Gebz:Vdraft AddendaKwalificatieKernsetGeboortezorg23 Dekkingsgraad: verschil tussen versies
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− | {{ | + | {{DISPLAYTITLE:Kernset Geboortezorg 2.3.6 - dekkingsgraad scenario's}} |
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− | =Dekkingsgraad scenario's voor Kernset Geboortezorg 2.3= | + | =Dekkingsgraad scenario's voor Kernset Geboortezorg 2.3.6= |
− | + | De volgende scenario's zijn meegenomen: | |
− | + | * 1. Zorg volledig 1e lijn, herpes, strippen, gezonde eenling.(id: scenario1-23) | |
+ | * 2. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling.(id: scenario2_1elijn-23) | ||
+ | * 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling.(id: scenario2_2elijn-23) | ||
+ | * 3. zorg volledig in 2e lijn, meerling, 1 kind overleden.(id: scenario3-23) | ||
+ | * 4. 1e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden.(id: scenario4_1elijn-23) | ||
+ | * 4. 2e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden(id: scenario4_2elijn-23) | ||
+ | * 5. zorg volledig 2e lijn, vrouw overleden.(id: scenario5-23) | ||
+ | * 6. 2de lijn met comorbiditeit. (id: scenario6-23) | ||
+ | * 7. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling, pijnstilling.(id: scenario7_1elijn-23) | ||
+ | * 7. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling, pijnstilling.(id: scenario7_2elijn-23) | ||
+ | Zie voor de inhoud van deze scenario's: [[Gebz:Vdraft_AddendaKwalificatieKernsetGeboortezorg23]]. Onderstaande tabel toont de unieke waarden voor ieder veld. Lege velden worden niet geraakt door de meegenomen bovenstaande scenario's. | ||
+ | ==Vrouw == | ||
+ | |||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw | ||
Regel 16: | Regel 28: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Burgerservicenummer | |colspan="2"|Burgerservicenummer | ||
− | |style="background-color: white;"|999910413 | + | |style="background-color: white;"|<br/>999910413 (in identificerend systeem: BSN)<br/><br/>961921821 (in identificerend systeem: BSN)<br/><br/>895623146 (in identificerend systeem: BSN)<br/><br/>850810711 (in identificerend systeem: BSN)<br/><br/>912345676 (in identificerend systeem: BSN)<br/><br/>100202020 (in identificerend systeem: BSN)<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lokale persoonsidentificatie | |colspan="2"|Lokale persoonsidentificatie | ||
− | |style="background-color: white;"|000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) | + | |style="background-color: white;"|<br/>000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)<br/><br/>* (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)<br/><br/>987654321 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Geboortedatum | |colspan="2"|Geboortedatum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>T - 39 jaar<br/><br/>T - 41 jaar<br/><br/>T - 30 jaar<br/><br/>T - 28 jaar<br/><br/>T - 22 jaar<br/><br/>T - 31 jaar<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Adres - postcode | |colspan="2"|Adres - postcode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>4563 AB<br/><br/>5689 CZ<br/><br/>5421 JG<br/><br/>4589 BA<br/><br/>9562 GF<br/><br/>1234 AB<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Etniciteit | |colspan="2"|Etniciteit | ||
− | |style="background-color: white;"|Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | + | |style="background-color: white;"|<br/>Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28')<br/><br/>Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28')<br/><br/>Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28')<br/><br/>Latijns Amerikaans (code = '14' in codeSystem '2.16.840.1.113883.2.4.4.13.28')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lengte gemeten | |colspan="2"|Lengte gemeten | ||
− | |style="background-color: white;"|170 cm | + | |style="background-color: white;"|<br/>170 cm<br/><br/>184 cm<br/><br/>167 cm<br/><br/>162 cm<br/><br/>186 cm<br/><br/>172 cm<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Vrouwelijke genitale verminking? | |colspan="2"|Vrouwelijke genitale verminking? | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"|<br/>Ja<br/><br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Type vrouwelijke genitale verminking | |colspan="2"|Type vrouwelijke genitale verminking | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Type 2 (code = '130621000119105' in codeSystem 'SNOMED CT')<br/><br/>Type 1 (code = '130631000119108' in codeSystem 'SNOMED CT')<br/> |
− | |} | + | |} |
=== Anamnese === | === Anamnese === | ||
− | + | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese | ||
Regel 49: | Regel 61: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Onder behandeling geweest? | |colspan="3"|Onder behandeling geweest? | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"|<br/>Ja<br/><br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Algemene anamnese | |colspan="4"|Algemene anamnese | ||
Regel 56: | Regel 68: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Autoimmuun aandoening | |colspan="2"|Autoimmuun aandoening | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Reuma (code = '396332003' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Cardiovasculaire aandoening | |colspan="2"|Cardiovasculaire aandoening | ||
− | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem ' | + | |style="background-color: white;"|<br/>Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor')<br/><br/>Hartritmestoornis (code = '698247007' in codeSystem 'SNOMED CT')<br/><br/>Hypertensie (code = '38341003' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Urogenitale aandoening | |colspan="2"|Urogenitale aandoening | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Bacteriurie (code = '61373006' in codeSystem 'SNOMED CT')<br/><br/>Pyelonefritis (code = '45816000' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Oncologische aandoening | |colspan="2"|Oncologische aandoening | ||
− | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem ' | + | |style="background-color: white;"|<br/>Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Schildklier aandoening | |colspan="2"|Schildklier aandoening | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Hyperthyreoidie (code = '34486009' in codeSystem 'SNOMED CT')<br/><br/>Hypothyreoidie (code = '40930008' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Diabetes mellitus? | |colspan="2"|Diabetes mellitus? | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"|<br/>Ja<br/><br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Neurologische aandoening | |colspan="2"|Neurologische aandoening | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Epilepsie (code = '84757009' in codeSystem 'SNOMED CT')<br/><br/>Hernia nuclei pulposi (code = '84857004' in codeSystem 'SNOMED CT')<br/><br/>Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Overig, niet nader omschreven<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Infectieziekte | |colspan="2"|Infectieziekte | ||
− | |style="background-color: white;"|Herpes (code = '23513009' in codeSystem ' | + | |style="background-color: white;"|<br/>Herpes (code = '23513009' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Mdl aandoening | |colspan="2"|Mdl aandoening | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Chronische leveraandoeningen (code = '328383001' in codeSystem 'SNOMED CT')<br/><br/>M. Crohn (code = '34000006' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Anemie | |colspan="2"|Anemie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>IJzergebrek (code = '87522002' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Longaandoening | |colspan="2"|Longaandoening | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Astma (code = '195967001' in codeSystem 'SNOMED CT')<br/><br/>Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Gynaecologische aandoening | |colspan="2"|Gynaecologische aandoening | ||
Regel 92: | Regel 104: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Orthopedische afwijking | |colspan="2"|Orthopedische afwijking | ||
− | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem ' | + | |style="background-color: white;"|<br/>Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor')<br/><br/>Trauma bekken (code = '282771003' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Bloedtransfusie? | |colspan="2"|Bloedtransfusie? | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"|<br/>Ja<br/><br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Transfusiereactie? | |colspan="2"|Transfusiereactie? | ||
Regel 101: | Regel 113: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Type operatie | |colspan="2"|Type operatie | ||
− | |style="background-color: white;"|Orthopedisch (code = '112697007' in codeSystem ' | + | |style="background-color: white;"|<br/>Orthopedisch (code = '112697007' in codeSystem 'SNOMED CT')<br/><br/>Hart (code = '64915003' in codeSystem 'SNOMED CT')<br/><br/>Appendectomie (code = '80146002' in codeSystem 'SNOMED CT')<br/><br/>Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor')<br/><br/>Sectio (code = '11466000' in codeSystem 'SNOMED CT')<br/><br/>Rug (code = '129152004:260686004=129284003' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Type stollingsprobleem | |colspan="2"|Type stollingsprobleem | ||
− | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem ' | + | |style="background-color: white;"|<br/>Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Psychiatrie? | |colspan="2"|Psychiatrie? | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"|<br/>Ja<br/><br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Overige aandoening? | |colspan="2"|Overige aandoening? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Overige aandoening | |colspan="2"|Overige aandoening | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
− | |} | + | |} |
=== Zorgverlening === | === Zorgverlening === | ||
− | + | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Zorgverlening | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Zorgverlening | ||
Regel 125: | Regel 137: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Datum start zorgverantwoordelijkheid | |colspan="7"|Datum start zorgverantwoordelijkheid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>T - 306 dagen<br/><br/>T - 332 dagen<br/><br/>T - 234 dagen<br/><br/>T - 297 dagen<br/><br/>T - 147 dagen<br/><br/>T - 388 dagen<br/><br/>T - 80 dagen<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Datum einde zorgverantwoordelijkheid | |colspan="7"|Datum einde zorgverantwoordelijkheid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>T - 50 dagen<br/><br/>T - 240 dagen<br/><br/>T - 84 dagen<br/><br/>T - 59 dagen<br/><br/>T - 108 dagen<br/><br/>T - 148 dagen<br/><br/>T - 150 dagen<br/><br/>T - 78 dagen<br/><br/>T - 80 dagen<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Eindverantwoordelijk in welke perinatale periode? | |colspan="7"|Eindverantwoordelijk in welke perinatale periode? | ||
− | |style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | + | |style="background-color: white;"|<br/>start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')<br/><br/>zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')<br/><br/>start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')<br/><br/>uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')<br/><br/>nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')<br/><br/>1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')<br/><br/>2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')<br/><br/>follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Conclusie risicostatus na intake | |colspan="7"|Conclusie risicostatus na intake | ||
− | |style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | + | |style="background-color: white;"|<br/>1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26')<br/><br/>2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26')<br/><br/>3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="8"|Verwijsdetails | |colspan="8"|Verwijsdetails | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="104"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Datum verwijzing | |colspan="6"|Datum verwijzing | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>T - 240 dagen<br/><br/>T - 148 dagen<br/><br/>T - 80 dagen<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Verwijzing van | |colspan="7"|Verwijzing van | ||
Regel 152: | Regel 164: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorgaanbieder identificatie nummer | |colspan="4"|Zorgaanbieder identificatie nummer | ||
