;"|Necrotizing enterocolitis in fetus OR newborn - Bell stage IIIA (disorder) (code = '21941000146103' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Probleem status
+
|colspan="3"|Verificatie status
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Verpleegkundige interventie
+
|colspan="5"|Verrichting
 
|-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;;"
 
|colspan="3"|Interventie
 
|style="background-color: white;"|aanleggen van verband op wond (code = '182531007' in codeSystem 'SNOMED Clinical Terms')
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="4"|Indicatie
 
|colspan="4"|Indicatie
Regel 432: Regel 1.798:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Probleem
 
|colspan="2"|Probleem
|style="background-color: white;"|Zie [[#tst-1.1-patientprobleem-03|Probleem: tst-1.1-patientprobleem-03]]
+
|style="background-color: white;"|Zie [[#enterocolitis|Probleem: enterocolitis]]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verrichting type
 +
|style="background-color: white;"|Laparotomy (procedure) (code = '86481000' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Verpleegkundige interventie
+
|colspan="5"|Verrichting
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="10"|
+
|rowspan="5"|
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Interventie
 
|style="background-color: white;"|wisselen van positie van patiënt (code = '225286008' in codeSystem 'SNOMED Clinical Terms')
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="4"|Indicatie
 
|colspan="4"|Indicatie
Regel 446: Regel 1.812:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Probleem
 
|colspan="2"|Probleem
|style="background-color: white;"|Zie [[#tst-1.1-patientprobleem-03|Probleem: tst-1.1-patientprobleem-03]]
+
|style="background-color: white;"|Zie [[#enterocolitis|Probleem: enterocolitis]]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verrichting type
 +
|style="background-color: white;"|Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Hematologisch
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Actie start datum tijd
+
|rowspan="5"|
|style="background-color: white;"|T - 10 dagen
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Actie eind datum tijd
+
|colspan="4"|Problemen aanwezig?
|style="background-color: white;"|T - 1 dag
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Uitvoerder
+
|colspan="5"|Verrichting
 
|-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"|Zorgverlener
+
|colspan="3"|Verrichting type
 +
|style="background-color: white;"|Transfusion for anemia (procedure) (code = '59071000146107' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Metabool en endocrien
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="22"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 
|style="background-color: white;"|Ja
 
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="6"|Patientprobleem
+
|colspan="5"|<span id="hyperbilirubinemie" title="Intern ID = hyperbilirubinemie">Probleem hyperbilirubinemie</span>
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="11"|
+
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verificatie status
 +
|style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|<span id="tst-1.1-patientprobleem-04" title="Intern ID = tst-1.1-patientprobleem-04">Probleem tst-1.1-patientprobleem-04</span>
+
|colspan="5"|<span id="hypoglycemia" title="Intern ID = hypoglycemia">Probleem hypoglycemia</span>
 
|-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"|Probleem naam
 
|colspan="3"|Probleem naam
|style="background-color: white;"|loopt risico op delier (code = '430794006' in codeSystem 'Referentieset Nationale kernset patientproblemen')
+
|style="background-color: white;"|Hypoglycemia (disorder) (code = '302866003' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Probleem status
+
|colspan="3"|Verificatie status
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|Differentiaal (code = '410590009' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Verpleegkundige interventie
+
|colspan="5"|Verrichting
 
|-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;;" 
 +
|colspan="4"|Indicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem
 +
|style="background-color: white;"|Zie [[#hyperbilirubinemie|Probleem: hyperbilirubinemie]]
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Interventie
+
|colspan="3"|Verrichting type
|style="background-color: white;"|bevorderen van vochtinname (code = '113148007' in codeSystem 'SNOMED Clinical Terms')
+
|style="background-color: white;"|Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verrichting
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="4"|Indicatie
 
|colspan="4"|Indicatie
Regel 487: Regel 1.881:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Probleem
 
|colspan="2"|Probleem
|style="background-color: white;"|Zie [[#tst-1.1-patientprobleem-04|Probleem: tst-1.1-patientprobleem-04]]
+
|style="background-color: white;"|Zie [[#hypoglycemia|Probleem: hypoglycemia]]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verrichting type
 +
|style="background-color: white;"|Intravenous infusion of glucose in hypoglycemia (procedure) (code = '109091000146105' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Zintuigen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|NullFlavor: NI
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Congenitale aandoeningen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Chirurgische ingrepen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Verrichting
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Verrichting type
 +
|style="background-color: white;"|Endoscopie van oesofagus (verrichting) (code = '49230008' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Ontslagoverplaatsing
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="10"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Nog opgenomen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Bestemming kind
 +
|style="background-color: white;"|Discharge to other location within hospital premises (procedure) (code = '115841000146105' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Lichamelijk onderzoek
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Lichaamsgewicht
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Gewicht waarde
 +
|style="background-color: white;"|2800 gram
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Gewicht datum tijd
 +
|style="background-color: white;"|T - 11 dagen om 15 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Voeding kind
 +
|style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Mortaliteit
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Overlijden lt12 uur na opname nicu?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Overleden op verloskamer?
 +
|style="background-color: white;"|Nee
 
|}
 
|}
=== Verpleegkundige context specificatie gezondheidstoestand===
+
==Scenario Testscenario 5: zintuigen + FU ==
 +
       
 +
=== Documentgegevens ===
  
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="8" | Verpleegkundige context specificatie gezondheidstoestand
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Documentgegevens
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="7" width="30%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Identificatie
 +
|style="background-color: white;"|0000
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Document datum
 +
|style="background-color: white;"|T - 14 dagen om 10 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Set identificatie
 +
|style="background-color: white;"|0000
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Versienummer
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Software naam
 +
|style="background-color: white;"|InformatieSysteemX
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="8"|Voedingvocht
+
|colspan="4"|Verificatie zorgverlener
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="32"|
+
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Geverifieerd door zorgverlener?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Verificatie datum
 +
|style="background-color: white;"|T - 14 dagen om 11 uur
 +
|}
 +
=== Zorgaanbieder ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgaanbieder
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorgaanbieder identificatienummer
 +
|style="background-color: white;"|
 +
|}
 +
=== Zwangerschapsgegevens ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Zwangerschapsgegevens
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="4" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Graviditeit
 +
|style="background-color: white;"|5
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Pariteit voor deze zwangerschap
 +
|style="background-color: white;"|4
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="7"|Sonde systeem
+
|colspan="5"|Complicaties tijdens zwangerschap
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="9"|
 
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Complicaties zwangerschap?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|preterm en prematuur gebroken vliezen (aandoening) (code = '312974005' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Verificatie status
 +
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Magnesiumsulfaat
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Antenatale steroiden gegeven?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Antenatale steroiden
 +
|style="background-color: white;"|Complete steroid therapy for fetal lung maturation (procedure) (code = '255594003434601000124108' in codeSystem 'SNOMED CT')
 +
|}
 +
=== Kind ===
 +
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Kind
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="6" width="25%"| Gegevenselement
 +
|| Waarde
 +
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Demografische gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="13"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="6"|Sonde
+
|colspan="6"|Patient
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="7"|
+
|rowspan="11"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Medisch hulpmiddel
+
|colspan="5"|Adresgegevens
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="5"|
+
|rowspan="4"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Product
+
|colspan="4"|Adresgegevens
 
|-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"|Product type
+
|colspan="2"|Postcode
|style="background-color: white;"|PEJ sonde (code = '8911000146104' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|1234 AB
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Product omschrijving
+
|colspan="4"|Identificatienummer
|style="background-color: white;"|PEJ sonde
+
|style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geboortedatum
 +
|style="background-color: white;"|T - 179 dagen om 14 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geslacht
 +
|style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Meerling indicator
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Overlijdens indicator
 +
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="7"|Infuus
+
|colspan="7"|Bevallingsgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Zwangerschapsduur
 +
|style="background-color: white;"|177 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Type partus
 +
|style="background-color: white;"|Sectio Caesarea (code = '11466000' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="10"|
+
|colspan="5"|Locatie partus
 +
|style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="6"|Infuuskatheter
+
|colspan="7"|Ondersteuning opvang
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="7"|
 