− | |style="background-color: white;"|1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | + | |style="background-color: white;"|<br/>1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/><br/>0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Specialisme | |colspan="4"|Specialisme | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>verloskundige (code = '01' in codeSystem '2.16.840.1.113883.2.4.4.15.1')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Verwijzing naar | |colspan="7"|Verwijzing naar | ||
Regel 166: | Regel 178: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorgaanbieder identificatie nummer | |colspan="4"|Zorgaanbieder identificatie nummer | ||
− | |style="background-color: white;"|0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | + | |style="background-color: white;"|<br/>0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/><br/>1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/><br/>0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Specialisme | |colspan="4"|Specialisme | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>gynaecoloog 2e lijn (code = '02' in codeSystem '2.16.840.1.113883.2.4.4.15.1')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Type verwijzing | |colspan="5"|Type verwijzing | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Consult (code = '11429006' in codeSystem 'SNOMED CT')<br/><br/>Overname (code = '308292007' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Redenen van verwijzing | |colspan="7"|Redenen van verwijzing | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="87"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Van 1e naar 2e lijn | |colspan="6"|Van 1e naar 2e lijn | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="82"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Algemene anamnese | |colspan="5"|Algemene anamnese | ||
Regel 291: | Regel 303: | ||
|colspan="5"|Zwangerschap | |colspan="5"|Zwangerschap | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="22"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Gynaecologische aandoening | |colspan="3"|Gynaecologische aandoening | ||
Regel 312: | Regel 324: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Hypertensieve aandoening | |colspan="3"|Hypertensieve aandoening | ||
− | |style="background-color: white;"|Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT') | + | |style="background-color: white;"|<br/>Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT')<br/><br/>Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Zwangerschapscholestase? | |colspan="3"|Zwangerschapscholestase? | ||
Regel 336: | Regel 348: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Liggingsafwijking | |colspan="3"|Liggingsafwijking | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Meerlingzwangerschap? | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Serotiniteit? | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 344: | Regel 362: | ||
|colspan="2"|Vermoeden intrauteriene vruchtdood? | |colspan="2"|Vermoeden intrauteriene vruchtdood? | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Surmenage? | ||
+ | |style="background-color: white;"|<br/>Ja<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Einde zwangerschap | |colspan="4"|Einde zwangerschap | ||
Regel 350: | Regel 371: | ||
|colspan="5"|Bevalling | |colspan="5"|Bevalling | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="15"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Pprom? | |colspan="3"|Pprom? | ||
Regel 368: | Regel 389: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verdenking foetale nood? | |colspan="3"|Verdenking foetale nood? | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Meconiumhoudend vruchtwater? | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 385: | Regel 409: | ||
|colspan="3"|Fluxus postpartum? | |colspan="3"|Fluxus postpartum? | ||
|style="background-color: white;"| | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Behoefte aan pijnbestrijding? | ||
+ | |style="background-color: white;"|<br/>Ja<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Postnatale fase | |colspan="5"|Postnatale fase | ||
Regel 400: | Regel 427: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Van 2e naar 1e lijn | |colspan="5"|Van 2e naar 1e lijn | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Zwangerschap/baring/kraamperiode/kind ongestoord, fysiologie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.10.3')<br/><br/>Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Van 3e naar 2e lijn | |colspan="5"|Van 3e naar 2e lijn | ||
Regel 406: | Regel 433: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Perinatale periode | |colspan="6"|Perinatale periode | ||
− | |style="background-color: white;"|voor 28e week (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') | + | |style="background-color: white;"|<br/>voor 28e week (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52')<br/><br/>2e t/m 7e dag (code = '92' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52')<br/><br/>tijdens uitdrijving (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52')<br/> |
− | + | |} | |
=== Zorgverlenerzorginstelling === | === Zorgverlenerzorginstelling === | ||
− | + | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zorgverlenerzorginstelling | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zorgverlenerzorginstelling | ||
Regel 422: | Regel 449: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling agbid | |colspan="2"|Zorginstelling agbid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>12345678 (in identificerend systeem: AGB-Z)<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
− | |style="background-color: white;"|1808 | + | |style="background-color: white;"|<br/>1808 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/><br/>1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/><br/>0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/><br/>9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/><br/>1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/><br/>0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/><br/>0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/><br/>0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/> |
− | |} | + | |} |
=== Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === | === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === | ||
− | + | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | ||
Regel 437: | Regel 464: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Wijze einde zwangerschap | |colspan="7"|Wijze einde zwangerschap | ||
− | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | + | |style="background-color: white;"|<br/>Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')<br/><br/>Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Definitieve a terme datum | |colspan="7"|Definitieve a terme datum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>T - 1127 dagen<br/><br/>T - 575 dagen<br/><br/>T - 940 dagen<br/><br/>T - 1064 dagen<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="8"|Diagnose | |colspan="8"|Diagnose | ||
Regel 447: | Regel 474: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Gynaecologische aandoening | |colspan="6"|Gynaecologische aandoening | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Uterus anomalie (code = '37849005' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Bloedverlies? | |colspan="6"|Bloedverlies? | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"|<br/>Ja<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Cervixinsufficientie? | |colspan="6"|Cervixinsufficientie? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Infectie | |colspan="6"|Infectie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Urineweg infectie (code = '307534009' in codeSystem 'SNOMED CT')<br/><br/>Intra-uterien (code = '301775005' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Hyperemesis gravidarum? | |colspan="6"|Hyperemesis gravidarum? | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"|<br/>Ja<br/><br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Hypertensieve aandoening | |colspan="6"|Hypertensieve aandoening | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Zwangerschapscholestase? | |colspan="6"|Zwangerschapscholestase? | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"|<br/>Ja<br/><br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Diabetes gravidarum met insuline? | |colspan="6"|Diabetes gravidarum met insuline? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Afwijkende groei foetus | |colspan="6"|Afwijkende groei foetus | ||
− | |style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem ' | + | |style="background-color: white;"|<br/>Geen informatie (code = 'NI' in codeSystem 'HL7 NullFlavor')<br/><br/>Macrosomie (code = '199616008' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Dreigende partus immaturus? | |colspan="6"|Dreigende partus immaturus? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Dreigende partus prematurus? | |colspan="6"|Dreigende partus prematurus? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Abruptio placentae? | |colspan="6"|Abruptio placentae? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Ja<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Irregulaire antistoffen? | |colspan="7"|Irregulaire antistoffen? | ||
− | |style="background-color: white;"|Nee | + | |style="background-color: white;"|<br/>Nee<br/><br/>Ja<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="8"|Eerdere bevalling | |colspan="8"|Eerdere bevalling | ||
Regel 494: | Regel 521: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Geboorte placenta | |colspan="5"|Geboorte placenta | ||
− | |style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | + | |style="background-color: white;"|<br/>Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')<br/><br/>Placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Hoeveelheid bloedverlies | |colspan="6"|Hoeveelheid bloedverlies | ||
− | |style="background-color: white;"|550 ml | + | |style="background-color: white;"|<br/>550 ml<br/><br/>895 ml<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Vorige uitkomst per kind | |colspan="7"|Vorige uitkomst per kind | ||
Regel 508: | Regel 535: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geboortedatum | |colspan="4"|Geboortedatum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>T - 1120 dagen<br/><br/>T - 936 dagen<br/><br/>T - 1112 dagen<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Kindspecifieke gegevens vorige uitkomsten | |colspan="5"|Kindspecifieke gegevens vorige uitkomsten | ||
Regel 515: | Regel 542: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Type partus | |colspan="3"|Type partus | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Spontaan (code = '177184002' in codeSystem 'SNOMED CT')<br/><br/>Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT')<br/><br/>Secundair (code = '274130007' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Percentiel van het geboortegewicht | |colspan="3"|Percentiel van het geboortegewicht | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>p50 tot p90 (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.50')<br/><br/>p10 tot p50 (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.50')<br/><br/>p2,3 tot p10 (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.50')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Apgarscore na 5 min | |colspan="3"|Apgarscore na 5 min | ||
− | |style="background-color: white;"|8 | + | |style="background-color: white;"|<br/>8<br/><br/>10<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Congenitale afwijkingen? | |colspan="3"|Congenitale afwijkingen? | ||
− | |style="background-color: white;"|Nee | + | |style="background-color: white;"|<br/>Nee<br/><br/>Ja<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Congenitale afwijkingen groep | |colspan="4"|Congenitale afwijkingen groep | ||
Regel 531: | Regel 558: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Chromosomale afwijkingen? | |colspan="2"|Chromosomale afwijkingen? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Nee<br/> |
− | |} | + | |} |
=== Zwangerschap === | === Zwangerschap === | ||
− | + | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zwangerschap | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zwangerschap | ||
Regel 541: | Regel 568: | ||
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Dossiernummer | ||