|rowspan="7"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Medisch hulpmiddel
+
|colspan="6"|Verrichting
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="5"|
+
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Verrichting type
 +
|style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Product
+
|colspan="6"|Verrichting
 
|-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"|Product type
+
|colspan="4"|Verrichting type
|style="background-color: white;"|Centraal veneuze katheter (code = '52124006' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Opname gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="33"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Opname
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Opname datum
 +
|style="background-color: white;"|T - 179 dagen om 14:30 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ic opname?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Heropname?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Herkomst kind
 +
|style="background-color: white;"|Hospital admission, transfer from other hospital or health care facility (procedure) (code = '4563007' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Product omschrijving
+
|colspan="4"|Opname indicatie
|style="background-color: white;"|centraal veneuze katheter
+
|style="background-color: white;"|Finding of length of gestation (finding) (code = '366323009' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="5"|Toelichting
+
|colspan="4"|Ontslag datum
|style="background-color: white;"|voor voeding
+
|style="background-color: white;"|T - 44 dagen om 12 uur
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="7"|Infuus
+
|colspan="6"|Onderzoek
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="9"|
+
|rowspan="23"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="6"|Infuuskatheter
+
|colspan="5"|Lichaamsgewicht
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="7"|
+
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Gewicht waarde
 +
|style="background-color: white;"|710 g
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Gewicht datum tijd
 +
|style="background-color: white;"|T - 179 dagen om 14:30 uur
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Medisch hulpmiddel
+
|colspan="5"|Lichaamstemperatuur
 
|-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;;"
 +
|colspan="3"|Temperatuur waarde
 +
|style="background-color: white;"|36.7
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Temperatuur datum tijd
 +
|style="background-color: white;"|T - 179 dagen om 14:35 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Toelichting
 +
|style="background-color: white;"|geen bijzonderheden
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Temperatuur type
 +
|style="background-color: white;"|Orale temperatuur (onder de tong) (code = '415945006' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Product
+
|colspan="5"|Schedelomvang
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Schedelomvang waarde
 +
|style="background-color: white;"|25.5
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Schedelomvang datum tijd
 +
|style="background-color: white;"|T - 179 dagen om 14:35 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Apgar score na 1 min
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-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"|Product type
+
|colspan="3"|Apgar score totaal
|style="background-color: white;"|Perifeer intraveneus infuus (code = '82449006' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Apgar score na 5 min
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Product omschrijving
+
|rowspan="2"|
|style="background-color: white;"|voor medicatie
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Apgar score totaal
 +
|style="background-color: white;"|4
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Nsp h arterieel
 +
|style="background-color: white;"|7.21 ph
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Be
 +
|style="background-color: white;"|-11 mmol/l
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Problematiek kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="127"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Geboortetrauma
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Ademhalingsondersteuning
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="15"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ademhalingsondersteuning?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="8"|Uitscheiding
+
|colspan="5"|Verrichting
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="8"|
+
|colspan="3"|Verrichting type
 +
|style="background-color: white;"|toedienen van zuurstof via neusbril (verrichting) (code = '371907003' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="7"|Stoma
+
|colspan="5"|Verrichting
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="3"|
+
|colspan="3"|Verrichting type
 +
|style="background-color: white;"|Oxygen therapy using high flow oxygen nasal cannula (procedure) (code = '57485005:424226004=426854004' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verrichting
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="5"|Stoma type
+
|rowspan="2"|
|style="background-color: white;"|eindstandige ileostoma (code = '311412005' in codeSystem 'SNOMED CT')
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="5"|Toelichting
+
|colspan="3"|Verrichting type
|style="background-color: white;"|na subtotale darmresectie
+
|style="background-color: white;"|Continuous positive airway pressure ventilation treatment (procedure) (code = '47545007' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="7"|Stoma
+
|colspan="5"|Verrichting
 
|-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="5"|Stoma type
+
|colspan="3"|Verrichting type
|style="background-color: white;"|urostoma (code = '281601009' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|Noninvasive ventilation (procedure) (code = '428311008' in codeSystem 'SNOMED CT')
|}<section end=eovd-saa-tst-1.1-alle_zibs />
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
<section begin=eovd-saa-tst-1.1b-alle_zibs />
+
|colspan="4"|O2 op dag 28?
==Scenario Aanmeldbericht - overlap BgZ==
+
|style="background-color: white;"|Ja
 
+
|-style="vertical-align:top; background-color: #E3E3E3;;" 
=== Administratieve gegevens===
+
|colspan="6"|Respiratoir
 
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
{| class="wikitable" width="85%"
+
|rowspan="21"|
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Administratieve gegevens
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
|-style="background-color: #1F497D;; color: white; text-align:left;"  
+
|colspan="4"|Problemen aanwezig?
|colspan="6" width="30%"| Gegevenselement
+
|style="background-color: white;"|Ja
|| Waarde
+
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 
+
|colspan="5"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|Respiratory distress syndrome in the newborn (disorder) (code = '46775006' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem begin datum
 +
|style="background-color: white;"|T - 152 dagen om 08 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Aanvang
 +
|style="background-color: white;"|Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="6"|Datum overplaatsing
+
|colspan="3"|Probleem naam
|style="background-color: white;"|T + 1 dag
+
|style="background-color: white;"|Bronchopulmonary dysplasia of newborn - grade 3 (disorder) (code = '22041000146108' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="7"|Persoonsgegevens
+
|colspan="5"|Verrichting
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="47"|
+
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verrichting type
 +
|style="background-color: white;"|Extracorporeal membrane oxygenation (procedure) (code = '233573008' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="6"|Patient
+
|colspan="5"|Medicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Stimulatie ademhaling
 +
|style="background-color: white;"|COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Surfactant
 +
|style="background-color: white;"|NATUURLIJKE FOSFOLIPIDEN - LONGSURFACTANTS (code = 'R07AA02' in codeSystem 'ATC-NL')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="18"|
+
|colspan="3"|Systemische steroiden
 +
|style="background-color: white;"|CORTICOSTEROIDEN VOOR SYSTEMISCH GEBRUIK - SYSTEMISCHE HORMOONPREPARATEN, EXCL GESLACHTSHORMONEN (code = 'H02' in codeSystem 'ATC-NL')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Naamgegevens
+
|colspan="5"|Medicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="6"|
+
|colspan="3"|Stimulatie ademhaling
 +
|style="background-color: white;"|DOXAPRAM (code = 'R07AB01' in codeSystem 'ATC-NL')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Circulatoir
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Voornamen
+
|rowspan="5"|
|style="background-color: white;"|Erik
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Initialen
+
|colspan="4"|Problemen aanwezig?
|style="background-color: white;"|E
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Geslachtsnaam
+
|colspan="5"|Probleem
 
|-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"|Achternaam
+
|colspan="3"|Probleem naam
|style="background-color: white;"|XXX_Altenborg
+
|style="background-color: white;"|Low blood pressure (disorder) (code = '45007003' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Adresgegevens
+
|colspan="6"|Infectieus
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="15"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="6"|
+
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Probleem
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Straat
+
|rowspan="4"|
|style="background-color: white;"|Knolweg
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Huisnummer
+
|colspan="3"|Probleem naam
|style="background-color: white;"|1000
+
|style="background-color: white;"|neonatale sepsis (aandoening) (code = '206376005' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Postcode
+
|colspan="3"|Lijnsepsis?
|style="background-color: white;"|9999XA
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Woonplaats
+
|colspan="3"|Onset
|style="background-color: white;"|Stitswerd
+
|style="background-color: white;"|vroege neonatale periode (kwalificatiewaarde) (code = '303114002' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Probleem
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Adres soort
+
|rowspan="3"|
|style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse')
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="4"|Identificatienummer
+
|colspan="3"|Probleem naam
|style="background-color: white;"|999911612 (in identificerend systeem: BSN)
+
|style="background-color: white;"|urineweginfectie (aandoening) (code = '68566005' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verificatie status
 +
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="4"|Geboortedatum
+
|colspan="3"|Probleem naam
|style="background-color: white;"|14 aug 1964
+
|style="background-color: white;"|Neonatal pneumonia (disorder) (code = '233619008' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="4"|Geslacht
+
|colspan="4"|Antibiotica eerste 3 dagen?
|style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender')
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="6"|Betaler
+
|colspan="6"|Infuus
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="7"|
 
|rowspan="7"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Verzekeraar
+
|colspan="5"|Infuuskatheter
 
|-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"|Verzekering
+
|colspan="4"|Medisch hulpmiddel
 
|-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"|Eind datum tijd
+
|colspan="2"|Begin datum
|style="background-color: white;"|T + 1 jaar
+
|style="background-color: white;"|T - 179 dagen om 17 uur
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Verzekeringssoort
+
|colspan="2"|Einddatum
|style="background-color: white;"|Basis (code = 'B' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.1')
+
|style="background-color: white;"|T - 148 dagen om 08 uur
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="6"|Contactpersoon
+
|colspan="6"|Gastrointestinaal
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verrichting
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Indicatie
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem
 +
|style="background-color: white;"|Zie [[#|: ]]
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verrichting type
 +
|style="background-color: white;"|Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Hematologisch
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verrichting
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verrichting type
 +
|style="background-color: white;"|Treatment for trombocytopenia (procedure) (code = '59091000146106' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Metabool en endocrien
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="14"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="18"|
+
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Naamgegevens
+
|colspan="5"|Probleem
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="7"|
+
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Voornamen
+
|colspan="3"|Probleem naam
|style="background-color: white;"|Johanna
+
|style="background-color: white;"|Hypoglycemia (disorder) (code = '302866003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verrichting
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Initialen
+
|rowspan="2"|
|style="background-color: white;"|J
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="3"|Roepnaam
+
|colspan="3"|Verrichting type
|style="background-color: white;"|Hanna
+
|style="background-color: white;"|Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Geslachtsnaam
+
|colspan="5"|Verrichting
 
|-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"|Achternaam
+
|colspan="3"|Verrichting type
|style="background-color: white;"|Bakker
+
|style="background-color: white;"|Intravenous infusion of glucose in hypoglycemia (procedure) (code = '109091000146105' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Contactgegevens
+
|colspan="6"|Neurologisch
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="7"|
+
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Telefoonnummers
+
|colspan="5"|Verrichting
 
|-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"|Telefoonnummer
+
|colspan="3"|Verrichting type
|style="background-color: white;"|+31645678912
+
|style="background-color: white;"|echografische beeldvorming van hoofd (verrichting) (code = '241449005' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Email adressen
+
|colspan="5"|Verrichting
 
|-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"|Email adres
+
|colspan="3"|Verrichting type
|style="background-color: white;"|jbakker@123net.nl
+
|style="background-color: white;"|'magnetic resonance imaging' van hoofd (verrichting) (code = '241601008' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Zintuigen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="15"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Probleem naam
 +
|style="background-color: white;"|Plus disease (disorder) (code = '56341000146109' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Verificatie status
 +
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Rop screening verricht?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Rop screening afgesloten?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Aabr verricht?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Aabr afwijkend?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Bera verricht?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Bera
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Bera afwijkend?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Bera lateraliteit
 +
|style="background-color: white;"|Links (code = '7771000' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Ontslagoverplaatsing
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="15"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Nog opgenomen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Bestemming kind
 +
|style="background-color: white;"|Discharge to other hospital (procedure) (code = '115851000146108' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Lichamelijk onderzoek
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="10"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Lichaamsgewicht
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Gewicht waarde
 +
|style="background-color: white;"|4 kg
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Gewicht datum tijd
 +
|style="background-color: white;"|T - 44 dagen om 09 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Schedelomvang
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Schedelomvang meetmethode
 +
|style="background-color: white;"|Meten van schedelomvang m.b.v. echografisch onderzoek (code = '31561000146107' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Schedelomvang waarde
 +
|style="background-color: white;"|34.6
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Schedelomvang datum tijd
 +
|style="background-color: white;"|T - 45 dagen om 10:20 uur
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="4"|Relatie
+
|colspan="5"|Voeding kind
|style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): achterneef
+
|style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="7"|Sturende organisatie
+
|colspan="7"|Mortaliteit
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Overlijden lt12 uur na opname nicu?
 +
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="16"|
+
|colspan="5"|Overleden op verloskamer?
 +
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="6"|Zorgaanbieder
+
|colspan="7"|Follow up
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="14"|
+
|rowspan="21"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Na ontslag
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="4"|Zorgaanbieder identificatienummer
+
|rowspan="19"|
|style="background-color: white;"|06590457 (in identificerend systeem: AGB-Z)
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="4"|Organisatie naam
+
|colspan="4"|O2 op dag 28?
|style="background-color: white;"|AB-zkh
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="4"|Organisatie locatie
+
|colspan="4"|Gradatie bpd
|style="background-color: white;"|Noord
+
|style="background-color: white;"|Bronchopulmonary dysplasia of newborn - grade 1 (disorder) (code = '22021000146102' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Zintuigen
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="4"|Afdeling specialisme
+
|rowspan="15"|
|style="background-color: white;"|Medisch specialisten, neurologie (code = '0330' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Problemen aanwezig?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Contactgegevens
+
|colspan="4"|Probleem
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Probleem naam
 +
|style="background-color: white;"|Plus disease (disorder) (code = '56341000146109' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="7"|
+
|colspan="2"|Verificatie status
 +
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Rop screening verricht?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Rop screening afgesloten?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Aabr verricht?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Aabr afwijkend?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Bera verricht?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Telefoonnummers
+
|colspan="4"|Bera
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="2"|
+
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Bera afwijkend?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Telefoonnummer
+
|colspan="2"|Bera lateraliteit
|style="background-color: white;"|+31182435770
+
|style="background-color: white;"|Links (code = '7771000' in codeSystem 'SNOMED CT')
 +
|}
 +
==Scenario Testscenario 6: overleden op verloskamer ==
 +
       
 +
=== Documentgegevens ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Documentgegevens
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Email adressen
+
|colspan="4"|Verificatie zorgverlener
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="2"|
+
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Geverifieerd door zorgverlener?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Email adres
+
|colspan="2"|Verificatie datum
|style="background-color: white;"|neurologie@ABZ.nl
+
|style="background-color: white;"|
 +
|}
 +
=== Zorgaanbieder ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgaanbieder
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="4"|Organisatie type
+
|colspan="2"|Zorgaanbieder identificatienummer
|style="background-color: white;"|Algemeen ziekenhuis (code = 'V6' in codeSystem '2.16.840.1.113883.2.4.15.1060')
+
|style="background-color: white;"|
 +
|}
 +
=== Vrouw ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Vrouw
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 +
|colspan="4" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="7"|Ontvangende organisatie
+
|colspan="5"|Demografische gegevens
 
|-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="6"|Zorgaanbieder
+
|colspan="4"|Patient
 
|-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="4"|Afdeling specialisme
+
|colspan="2"|Identificatienummer
|style="background-color: white;"|Thuiszorg, kruiswerk en gezinsverzorging (code = '7500' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)')
+
|style="background-color: white;"|000000000 (in identificerend systeem: BSN)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="4"|Organisatie type
+
|colspan="2"|Geboortedatum
|style="background-color: white;"|Thuiszorg (code = 'T2' in codeSystem '2.16.840.1.113883.2.4.15.1060')
+
|style="background-color: white;"|T - 29 jaar
 
|}
 
|}
=== Medische context===
+
=== Zwangerschapsgegevens ===
  
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Medische context
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Zwangerschapsgegevens
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="4" width="30%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Graviditeit
 +
|style="background-color: white;"|2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pariteit voor deze zwangerschap
 +
|style="background-color: white;"|1
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Medische diagnose
+
|colspan="4"|Complicaties tijdens zwangerschap
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="18"|
+
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Complicaties zwangerschap?
 +
|style="background-color: white;"|Nee
 +
|}
 +
=== Kind ===
 +
 