+ | |style="background-color: white;"|<br/>0cbda760-1fdd-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)<br/><br/>5460cff0-2089-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)<br/><br/>c2204d20-209a-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)<br/><br/>ad9c3280-209d-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)<br/><br/>05e54070-209f-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)<br/><br/>e1691540-209f-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)<br/><br/>68a34ee0-20a0-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)<br/><br/>0af1e5b1-bf99-40a2-ade9-728186c32f31 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Graviditeit | |colspan="4"|Graviditeit | ||
− | |style="background-color: white;"|2 | + | |style="background-color: white;"|<br/>2<br/><br/>1<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Pariteit voor deze zwangerschap | |colspan="4"|Pariteit voor deze zwangerschap | ||
− | |style="background-color: white;"|1 | + | |style="background-color: white;"|<br/>1<br/><br/>0<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Definitieve a terme datum | |colspan="4"|Definitieve a terme datum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>T - 84 dagen<br/><br/>T - 115 dagen<br/><br/>T - 101 dagen<br/><br/>T - 136 dagen<br/><br/>T - 163 dagen<br/><br/>T - 91 dagen<br/><br/>T - 78 dagen<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Voornemens | |colspan="5"|Voornemens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="7"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Voorgenomen plaats baring tijdens zwangerschap type locatie | |colspan="3"|Voorgenomen plaats baring tijdens zwangerschap type locatie | ||
− | |style="background-color: white;"|Thuis (code = '169813005' in codeSystem ' | + | |style="background-color: white;"|<br/>Thuis (code = '169813005' in codeSystem 'SNOMED CT')<br/><br/>Nog niet bepaald (code = '05' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7')<br/><br/>Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT')<br/><br/>Geen informatie (code = 'NI' in codeSystem 'HL7 NullFlavor')<br/><br/>Geen voorkeur (code = '00' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7')<br/> |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Naar welk ziekenhuis wil de vrouw worden verwezen? | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorginstelling agbid | ||
+ | |style="background-color: white;"|<br/>00000010 (in identificerend systeem: AGB-Z)<br/> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorginstelling lvrid | ||
+ | |style="background-color: white;"|<br/>1999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Naam zorginstelling | ||
+ | |style="background-color: white;"|<br/>UMC Papendorp<br/> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Prenatale controle | |colspan="5"|Prenatale controle | ||
Regel 563: | Regel 606: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Datum controle | |colspan="3"|Datum controle | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>T - 305 dagen<br/><br/>T - 240 dagen<br/><br/>T - 234 dagen<br/><br/>T - 225 dagen<br/><br/>T - 147 dagen<br/><br/>T - 239 dagen<br/><br/>T - 357 dagen<br/><br/>T - 306 dagen<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Zwangerschapsduur | |colspan="3"|Zwangerschapsduur | ||
− | |style="background-color: white;"|59 dagen | + | |style="background-color: white;"|<br/>59 dagen<br/><br/>155 dagen<br/><br/>161 dagen<br/><br/>156 dagen<br/><br/>269 dagen<br/><br/>177 dagen<br/><br/>86 dagen<br/><br/>65 dagen<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Leven voelen | |colspan="3"|Leven voelen | ||
− | |style="background-color: white;"|goed (code = '289431008' in codeSystem ' | + | |style="background-color: white;"|<br/>goed (code = '289431008' in codeSystem 'SNOMED CT')<br/><br/>weinig (code = '276372004' in codeSystem 'SNOMED CT')<br/><br/>verminderd (code = '276369006' in codeSystem 'SNOMED CT')<br/><br/>geen (code = '289432001' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Rookgedrag | |colspan="3"|Rookgedrag | ||
− | |style="background-color: white;"|niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | + | |style="background-color: white;"|<br/>niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58')<br/><br/>gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58')<br/><br/>gestopt tijdens huidige zwangerschap (code = '6' in codeSystem '2.16.840.1.113883.2.4.4.13.58')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Alcoholgebruik | |colspan="3"|Alcoholgebruik | ||
− | |style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | + | |style="background-color: white;"|<br/>geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')<br/><br/>geen informatie (code = 'NI' in codeSystem 'HL7 NullFlavor')<br/><br/>onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Drugsgebruik? | |colspan="3"|Drugsgebruik? | ||
− | |style="background-color: white;"|Nee | + | |style="background-color: white;"|<br/>Nee<br/><br/>Ja<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Gewicht gemeten | |colspan="3"|Gewicht gemeten | ||
− | |style="background-color: white;"|70 kg | + | |style="background-color: white;"|<br/>70 kg<br/><br/>85 kg<br/><br/>67 kg<br/><br/>82 kg<br/><br/>89 kg<br/><br/>68 kg<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Diagnose | |colspan="5"|Diagnose | ||
Regel 588: | Regel 631: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Datum | |colspan="3"|Datum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>T - 305 dagen<br/><br/>T - 240 dagen<br/><br/>T - 234 dagen<br/><br/>T - 225 dagen<br/><br/>T - 239 dagen<br/><br/>T - 357 dagen<br/><br/>T - 306 dagen<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Zwangerschapsduur | |colspan="3"|Zwangerschapsduur | ||
− | |style="background-color: white;"|59 dagen | + | |style="background-color: white;"|<br/>59 dagen<br/><br/>155 dagen<br/><br/>161 dagen<br/><br/>156 dagen<br/><br/>177 dagen<br/><br/>86 dagen<br/><br/>65 dagen<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Gynaecologische aandoening | |colspan="3"|Gynaecologische aandoening | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Uterus anomalie (code = '37849005' in codeSystem 'SNOMED CT')<br/><br/>Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Overig, niet nader gespecificeerd<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Bloedverlies? | |colspan="3"|Bloedverlies? | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"|<br/>Ja<br/><br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Partiele mola? | |colspan="3"|Partiele mola? | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"|<br/>Ja<br/><br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Cervixinsufficientie? | |colspan="3"|Cervixinsufficientie? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Infectie | |colspan="3"|Infectie | ||
− | |style="background-color: white;"|Urineweg infectie (code = '307534009' in codeSystem ' | + | |style="background-color: white;"|<br/>Urineweg infectie (code = '307534009' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Hyperemesis gravidarum? | |colspan="3"|Hyperemesis gravidarum? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Hypertensieve aandoening | |colspan="3"|Hypertensieve aandoening | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT')<br/><br/>Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Zwangerschapscholestase? | |colspan="3"|Zwangerschapscholestase? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Diabetes gravidarum met insuline? | |colspan="3"|Diabetes gravidarum met insuline? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Afwijkende groei foetus | |colspan="3"|Afwijkende groei foetus | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Dysmaturiteit (code = '267258002' in codeSystem 'SNOMED CT')<br/><br/>Macrosomie (code = '199616008' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Dreigende partus immaturus? | |colspan="3"|Dreigende partus immaturus? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Dreigende partus prematurus? | |colspan="3"|Dreigende partus prematurus? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Abruptio placentae? | |colspan="3"|Abruptio placentae? | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"|<br/>Ja<br/><br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Navelstrengprolaps? | |colspan="3"|Navelstrengprolaps? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>NullFlavor: NI<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Liggingsafwijking | |colspan="3"|Liggingsafwijking | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Intrauteriene vruchtdood | |colspan="4"|Intrauteriene vruchtdood | ||
Regel 643: | Regel 686: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Vermoeden intrauteriene vruchtdood? | |colspan="2"|Vermoeden intrauteriene vruchtdood? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Vermoeden iuvd op basis van | |colspan="2"|Vermoeden iuvd op basis van | ||
Regel 649: | Regel 692: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Intrauteriene behandeling | |colspan="4"|Intrauteriene behandeling | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Selectieve foeticide (code = '265633004' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Maternale sterfte? | |colspan="4"|Maternale sterfte? | ||
− | |style="background-color: white;"|Nee | + | |style="background-color: white;"|<br/>Nee<br/><br/>Ja<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Wijze einde zwangerschap | |colspan="4"|Wijze einde zwangerschap | ||
− | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | + | |style="background-color: white;"|<br/>Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')<br/> |
− | |} | + | |} |
=== Bevalling === | === Bevalling === | ||
− | + | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Bevalling | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Bevalling | ||
Regel 667: | Regel 710: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Partusnummer | |colspan="4"|Partusnummer | ||
− | |style="background-color: white;"|000000 | + | |style="background-color: white;"|<br/>000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.7)<br/><br/>4567890123 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.7)<br/><br/>21123 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.7)<br/><br/>21234 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.7)<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Diagnose bevalling | |colspan="5"|Diagnose bevalling | ||
Regel 674: | Regel 717: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Pprom? | |colspan="3"|Pprom? | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"|<br/>Ja<br/><br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Prom? | |colspan="3"|Prom? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Koorts? | |colspan="3"|Koorts? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Niet vorderende ontsluiting? | |colspan="3"|Niet vorderende ontsluiting? | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"|<br/>Ja<br/><br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Niet vorderende uitdrijving? | |colspan="3"|Niet vorderende uitdrijving? | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"|<br/>Ja<br/><br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verdenking foetale nood? | |colspan="3"|Verdenking foetale nood? | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"|<br/>Ja<br/><br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Intrauteriene vruchtdood | |colspan="4"|Intrauteriene vruchtdood | ||
Regel 696: | Regel 739: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Vermoeden intrauteriene vruchtdood? | |colspan="2"|Vermoeden intrauteriene vruchtdood? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Vermoeden iuvd op basis van | |colspan="2"|Vermoeden iuvd op basis van | ||
Regel 702: | Regel 745: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Vastzittende placenta? | |colspan="3"|Vastzittende placenta? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Fluxus postpartum? | |colspan="3"|Fluxus postpartum? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Ja<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Aantal geboren kinderen | |colspan="4"|Aantal geboren kinderen | ||
− | |style="background-color: white;"|1 | + | |style="background-color: white;"|<br/>1<br/><br/>2<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Risicostatus voor baring | |colspan="4"|Risicostatus voor baring | ||
− | |style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | + | |style="background-color: white;"|<br/>1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')<br/><br/>2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Interventies begin baring | |colspan="5"|Interventies begin baring | ||