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Kind
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Demografische gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Probleem
+
|colspan="5"|Patient
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Identificatienummer
 +
|style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Geboortedatum
 +
|style="background-color: white;"|T - 18 dagen om 13:20 uur
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="4"|
+
|colspan="3"|Geslacht
 +
|style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Probleem naam
+
|colspan="3"|Meerling indicator
|style="background-color: white;"|ischemisch cerebrovasculair (code = '422504002' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Probleem status
+
|colspan="3"|Overlijdens indicator
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Toelichting
+
|colspan="3"|Datum overlijden
|style="background-color: white;"|niet bekend met neurologische klachten
+
|style="background-color: white;"|T - 18 dagen om 19 uur
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Probleem
+
|colspan="6"|Bevallingsgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Zwangerschapsduur
 +
|style="background-color: white;"|266 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Aantal geboren kinderen
 +
|style="background-color: white;"|1
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="3"|
+
|colspan="4"|Type partus
 +
|style="background-color: white;"|Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Probleem naam
+
|colspan="4"|Locatie partus
|style="background-color: white;"|neoplasma van colon (code = '126838000')
+
|style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Ondersteuning opvang
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Probleem status
+
|rowspan="10"|
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Probleem
+
|colspan="5"|Verrichting
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="3"|
+
|colspan="3"|Verrichting type
 +
|style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verrichting
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Probleem naam
+
|rowspan="2"|
|style="background-color: white;"|oksel (code = '238600001' in codeSystem 'SNOMED Clinical Terms')
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Probleem status
+
|colspan="3"|Verrichting type
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|mechanische thoraxcompressies (verrichting) (code = '33631000146101' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Probleem
+
|colspan="5"|Verrichting
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="3"|
+
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Probleem naam
+
|colspan="3"|Verrichting type
|style="background-color: white;"|inverse psoriasis (code = '238600001')
+
|style="background-color: white;"|injectie van adrenaline (verrichting) (code = '313191000' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Opname gegevens
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Probleem status
+
|rowspan="21"|
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Voorgeschiedenis
+
|colspan="5"|Opname
 
|-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;;"
 +
|colspan="3"|Opname datum
 +
|style="background-color: white;"|T - 18 dagen om 13:30 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Ic opname?
 +
|style="background-color: white;"|NullFlavor: NA
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Heropname?
 +
|style="background-color: white;"|NullFlavor: NA
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Ontslag datum
 +
|style="background-color: white;"|T - 18 dagen om 19 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Onderzoek
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="13"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Probleem
+
|colspan="4"|Lichaamsgewicht
 
|-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"|Probleem naam
+
|colspan="2"|Gewicht waarde
|style="background-color: white;"|diabetes mellitus (code = '73211009')
+
|style="background-color: white;"|3100 g
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Gewicht datum tijd
 +
|style="background-color: white;"|T - 18 dagen om 13:30 uur
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Apgar score na 1 min
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Apgar score totaal
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Apgar score na 5 min
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Apgar score totaal
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Nsp h arterieel
 +
|style="background-color: white;"|7.13 ph
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Be
 +
|style="background-color: white;"|-6.9 mmol/l
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Problematiek kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="19"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Ademhalingsondersteuning
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Ademhalingsondersteuning?
 +
|style="background-color: white;"|NullFlavor: NI
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Circulatoir
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Problemen aanwezig?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Infectieus
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Probleem status
+
|colspan="3"|Problemen aanwezig?
|style="background-color: white;"|Actueel (code = '55561003' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="5"|Let op
+
|colspan="5"|Hematologisch
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|rowspan="7"|
+
|colspan="3"|Problemen aanwezig?
 +
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Alert
+
|colspan="5"|Zintuigen
 
|-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"|Alert naam
+
|colspan="3"|Problemen aanwezig?
|style="background-color: white;"|Drager MRSA (code = '432415000' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
|colspan="4"|Alert
+
|colspan="5"|Congenitale aandoeningen
 
|-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"|Alert naam
+
|colspan="3"|Problemen aanwezig?
|style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): ernstige claustrofobie
+
|style="background-color: white;"|Nee
|}<section end=eovd-saa-tst-1.1b-alle_zibs />
+
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Mortaliteit
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Overlijden lt12 uur na opname nicu?
 +
|style="background-color: white;"|NullFlavor: NA
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Overleden op verloskamer?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Oorzaak overlijden
 +
|style="background-color: white;"|ernstige asfyxie bij geboorte (aandoening) (code = '57284007' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Staken icbehandeling?
 +
|style="background-color: white;"|NullFlavor: NA
 +
|}
 +
[[Categorie:Kwalificatie]]

Versie van 12 jan 2022 10:24



1 Addenda voor inhoudelijke gegevens Kernset Neonatologie 3.0

1.1 Scenario Testscenario 1: uitgebreide problematiek

1.1.1 Documentgegevens

Documentgegevens
Gegevenselement Waarde
Identificatie 0000 (in identificerend systeem: abc123)
Document datum T - 1 dag
Set identificatie 0000 (in identificerend systeem: abc123)
Versienummer 1
Software naam InformatieSysteemX
Verificatie zorgverlener
Geverifieerd door zorgverlener? Ja
Verificatie datum T - 0 dagen

1.1.2 Zorgaanbieder

Zorgaanbieder
Gegevenselement Waarde
Zorgaanbieder identificatienummer 0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2)
Zorgaanbieder identificatienummer 0000 (in identificerend systeem: AGB-Z)
Zorgaanbieder identificatienummer 0000 (in identificerend systeem: URA)

1.1.3 Zorgverlener

Zorgverlener
Gegevenselement Waarde
Zorgverlener identificatienummer 0000 (in identificerend systeem: 2.16.528.1.1007.5.1)
Naamgegevens
Voornamen Hans Peter
Initialen HP
Roepnaam Hans
Naamgebruik Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')
Geslachtsnaam
Voorvoegsels van den
Achternaam Akker
Geslachtsnaam partner
Achternaam partner Pieterse

1.1.4 Vrouw

Vrouw
Gegevenselement Waarde
Demografische gegevens
Patient
Identificatienummer 000000000 (in identificerend systeem: BSN)
Geboortedatum T - 27 jaar

1.1.5 Zwangerschapsgegevens

Zwangerschapsgegevens
Gegevenselement Waarde
Graviditeit 1
Pariteit voor deze zwangerschap 0
Complicaties tijdens zwangerschap
Complicaties zwangerschap? Ja
Probleem
Probleem naam koorts (code = '386661006' in codeSystem 'SNOMED CT')
Verificatie status Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
Magnesiumsulfaat Ja
Antenatale steroiden gegeven? Nee

1.1.6 Kind

Kind
Gegevenselement Waarde
Demografische gegevens
Patient
Adresgegevens
Adresgegevens
Postcode 1234 AB
Identificatienummer 123 (in identificerend systeem: 1.2.3.999)
Geboortedatum T - 90 dagen om 12:13 uur
Geslacht Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender')
Meerling indicator Ja
Rangnummer kind 2
Overlijdens indicator Nee
Bevallingsgegevens
Zwangerschapsduur 179 dagen
Aantal geboren kinderen 2
Type partus Primair (code = '177141003' in codeSystem 'SNOMED CT')
Locatie partus Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT')
Zorgaanbieder
Zorgaanbieder identificatienummer 0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2)
Organisatie naam UMC Papendorp
Ondersteuning opvang
Verrichting
Verrichting type Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
Verrichting
Verrichting type endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT')
Opname gegevens
Opname
Opname datum T - 90 dagen om 13:30 uur
Ic opname? Ja
Heropname? Nee
Herkomst kind In-hospital admission from obstetrical ward (procedure) (code = '59151000146103' in codeSystem 'SNOMED CT')
Opname indicatie Finding of length of gestation (finding) (code = '366323009' in codeSystem 'SNOMED CT')
Ontslag datum T - 31 dagen om 12 uur
Onderzoek
Lichaamslengte
Lengte waarde 31 cm
Lengte datum tijd T - 90 dagen om 13:20 uur
Lichaamsgewicht
Gewicht waarde 710 g
Gewicht datum tijd T - 90 dagen om 13:21 uur
Lichaamstemperatuur
Temperatuur waarde 37.4 graden celsius
Temperatuur datum tijd T - 90 dagen om 13:22 uur
Toelichting abc
Temperatuur type Rectale temperatuur (code = '307047009' in codeSystem 'SNOMED CT')
Schedelomvang
Schedelomvang waarde 22.5 cm
Schedelomvang datum tijd T - 90 dagen om 13:23 uur
Apgar score na 1 min
Apgar score totaal 1
Apgar score na 5 min
Apgar score totaal 5
Nsp h arterieel 7.05 ph
Be -12.0 mmol/l
Problematiek kind
Geboortetrauma
Problemen aanwezig? Nee
Ademhalingsondersteuning
Ademhalingsondersteuning? Ja
Verrichting
Verrichting start datum T - 90 dagen om 13:35 uur
Verrichting eind datum T - 33 dagen om 12 uur
Verrichting type Oxygen therapy using high flow oxygen nasal cannula (procedure) (code = '57485005:424226004=426854004' in codeSystem 'SNOMED CT')
Verrichting
Verrichting start datum T - 33 dagen om 12 uur
Verrichting eind datum T - 31 dagen om 10 uur
Verrichting type Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
O2 op dag 28? Ja
Respiratoir
Problemen aanwezig? Ja
Probleem
Probleem naam Respiratory distress syndrome in the newborn (disorder) (code = '46775006' in codeSystem 'SNOMED CT')
Verificatie status Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
Aanvang Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT')
Medicatie
Stimulatie ademhaling COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL')
Surfactant NATUURLIJKE FOSFOLIPIDEN - LONGSURFACTANTS (code = 'R07AA02' in codeSystem 'ATC-NL')
Medicatie
Stimulatie ademhaling DOXAPRAM (code = 'R07AB01' in codeSystem 'ATC-NL')
Circulatoir
Problemen aanwezig? Ja
Probleem
Probleem naam Patent ductus arteriosus (disorder) (code = '83330001' in codeSystem 'SNOMED CT')
Verificatie status Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
Verrichting
Verrichting type Drug therapy for patent ductus arteriosus (procedure) (code = '58801000146104' in codeSystem 'SNOMED CT')
Infectieus
Problemen aanwezig? Ja
Probleem
Probleem naam Suspected sepsis (situation) (code = '9331000146100' in codeSystem 'SNOMED CT')
Probleem begin datum T - 89 dagen
Probleem eind datum T - 86 dagen
Verificatie status Werk (code = '415684004' in codeSystem 'SNOMED CT')
Aanvang Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT')
Microorganisme sepsis meningitis Other, specify (code = 'OTH' in codeSystem 'HL7 NullFlavor'): abc
Lijnsepsis? Nee
Onset vroege neonatale periode (kwalificatiewaarde) (code = '303114002' in codeSystem 'SNOMED CT')
Antibiotica eerste 3 dagen? Ja
Gastrointestinaal
Problemen aanwezig? Ja
Verrichting
Verrichting type Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT')
Hematologisch
Problemen aanwezig? Ja
Verrichting
Verrichting type Transfusion for anemia (procedure) (code = '59071000146107' in codeSystem 'SNOMED CT')
Metabool en endocrien
Problemen aanwezig? Ja
Probleem hyperbilirubemie
Probleem naam hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT')
Verificatie status Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
Verrichting
Indicatie
Probleem Zie Probleem: hyperbilirubemie
Verrichting type Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT')
Neurologisch
Problemen aanwezig? Nee
Zintuigen
Problemen aanwezig? Ja
Probleem
Probleem naam Retinopathy of prematurity stage 2 - intraretinal ridge (disorder) (code = '408848001' in codeSystem 'SNOMED CT')
Verificatie status Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
Rop screening verricht? Ja
Rop screening afgesloten? Ja
Aabr verricht? Ja
Aabr afwijkend? Ja
Bera verricht? Nee
Congenitale aandoeningen
Problemen aanwezig? Nee
Ontslagoverplaatsing
Nog opgenomen? Nee
Bestemming kind Discharge to other hospital (procedure) (code = '115851000146108' in codeSystem 'SNOMED CT')
Lichamelijk onderzoek
Lichaamsgewicht
Gewicht waarde 1740 gram
Gewicht datum tijd T - 31 dagen om 09 uur
Schedelomvang
Schedelomvang meetmethode Meten van schedelomvang m.b.v. meetlint (code = '31551000146109' in codeSystem 'SNOMED CT')
Schedelomvang waarde 30 cm
Schedelomvang datum tijd T - 31 dagen om 09:01 uur
Voeding kind niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor')
Mortaliteit
Overlijden lt12 uur na opname nicu? Nee
Overleden op verloskamer? Nee
Staken icbehandeling? Nee
Follow up
Na ontslag
O2 op dag 28? Nee
Gradatie bpd niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor')
Zintuigen
Problemen aanwezig? NullFlavor: UNK

1.2 Scenario Testscenario 2: geb.trauma + neurologisch + anat afw + overlijden

1.2.1 Documentgegevens

Documentgegevens
Gegevenselement Waarde
Identificatie 0000 (in identificerend systeem: abc123)
Document datum
Set identificatie 0000 (in identificerend systeem: abc123)
Versienummer 2
Software naam XIS
Verificatie zorgverlener
Geverifieerd door zorgverlener? Ja
Verificatie datum

1.2.2 Zorgaanbieder

Zorgaanbieder
Gegevenselement Waarde
Zorgaanbieder identificatienummer 0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2)

1.2.3 Zorgverlener

Zorgverlener
Gegevenselement Waarde
Zorgverlener identificatienummer 0000 (in identificerend systeem: UZI Personen)
Naamgegevens
Voornamen Hans Paul
Initialen H.P.
Roepnaam Hans
Naamgebruik Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4')
Geslachtsnaam
Achternaam Pieterse

1.2.4 Vrouw

Vrouw
Gegevenselement Waarde
Demografische gegevens
Patient
Identificatienummer (in identificerend systeem: BSN)
Geboortedatum T - 26 jaar

1.2.5 Zwangerschapsgegevens

Zwangerschapsgegevens
Gegevenselement Waarde
Graviditeit 3
Pariteit voor deze zwangerschap 2
Complicaties tijdens zwangerschap
Complicaties zwangerschap? Ja
Probleem
Probleem naam hypertensieve aandoening (aandoening) (code = '38341003' in codeSystem 'SNOMED CT')
Verificatie status Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
Magnesiumsulfaat Nee
Antenatale steroiden gegeven? NullFlavor: NA