Regel 718: | Regel 761: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Interventie begin baring | |colspan="3"|Interventie begin baring | ||
− | |style="background-color: white;"|Strippen (code = '236960006' in codeSystem ' | + | |style="background-color: white;"|<br/>Strippen (code = '236960006' in codeSystem 'SNOMED CT')<br/><br/>Primaire sectio caesarea (code = '80771000146107' in codeSystem 'SNOMED CT')<br/><br/>Primaire sectio caesarea (code = '80771000146107' in codeSystem 'SNOMED CT')<br/><br/>Primen prostaglandine (code = '236966000' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Indicatie interventie begin baring | |colspan="3"|Indicatie interventie begin baring | ||
− | |style="background-color: white;"|wens patiënt (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') - acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') - | + | |style="background-color: white;"|<br/>wens patiënt (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7')<br/><br/>conditie moeder - acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7')<br/><br/>conditie moeder - niet levensbedreigend (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Wijze waarop de baring begon | |colspan="4"|Wijze waarop de baring begon | ||
− | |style="background-color: white;"|Interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | + | |style="background-color: white;"|<br/>Interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')<br/><br/>Spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')<br/><br/>Spontane weeën (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Tijdstip begin actieve ontsluiting | |colspan="4"|Tijdstip begin actieve ontsluiting | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>T - 86 dagen om 14:30 uur<br/><br/>T - 124 dagen om 14:09 uur<br/><br/>T - 127 dagen om 22:09 uur<br/><br/>T - 151 dagen om 21:09 uur<br/><br/>T - 78 dagen om 03:45 uur<br/><br/>T - 81 dagen om 22 uur<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Medicatie nageboortetijdperk groep | |colspan="5"|Medicatie nageboortetijdperk groep | ||
Regel 734: | Regel 777: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Medicatie nageboortetijdperk? | |colspan="3"|Medicatie nageboortetijdperk? | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"|<br/>Ja<br/><br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Soort medicatie nageboortetijdperk | |colspan="3"|Soort medicatie nageboortetijdperk | ||
− | |style="background-color: white;"|Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') | + | |style="background-color: white;"|<br/>Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73')<br/><br/>Prostaglandine (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73')<br/><br/>Pabal (code = 'H01BB03' in codeSystem 'ATC-NL')<br/><br/>Prostaglandine (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Placenta | |colspan="5"|Placenta | ||
Regel 744: | Regel 787: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Geboorte placenta | |colspan="3"|Geboorte placenta | ||
− | |style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | + | |style="background-color: white;"|<br/>Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')<br/><br/>Placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19')<br/><br/>Controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Hoeveelheid bloedverlies | |colspan="4"|Hoeveelheid bloedverlies | ||
− | |style="background-color: white;"|615 ml | + | |style="background-color: white;"|<br/>615 ml<br/><br/>980 ml<br/><br/>1740 ml<br/><br/>1120 ml<br/><br/>1500 ml<br/><br/>1050 ml<br/><br/>850 ml<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Conditie perineum postpartum | |colspan="4"|Conditie perineum postpartum | ||
− | |style="background-color: white;"|1e graads perineumruptuur (code = '199916005' in codeSystem ' | + | |style="background-color: white;"|<br/>1e graads perineumruptuur (code = '199916005' in codeSystem 'SNOMED CT')<br/><br/>Gaaf (code = '289854007' in codeSystem 'SNOMED CT')<br/><br/>Episiotomiewond (code = '609344008' in codeSystem 'SNOMED CT')<br/><br/>3e graads ruptuur (code = '199930000' in codeSystem 'SNOMED CT')<br/><br/>2e graads perineumruptuur (code = '199925004' in codeSystem 'SNOMED CT')<br/> |
− | |} | + | |} |
=== Uitkomst per kind === | === Uitkomst per kind === | ||
− | + | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind | ||
Regel 766: | Regel 809: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Werkelijke plaats baring type locatie | |colspan="6"|Werkelijke plaats baring type locatie | ||
− | |style="background-color: white;"|Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') | + | |style="background-color: white;"|<br/>Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7')<br/><br/>Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Ziekenhuis baring | |colspan="7"|Ziekenhuis baring | ||
Regel 773: | Regel 816: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Ziekenhuisnummer lvrid | |colspan="5"|Ziekenhuisnummer lvrid | ||
− | |style="background-color: white;"|0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | + | |style="background-color: white;"|<br/>0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/><br/>9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/><br/>0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/><br/>0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/><br/>0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/><br/>0110<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Demografische gegevens | |colspan="7"|Demografische gegevens | ||
Regel 784: | Regel 827: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Bsn kind | |colspan="4"|Bsn kind | ||
− | |style="background-color: white;"|999910383 | + | |style="background-color: white;"|<br/>999910383 (in identificerend systeem: BSN)<br/><br/>951847624 (in identificerend systeem: BSN)<br/><br/>847035116 (in identificerend systeem: BSN)<br/><br/>847035128 (in identificerend systeem: BSN)<br/><br/>840736526 (in identificerend systeem: BSN)<br/><br/>528741913 (in identificerend systeem: BSN)<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Geslacht medische observatie | |colspan="5"|Geslacht medische observatie | ||
− | |style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | + | |style="background-color: white;"|<br/>vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21')<br/><br/>mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21')<br/><br/>niet conclusief (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.21')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Geboortedatum | |colspan="5"|Geboortedatum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>T - 85 dagen<br/><br/>T - 122 dagen om 02:34 uur<br/><br/>T - 126 dagen om 06:30 uur<br/><br/>T - 126 dagen om 07:02 uur<br/><br/>T - 150 dagen om 23:35 uur<br/><br/>T - 161 dagen om 02:30 uur<br/><br/>T - 78 dagen<br/><br/>T - 80 dagen om 14:50 uur<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Rangnummer kind | |colspan="5"|Rangnummer kind | ||
− | |style="background-color: white;"|1 | + | |style="background-color: white;"|<br/>1<br/><br/>2<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Perinatale sterfte groep | |colspan="6"|Perinatale sterfte groep | ||
Regel 800: | Regel 843: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Perinatale sterfte? | |colspan="4"|Perinatale sterfte? | ||
− | |style="background-color: white;"|Nee | + | |style="background-color: white;"|<br/>Nee<br/><br/>Ja<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Fase perinatale sterfte | |colspan="4"|Fase perinatale sterfte | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Postpartum (code = '276506001' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Datumtijd vaststelling perinatale sterfte | |colspan="4"|Datumtijd vaststelling perinatale sterfte | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>T - 126 dagen om 08:10 uur<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Kindspecifieke maternale gegevens | |colspan="7"|Kindspecifieke maternale gegevens | ||
Regel 813: | Regel 856: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Bijstimulatie toegediend? | |colspan="5"|Bijstimulatie toegediend? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Ja<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Tijdstip breken vliezen | |colspan="5"|Tijdstip breken vliezen | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>T - 85 dagen om 09:15 uur<br/><br/>T - 124 dagen om 23:04 uur<br/><br/>T - 127 dagen om 22:09 uur<br/><br/>T - 127 dagen om 23:13 uur<br/><br/>T - 151 dagen om 07:04 uur<br/><br/>T - 78 dagen om 04:30 uur<br/><br/>T - 80 dagen om 12:34 uur<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Kleur en consistentie vruchtwater | |colspan="5"|Kleur en consistentie vruchtwater | ||
− | |style="background-color: white;"|Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | + | |style="background-color: white;"|<br/>Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18')<br/><br/>geen informatie (code = 'NI' in codeSystem 'HL7 NullFlavor')<br/><br/>Bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18')<br/><br/>Meconium (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.18')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Tijdstip actief meepersen | |colspan="5"|Tijdstip actief meepersen | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>T - 85 dagen om 12:13 uur<br/><br/>T - 127 dagen om 23:49 uur<br/><br/>T - 126 dagen om 06:45 uur<br/><br/>T - 150 dagen om 22:15 uur<br/><br/>T - 78 dagen om 05 uur<br/><br/>T - 80 dagen om 14:30 uur<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Episiotomie? | |colspan="5"|Episiotomie? | ||
− | |style="background-color: white;"|Nee | + | |style="background-color: white;"|<br/>Nee<br/><br/>Ja<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Indicatie episiotomie | |colspan="5"|Indicatie episiotomie | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>overig (code = 'OTH' in codeSystem 'HL7 NullFlavor')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Locatie episiotomie | |colspan="5"|Locatie episiotomie | ||
− | |style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | + | |style="background-color: white;"|<br/>mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Ruggenprik gewenst niet gekregen? |
− | |style="background-color: white;"|Nee | + | |style="background-color: white;"|<br/>Nee<br/><br/>Ja<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Pijnbestrijding? | |colspan="5"|Pijnbestrijding? | ||
− | |style="background-color: white;"|Nee | + | |style="background-color: white;"|<br/>Nee<br/><br/>Ja<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Pijnbestrijding | |colspan="6"|Pijnbestrijding | ||
Regel 848: | Regel 891: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Methode | |colspan="3"|Methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Epidurale analgesie (code = '18946005' in codeSystem 'SNOMED CT')<br/><br/>Overig middel (code = 'OTH' in codeSystem 'HL7 NullFlavor')<br/><br/>Algehele anesthesie (code = '50697003' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Overig middel | |colspan="4"|Overig middel | ||
Regel 855: | Regel 898: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Middel | |colspan="2"|Middel | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Morfinometica (code = '52685006:363701004=404642006' in codeSystem 'SNOMED CT')<br/><br/>Entonox (code = '426060003' in codeSystem 'SNOMED CT')<br/><br/>TENS (code = '229559001' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Toediening | |colspan="2"|Toediening | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Intraveneus (code = '431215000' in codeSystem 'SNOMED CT')<br/><br/>Inhalatie (code = '241717009' in codeSystem 'SNOMED CT')<br/><br/>Elektroden (code = '78746004' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Periode | |colspan="4"|Periode | ||
− | |style="background-color: white;"|tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | + | |style="background-color: white;"|<br/>tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60')<br/><br/>tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60')<br/><br/>tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60')<br/><br/>tijdens ontsluitingsperiode > 3 cm (code = 'OntMt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Sedatie? | |colspan="5"|Sedatie? | ||
− | |style="background-color: white;"|Nee | + | |style="background-color: white;"|<br/>Nee<br/><br/>Ja<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Kindspecifieke uitkomstgegevens | |colspan="7"|Kindspecifieke uitkomstgegevens | ||
Regel 871: | Regel 914: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Type partus | |colspan="5"|Type partus | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Spontaan (code = '177184002' in codeSystem 'SNOMED CT')<br/><br/>Secundair (code = '274130007' in codeSystem 'SNOMED CT')<br/><br/>Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Ligging bij geboorte | |colspan="5"|Ligging bij geboorte | ||
− | |style="background-color: white;"|Achterhoofd-achter (code = '37235006' in codeSystem ' | + | |style="background-color: white;"|<br/>Achterhoofd-achter (code = '37235006' in codeSystem 'SNOMED CT')<br/><br/>Geen informatie (code = 'NI' in codeSystem 'HL7 NullFlavor')<br/><br/>Aangezicht (code = '21882006' in codeSystem 'SNOMED CT')<br/><br/>Volkomen stuit (code = '49168004' in codeSystem 'SNOMED CT')<br/><br/>Kruin (code = '249079005' in codeSystem 'SNOMED CT')<br/><br/>Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor')<br/><br/>Achterhoofd-voor (code = '70028003' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Aanpakker kind - rol aanpakker kind | |colspan="5"|Aanpakker kind - rol aanpakker kind | ||
− | |style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | + | |style="background-color: white;"|<br/>1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')<br/><br/>gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')<br/><br/>arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')<br/><br/>co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')<br/><br/>gynaecoloog (code = '01.046' in codeSystem 'UZI Rolcodes')<br/><br/>klinisch verloskundige (code = '25' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Supervisor - rol supervisor | |colspan="5"|Supervisor - rol supervisor | ||
− | |style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | + | |style="background-color: white;"|<br/>1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')<br/><br/>gynaecoloog (code = '01.046' in codeSystem 'UZI Rolcodes')<br/><br/>gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Vaginale kunstverlossing groep | |colspan="6"|Vaginale kunstverlossing groep | ||
Regel 887: | Regel 930: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Vaginale kunstverlossing | |colspan="4"|Vaginale kunstverlossing | ||
− | |style="background-color: white;"|Forceps | + | |style="background-color: white;"|<br/>Forceps (code = '302383004' in codeSystem 'SNOMED CT')<br/><br/>Stuitextractie (code = '416055001' in codeSystem 'SNOMED CT')<br/><br/>Vacuüm (code = '61586001' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Succes vaginale kunstverlossing? | |colspan="4"|Succes vaginale kunstverlossing? | ||
− | |style="background-color: white;"|Ja | + | |style="background-color: white;"|<br/>Ja<br/><br/>Nee<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Sectio caesarea group | |colspan="6"|Sectio caesarea group | ||
Regel 897: | Regel 940: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Beslismoment sectio caesarea | |colspan="4"|Beslismoment sectio caesarea | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Tijdens ontsluiting besloten (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.5')<br/><br/>Tijdens uitdrijving besloten (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.5')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Indicatie primaire sectio | |colspan="4"|Indicatie primaire sectio | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Indicatie secundaire sectio | |colspan="4"|Indicatie secundaire sectio | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>verdenking foetale nood (code = '444433005:246090004=130955003' in codeSystem 'SNOMED CT')<br/><br/>maternale conditie (code = '418138009' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Overige interventies | |colspan="5"|Overige interventies | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Opheffen schouderdystocie (code = '237008007' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Lichamelijk onderzoek kind | |colspan="6"|Lichamelijk onderzoek kind | ||
Regel 913: | Regel 956: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Apgarscore na 5 min | |colspan="4"|Apgarscore na 5 min | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>9<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geboortegewicht | |colspan="4"|Geboortegewicht | ||
− | |style="background-color: white;"|3450 gram | + | |style="background-color: white;"|<br/>3450 gram<br/><br/>3620 gram<br/><br/>2040 gram<br/><br/>1580 gram<br/><br/>4205 gram<br/><br/>3750 gram<br/><br/>3550 gram<br/><br/>3720 gram<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Congenitale afwijkingen? | |colspan="5"|Congenitale afwijkingen? | ||
− | |style="background-color: white;"|Nee | + | |style="background-color: white;"|<br/>Nee<br/><br/>Ja<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Congenitale afwijkingen groep | |colspan="6"|Congenitale afwijkingen groep | ||
Regel 930: | Regel 973: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Specificatie congenitale afwijking | |colspan="3"|Specificatie congenitale afwijking | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>spina bifida occulta (code = '76916001' in codeSystem 'SNOMED CT')<br/><br/>gecompliceerd vitium (code = '94702005' in codeSystem 'SNOMED CT')<br/><br/>overige congenitale huidafwijking (code = '74' in codeSystem '2.16.840.1.113883.2.4.4.13.8')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Chromosomale afwijkingen? | |colspan="4"|Chromosomale afwijkingen? | ||
− | |style="background-color: white;"|Nee | + | |style="background-color: white;"|<br/>Nee<br/><br/>Ja<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Specificatie chromosomale afwijking groep | |colspan="5"|Specificatie chromosomale afwijking groep | ||
Regel 940: | Regel 983: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Specificatie chromosomale afwijking | |colspan="3"|Specificatie chromosomale afwijking | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>trisomie 21 (code = '41040004' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Problematiek kind? | |colspan="5"|Problematiek kind? | ||
− | |style="background-color: white;"|Nee | + | |style="background-color: white;"|<br/>Nee<br/><br/>Ja<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Problematiek kind | |colspan="5"|Problematiek kind | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Geboortetrauma (code = '56110009' in codeSystem 'SNOMED CT')<br/><br/>Subdurale bloeding (code = '126941005' in codeSystem 'SNOMED CT')<br/><br/>Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor')<br/><br/>Gehoor (code = '95827002' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Kinderarts betrokken? | |colspan="5"|Kinderarts betrokken? | ||
− | |style="background-color: white;"|Nee | + | |style="background-color: white;"|<br/>Nee<br/><br/>Ja<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Betrokkenheid kinderarts | |colspan="6"|Betrokkenheid kinderarts | ||
Regel 956: | Regel 999: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Datum betrokkenheid | |colspan="4"|Datum betrokkenheid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>T - 122 dagen<br/><br/>T - 126 dagen<br/><br/>T - 150 dagen<br/><br/>T - 78 dagen<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Reden betrokkenheid | |colspan="4"|Reden betrokkenheid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>overig (code = 'OTH' in codeSystem 'HL7 NullFlavor')<br/><br/>kunstverlossing (code = '8571000146103' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Type betrokkenheid | |colspan="4"|Type betrokkenheid | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17')<br/><br/>Overdracht (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.17')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorginstelling lvrid | |colspan="4"|Zorginstelling lvrid | ||
− | |style="background-color: white;"|0003 | + | |style="background-color: white;"|<br/>0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/><br/>9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/><br/>0001 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/><br/>0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/><br/>0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)<br/> |
− | |} | + | |} |
=== Medisch onderzoek === | === Medisch onderzoek === | ||
− | + | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek | ||
Regel 981: | Regel 1.024: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Irregulaire antistoffen? | |colspan="2"|Irregulaire antistoffen? | ||
− | |style="background-color: white;"|Nee | + | |style="background-color: white;"|<br/>Nee<br/><br/>Ja<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Welke irregulaire antistoffen vrouw aanwezig | |colspan="2"|Welke irregulaire antistoffen vrouw aanwezig | ||
− | |style="background-color: white;"|Rhesus D (code = '112162009' in codeSystem ' | + | |style="background-color: white;"|<br/>Rhesus D (code = '112162009' in codeSystem 'SNOMED CT')<br/><br/>Kell (code = '405844003' in codeSystem 'SNOMED CT')<br/> |
− | |} | + | |} |
=== Postnatale fase === | === Postnatale fase === | ||
− | + | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase | ||
Regel 995: | Regel 1.038: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|Diagnoseinterventie | + | |colspan="5"|Diagnoseinterventie postnataal |
|-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"|Datum | |colspan="3"|Datum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>T - 120 dagen<br/><br/>T - 146 dagen<br/><br/>T - 161 dagen<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Pathologie vrouw | |colspan="3"|Pathologie vrouw | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>Urineweginfectie (code = '68566005' in codeSystem 'SNOMED CT')<br/><br/>Embolie (code = '414086009' in codeSystem 'SNOMED CT')<br/><br/>Mastitis (code = '266579006' in codeSystem 'SNOMED CT')<br/><br/>Trombose diep veneuze postpartum (code = '56272000' in codeSystem 'SNOMED CT')<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Kindspecifieke gegevens | |colspan="5"|Kindspecifieke gegevens | ||
Regel 1.010: | Regel 1.053: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Rangnummer kind | |colspan="3"|Rangnummer kind | ||
− | |style="background-color: white;"|1 | + | |style="background-color: white;"|<br/>1<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Voeding kind groep | |colspan="4"|Voeding kind groep | ||
Regel 1.017: | Regel 1.060: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Voeding kind datum | |colspan="2"|Voeding kind datum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|<br/>T - 81 dagen<br/><br/>T - 86 dagen<br/><br/>T - 120 dagen<br/><br/>T - 108 dagen<br/><br/>T - 161 dagen<br/><br/>T - 78 dagen<br/><br/>T - 79 dagen<br/> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Substantie voeding kind | |colspan="2"|Substantie voeding kind | ||
− | |style="background-color: white;"|borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | + | |style="background-color: white;"|<br/>borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')<br/><br/>kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')<br/> |
− | |} | + | |} |
[[Categorie:Kwalificatie]] | [[Categorie:Kwalificatie]] |
Huidige versie van 25 apr 2022 om 12:11
Deze pagina is nog in bewerking |
1 Dekkingsgraad scenario's voor Kernset Geboortezorg 2.3.6
De volgende scenario's zijn meegenomen:
- 1. Zorg volledig 1e lijn, herpes, strippen, gezonde eenling.(id: scenario1-23)
- 2. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling.(id: scenario2_1elijn-23)
- 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling.(id: scenario2_2elijn-23)
- 3. zorg volledig in 2e lijn, meerling, 1 kind overleden.(id: scenario3-23)
- 4. 1e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden.(id: scenario4_1elijn-23)
- 4. 2e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden(id: scenario4_2elijn-23)
- 5. zorg volledig 2e lijn, vrouw overleden.(id: scenario5-23)
- 6. 2de lijn met comorbiditeit. (id: scenario6-23)
- 7. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling, pijnstilling.(id: scenario7_1elijn-23)
- 7. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling, pijnstilling.(id: scenario7_2elijn-23)
Zie voor de inhoud van deze scenario's: Gebz:Vdraft_AddendaKwalificatieKernsetGeboortezorg23. Onderstaande tabel toont de unieke waarden voor ieder veld. Lege velden worden niet geraakt door de meegenomen bovenstaande scenario's.