1.2.6 Kind

Kind
Gegevenselement Waarde
Demografische gegevens
Patient
Identificatienummer 123 (in identificerend systeem: 1.2.3.999)
Geboortedatum T - 10 dagen om 10:44 uur
Geslacht Man (code = 'M' in codeSystem 'HL7 AdministrativeGender')
Meerling indicator Nee
Overlijdens indicator Ja
Datum overlijden T - 10 dagen om 21 uur
Bevallingsgegevens
Zwangerschapsduur 254 dagen
Aantal geboren kinderen 1
Type partus Primair (code = '177141003' in codeSystem 'SNOMED CT')
Locatie partus Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT')
Zorgaanbieder
Zorgaanbieder identificatienummer 234 (in identificerend systeem: AGB-Z)
Organisatie naam UMC Papendorp
Ondersteuning opvang
Verrichting
Verrichting type endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT')
Opname gegevens
Opname
Opname datum T - 10 dagen om 11:15 uur
Ic opname? Ja
Heropname? Nee
Herkomst kind In-hospital admission from obstetrical ward (procedure) (code = '59151000146103' in codeSystem 'SNOMED CT')
Opname indicatie Perinatal asphyxia (disorder) (code = '281578009' in codeSystem 'SNOMED CT')
Opname indicatie Infant in poor condition at birth (finding) (code = '276707008' in codeSystem 'SNOMED CT')
Opname indicatie Congenital disease (disorder) (code = '66091009' in codeSystem 'SNOMED CT')
Ontslag datum T - 10 dagen om 21 uur
Onderzoek
Lichaamsgewicht
Gewicht waarde 3870 g
Gewicht datum tijd T - 10 dagen om 11:01 uur
Lichaamstemperatuur
Temperatuur waarde 36.1 graden celsius
Temperatuur datum tijd T - 10 dagen om 11:02 uur
Temperatuur type Rectale temperatuur (code = '307047009' in codeSystem 'SNOMED CT')
Apgar score na 1 min
Apgar score totaal 0
Apgar score na 5 min
Apgar score totaal 2
Problematiek kind
Geboortetrauma
Problemen aanwezig? Ja
Probleem
Probleem naam Spinal cord injury due to birth trauma (disorder) (code = '698500002' in codeSystem 'SNOMED CT')
Verificatie status Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
Ademhalingsondersteuning
Ademhalingsondersteuning? Ja
Verrichting
Verrichting start datum T - 10 dagen om 11:16 uur
Verrichting type Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
O2 op dag 28? NullFlavor: NA
Respiratoir
Problemen aanwezig? Nee
Circulatoir
Problemen aanwezig? Ja
Probleem
Probleem naam Neonatal hypotension (disorder) (code = '276519002' in codeSystem 'SNOMED CT')
Verificatie status Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
Infectieus
Problemen aanwezig? Ja
Gastrointestinaal
Problemen aanwezig? Nee
Hematologisch
Problemen aanwezig? Ja
Metabool en endocrien
Problemen aanwezig? Nee
Neurologisch
Problemen aanwezig? Ja
Probleem neonatal_encephalopathy
Probleem naam Neonatal encephalopathy (disorder) (code = '95628005' in codeSystem 'SNOMED CT')
Ernst encefalopathie Ernstig (code = '24484000' in codeSystem 'SNOMED CT')
Verificatie status Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
Probleem
Probleem naam asfyxie bij geboorte (code = '413654009' in codeSystem 'SNOMED CT')
Verificatie status Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
Probleem
Probleem naam Intraventricular (nontraumatic) hemorrhage, grade 2, of fetus and newborn (disorder) (code = '206396002' in codeSystem 'SNOMED CT')
Verrichting
Indicatie
Probleem Zie Probleem: neonatal_encephalopathy
Verrichting type echografische beeldvorming van hoofd (verrichting) (code = '241449005' in codeSystem 'SNOMED CT')
Zintuigen
Problemen aanwezig? NullFlavor: UNK
Congenitale aandoeningen
Problemen aanwezig? Ja
Aangeboren anatomische afwijkingen majorsyndromen
Probleem
Probleem naam Overige congenitale afwijkingen zenuwstelsel (code = '09' in codeSystem '2.16.840.1.113883.2.4.4.13.8')
Verificatie status Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
Ontslagoverplaatsing
Nog opgenomen? Nee
Voeding kind niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor')
Mortaliteit
Overlijden lt12 uur na opname nicu? Ja
Overleden op verloskamer? Nee
Oorzaak overlijden multiorgaanfalen (aandoening) (code = '57653000' in codeSystem 'SNOMED CT')
Staken icbehandeling? Ja

1.3 Scenario Testscenario 3: stofwisselingsziekte

1.3.1 Documentgegevens

Documentgegevens
Gegevenselement Waarde
Identificatie 0000 (in identificerend systeem: abc123)
Document datum T - 0 dagen om 17 uur
Set identificatie 0000 (in identificerend systeem: abc123)
Versienummer 3
Software naam XIS
Verificatie zorgverlener
Geverifieerd door zorgverlener? Nee
Verificatie datum

1.3.2 Zorgaanbieder

Zorgaanbieder
Gegevenselement Waarde
Zorgaanbieder identificatienummer 0000 (in identificerend systeem: AGB-Z)
Zorgaanbieder identificatienummer (in identificerend systeem: URA)

1.3.3 Zorgverlener

Zorgverlener
Gegevenselement Waarde
Zorgverlener identificatienummer 0000 (in identificerend systeem: AGB-Z)
Naamgegevens
Voornamen Hans Peter
Initialen HP
Roepnaam Hans
Naamgebruik Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor')
Geslachtsnaam
Voorvoegsels van de
Achternaam Velde

1.3.4 Zwangerschapsgegevens

Zwangerschapsgegevens
Gegevenselement Waarde
Graviditeit 4
Pariteit voor deze zwangerschap 2
Complicaties tijdens zwangerschap
Complicaties zwangerschap? Ja
Antenatale steroiden gegeven? Ja
Antenatale steroiden Complete steroid therapy for fetal lung maturation (procedure) (code = '255594003434601000124108' in codeSystem 'SNOMED CT')

1.3.5 Kind

Kind
Gegevenselement Waarde
Demografische gegevens
Patient
Identificatienummer 123 (in identificerend systeem: 1.2.3.999)
Geboortedatum T - 76 dagen om 06:55 uur
Geslacht Ongedifferentieerd (code = 'UN' in codeSystem 'HL7 AdministrativeGender')
Overlijdens indicator Nee
Bevallingsgegevens
Zwangerschapsduur 215 dagen
Aantal geboren kinderen 1
Type partus Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT')
Locatie partus Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT')
Opname gegevens
Opname
Opname datum T - 0 dagen om 09:15 uur
Ic opname? Nee
Heropname? Ja
Herkomst kind Hospital admission from home or birth center (procedure) (code = '59141000146101' in codeSystem 'SNOMED CT')
Opname indicatie Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): vaccinatie onder observatie
Ontslag datum T - 0 dagen om 16 uur
Onderzoek
Lichaamslengte
Lengte waarde 43 cm
Lengte datum tijd T - 0 dagen om 09:30 uur
Lichaamsgewicht
Gewicht waarde 1800 g
Gewicht datum tijd T - 0 dagen om 09:30 uur
Lichaamstemperatuur
Temperatuur waarde 37.1
Temperatuur datum tijd T - 0 dagen om 09:30 uur
Schedelomvang
Schedelomvang waarde 31 centimeter
Schedelomvang datum tijd T - 0 dagen om 09:32 uur
Nsp h arterieel 7.35 ph
Be 0.0 mmol/l
Problematiek kind
Congenitale aandoeningen
Problemen aanwezig? Ja
Stofwisselingsziekten
Probleem
Probleem naam stoornis van mineraalstofwisseling (aandoening) (code = '45744005' in codeSystem 'SNOMED CT')
Verificatie status Differentiaal (code = '410590009' in codeSystem 'SNOMED CT')
Ontslagoverplaatsing
Nog opgenomen? Nee
Bestemming kind Discharge to home (procedure) (code = '306689006' in codeSystem 'SNOMED CT')
Voeding kind moedermelk (substantie) (code = '226789007' in codeSystem 'SNOMED CT')
Ondersteuning bij ontslag naar huis monitoren met cardiotachometer (regime/therapie) (code = '63818009' in codeSystem 'SNOMED CT')
Mortaliteit
Overlijden lt12 uur na opname nicu? NullFlavor: NA
Overleden op verloskamer? Nee
Staken icbehandeling? NullFlavor: NA

1.4 Scenario Testscenario 4: gastro + chirurgie

1.4.1 Documentgegevens

Documentgegevens
Gegevenselement Waarde
Identificatie 0000
Document datum T - 10 dagen om 10 uur
Set identificatie 0000
Versienummer 1
Software naam InformatieSysteemX
Verificatie zorgverlener
Geverifieerd door zorgverlener? NullFlavor: NI
Verificatie datum

1.4.2 Zorgaanbieder

Zorgaanbieder
Gegevenselement Waarde
Zorgaanbieder identificatienummer 0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2)

1.4.3 Vrouw

Vrouw
Gegevenselement Waarde
Demografische gegevens
Patient
Identificatienummer (in identificerend systeem: BSN)
Geboortedatum

1.4.4 Zwangerschapsgegevens

Zwangerschapsgegevens
Gegevenselement Waarde
Graviditeit 1
Pariteit voor deze zwangerschap 0

1.4.5 Kind

Kind
Gegevenselement Waarde
Demografische gegevens
Patient
Identificatienummer 123 (in identificerend systeem: 1.2.3.999)
Geboortedatum T - 87 dagen om 13 uur
Geslacht Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender')
Meerling indicator Ja
Rangnummer kind 2
Overlijdens indicator Nee
Bevallingsgegevens
Zwangerschapsduur 236 dagen
Aantal geboren kinderen 2
Type partus Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT')
Locatie partus Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT')
Ondersteuning opvang
Verrichting
Verrichting type Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
Opname gegevens
Opname
Opname datum T - 80 dagen om 09 uur
Ic opname? Ja
Heropname? Ja
Herkomst kind Hospital admission, transfer from other hospital or health care facility (procedure) (code = '4563007' in codeSystem 'SNOMED CT')
Zorgaanbieder
Zorgaanbieder identificatienummer 0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2)
Organisatie naam AZ Papendorp
Opname indicatie Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): abc
Ontslag datum T - 11 dagen om 16 uur
Onderzoek
Lichaamslengte
Lengte waarde 43 cm
Lengte datum tijd T - 80 dagen om 09:30 uur
Lichaamsgewicht
Gewicht waarde 1530 g
Gewicht datum tijd T - 80 dagen om 09:30 uur
Problematiek kind
Geboortetrauma
Problemen aanwezig? Nee
Ademhalingsondersteuning
Ademhalingsondersteuning? Ja
Verrichting
Verrichting type Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
O2 op dag 28? Nee
Respiratoir
Problemen aanwezig? Ja
Probleem
Probleem naam Bronchopulmonary dysplasia of newborn (disorder) (code = '67569000' in codeSystem 'SNOMED CT')
Verificatie status Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
Medicatie
Stimulatie ademhaling COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL')
Circulatoir
Problemen aanwezig? Ja
Probleem
Probleem naam Neonatal hypotension (disorder) (code = '276519002' in codeSystem 'SNOMED CT')
Infectieus
Problemen aanwezig? Ja
Probleem
Probleem naam neonatale sepsis (aandoening) (code = '206376005' in codeSystem 'SNOMED CT')
Microorganisme sepsis meningitis Listeria monocytogenes (organism) (code = '36094007' in codeSystem 'SNOMED CT')
Lijnsepsis? Ja
Onset late neonatale periode (kwalificatiewaarde) (code = '303115001' in codeSystem 'SNOMED CT')
Antibiotica eerste 3 dagen? NullFlavor: NA
Infuus
Infuuskatheter
Medisch hulpmiddel
Begin datum T - 80 dagen om 10 uur
Einddatum T - 17 dagen om 09 uur
Gastrointestinaal
Problemen aanwezig? Ja
Probleem enterocolitis
Probleem naam Necrotizing enterocolitis in fetus OR newborn - Bell stage IIIA (disorder) (code = '21941000146103' in codeSystem 'SNOMED CT')
Verificatie status Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
Verrichting
Indicatie
Probleem Zie Probleem: enterocolitis
Verrichting type Laparotomy (procedure) (code = '86481000' in codeSystem 'SNOMED CT')
Verrichting
Indicatie
Probleem Zie Probleem: enterocolitis
Verrichting type Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT')
Hematologisch
Problemen aanwezig? Ja
Verrichting
Verrichting type Transfusion for anemia (procedure) (code = '59071000146107' in codeSystem 'SNOMED CT')
Metabool en endocrien
Problemen aanwezig? Ja
Probleem hyperbilirubinemie
Probleem naam hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT')
Verificatie status Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor')
Probleem hypoglycemia
Probleem naam Hypoglycemia (disorder) (code = '302866003' in codeSystem 'SNOMED CT')
Verificatie status Differentiaal (code = '410590009' in codeSystem 'SNOMED CT')
Verrichting
Indicatie
Probleem Zie Probleem: hyperbilirubinemie
Verrichting type Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT')
Verrichting
Indicatie
Probleem Zie Probleem: hypoglycemia
Verrichting type Intravenous infusion of glucose in hypoglycemia (procedure) (code = '109091000146105' in codeSystem 'SNOMED CT')
Zintuigen
Problemen aanwezig? NullFlavor: NI
Congenitale aandoeningen
Problemen aanwezig? Ja
Chirurgische ingrepen
Verrichting
Verrichting type Endoscopie van oesofagus (verrichting) (code = '49230008' in codeSystem 'SNOMED CT')
Ontslagoverplaatsing
Nog opgenomen? Nee
Bestemming kind Discharge to other location within hospital premises (procedure) (code = '115841000146105' in codeSystem 'SNOMED CT')
Lichamelijk onderzoek
Lichaamsgewicht
Gewicht waarde 2800 gram
Gewicht datum tijd T - 11 dagen om 15 uur
Voeding kind niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor')
Mortaliteit
Overlijden lt12 uur na opname nicu? Nee
Overleden op verloskamer? Nee

1.5 Scenario Testscenario 5: zintuigen + FU

1.5.1 Documentgegevens

Documentgegevens
Gegevenselement Waarde
Identificatie 0000
Document datum T - 14 dagen om 10 uur
Set identificatie 0000
Versienummer 1
Software naam InformatieSysteemX
Verificatie zorgverlener
Geverifieerd door zorgverlener? Ja
Verificatie datum T - 14 dagen om 11 uur

1.5.2 Zorgaanbieder

Zorgaanbieder
Gegevenselement Waarde
Zorgaanbieder identificatienummer

1.5.3 Zwangerschapsgegevens

Zwangerschapsgegevens
Gegevenselement Waarde
Graviditeit 5
Pariteit voor deze zwangerschap 4
Complicaties tijdens zwangerschap
Complicaties zwangerschap? Ja
Probleem
Probleem naam preterm en prematuur gebroken vliezen (aandoening) (code = '312974005' in codeSystem 'SNOMED CT')
Verificatie status Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
Magnesiumsulfaat Ja
Antenatale steroiden gegeven? Ja
Antenatale steroiden Complete steroid therapy for fetal lung maturation (procedure) (code = '255594003434601000124108' in codeSystem 'SNOMED CT')

1.5.4 Kind

Kind
Gegevenselement Waarde
Demografische gegevens
Patient
Adresgegevens
Adresgegevens
Postcode 1234 AB
Identificatienummer 123 (in identificerend systeem: 1.2.3.999)
Geboortedatum T - 179 dagen om 14 uur
Geslacht Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor')
Meerling indicator Nee
Overlijdens indicator Nee
Bevallingsgegevens
Zwangerschapsduur 177 dagen
Type partus Sectio Caesarea (code = '11466000' in codeSystem 'SNOMED CT')
Locatie partus Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT')
Ondersteuning opvang
Verrichting
Verrichting type Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
Verrichting
Verrichting type endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT')
Opname gegevens
Opname
Opname datum T - 179 dagen om 14:30 uur
Ic opname? Ja
Heropname? Nee
Herkomst kind Hospital admission, transfer from other hospital or health care facility (procedure) (code = '4563007' in codeSystem 'SNOMED CT')
Opname indicatie Finding of length of gestation (finding) (code = '366323009' in codeSystem 'SNOMED CT')
Ontslag datum T - 44 dagen om 12 uur
Onderzoek
Lichaamsgewicht
Gewicht waarde 710 g
Gewicht datum tijd T - 179 dagen om 14:30 uur
Lichaamstemperatuur
Temperatuur waarde 36.7
Temperatuur datum tijd T - 179 dagen om 14:35 uur
Toelichting geen bijzonderheden
Temperatuur type Orale temperatuur (onder de tong) (code = '415945006' in codeSystem 'SNOMED CT')
Schedelomvang
Schedelomvang waarde 25.5
Schedelomvang datum tijd T - 179 dagen om 14:35 uur
Apgar score na 1 min
Apgar score totaal 1
Apgar score na 5 min
Apgar score totaal 4
Nsp h arterieel 7.21 ph
Be -11 mmol/l
Problematiek kind
Geboortetrauma
Problemen aanwezig? Nee
Ademhalingsondersteuning
Ademhalingsondersteuning? Ja
Verrichting
Verrichting type toedienen van zuurstof via neusbril (verrichting) (code = '371907003' in codeSystem 'SNOMED CT')
Verrichting
Verrichting type Oxygen therapy using high flow oxygen nasal cannula (procedure) (code = '57485005:424226004=426854004' in codeSystem 'SNOMED CT')
Verrichting
Verrichting type Continuous positive airway pressure ventilation treatment (procedure) (code = '47545007' in codeSystem 'SNOMED CT')
Verrichting
Verrichting type Noninvasive ventilation (procedure) (code = '428311008' in codeSystem 'SNOMED CT')
O2 op dag 28? Ja
Respiratoir
Problemen aanwezig? Ja
Probleem
Probleem naam Respiratory distress syndrome in the newborn (disorder) (code = '46775006' in codeSystem 'SNOMED CT')
Probleem begin datum T - 152 dagen om 08 uur
Aanvang Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT')
Probleem
Probleem naam Bronchopulmonary dysplasia of newborn - grade 3 (disorder) (code = '22041000146108' in codeSystem 'SNOMED CT')
Verrichting
Verrichting type Extracorporeal membrane oxygenation (procedure) (code = '233573008' in codeSystem 'SNOMED CT')
Medicatie
Stimulatie ademhaling COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL')
Surfactant NATUURLIJKE FOSFOLIPIDEN - LONGSURFACTANTS (code = 'R07AA02' in codeSystem 'ATC-NL')
Systemische steroiden CORTICOSTEROIDEN VOOR SYSTEMISCH GEBRUIK - SYSTEMISCHE HORMOONPREPARATEN, EXCL GESLACHTSHORMONEN (code = 'H02' in codeSystem 'ATC-NL')
Medicatie
Stimulatie ademhaling DOXAPRAM (code = 'R07AB01' in codeSystem 'ATC-NL')
Circulatoir
Problemen aanwezig? Ja
Probleem
Probleem naam Low blood pressure (disorder) (code = '45007003' in codeSystem 'SNOMED CT')
Infectieus
Problemen aanwezig? Ja
Probleem
Probleem naam neonatale sepsis (aandoening) (code = '206376005' in codeSystem 'SNOMED CT')
Lijnsepsis? Nee
Onset vroege neonatale periode (kwalificatiewaarde) (code = '303114002' in codeSystem 'SNOMED CT')
Probleem
Probleem naam urineweginfectie (aandoening) (code = '68566005' in codeSystem 'SNOMED CT')
Verificatie status Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
Probleem
Probleem naam Neonatal pneumonia (disorder) (code = '233619008' in codeSystem 'SNOMED CT')
Antibiotica eerste 3 dagen? Ja
Infuus
Infuuskatheter
Medisch hulpmiddel
Begin datum T - 179 dagen om 17 uur
Einddatum T - 148 dagen om 08 uur
Gastrointestinaal
Problemen aanwezig? Ja
Verrichting
Indicatie
Probleem Zie :
Verrichting type Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT')
Hematologisch
Problemen aanwezig? Ja
Verrichting
Verrichting type Treatment for trombocytopenia (procedure) (code = '59091000146106' in codeSystem 'SNOMED CT')
Metabool en endocrien
Problemen aanwezig? Ja
Probleem
Probleem naam hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT')
Probleem
Probleem naam Hypoglycemia (disorder) (code = '302866003' in codeSystem 'SNOMED CT')
Verrichting
Verrichting type Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT')
Verrichting
Verrichting type Intravenous infusion of glucose in hypoglycemia (procedure) (code = '109091000146105' in codeSystem 'SNOMED CT')
Neurologisch
Problemen aanwezig? Ja
Verrichting
Verrichting type echografische beeldvorming van hoofd (verrichting) (code = '241449005' in codeSystem 'SNOMED CT')
Verrichting
Verrichting type 'magnetic resonance imaging' van hoofd (verrichting) (code = '241601008' in codeSystem 'SNOMED CT')
Zintuigen
Problemen aanwezig? Ja
Probleem
Probleem naam Plus disease (disorder) (code = '56341000146109' in codeSystem 'SNOMED CT')
Verificatie status Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
Rop screening verricht? Ja
Rop screening afgesloten? Nee
Aabr verricht? Ja
Aabr afwijkend? Ja
Bera verricht? Ja
Bera
Bera afwijkend? Ja
Bera lateraliteit Links (code = '7771000' in codeSystem 'SNOMED CT')
Ontslagoverplaatsing
Nog opgenomen? Nee
Bestemming kind Discharge to other hospital (procedure) (code = '115851000146108' in codeSystem 'SNOMED CT')
Lichamelijk onderzoek
Lichaamsgewicht
Gewicht waarde 4 kg
Gewicht datum tijd T - 44 dagen om 09 uur
Schedelomvang
Schedelomvang meetmethode Meten van schedelomvang m.b.v. echografisch onderzoek (code = '31561000146107' in codeSystem 'SNOMED CT')
Schedelomvang waarde 34.6
Schedelomvang datum tijd T - 45 dagen om 10:20 uur
Voeding kind niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor')
Mortaliteit
Overlijden lt12 uur na opname nicu? Nee
Overleden op verloskamer? Nee
Follow up
Na ontslag
O2 op dag 28? Nee
Gradatie bpd Bronchopulmonary dysplasia of newborn - grade 1 (disorder) (code = '22021000146102' in codeSystem 'SNOMED CT')
Zintuigen
Problemen aanwezig? Ja
Probleem
Probleem naam Plus disease (disorder) (code = '56341000146109' in codeSystem 'SNOMED CT')
Verificatie status Bevestigd (code = '410605003' in codeSystem 'SNOMED CT')
Rop screening verricht? Ja
Rop screening afgesloten? Ja
Aabr verricht? Ja
Aabr afwijkend? Ja
Bera verricht? Ja
Bera
Bera afwijkend? Ja
Bera lateraliteit Links (code = '7771000' in codeSystem 'SNOMED CT')

1.6 Scenario Testscenario 6: overleden op verloskamer

1.6.1 Documentgegevens

Documentgegevens
Gegevenselement Waarde
Verificatie zorgverlener
Geverifieerd door zorgverlener? Ja
Verificatie datum

1.6.2 Zorgaanbieder

Zorgaanbieder
Gegevenselement Waarde
Zorgaanbieder identificatienummer

1.6.3 Vrouw

Vrouw
Gegevenselement Waarde
Demografische gegevens
Patient
Identificatienummer 000000000 (in identificerend systeem: BSN)
Geboortedatum T - 29 jaar

1.6.4 Zwangerschapsgegevens

Zwangerschapsgegevens
Gegevenselement Waarde
Graviditeit 2
Pariteit voor deze zwangerschap 1
Complicaties tijdens zwangerschap
Complicaties zwangerschap? Nee

1.6.5 Kind

Kind
Gegevenselement Waarde
Demografische gegevens
Patient
Identificatienummer 123 (in identificerend systeem: 1.2.3.999)
Geboortedatum T - 18 dagen om 13:20 uur
Geslacht Man (code = 'M' in codeSystem 'HL7 AdministrativeGender')
Meerling indicator Nee
Overlijdens indicator Ja
Datum overlijden T - 18 dagen om 19 uur
Bevallingsgegevens
Zwangerschapsduur 266 dagen
Aantal geboren kinderen 1
Type partus Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT')
Locatie partus Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT')
Ondersteuning opvang
Verrichting
Verrichting type Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT')
Verrichting
Verrichting type mechanische thoraxcompressies (verrichting) (code = '33631000146101' in codeSystem 'SNOMED CT')
Verrichting
Verrichting type injectie van adrenaline (verrichting) (code = '313191000' in codeSystem 'SNOMED CT')
Opname gegevens
Opname
Opname datum T - 18 dagen om 13:30 uur
Ic opname? NullFlavor: NA
Heropname? NullFlavor: NA
Ontslag datum T - 18 dagen om 19 uur
Onderzoek
Lichaamsgewicht
Gewicht waarde 3100 g
Gewicht datum tijd T - 18 dagen om 13:30 uur
Apgar score na 1 min
Apgar score totaal 1
Apgar score na 5 min
Apgar score totaal 1
Nsp h arterieel 7.13 ph
Be -6.9 mmol/l
Problematiek kind
Ademhalingsondersteuning
Ademhalingsondersteuning? NullFlavor: NI
Circulatoir
Problemen aanwezig? Nee
Infectieus
Problemen aanwezig? Nee
Hematologisch
Problemen aanwezig? Nee
Zintuigen
Problemen aanwezig? Nee
Congenitale aandoeningen
Problemen aanwezig? Nee
Mortaliteit
Overlijden lt12 uur na opname nicu? NullFlavor: NA
Overleden op verloskamer? Ja
Oorzaak overlijden ernstige asfyxie bij geboorte (aandoening) (code = '57284007' in codeSystem 'SNOMED CT')
Staken icbehandeling? NullFlavor: NA