1.1 Vrouw
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 999910413 (in identificerend systeem: BSN) 961921821 (in identificerend systeem: BSN) 895623146 (in identificerend systeem: BSN) 850810711 (in identificerend systeem: BSN) 912345676 (in identificerend systeem: BSN) 100202020 (in identificerend systeem: BSN) | |
Lokale persoonsidentificatie | 000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) 987654321 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) | |
Geboortedatum | T - 39 jaar T - 41 jaar T - 30 jaar T - 28 jaar T - 22 jaar T - 31 jaar | |
Adres - postcode | 4563 AB 5689 CZ 5421 JG 4589 BA 9562 GF 1234 AB | |
Etniciteit | Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28') Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') Latijns Amerikaans (code = '14' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 170 cm 184 cm 167 cm 162 cm 186 cm 172 cm | |
Vrouwelijke genitale verminking? | Ja Nee | |
Type vrouwelijke genitale verminking | Type 2 (code = '130621000119105' in codeSystem 'SNOMED CT') Type 1 (code = '130631000119108' in codeSystem 'SNOMED CT') |
1.1.1 Anamnese
Anamnese | |||
Gegevenselement | Waarde | ||
Onder behandeling geweest? | Ja Nee | ||
Algemene anamnese | |||
Autoimmuun aandoening | Reuma (code = '396332003' in codeSystem 'SNOMED CT') | ||
Cardiovasculaire aandoening | Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') Hartritmestoornis (code = '698247007' in codeSystem 'SNOMED CT') Hypertensie (code = '38341003' in codeSystem 'SNOMED CT') | ||
Urogenitale aandoening | Bacteriurie (code = '61373006' in codeSystem 'SNOMED CT') Pyelonefritis (code = '45816000' in codeSystem 'SNOMED CT') | ||
Oncologische aandoening | Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
Schildklier aandoening | Hyperthyreoidie (code = '34486009' in codeSystem 'SNOMED CT') Hypothyreoidie (code = '40930008' in codeSystem 'SNOMED CT') | ||
Diabetes mellitus? | Ja Nee | ||
Neurologische aandoening | Epilepsie (code = '84757009' in codeSystem 'SNOMED CT') Hernia nuclei pulposi (code = '84857004' in codeSystem 'SNOMED CT') Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Overig, niet nader omschreven | ||
Infectieziekte | Herpes (code = '23513009' in codeSystem 'SNOMED CT') | ||
Mdl aandoening | Chronische leveraandoeningen (code = '328383001' in codeSystem 'SNOMED CT') M. Crohn (code = '34000006' in codeSystem 'SNOMED CT') | ||
Anemie | IJzergebrek (code = '87522002' in codeSystem 'SNOMED CT') | ||
Longaandoening | Astma (code = '195967001' in codeSystem 'SNOMED CT') Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
Gynaecologische aandoening | |||
Orthopedische afwijking | Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') Trauma bekken (code = '282771003' in codeSystem 'SNOMED CT') | ||
Bloedtransfusie? | Ja Nee | ||
Transfusiereactie? | |||
Type operatie | Orthopedisch (code = '112697007' in codeSystem 'SNOMED CT') Hart (code = '64915003' in codeSystem 'SNOMED CT') Appendectomie (code = '80146002' in codeSystem 'SNOMED CT') Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') Sectio (code = '11466000' in codeSystem 'SNOMED CT') Rug (code = '129152004:260686004=129284003' in codeSystem 'SNOMED CT') | ||
Type stollingsprobleem | Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||
Psychiatrie? | Ja Nee | ||
Overige aandoening? | Nee | ||
Overige aandoening |
1.1.2 Zorgverlening
Zorgverlening | |||||||
Gegevenselement | Waarde | ||||||
Datum start zorgverantwoordelijkheid | T - 306 dagen T - 332 dagen T - 234 dagen T - 297 dagen T - 147 dagen T - 388 dagen T - 80 dagen | ||||||
Datum einde zorgverantwoordelijkheid | T - 50 dagen T - 240 dagen T - 84 dagen T - 59 dagen T - 108 dagen T - 148 dagen T - 150 dagen T - 78 dagen T - 80 dagen | ||||||
Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||||||
Conclusie risicostatus na intake | 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') 3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | ||||||
Verwijsdetails | |||||||
Datum verwijzing | T - 240 dagen T - 148 dagen T - 80 dagen | ||||||
Verwijzing van | |||||||
Zorginstelling | |||||||
Zorgaanbieder identificatie nummer | 1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||||
Specialisme | verloskundige (code = '01' in codeSystem '2.16.840.1.113883.2.4.4.15.1') | ||||||
Verwijzing naar | |||||||
Zorginstelling | |||||||
Zorgaanbieder identificatie nummer | 0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) 0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||||
Specialisme | gynaecoloog 2e lijn (code = '02' in codeSystem '2.16.840.1.113883.2.4.4.15.1') | ||||||
Type verwijzing | Consult (code = '11429006' in codeSystem 'SNOMED CT') Overname (code = '308292007' in codeSystem 'SNOMED CT') | ||||||
Redenen van verwijzing | |||||||
Van 1e naar 2e lijn | |||||||
Algemene anamnese | |||||||
Autoimmuun aandoening | |||||||
Cardiovasculaire aandoening | |||||||
Urogenitale aandoening | |||||||
Oncologische aandoening | |||||||
Schildklier aandoening | |||||||
Diabetes mellitus? | |||||||
Neurologische aandoening | |||||||
Infectieziekte | |||||||
Mdl aandoening | |||||||
Anemie | |||||||
Longaandoening | |||||||
Gynaecologische aandoening | |||||||
Orthopedische afwijking | |||||||
Bloedtransfusie? | |||||||
Transfusiereactie? | |||||||
Type operatie | |||||||
Type stollingsprobleem | |||||||
Psychiatrie? | |||||||
Overige aandoening? | |||||||
Obstetrische anamnese | |||||||
Gynaecologische aandoening | |||||||
Bloedverlies? | |||||||
Partiele mola? | |||||||
Cervixinsufficientie? | |||||||
Infectie | |||||||
Hyperemesis gravidarum? | |||||||
Hypertensieve aandoening | |||||||
Zwangerschapscholestase? | |||||||
Diabetes gravidarum met insuline? | |||||||
Afwijkende groei foetus | |||||||
Dreigende partus immaturus? | |||||||
Dreigende partus prematurus? | |||||||
Abruptio placentae? | |||||||
Fluxus postpartum? | |||||||
Zwangerschap | |||||||
Gynaecologische aandoening | |||||||
Bloedverlies? | |||||||
Partiele mola? | |||||||
Cervixinsufficientie? | |||||||
Infectie | |||||||
Hyperemesis gravidarum? | |||||||
Hypertensieve aandoening | Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT') Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT') | ||||||
Zwangerschapscholestase? | |||||||
Diabetes gravidarum met insuline? | |||||||
Afwijkende groei foetus | |||||||
Dreigende partus immaturus? | |||||||
Dreigende partus prematurus? | |||||||
Abruptio placentae? | |||||||
Navelstrengprolaps? | |||||||
Liggingsafwijking | |||||||
Meerlingzwangerschap? | |||||||
Serotiniteit? | |||||||
Intrauteriene vruchtdood | |||||||
Vermoeden intrauteriene vruchtdood? | |||||||
Surmenage? | Ja | ||||||
Einde zwangerschap | |||||||
Bevalling | |||||||
Pprom? | |||||||
Prom? | |||||||
Koorts? | |||||||
Niet vorderende ontsluiting? | |||||||
Niet vorderende uitdrijving? | |||||||
Verdenking foetale nood? | |||||||
Meconiumhoudend vruchtwater? | |||||||
Intrauteriene vruchtdood | |||||||
Vermoeden intrauteriene vruchtdood? | |||||||
Vastzittende placenta? | |||||||
Conditie perineum postpartum | |||||||
Fluxus postpartum? | |||||||
Behoefte aan pijnbestrijding? | Ja | ||||||
Postnatale fase | |||||||
Pathologie vrouw | |||||||
Overig | |||||||
Van 2e naar 3e lijn | |||||||
Van 2e naar 1e lijn | Zwangerschap/baring/kraamperiode/kind ongestoord, fysiologie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.10.3') Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||||||
Van 3e naar 2e lijn | |||||||
Perinatale periode | voor 28e week (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') 2e t/m 7e dag (code = '92' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') tijdens uitdrijving (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') |
1.1.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | |||
Gegevenselement | Waarde | ||
Zorginstelling | |||
Zorginstelling agbid | 12345678 (in identificerend systeem: AGB-Z) | ||
Zorginstelling lvrid | 1808 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) 1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) 0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) 0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) 0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.1.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||||||
Gegevenselement | Waarde | ||||||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||||||
Definitieve a terme datum | T - 1127 dagen T - 575 dagen T - 940 dagen T - 1064 dagen | ||||||
Diagnose | |||||||
Gynaecologische aandoening | Uterus anomalie (code = '37849005' in codeSystem 'SNOMED CT') | ||||||
Bloedverlies? | Ja | ||||||
Cervixinsufficientie? | Nee | ||||||
Infectie | Urineweg infectie (code = '307534009' in codeSystem 'SNOMED CT') Intra-uterien (code = '301775005' in codeSystem 'SNOMED CT') | ||||||
Hyperemesis gravidarum? | Ja Nee | ||||||
Hypertensieve aandoening | Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT') | ||||||
Zwangerschapscholestase? | Ja Nee | ||||||
Diabetes gravidarum met insuline? | Nee | ||||||
Afwijkende groei foetus | Geen informatie (code = 'NI' in codeSystem 'HL7 NullFlavor') Macrosomie (code = '199616008' in codeSystem 'SNOMED CT') | ||||||
Dreigende partus immaturus? | Nee | ||||||
Dreigende partus prematurus? | Nee | ||||||
Abruptio placentae? | Ja | ||||||
Irregulaire antistoffen? | Nee Ja | ||||||
Eerdere bevalling | |||||||
Placenta | |||||||
Geboorte placenta | Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') Placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||||||
Hoeveelheid bloedverlies | 550 ml 895 ml | ||||||
Vorige uitkomst per kind | |||||||
Vorige baring | |||||||
Geboortedatum | T - 1120 dagen T - 936 dagen T - 1112 dagen | ||||||
Kindspecifieke gegevens vorige uitkomsten | |||||||
Type partus | Spontaan (code = '177184002' in codeSystem 'SNOMED CT') Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') Secundair (code = '274130007' in codeSystem 'SNOMED CT') | ||||||
Percentiel van het geboortegewicht | p50 tot p90 (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.50') p10 tot p50 (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.50') p2,3 tot p10 (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.50') | ||||||
Apgarscore na 5 min | 8 10 | ||||||
Congenitale afwijkingen? | Nee Ja | ||||||
Congenitale afwijkingen groep | |||||||
Chromosomale afwijkingen? | Nee |
1.1.5 Zwangerschap
Zwangerschap | ||||
Gegevenselement | Waarde | |||
Dossiernummer | 0cbda760-1fdd-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4) 5460cff0-2089-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4) c2204d20-209a-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4) ad9c3280-209d-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4) 05e54070-209f-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4) e1691540-209f-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4) 68a34ee0-20a0-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4) 0af1e5b1-bf99-40a2-ade9-728186c32f31 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4) | |||
Graviditeit | 2 1 | |||
Pariteit voor deze zwangerschap | 1 0 | |||
Definitieve a terme datum | T - 84 dagen T - 115 dagen T - 101 dagen T - 136 dagen T - 163 dagen T - 91 dagen T - 78 dagen | |||
Voornemens | ||||
Voorgenomen plaats baring tijdens zwangerschap type locatie | Thuis (code = '169813005' in codeSystem 'SNOMED CT') Nog niet bepaald (code = '05' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') Geen informatie (code = 'NI' in codeSystem 'HL7 NullFlavor') Geen voorkeur (code = '00' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') | |||
Naar welk ziekenhuis wil de vrouw worden verwezen? | ||||
Zorginstelling agbid | 00000010 (in identificerend systeem: AGB-Z) | |||
Zorginstelling lvrid | 1999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | |||
Naam zorginstelling | UMC Papendorp | |||
Prenatale controle | ||||
Datum controle | T - 305 dagen T - 240 dagen T - 234 dagen T - 225 dagen T - 147 dagen T - 239 dagen T - 357 dagen T - 306 dagen | |||
Zwangerschapsduur | 59 dagen 155 dagen 161 dagen 156 dagen 269 dagen 177 dagen 86 dagen 65 dagen | |||
Leven voelen | goed (code = '289431008' in codeSystem 'SNOMED CT') weinig (code = '276372004' in codeSystem 'SNOMED CT') verminderd (code = '276369006' in codeSystem 'SNOMED CT') geen (code = '289432001' in codeSystem 'SNOMED CT') | |||
Rookgedrag | niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') gestopt tijdens huidige zwangerschap (code = '6' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | |||
Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') geen informatie (code = 'NI' in codeSystem 'HL7 NullFlavor') onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor') | |||
Drugsgebruik? | Nee Ja | |||
Gewicht gemeten | 70 kg 85 kg 67 kg 82 kg 89 kg 68 kg | |||
Diagnose | ||||
Datum | T - 305 dagen T - 240 dagen T - 234 dagen T - 225 dagen T - 239 dagen T - 357 dagen T - 306 dagen | |||
Zwangerschapsduur | 59 dagen 155 dagen 161 dagen 156 dagen 177 dagen 86 dagen 65 dagen | |||
Gynaecologische aandoening | Uterus anomalie (code = '37849005' in codeSystem 'SNOMED CT') Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor'): Overig, niet nader gespecificeerd | |||
Bloedverlies? | Ja Nee | |||
Partiele mola? | Ja Nee | |||
Cervixinsufficientie? | Nee | |||
Infectie | Urineweg infectie (code = '307534009' in codeSystem 'SNOMED CT') | |||
Hyperemesis gravidarum? | Nee | |||
Hypertensieve aandoening | Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT') Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT') | |||
Zwangerschapscholestase? | Nee | |||
Diabetes gravidarum met insuline? | Nee | |||
Afwijkende groei foetus | Dysmaturiteit (code = '267258002' in codeSystem 'SNOMED CT') Macrosomie (code = '199616008' in codeSystem 'SNOMED CT') | |||
Dreigende partus immaturus? | Nee | |||
Dreigende partus prematurus? | Nee | |||
Abruptio placentae? | Ja Nee | |||
Navelstrengprolaps? | NullFlavor: NI | |||
Liggingsafwijking | onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor') | |||
Intrauteriene vruchtdood | ||||
Vermoeden intrauteriene vruchtdood? | Nee | |||
Vermoeden iuvd op basis van | ||||
Intrauteriene behandeling | Selectieve foeticide (code = '265633004' in codeSystem 'SNOMED CT') | |||
Maternale sterfte? | Nee Ja | |||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.1.6 Bevalling
Bevalling | ||||
Gegevenselement | Waarde | |||
Partusnummer | 000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.7) 4567890123 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.7) 21123 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.7) 21234 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.7) | |||
Diagnose bevalling | ||||
Pprom? | Ja Nee | |||
Prom? | Nee | |||
Koorts? | Nee | |||
Niet vorderende ontsluiting? | Ja Nee | |||
Niet vorderende uitdrijving? | Ja Nee | |||
Verdenking foetale nood? | Ja Nee | |||
Intrauteriene vruchtdood | ||||
Vermoeden intrauteriene vruchtdood? | Nee | |||
Vermoeden iuvd op basis van | ||||
Vastzittende placenta? | Nee | |||
Fluxus postpartum? | Ja | |||
Aantal geboren kinderen | 1 2 | |||
Risicostatus voor baring | 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | |||
Interventies begin baring | ||||
Interventie begin baring | Strippen (code = '236960006' in codeSystem 'SNOMED CT') Primaire sectio caesarea (code = '80771000146107' in codeSystem 'SNOMED CT') Primaire sectio caesarea (code = '80771000146107' in codeSystem 'SNOMED CT') Primen prostaglandine (code = '236966000' in codeSystem 'SNOMED CT') | |||
Indicatie interventie begin baring | wens patiënt (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') conditie moeder - acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') conditie moeder - niet levensbedreigend (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | |||
Wijze waarop de baring begon | Interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') Spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') Spontane weeën (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | |||
Tijdstip begin actieve ontsluiting | T - 86 dagen om 14:30 uur T - 124 dagen om 14:09 uur T - 127 dagen om 22:09 uur T - 151 dagen om 21:09 uur T - 78 dagen om 03:45 uur T - 81 dagen om 22 uur | |||
Medicatie nageboortetijdperk groep | ||||
Medicatie nageboortetijdperk? | Ja Nee | |||
Soort medicatie nageboortetijdperk | Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') Prostaglandine (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') Pabal (code = 'H01BB03' in codeSystem 'ATC-NL') Prostaglandine (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') | |||
Placenta | ||||
Geboorte placenta | Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') Placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') Controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | |||
Hoeveelheid bloedverlies | 615 ml 980 ml 1740 ml 1120 ml 1500 ml 1050 ml 850 ml | |||
Conditie perineum postpartum | 1e graads perineumruptuur (code = '199916005' in codeSystem 'SNOMED CT') Gaaf (code = '289854007' in codeSystem 'SNOMED CT') Episiotomiewond (code = '609344008' in codeSystem 'SNOMED CT') 3e graads ruptuur (code = '199930000' in codeSystem 'SNOMED CT') 2e graads perineumruptuur (code = '199925004' in codeSystem 'SNOMED CT') |
1.1.7 Uitkomst per kind
Uitkomst per kind | |||||||
Gegevenselement | Waarde | ||||||
Baring | |||||||
Werkelijke plaats baring type locatie | Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') Ziekenhuis (code = '22232009' in codeSystem 'SNOMED CT') | ||||||
Ziekenhuis baring | |||||||
Ziekenhuisnummer lvrid | 0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) 0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) 0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) 0110 | ||||||
Demografische gegevens | |||||||
Identificaties kind | |||||||
Bsn kind | 999910383 (in identificerend systeem: BSN) 951847624 (in identificerend systeem: BSN) 847035116 (in identificerend systeem: BSN) 847035128 (in identificerend systeem: BSN) 840736526 (in identificerend systeem: BSN) 528741913 (in identificerend systeem: BSN) | ||||||
Geslacht medische observatie | vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21') niet conclusief (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||||||
Geboortedatum | T - 85 dagen T - 122 dagen om 02:34 uur T - 126 dagen om 06:30 uur T - 126 dagen om 07:02 uur T - 150 dagen om 23:35 uur T - 161 dagen om 02:30 uur T - 78 dagen T - 80 dagen om 14:50 uur | ||||||
Rangnummer kind | 1 2 | ||||||
Perinatale sterfte groep | |||||||
Perinatale sterfte? | Nee Ja | ||||||
Fase perinatale sterfte | Postpartum (code = '276506001' in codeSystem 'SNOMED CT') | ||||||
Datumtijd vaststelling perinatale sterfte | T - 126 dagen om 08:10 uur | ||||||
Kindspecifieke maternale gegevens | |||||||
Bijstimulatie toegediend? | Ja | ||||||
Tijdstip breken vliezen | T - 85 dagen om 09:15 uur T - 124 dagen om 23:04 uur T - 127 dagen om 22:09 uur T - 127 dagen om 23:13 uur T - 151 dagen om 07:04 uur T - 78 dagen om 04:30 uur T - 80 dagen om 12:34 uur | ||||||
Kleur en consistentie vruchtwater | Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') geen informatie (code = 'NI' in codeSystem 'HL7 NullFlavor') Bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18') Meconium (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
Tijdstip actief meepersen | T - 85 dagen om 12:13 uur T - 127 dagen om 23:49 uur T - 126 dagen om 06:45 uur T - 150 dagen om 22:15 uur T - 78 dagen om 05 uur T - 80 dagen om 14:30 uur | ||||||
Episiotomie? | Nee Ja | ||||||
Indicatie episiotomie | overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') | ||||||
Locatie episiotomie | mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||||||
Ruggenprik gewenst niet gekregen? | Nee Ja | ||||||
Pijnbestrijding? | Nee Ja | ||||||
Pijnbestrijding | |||||||
Methode | |||||||
Methode | Epidurale analgesie (code = '18946005' in codeSystem 'SNOMED CT') Overig middel (code = 'OTH' in codeSystem 'HL7 NullFlavor') Algehele anesthesie (code = '50697003' in codeSystem 'SNOMED CT') | ||||||
Overig middel | |||||||
Middel | Morfinometica (code = '52685006:363701004=404642006' in codeSystem 'SNOMED CT') Entonox (code = '426060003' in codeSystem 'SNOMED CT') TENS (code = '229559001' in codeSystem 'SNOMED CT') | ||||||
Toediening | Intraveneus (code = '431215000' in codeSystem 'SNOMED CT') Inhalatie (code = '241717009' in codeSystem 'SNOMED CT') Elektroden (code = '78746004' in codeSystem 'SNOMED CT') | ||||||
Periode | tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') tijdens ontsluitingsperiode > 3 cm (code = 'OntMt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||||||
Sedatie? | Nee Ja | ||||||
Kindspecifieke uitkomstgegevens | |||||||
Type partus | Spontaan (code = '177184002' in codeSystem 'SNOMED CT') Secundair (code = '274130007' in codeSystem 'SNOMED CT') Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | ||||||
Ligging bij geboorte | Achterhoofd-achter (code = '37235006' in codeSystem 'SNOMED CT') Geen informatie (code = 'NI' in codeSystem 'HL7 NullFlavor') Aangezicht (code = '21882006' in codeSystem 'SNOMED CT') Volkomen stuit (code = '49168004' in codeSystem 'SNOMED CT') Kruin (code = '249079005' in codeSystem 'SNOMED CT') Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor') Achterhoofd-voor (code = '70028003' in codeSystem 'SNOMED CT') | ||||||
Aanpakker kind - rol aanpakker kind | 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') gynaecoloog (code = '01.046' in codeSystem 'UZI Rolcodes') klinisch verloskundige (code = '25' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||||||
Supervisor - rol supervisor | 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') gynaecoloog (code = '01.046' in codeSystem 'UZI Rolcodes') gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||||||
Vaginale kunstverlossing groep | |||||||
Vaginale kunstverlossing | Forceps (code = '302383004' in codeSystem 'SNOMED CT') Stuitextractie (code = '416055001' in codeSystem 'SNOMED CT') Vacuüm (code = '61586001' in codeSystem 'SNOMED CT') | ||||||
Succes vaginale kunstverlossing? | Ja Nee | ||||||
Sectio caesarea group | |||||||
Beslismoment sectio caesarea | Tijdens ontsluiting besloten (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.5') Tijdens uitdrijving besloten (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.5') | ||||||
Indicatie primaire sectio | |||||||
Indicatie secundaire sectio | verdenking foetale nood (code = '444433005:246090004=130955003' in codeSystem 'SNOMED CT') maternale conditie (code = '418138009' in codeSystem 'SNOMED CT') | ||||||
Overige interventies | Opheffen schouderdystocie (code = '237008007' in codeSystem 'SNOMED CT') | ||||||
Lichamelijk onderzoek kind | |||||||
Apgarscore na 5 min | 9 | ||||||
Geboortegewicht | 3450 gram 3620 gram 2040 gram 1580 gram 4205 gram 3750 gram 3550 gram 3720 gram | ||||||
Congenitale afwijkingen? | Nee Ja | ||||||
Congenitale afwijkingen groep | |||||||
Specificatie congenitale afwijking groep | |||||||
Specificatie congenitale afwijking | spina bifida occulta (code = '76916001' in codeSystem 'SNOMED CT') gecompliceerd vitium (code = '94702005' in codeSystem 'SNOMED CT') overige congenitale huidafwijking (code = '74' in codeSystem '2.16.840.1.113883.2.4.4.13.8') | ||||||
Chromosomale afwijkingen? | Nee Ja | ||||||
Specificatie chromosomale afwijking groep | |||||||
Specificatie chromosomale afwijking | trisomie 21 (code = '41040004' in codeSystem 'SNOMED CT') | ||||||
Problematiek kind? | Nee Ja | ||||||
Problematiek kind | Geboortetrauma (code = '56110009' in codeSystem 'SNOMED CT') Subdurale bloeding (code = '126941005' in codeSystem 'SNOMED CT') Overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') Gehoor (code = '95827002' in codeSystem 'SNOMED CT') | ||||||
Kinderarts betrokken? | Nee Ja | ||||||
Betrokkenheid kinderarts | |||||||
Datum betrokkenheid | T - 122 dagen T - 126 dagen T - 150 dagen T - 78 dagen | ||||||
Reden betrokkenheid | overig (code = 'OTH' in codeSystem 'HL7 NullFlavor') kunstverlossing (code = '8571000146103' in codeSystem 'SNOMED CT') | ||||||
Type betrokkenheid | Consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') Overdracht (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
Zorginstelling lvrid | 0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) 0001 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) 0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
1.1.8 Medisch onderzoek
Medisch onderzoek | |||
Gegevenselement | Waarde | ||
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
Irregulaire antistoffen? | Nee Ja | ||
Welke irregulaire antistoffen vrouw aanwezig | Rhesus D (code = '112162009' in codeSystem 'SNOMED CT') Kell (code = '405844003' in codeSystem 'SNOMED CT') |
1.1.9 Postnatale fase
Postnatale fase | ||||
Gegevenselement | Waarde | |||
Diagnoseinterventie postnataal | ||||
Datum | T - 120 dagen T - 146 dagen T - 161 dagen | |||
Pathologie vrouw | Urineweginfectie (code = '68566005' in codeSystem 'SNOMED CT') Embolie (code = '414086009' in codeSystem 'SNOMED CT') Mastitis (code = '266579006' in codeSystem 'SNOMED CT') Trombose diep veneuze postpartum (code = '56272000' in codeSystem 'SNOMED CT') | |||
Kindspecifieke gegevens | ||||
Rangnummer kind | 1 | |||
Voeding kind groep | ||||
Voeding kind datum | T - 81 dagen T - 86 dagen T - 120 dagen T - 108 dagen T - 161 dagen T - 78 dagen T - 79 dagen | |||
Substantie voeding kind | borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |