Gebz:Vdraft AddendaKwalificatieAanleverberichtKernset: verschil tussen versies
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Regel 23: | Regel 23: | ||
|style="background-color: white;"|2 mei 1976 | |style="background-color: white;"|2 mei 1976 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Adres - postcode |
|style="background-color: white;"|4563 AB | |style="background-color: white;"|4563 AB | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 32: | Regel 32: | ||
|style="background-color: white;"|170 cm | |style="background-color: white;"|170 cm | ||
|}<section end=999910413 /> | |}<section end=999910413 /> | ||
− | === | + | === Anamnese === |
<section begin=anamnese_999910413 /> | <section begin=anamnese_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 72: | Regel 72: | ||
|style="background-color: white;"|Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=anamnese_999910413 /> | |}<section end=anamnese_999910413 /> | ||
− | === | + | === Zorgverlening === |
<section begin=zorgverlening_999910413 /> | <section begin=zorgverlening_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlening |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="2" width="25%"| Gegevenselement | |colspan="2" width="25%"| Gegevenselement | ||
Regel 114: | Regel 114: | ||
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
|}<section end=zorgverlening_999910413 /> | |}<section end=zorgverlening_999910413 /> | ||
− | === | + | === Zorgverlenerzorginstelling === |
<section begin=zorgverlenerzorginstelling_999910413 /> | <section begin=zorgverlenerzorginstelling_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="2" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
|style="background-color: white;"|1808 | |style="background-color: white;"|1808 | ||
|}<section end=zorgverlenerzorginstelling_999910413 /> | |}<section end=zorgverlenerzorginstelling_999910413 /> | ||
− | === | + | === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === |
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 /> | <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="5" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Wijze einde zwangerschap |
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Definitieve a terme datum |
|style="background-color: white;"|1 dec 2011 | |style="background-color: white;"|1 dec 2011 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Irregulaire antistoffen? |
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Eerdere bevalling |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="12"| |
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Placenta - geboorte placenta |
|style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | |style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Hoeveelheid bloedverlies |
|style="background-color: white;"|550 ml | |style="background-color: white;"|550 ml | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Vorige uitkomst per kind - vorige baring |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="8"| |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="3"|Demografische gegevens - geboortedatum | |
− | |||
− | |colspan=" | ||
− | |||
− | |||
− | |||
− | |||
|style="background-color: white;"|8 dec 2011 | |style="background-color: white;"|8 dec 2011 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 193: | Regel 177: | ||
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 /> | |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 /> | ||
− | === | + | === Zwangerschap === |
<section begin=zwangerschap_999910413 /> | <section begin=zwangerschap_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 262: | Regel 246: | ||
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
|}<section end=zwangerschap_999910413 /> | |}<section end=zwangerschap_999910413 /> | ||
− | === | + | === Bevalling === |
<section begin=bevalling_999910413 /> | <section begin=bevalling_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 308: | Regel 292: | ||
|colspan="2"|Soort medicatie nageboortetijdperk | |colspan="2"|Soort medicatie nageboortetijdperk | ||
|style="background-color: white;"|Oxytocin (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') | |style="background-color: white;"|Oxytocin (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Placenta - geboorte placenta |
− | |||
− | |||
|style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | |style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 322: | Regel 302: | ||
|style="background-color: white;"|First degree perineal tear during delivery - delivered (disorder) (code = '199916005' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|First degree perineal tear during delivery - delivered (disorder) (code = '199916005' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=bevalling_999910413 /> | |}<section end=bevalling_999910413 /> | ||
− | === | + | === Uitkomst per kind === |
<section begin=uitkomst_per_kind_999910413 /> | <section begin=uitkomst_per_kind_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Uitkomst per kind |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="4" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Baring |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="23"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Werkelijke plaats baring type locatie |
|style="background-color: white;"|Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') | |style="background-color: white;"|Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Demografische gegevens - geboortedatum |
+ | |style="background-color: white;"|8 okt 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Kindspecifieke maternale gegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="8"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Tijdstip breken vliezen |
− | |style="background-color: white;"| | + | |style="background-color: white;"|8 okt 2014 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Kleur en consistentie vruchtwater |
− | |style="background-color: white;"| | + | |style="background-color: white;"|kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Tijdstip actief meepersen |
|style="background-color: white;"|8 okt 2014 | |style="background-color: white;"|8 okt 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Episiotomie? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="2"|Ruggeprik gewenst niet gekregen? | |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |colspan=" | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Pijnbestrijding? |
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Sedatie? |
− | |||
− | |||
− | |||
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Kindspecifieke uitkomstgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="10"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Type partus |
|style="background-color: white;"|Delivery normal (finding) (code = '48782003' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Delivery normal (finding) (code = '48782003' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Apgarscore na 5 min |
|style="background-color: white;"|9 | |style="background-color: white;"|9 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Ligging bij geboorte |
|style="background-color: white;"|Occipitoposterior position (finding) (code = '37235006' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Occipitoposterior position (finding) (code = '37235006' in codeSystem '2.16.840.1.113883.6.96') | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Aanpakker kind - rol aanpakker kind |
− | |||
− | |||
|style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | |style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Supervisor - rol supervisor |
− | |||
− | |||
|style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | |style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Lichamelijk onderzoek kind - geboortegewicht |
|style="background-color: white;"|3450 gram | |style="background-color: white;"|3450 gram | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Congenitale afwijkingen? |
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Problematiek kind? |
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Kinderarts betrokken? |
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
|}<section end=uitkomst_per_kind_999910413 /> | |}<section end=uitkomst_per_kind_999910413 /> | ||
− | === | + | === Medisch onderzoek === |
<section begin=medisch_onderzoek_999910413 /> | <section begin=medisch_onderzoek_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="2"| |
− | |||
− | |||
|-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;"|Nee | ||
|}<section end=medisch_onderzoek_999910413 /> | |}<section end=medisch_onderzoek_999910413 /> | ||
− | === | + | === Postnatale fase === |
<section begin=postnatale_fase_999910413 /> | <section begin=postnatale_fase_999910413 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="4" width="25%"| Gegevenselement | |colspan="4" width="25%"| Gegevenselement | ||
Regel 501: | Regel 437: | ||
|style="background-color: white;"|11 sep 1974 | |style="background-color: white;"|11 sep 1974 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Adres - postcode |
|style="background-color: white;"|5689 CZ | |style="background-color: white;"|5689 CZ | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 510: | Regel 446: | ||
|style="background-color: white;"|184 cm | |style="background-color: white;"|184 cm | ||
|}<section end=961921821 /> | |}<section end=961921821 /> | ||
− | === | + | === Anamnese === |
<section begin=anamnese_961921821 /> | <section begin=anamnese_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Anamnese |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="2" width="25%"| Gegevenselement | |colspan="2" width="25%"| Gegevenselement | ||
Regel 522: | Regel 458: | ||
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
|}<section end=anamnese_961921821 /> | |}<section end=anamnese_961921821 /> | ||
− | === | + | === Zorgverlening === |
<section begin=zorgverlening_961921821 /> | <section begin=zorgverlening_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zorgverlening |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="4" width="25%"| Gegevenselement | |colspan="4" width="25%"| Gegevenselement | ||
Regel 569: | Regel 505: | ||
|style="background-color: white;"|Zwangerschapshypertensie, systolische RR >140 mm Hg (code = '4284' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.1') | |style="background-color: white;"|Zwangerschapshypertensie, systolische RR >140 mm Hg (code = '4284' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.1') | ||
|}<section end=zorgverlening_961921821 /> | |}<section end=zorgverlening_961921821 /> | ||
− | === | + | === Zorgverlenerzorginstelling === |
<section begin=zorgverlenerzorginstelling_961921821 /> | <section begin=zorgverlenerzorginstelling_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="2" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
|style="background-color: white;"|1504 | |style="background-color: white;"|1504 | ||
|}<section end=zorgverlenerzorginstelling_961921821 /> | |}<section end=zorgverlenerzorginstelling_961921821 /> | ||
− | === | + | === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === |
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 613: | Regel 545: | ||
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | ||
− | === | + | === Zwangerschap === |
<section begin=zwangerschap_961921821 /> | <section begin=zwangerschap_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 697: | Regel 629: | ||
|style="background-color: white;"|11 sep 1974 | |style="background-color: white;"|11 sep 1974 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Adres - postcode |
|style="background-color: white;"|5689 CZ | |style="background-color: white;"|5689 CZ | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 706: | Regel 638: | ||
|style="background-color: white;"|184 cm | |style="background-color: white;"|184 cm | ||
|}<section end=961921821 /> | |}<section end=961921821 /> | ||
− | === | + | === Anamnese === |
<section begin=anamnese_961921821 /> | <section begin=anamnese_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Anamnese |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="2" width="25%"| Gegevenselement | |colspan="2" width="25%"| Gegevenselement | ||
Regel 718: | Regel 650: | ||
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
|}<section end=anamnese_961921821 /> | |}<section end=anamnese_961921821 /> | ||
− | === | + | === Zorgverlening === |
<section begin=zorgverlening_961921821 /> | <section begin=zorgverlening_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zorgverlening |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="4" width="25%"| Gegevenselement | |colspan="4" width="25%"| Gegevenselement | ||
Regel 775: | Regel 707: | ||
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
|}<section end=zorgverlening_961921821 /> | |}<section end=zorgverlening_961921821 /> | ||
− | === | + | === Zorgverlenerzorginstelling === |
<section begin=zorgverlenerzorginstelling_961921821 /> | <section begin=zorgverlenerzorginstelling_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="2" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
|style="background-color: white;"|0003 | |style="background-color: white;"|0003 | ||
|}<section end=zorgverlenerzorginstelling_961921821 /> | |}<section end=zorgverlenerzorginstelling_961921821 /> | ||
− | === | + | === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === |
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 822: | Regel 750: | ||
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 /> | ||
− | === | + | === Zwangerschap === |
<section begin=zwangerschap_961921821 /> | <section begin=zwangerschap_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 894: | Regel 822: | ||
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
|}<section end=zwangerschap_961921821 /> | |}<section end=zwangerschap_961921821 /> | ||
− | === | + | === Bevalling === |
<section begin=bevalling_961921821 /> | <section begin=bevalling_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 937: | Regel 865: | ||
|colspan="2"|Medicatie nageboortetijdperk? | |colspan="2"|Medicatie nageboortetijdperk? | ||
|style="background-color: white;"|UNK | |style="background-color: white;"|UNK | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Placenta - geboorte placenta |
|style="background-color: white;"|placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | |style="background-color: white;"|placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 951: | Regel 875: | ||
|style="background-color: white;"|Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=bevalling_961921821 /> | |}<section end=bevalling_961921821 /> | ||
− | === | + | === Uitkomst per kind === |
<section begin=uitkomst_per_kind_961921821 /> | <section begin=uitkomst_per_kind_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Uitkomst per kind |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="6" width="25%"| Gegevenselement | |colspan="6" width="25%"| Gegevenselement | ||
Regel 962: | Regel 886: | ||
|colspan="7"|Baring | |colspan="7"|Baring | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="40"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Werkelijke plaats baring type locatie | |colspan="5"|Werkelijke plaats baring type locatie | ||
Regel 973: | Regel 897: | ||
|colspan="4"|Ziekenhuisnummer lvrid | |colspan="4"|Ziekenhuisnummer lvrid | ||
|style="background-color: white;"|0003 | |style="background-color: white;"|0003 | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="5"|Demografische gegevens - geboortedatum | |
− | |||
− | |colspan="5"| | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|style="background-color: white;"|1 sep 2014 | |style="background-color: white;"|1 sep 2014 | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Kindspecifieke maternale gegevens | |colspan="6"|Kindspecifieke maternale gegevens | ||
Regel 1.036: | Regel 936: | ||
|colspan="6"|Kindspecifieke uitkomstgegevens | |colspan="6"|Kindspecifieke uitkomstgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="20"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Type partus | |colspan="4"|Type partus | ||
Regel 1.046: | Regel 946: | ||
|colspan="4"|Ligging bij geboorte | |colspan="4"|Ligging bij geboorte | ||
|style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | |style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Aanpakker kind - rol aanpakker kind |
+ | |style="background-color: white;"|gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Supervisor - rol supervisor |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 1.070: | Regel 962: | ||
|colspan="3"|Indicatie sectio caesarea | |colspan="3"|Indicatie sectio caesarea | ||
|style="background-color: white;"|Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Lichamelijk onderzoek kind - geboortegewicht |
|style="background-color: white;"|3620 gram | |style="background-color: white;"|3620 gram | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 1.103: | Regel 991: | ||
|style="background-color: white;"|0003 | |style="background-color: white;"|0003 | ||
|}<section end=uitkomst_per_kind_961921821 /> | |}<section end=uitkomst_per_kind_961921821 /> | ||
− | === | + | === Medisch onderzoek === |
<section begin=medisch_onderzoek_961921821 /> | <section begin=medisch_onderzoek_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
Regel 1.130: | Regel 1.010: | ||
|style="background-color: white;"|Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=medisch_onderzoek_961921821 /> | |}<section end=medisch_onderzoek_961921821 /> | ||
− | === | + | === Postnatale fase === |
<section begin=postnatale_fase_961921821 /> | <section begin=postnatale_fase_961921821 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="4" width="25%"| Gegevenselement | |colspan="4" width="25%"| Gegevenselement | ||
Regel 1.184: | Regel 1.064: | ||
|style="background-color: white;"|5 aug 1985 | |style="background-color: white;"|5 aug 1985 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Adres - postcode |
|style="background-color: white;"|5421 JG | |style="background-color: white;"|5421 JG | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 1.199: | Regel 1.079: | ||
|style="background-color: white;"|Female genital mutilation type 2 (disorder) (code = '130621000119105' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Female genital mutilation type 2 (disorder) (code = '130621000119105' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=895623146 /> | |}<section end=895623146 /> | ||
− | === | + | === Anamnese === |
<section begin=anamnese_895623146 /> | <section begin=anamnese_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 1.242: | Regel 1.122: | ||
|style="background-color: white;"|Operation on heart (procedure) (code = '64915003' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Operation on heart (procedure) (code = '64915003' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=anamnese_895623146 /> | |}<section end=anamnese_895623146 /> | ||
− | === | + | === Zorgverlening === |
<section begin=zorgverlening_895623146 /> | <section begin=zorgverlening_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlening |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="2" width="25%"| Gegevenselement | |colspan="2" width="25%"| Gegevenselement | ||
Regel 1.287: | Regel 1.167: | ||
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
|}<section end=zorgverlening_895623146 /> | |}<section end=zorgverlening_895623146 /> | ||
− | === | + | === Zorgverlenerzorginstelling === |
<section begin=zorgverlenerzorginstelling_895623146 /> | <section begin=zorgverlenerzorginstelling_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="2" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
|style="background-color: white;"|9999 | |style="background-color: white;"|9999 | ||
|}<section end=zorgverlenerzorginstelling_895623146 /> | |}<section end=zorgverlenerzorginstelling_895623146 /> | ||
− | === | + | === Zwangerschap === |
<section begin=zwangerschap_895623146 /> | <section begin=zwangerschap_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 1.381: | Regel 1.257: | ||
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
|}<section end=zwangerschap_895623146 /> | |}<section end=zwangerschap_895623146 /> | ||
− | === | + | === Bevalling === |
<section begin=bevalling_895623146 /> | <section begin=bevalling_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 1.424: | Regel 1.300: | ||
|colspan="2"|Medicatie nageboortetijdperk? | |colspan="2"|Medicatie nageboortetijdperk? | ||
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Placenta - geboorte placenta |
− | |||
− | |||
|style="background-color: white;"|controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | |style="background-color: white;"|controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 1.438: | Regel 1.310: | ||
|style="background-color: white;"|Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=bevalling_895623146 /> | |}<section end=bevalling_895623146 /> | ||
− | === | + | === Uitkomst per kind === |
<section begin=uitkomst_per_kind_895623146 /> | <section begin=uitkomst_per_kind_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="7" width="25%"| Gegevenselement | |colspan="7" width="25%"| Gegevenselement | ||
Regel 1.449: | Regel 1.321: | ||
|colspan="8"|Baring | |colspan="8"|Baring | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="48"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Werkelijke plaats baring type locatie | |colspan="6"|Werkelijke plaats baring type locatie | ||
Regel 1.460: | Regel 1.332: | ||
|colspan="5"|Ziekenhuisnummer lvrid | |colspan="5"|Ziekenhuisnummer lvrid | ||
|style="background-color: white;"|9999 | |style="background-color: white;"|9999 | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="6"|Demografische gegevens - geboortedatum |
+ | |style="background-color: white;"|28 aug 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Kindspecifieke maternale gegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="19"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Tijdstip breken vliezen |
− | |style="background-color: white;"| | + | |style="background-color: white;"|27 aug 2014 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="5"|Kleur en consistentie vruchtwater | |
− | + | |style="background-color: white;"|kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |colspan="5"|Kleur en consistentie vruchtwater | ||
− | |style="background-color: white;"|kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Tijdstip actief meepersen | |colspan="5"|Tijdstip actief meepersen | ||
Regel 1.542: | Regel 1.390: | ||
|colspan="7"|Kindspecifieke uitkomstgegevens | |colspan="7"|Kindspecifieke uitkomstgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="21"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Type partus | |colspan="5"|Type partus | ||
Regel 1.552: | Regel 1.400: | ||
|colspan="5"|Ligging bij geboorte | |colspan="5"|Ligging bij geboorte | ||
|style="background-color: white;"|Face presentation (finding) (code = '21882006' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Face presentation (finding) (code = '21882006' in codeSystem '2.16.840.1.113883.6.96') | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="5"|Aanpakker kind - rol aanpakker kind |
− | |||
− | |||
|style="background-color: white;"|arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | |style="background-color: white;"|arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Supervisor - rol supervisor |
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 1.576: | Regel 1.416: | ||
|colspan="4"|Succes vaginale kunstverlossing? | |colspan="4"|Succes vaginale kunstverlossing? | ||
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="5"|Lichamelijk onderzoek kind - geboortegewicht |
− | |||
− | |||
|style="background-color: white;"|2040 gram | |style="background-color: white;"|2040 gram | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 1.612: | Regel 1.448: | ||
|style="background-color: white;"|9999 | |style="background-color: white;"|9999 | ||
|}<section end=uitkomst_per_kind_895623146 /> | |}<section end=uitkomst_per_kind_895623146 /> | ||
− | === | + | === Uitkomst per kind === |
<section begin=uitkomst_per_kind_895623146 /> | <section begin=uitkomst_per_kind_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="7" width="25%"| Gegevenselement | |colspan="7" width="25%"| Gegevenselement | ||
Regel 1.623: | Regel 1.459: | ||
|colspan="8"|Baring | |colspan="8"|Baring | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="58"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Werkelijke plaats baring type locatie | |colspan="6"|Werkelijke plaats baring type locatie | ||
Regel 1.634: | Regel 1.470: | ||
|colspan="5"|Ziekenhuisnummer lvrid | |colspan="5"|Ziekenhuisnummer lvrid | ||
|style="background-color: white;"|9999 | |style="background-color: white;"|9999 | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="6"|Demografische gegevens - geboortedatum |
+ | |style="background-color: white;"|28 aug 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Kindspecifieke maternale gegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |rowspan="19"| | |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |rowspan="19"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Tijdstip breken vliezen | |colspan="5"|Tijdstip breken vliezen | ||
Regel 1.722: | Regel 1.528: | ||
|colspan="7"|Kindspecifieke uitkomstgegevens | |colspan="7"|Kindspecifieke uitkomstgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="31"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Type partus | |colspan="5"|Type partus | ||
Regel 1.732: | Regel 1.538: | ||
|colspan="5"|Ligging bij geboorte | |colspan="5"|Ligging bij geboorte | ||
|style="background-color: white;"|Complete breech presentation (finding) (code = '49168004' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Complete breech presentation (finding) (code = '49168004' in codeSystem '2.16.840.1.113883.6.96') | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="5"|Aanpakker kind - rol aanpakker kind |
− | |||
− | |||
|style="background-color: white;"|arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | |style="background-color: white;"|arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="5"|Supervisor - rol supervisor |
− | |||
− | |||
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 1.759: | Regel 1.557: | ||
|colspan="5"|Overige interventies | |colspan="5"|Overige interventies | ||
|style="background-color: white;"|Maneuvers for delivery in shoulder dystocia (procedure) (code = '237008007' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Maneuvers for delivery in shoulder dystocia (procedure) (code = '237008007' in codeSystem '2.16.840.1.113883.6.96') | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Lichamelijk onderzoek kind - geboortegewicht |
|style="background-color: white;"|1580 gram | |style="background-color: white;"|1580 gram | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 1.816: | Regel 1.610: | ||
|style="background-color: white;"|0001 | |style="background-color: white;"|0001 | ||
|}<section end=uitkomst_per_kind_895623146 /> | |}<section end=uitkomst_per_kind_895623146 /> | ||
− | === | + | === Medisch onderzoek === |
<section begin=medisch_onderzoek_895623146 /> | <section begin=medisch_onderzoek_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
Regel 1.840: | Regel 1.626: | ||
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
|}<section end=medisch_onderzoek_895623146 /> | |}<section end=medisch_onderzoek_895623146 /> | ||
− | === | + | === Postnatale fase === |
<section begin=postnatale_fase_895623146 /> | <section begin=postnatale_fase_895623146 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="4" width="25%"| Gegevenselement | |colspan="4" width="25%"| Gegevenselement | ||
Regel 1.881: | Regel 1.667: | ||
|style="background-color: white;"|6 aug 1987 | |style="background-color: white;"|6 aug 1987 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Adres - postcode |
|style="background-color: white;"|4589 BA | |style="background-color: white;"|4589 BA | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 1.896: | Regel 1.682: | ||
|style="background-color: white;"|Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=850810711 /> | |}<section end=850810711 /> | ||
− | === | + | === Anamnese === |
<section begin=anamnese_850810711 /> | <section begin=anamnese_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 1.951: | Regel 1.737: | ||
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
|}<section end=anamnese_850810711 /> | |}<section end=anamnese_850810711 /> | ||
− | === | + | === Zorgverlening === |
<section begin=zorgverlening_850810711 /> | <section begin=zorgverlening_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zorgverlening |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="4" width="25%"| Gegevenselement | |colspan="4" width="25%"| Gegevenselement | ||
Regel 1.999: | Regel 1.785: | ||
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
|}<section end=zorgverlening_850810711 /> | |}<section end=zorgverlening_850810711 /> | ||
− | === | + | === Zorgverlenerzorginstelling === |
<section begin=zorgverlenerzorginstelling_850810711 /> | <section begin=zorgverlenerzorginstelling_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="2" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
|style="background-color: white;"|1410 | |style="background-color: white;"|1410 | ||
|}<section end=zorgverlenerzorginstelling_850810711 /> | |}<section end=zorgverlenerzorginstelling_850810711 /> | ||
− | === | + | === Zwangerschap === |
<section begin=zwangerschap_850810711 /> | <section begin=zwangerschap_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="2" width="25%"| Gegevenselement | |colspan="2" width="25%"| Gegevenselement | ||
Regel 2.039: | Regel 1.821: | ||
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
|}<section end=zwangerschap_850810711 /> | |}<section end=zwangerschap_850810711 /> | ||
− | === | + | === Bevalling === |
<section begin=bevalling_850810711 /> | <section begin=bevalling_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 2.072: | Regel 1.854: | ||
|colspan="2"|Soort medicatie nageboortetijdperk | |colspan="2"|Soort medicatie nageboortetijdperk | ||
|style="background-color: white;"|Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') | |style="background-color: white;"|Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Placenta - geboorte placenta |
|style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | |style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 2.086: | Regel 1.864: | ||
|style="background-color: white;"|Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=bevalling_850810711 /> | |}<section end=bevalling_850810711 /> | ||
− | === | + | === Uitkomst per kind === |
<section begin=uitkomst_per_kind_850810711 /> | <section begin=uitkomst_per_kind_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="7" width="25%"| Gegevenselement | |colspan="7" width="25%"| Gegevenselement | ||
Regel 2.097: | Regel 1.875: | ||
|colspan="8"|Baring | |colspan="8"|Baring | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="47"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Werkelijke plaats baring type locatie | |colspan="6"|Werkelijke plaats baring type locatie | ||
Regel 2.108: | Regel 1.886: | ||
|colspan="5"|Ziekenhuisnummer lvrid | |colspan="5"|Ziekenhuisnummer lvrid | ||
|style="background-color: white;"|0010 | |style="background-color: white;"|0010 | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="6"|Demografische gegevens - geboortedatum | |
− | |||
− | |colspan="6"| | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|style="background-color: white;"|4 aug 2014 | |style="background-color: white;"|4 aug 2014 | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Kindspecifieke maternale gegevens | |colspan="7"|Kindspecifieke maternale gegevens | ||
Regel 2.190: | Regel 1.944: | ||
|colspan="7"|Kindspecifieke uitkomstgegevens | |colspan="7"|Kindspecifieke uitkomstgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="20"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Type partus | |colspan="5"|Type partus | ||
Regel 2.200: | Regel 1.954: | ||
|colspan="5"|Ligging bij geboorte | |colspan="5"|Ligging bij geboorte | ||
|style="background-color: white;"|Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Aanpakker kind - rol aanpakker kind |
|style="background-color: white;"|co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | |style="background-color: white;"|co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="5"|Supervisor - rol supervisor |
− | |||
− | |||
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 2.224: | Regel 1.970: | ||
|colspan="4"|Succes vaginale kunstverlossing? | |colspan="4"|Succes vaginale kunstverlossing? | ||
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Lichamelijk onderzoek kind - geboortegewicht |
|style="background-color: white;"|4205 gram | |style="background-color: white;"|4205 gram | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 2.257: | Regel 1.999: | ||
|style="background-color: white;"|0010 | |style="background-color: white;"|0010 | ||
|}<section end=uitkomst_per_kind_850810711 /> | |}<section end=uitkomst_per_kind_850810711 /> | ||
− | === | + | === Postnatale fase === |
<section begin=postnatale_fase_850810711 /> | <section begin=postnatale_fase_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="4" width="25%"| Gegevenselement | |colspan="4" width="25%"| Gegevenselement | ||
Regel 2.324: | Regel 2.066: | ||
|style="background-color: white;"|6 aug 1987 | |style="background-color: white;"|6 aug 1987 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Adres - postcode |
|style="background-color: white;"|4589 BA | |style="background-color: white;"|4589 BA | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 2.339: | Regel 2.081: | ||
|style="background-color: white;"|Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=850810711 /> | |}<section end=850810711 /> | ||
− | === | + | === Anamnese === |
<section begin=anamnese_850810711 /> | <section begin=anamnese_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 2.394: | Regel 2.136: | ||
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
|}<section end=anamnese_850810711 /> | |}<section end=anamnese_850810711 /> | ||
− | === | + | === Zorgverlening === |
<section begin=zorgverlening_850810711 /> | <section begin=zorgverlening_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zorgverlening |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="4" width="25%"| Gegevenselement | |colspan="4" width="25%"| Gegevenselement | ||
Regel 2.453: | Regel 2.195: | ||
|style="background-color: white;"|anders (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | |style="background-color: white;"|anders (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
|}<section end=zorgverlening_850810711 /> | |}<section end=zorgverlening_850810711 /> | ||
− | === | + | === Zorgverlenerzorginstelling === |
<section begin=zorgverlenerzorginstelling_850810711 /> | <section begin=zorgverlenerzorginstelling_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="2" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
|style="background-color: white;"|0010 | |style="background-color: white;"|0010 | ||
|}<section end=zorgverlenerzorginstelling_850810711 /> | |}<section end=zorgverlenerzorginstelling_850810711 /> | ||
− | === | + | === Zwangerschap === |
<section begin=zwangerschap_850810711 /> | <section begin=zwangerschap_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 2.538: | Regel 2.276: | ||
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
|}<section end=zwangerschap_850810711 /> | |}<section end=zwangerschap_850810711 /> | ||
− | === | + | === Bevalling === |
<section begin=bevalling_850810711 /> | <section begin=bevalling_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 2.581: | Regel 2.319: | ||
|colspan="2"|Soort medicatie nageboortetijdperk | |colspan="2"|Soort medicatie nageboortetijdperk | ||
|style="background-color: white;"|Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') | |style="background-color: white;"|Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Placenta - geboorte placenta |
− | |||
− | |||
|style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | |style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 2.595: | Regel 2.329: | ||
|style="background-color: white;"|Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=bevalling_850810711 /> | |}<section end=bevalling_850810711 /> | ||
− | === | + | === Uitkomst per kind === |
<section begin=uitkomst_per_kind_850810711 /> | <section begin=uitkomst_per_kind_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="7" width="25%"| Gegevenselement | |colspan="7" width="25%"| Gegevenselement | ||
Regel 2.606: | Regel 2.340: | ||
|colspan="8"|Baring | |colspan="8"|Baring | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="47"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Werkelijke plaats baring type locatie | |colspan="6"|Werkelijke plaats baring type locatie | ||
Regel 2.617: | Regel 2.351: | ||
|colspan="5"|Ziekenhuisnummer lvrid | |colspan="5"|Ziekenhuisnummer lvrid | ||
|style="background-color: white;"|0010 | |style="background-color: white;"|0010 | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Demografische gegevens - geboortedatum |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|style="background-color: white;"|4 aug 2014 | |style="background-color: white;"|4 aug 2014 | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Kindspecifieke maternale gegevens | |colspan="7"|Kindspecifieke maternale gegevens | ||
Regel 2.699: | Regel 2.409: | ||
|colspan="7"|Kindspecifieke uitkomstgegevens | |colspan="7"|Kindspecifieke uitkomstgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="20"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Type partus | |colspan="5"|Type partus | ||
Regel 2.709: | Regel 2.419: | ||
|colspan="5"|Ligging bij geboorte | |colspan="5"|Ligging bij geboorte | ||
|style="background-color: white;"|Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="5"|Aanpakker kind - rol aanpakker kind |
− | |||
− | |||
|style="background-color: white;"|co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | |style="background-color: white;"|co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Supervisor - rol supervisor |
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 2.733: | Regel 2.435: | ||
|colspan="4"|Succes vaginale kunstverlossing? | |colspan="4"|Succes vaginale kunstverlossing? | ||
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="5"|Lichamelijk onderzoek kind - geboortegewicht |
− | |||
− | |||
|style="background-color: white;"|4205 gram | |style="background-color: white;"|4205 gram | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 2.766: | Regel 2.464: | ||
|style="background-color: white;"|0010 | |style="background-color: white;"|0010 | ||
|}<section end=uitkomst_per_kind_850810711 /> | |}<section end=uitkomst_per_kind_850810711 /> | ||
− | === | + | === Medisch onderzoek === |
<section begin=medisch_onderzoek_850810711 /> | <section begin=medisch_onderzoek_850810711 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="2"| |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="2"|Irregulaire antistoffen? | |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |colspan="2"|Irregulaire antistoffen? | ||
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
|}<section end=medisch_onderzoek_850810711 /> | |}<section end=medisch_onderzoek_850810711 /> | ||
Regel 2.808: | Regel 2.498: | ||
|style="background-color: white;"|4 mrt 1993 | |style="background-color: white;"|4 mrt 1993 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Adres - postcode |
|style="background-color: white;"|9562 GF | |style="background-color: white;"|9562 GF | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 2.817: | Regel 2.507: | ||
|style="background-color: white;"|186 cm | |style="background-color: white;"|186 cm | ||
|}<section end=912345676 /> | |}<section end=912345676 /> | ||
− | === | + | === Anamnese === |
<section begin=anamnese_912345676 /> | <section begin=anamnese_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 2.869: | Regel 2.559: | ||
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
|}<section end=anamnese_912345676 /> | |}<section end=anamnese_912345676 /> | ||
− | === | + | === Zorgverlening === |
<section begin=zorgverlening_912345676 /> | <section begin=zorgverlening_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlening |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="2" width="25%"| Gegevenselement | |colspan="2" width="25%"| Gegevenselement | ||
Regel 2.914: | Regel 2.604: | ||
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
|}<section end=zorgverlening_912345676 /> | |}<section end=zorgverlening_912345676 /> | ||
− | === | + | === Zorgverlenerzorginstelling === |
<section begin=zorgverlenerzorginstelling_912345676 /> | <section begin=zorgverlenerzorginstelling_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="2" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorginstelling lvrid | |colspan="2"|Zorginstelling lvrid | ||
|style="background-color: white;"|0179 | |style="background-color: white;"|0179 | ||
|}<section end=zorgverlenerzorginstelling_912345676 /> | |}<section end=zorgverlenerzorginstelling_912345676 /> | ||
− | === | + | === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap === |
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 /> | <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="5" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Wijze einde zwangerschap |
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Definitieve a terme datum |
|style="background-color: white;"|5 jun 2012 | |style="background-color: white;"|5 jun 2012 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Diagnose |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Infectie |
|style="background-color: white;"|Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Zwangerschapscholestase? |
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Afwijkende groei foetus |
|style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | |style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Irregulaire antistoffen? |
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Eerdere bevalling |
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="11"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Placenta - geboorte placenta |
|style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | |style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Vorige uitkomst per kind - vorige baring |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="8"| |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Demografische gegevens - geboortedatum |
|style="background-color: white;"|9 jun 2012 | |style="background-color: white;"|9 jun 2012 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 3.003: | Regel 2.677: | ||
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 /> | |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 /> | ||
− | === | + | === Zwangerschap === |
<section begin=zwangerschap_912345676 /> | <section begin=zwangerschap_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 3.078: | Regel 2.752: | ||
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
|}<section end=zwangerschap_912345676 /> | |}<section end=zwangerschap_912345676 /> | ||
− | === | + | === Bevalling === |
<section begin=bevalling_912345676 /> | <section begin=bevalling_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 3.118: | Regel 2.792: | ||
|colspan="2"|Medicatie nageboortetijdperk? | |colspan="2"|Medicatie nageboortetijdperk? | ||
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Placenta - geboorte placenta |
|style="background-color: white;"|placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | |style="background-color: white;"|placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 3.132: | Regel 2.802: | ||
|style="background-color: white;"|Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=bevalling_912345676 /> | |}<section end=bevalling_912345676 /> | ||
− | === | + | === Uitkomst per kind === |
<section begin=uitkomst_per_kind_912345676 /> | <section begin=uitkomst_per_kind_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Uitkomst per kind |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="6" width="25%"| Gegevenselement | |colspan="6" width="25%"| Gegevenselement | ||
Regel 3.143: | Regel 2.813: | ||
|colspan="7"|Baring | |colspan="7"|Baring | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="47"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Werkelijke plaats baring type locatie | |colspan="5"|Werkelijke plaats baring type locatie | ||
Regel 3.154: | Regel 2.824: | ||
|colspan="4"|Ziekenhuisnummer lvrid | |colspan="4"|Ziekenhuisnummer lvrid | ||
|style="background-color: white;"|0179 | |style="background-color: white;"|0179 | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="5"|Demografische gegevens - geboortedatum | |
− | |||
− | |colspan="5"| | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|style="background-color: white;"|24 jul 2014 | |style="background-color: white;"|24 jul 2014 | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Kindspecifieke maternale gegevens | |colspan="6"|Kindspecifieke maternale gegevens | ||
Regel 3.217: | Regel 2.863: | ||
|colspan="6"|Kindspecifieke uitkomstgegevens | |colspan="6"|Kindspecifieke uitkomstgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="27"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Type partus | |colspan="4"|Type partus | ||
Regel 3.227: | Regel 2.873: | ||
|colspan="4"|Ligging bij geboorte | |colspan="4"|Ligging bij geboorte | ||
|style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem '2.16.840.1.113883.5.1008') | |style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem '2.16.840.1.113883.5.1008') | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Aanpakker kind - rol aanpakker kind |
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Supervisor - rol supervisor |
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 3.261: | Regel 2.899: | ||
|colspan="3"|Indicatie sectio caesarea | |colspan="3"|Indicatie sectio caesarea | ||
|style="background-color: white;"|Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') | ||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Lichamelijk onderzoek kind - geboortegewicht |
|style="background-color: white;"|3750 gram | |style="background-color: white;"|3750 gram | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 3.299: | Regel 2.933: | ||
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee | ||
|}<section end=uitkomst_per_kind_912345676 /> | |}<section end=uitkomst_per_kind_912345676 /> | ||
− | === | + | === Medisch onderzoek === |
<section begin=medisch_onderzoek_912345676 /> | <section begin=medisch_onderzoek_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
Regel 3.326: | Regel 2.952: | ||
|style="background-color: white;"|Kell (code = '405844003' in codeSystem '2.16.840.1.113883.6.96') | |style="background-color: white;"|Kell (code = '405844003' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=medisch_onderzoek_912345676 /> | |}<section end=medisch_onderzoek_912345676 /> | ||
− | === | + | === Postnatale fase === |
<section begin=postnatale_fase_912345676 /> | <section begin=postnatale_fase_912345676 /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="4" width="25%"| Gegevenselement | |colspan="4" width="25%"| Gegevenselement |
Versie van 29 nov 2018 15:55
Deze pagina is nog in bewerking |
1 Addenda voor inhoudelijke gegevens
1.1 Scenario 1. Zorg volledig 1e lijn, herpes, strippen, gezonde eenling (voor vrouw met BSN: 999910413)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 999910413 | |
Lokale persoonsidentificatie | 000000 | |
Geboortedatum | 2 mei 1976 | |
Adres - postcode | 4563 AB | |
Etniciteit | Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 170 cm |
1.1.1 Anamnese
Anamnese | |||
Gegevenselement | Waarde | ||
Onder behandeling geweest? | Ja | ||
Algemene anamnese | |||
Cardiovasculaire aandoening? | Ja | ||
Cardiovasculaire aandoening | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
Oncologische aandoening? | Ja | ||
Oncologische aandoening | other (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
Infectieziekte? | Ja | ||
Infectieziekte | Herpesvirus infection (disorder) (code = '23513009' in codeSystem '2.16.840.1.113883.6.96') | ||
Operatie? | Ja | ||
Type operatie | Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96') |
1.1.2 Zorgverlening
Zorgverlening | ||
Gegevenselement | Waarde | |
Datum start zorgverantwoordelijkheid | 1 mrt 2014 | |
Datum einde zorgverantwoordelijkheid | 12 nov 2014 | |
Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Conclusie risicostatus na intake | 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | |
Is er sprake van overdracht aan? | Nee |
1.1.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | ||
Gegevenselement | Waarde | |
Zorginstelling lvrid | 1808 |
1.1.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||||
Gegevenselement | Waarde | ||||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||||
Definitieve a terme datum | 1 dec 2011 | ||||
Irregulaire antistoffen? | Nee | ||||
Eerdere bevalling | |||||
Placenta - geboorte placenta | spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||||
Hoeveelheid bloedverlies | 550 ml | ||||
Vorige uitkomst per kind - vorige baring | |||||
Demografische gegevens - geboortedatum | 8 dec 2011 | ||||
Kindspecifieke gegevens vorige uitkomsten | |||||
Type partus | Delivery normal (finding) (code = '48782003' in codeSystem '2.16.840.1.113883.6.96') | ||||
Percentiel van het geboortegewicht | 50 ≤ P < 90 (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.50') | ||||
Apgarscore na 5 min | 8 | ||||
Congenitale afwijkingen? | Nee |
1.1.5 Zwangerschap
Zwangerschap | |||
Gegevenselement | Waarde | ||
Graviditeit | 2 | ||
Pariteit voor deze zwangerschap | 1 | ||
Definitieve a terme datum | 9 okt 2014 | ||
Voornemens | |||
Voorgenomen plaats baring tijdens zwangerschap type locatie | Home birth (finding) (code = '169813005' in codeSystem '2.16.840.1.113883.6.96') | ||
Prenatale controle | |||
Datum controle | 2 mrt 2014 | ||
Zwangerschapsduur | 59 dagen | ||
Leven voelen | Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96') | ||
Rookgedrag | niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
Drugsgebruik? | Nee | ||
Gewicht gemeten | 70 kg | ||
Diagnose | |||
Datum | 2 mrt 2014 | ||
Zwangerschapsduur | 59 dagen | ||
Infectie | Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | ||
Maternale sterfte? | Nee | ||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.1.6 Bevalling
Bevalling | |||
Gegevenselement | Waarde | ||
Partusnummer | 000000 | ||
Aantal geboren kinderen | 1 | ||
Risicostatus voor baring | 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
Wijze waarop de baring begon | interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
Interventies begin baring groep | |||
Interventie begin baring | Sweeping of membrane (procedure) (code = '236960006' in codeSystem '2.16.840.1.113883.6.96') | ||
Indicatie interventie begin baring | wens patiënt (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | ||
Tijdstip begin actieve ontsluiting | 8 okt 2014 | ||
Bijstimulatie toegediend? | Nee | ||
Medicatie nageboortetijdperk groep | |||
Medicatie nageboortetijdperk? | Ja | ||
Soort medicatie nageboortetijdperk | Oxytocin (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') | ||
Placenta - geboorte placenta | spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
Hoeveelheid bloedverlies | 615 ml | ||
Conditie perineum postpartum | First degree perineal tear during delivery - delivered (disorder) (code = '199916005' in codeSystem '2.16.840.1.113883.6.96') |
1.1.7 Uitkomst per kind
Uitkomst per kind | ||||
Gegevenselement | Waarde | |||
Baring | ||||
Werkelijke plaats baring type locatie | Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') | |||
Demografische gegevens - geboortedatum | 8 okt 2014 | |||
Kindspecifieke maternale gegevens | ||||
Tijdstip breken vliezen | 8 okt 2014 | |||
Kleur en consistentie vruchtwater | kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | |||
Tijdstip actief meepersen | 8 okt 2014 | |||
Episiotomie? | Nee | |||
Ruggeprik gewenst niet gekregen? | Nee | |||
Pijnbestrijding? | Nee | |||
Sedatie? | Nee | |||
Kindspecifieke uitkomstgegevens | ||||
Type partus | Delivery normal (finding) (code = '48782003' in codeSystem '2.16.840.1.113883.6.96') | |||
Apgarscore na 5 min | 9 | |||
Ligging bij geboorte | Occipitoposterior position (finding) (code = '37235006' in codeSystem '2.16.840.1.113883.6.96') | |||
Aanpakker kind - rol aanpakker kind | 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | |||
Supervisor - rol supervisor | 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | |||
Lichamelijk onderzoek kind - geboortegewicht | 3450 gram | |||
Congenitale afwijkingen? | Nee | |||
Problematiek kind? | Nee | |||
Kinderarts betrokken? | Nee |
1.1.8 Medisch onderzoek
Medisch onderzoek | |||
Gegevenselement | Waarde | ||
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
Irregulaire antistoffen? | Nee |
1.1.9 Postnatale fase
Postnatale fase | ||||
Gegevenselement | Waarde | |||
Kindspecifieke gegevens | ||||
Voeding kind groep | ||||
Voeding kind datum | 12 okt 2014 | |||
Substantie voeding kind | borstmelk (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | |||
Substantie voeding kind | kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
1.2 Scenario 2. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 961921821 | |
Lokale persoonsidentificatie | * | |
Geboortedatum | 11 sep 1974 | |
Adres - postcode | 5689 CZ | |
Etniciteit | Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 184 cm |
1.2.1 Anamnese
Anamnese | ||
Gegevenselement | Waarde | |
Onder behandeling geweest? | Nee |
1.2.2 Zorgverlening
Zorgverlening | ||||
Gegevenselement | Waarde | |||
Datum start zorgverantwoordelijkheid | 3 feb 2014 | |||
Datum einde zorgverantwoordelijkheid | 6 mei 2014 | |||
Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
Conclusie risicostatus na intake | 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | |||
Is er sprake van overdracht aan? | Ja | |||
Overdrachtdetails | ||||
Datum van overdracht | 6 mei 2014 | |||
Overdracht aan zorginstelling specialisme | Gynaecoloog / obstetricus (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | |||
Perinatale periode van overdracht | voor 28e week (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') | |||
Redenen van overdracht aan | ||||
Reden overdracht aan lijst prn | Zwangerschapshypertensie, systolische RR >140 mm Hg (code = '4284' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.1') |
1.2.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | ||
Gegevenselement | Waarde | |
Zorginstelling lvrid | 1504 |
1.2.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||
Gegevenselement | Waarde | ||
Wijze einde zwangerschap | Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
Definitieve a terme datum | 5 jun 2013 | ||
Diagnose | |||
Bloedverlies? | Ja | ||
Hyperemesis gravidarum? | Ja | ||
Irregulaire antistoffen? | Ja |
1.2.5 Zwangerschap
Zwangerschap | |||
Gegevenselement | Waarde | ||
Graviditeit | 2 | ||
Pariteit voor deze zwangerschap | 0 | ||
Definitieve a terme datum | 8 sep 2014 | ||
Voornemens | |||
Voorgenomen plaats baring tijdens zwangerschap type locatie | Nog niet bepaald (code = '05' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') | ||
Prenatale controle | |||
Datum controle | 6 mei 2014 | ||
Zwangerschapsduur | 155 dagen | ||
Leven voelen | Weak fetal movements (finding) (code = '276372004' in codeSystem '2.16.840.1.113883.6.96') | ||
Rookgedrag | gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
Drugsgebruik? | Nee | ||
Gewicht gemeten | 85 kg | ||
Diagnose | |||
Datum | 6 mei 2014 | ||
Zwangerschapsduur | 155 dagen | ||
Hypertensieve aandoening | Pregnancy-induced hypertension (disorder) (code = '48194001' in codeSystem '2.16.840.1.113883.6.96') | ||
Maternale sterfte? | Nee |
1.3 Scenario 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 961921821 | |
Lokale persoonsidentificatie | * | |
Geboortedatum | 11 sep 1974 | |
Adres - postcode | 5689 CZ | |
Etniciteit | Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 184 cm |
1.3.1 Anamnese
Anamnese | ||
Gegevenselement | Waarde | |
Onder behandeling geweest? | Nee |
1.3.2 Zorgverlening
Zorgverlening | ||||
Gegevenselement | Waarde | |||
Datum start zorgverantwoordelijkheid | 12 mei 2014 | |||
Datum einde zorgverantwoordelijkheid | 9 okt 2014 | |||
Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
Eindverantwoordelijk in welke perinatale periode? | follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
Zorgverzoekdetails | ||||
Overname van zorginstelling | ||||
Overname van zorginstelling id | 1504 | |||
Redenen van overname | ||||
Reden van overname lijst prn | Pre-eclampsie tijdens zwangerschap (code = '4291' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.1') | |||
Is er sprake van overdracht aan? | Nee |
1.3.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | ||
Gegevenselement | Waarde | |
Zorginstelling lvrid | 0003 |
1.3.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||
Gegevenselement | Waarde | ||
Wijze einde zwangerschap | Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
Definitieve a terme datum | 5 jun 2013 | ||
Diagnose | |||
Gynaecologische aandoening | Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') | ||
Bloedverlies? | Ja | ||
Hyperemesis gravidarum? | Ja | ||
Irregulaire antistoffen? | Ja |
1.3.5 Zwangerschap
Zwangerschap | |||
Gegevenselement | Waarde | ||
Graviditeit | 2 | ||
Pariteit voor deze zwangerschap | 0 | ||
Definitieve a terme datum | 8 sep 2014 | ||
Voornemens | |||
Prenatale controle | |||
Datum controle | 12 mei 2014 | ||
Zwangerschapsduur | 161 dagen | ||
Leven voelen | Reduced fetal movement (finding) (code = '276369006' in codeSystem '2.16.840.1.113883.6.96') | ||
Rookgedrag | gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
Drugsgebruik? | Nee | ||
Gewicht gemeten | 85 kg | ||
Diagnose | |||
Datum | 12 mei 2014 | ||
Zwangerschapsduur | 161 dagen | ||
Gynaecologische aandoening | Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') | ||
Partiele mola? | Ja | ||
Hypertensieve aandoening | Pre-eclampsia (disorder) (code = '398254007' in codeSystem '2.16.840.1.113883.6.96') | ||
Maternale sterfte? | Nee | ||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.3.6 Bevalling
Bevalling | |||
Gegevenselement | Waarde | ||
Partusnummer | 000000 | ||
Aantal geboren kinderen | 1 | ||
Risicostatus voor baring | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
Wijze waarop de baring begon | interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
Interventies begin baring groep | |||
Interventie begin baring | Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96') | ||
Indicatie interventie begin baring | acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | ||
Tijdstip begin actieve ontsluiting | 30 aug 2014 | ||
Bijstimulatie toegediend? | Nee | ||
Medicatie nageboortetijdperk groep | |||
Medicatie nageboortetijdperk? | UNK | ||
Placenta - geboorte placenta | placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
Hoeveelheid bloedverlies | 980 ml | ||
Conditie perineum postpartum | Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') |
1.3.7 Uitkomst per kind
Uitkomst per kind | ||||||
Gegevenselement | Waarde | |||||
Baring | ||||||
Werkelijke plaats baring type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | |||||
Ziekenhuis baring | ||||||
Ziekenhuisnummer lvrid | 0003 | |||||
Demografische gegevens - geboortedatum | 1 sep 2014 | |||||
Kindspecifieke maternale gegevens | ||||||
Tijdstip breken vliezen | 30 aug 2014 | |||||
Kleur en consistentie vruchtwater | geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | |||||
Ruggeprik gewenst niet gekregen? | Nee | |||||
Pijnbestrijding? | Ja | |||||
Pijnbestrijding | ||||||
Methode | ||||||
Methode | Epidural anesthesia (procedure) (code = '18946005' in codeSystem '2.16.840.1.113883.6.96') | |||||
Periode | tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | |||||
Sedatie? | Ja | |||||
Kindspecifieke uitkomstgegevens | ||||||
Type partus | Cesarean delivery - delivered (finding) (code = '200146002' in codeSystem '2.16.840.1.113883.6.96') | |||||
Apgarscore na 5 min | 10 | |||||
Ligging bij geboorte | Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | |||||
Aanpakker kind - rol aanpakker kind | gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | |||||
Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | |||||
Sectio caesarea group | ||||||
Indicatie sectio caesarea | Suspected fetal distress (situation) (code = '444433005:246090004=130955003' in codeSystem '2.16.840.1.113883.6.96') | |||||
Indicatie sectio caesarea | Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') | |||||
Lichamelijk onderzoek kind - geboortegewicht | 3620 gram | |||||
Congenitale afwijkingen? | Nee | |||||
Problematiek kind? | Nee | |||||
Kinderarts betrokken? | Ja | |||||
Betrokkenheid kinderarts | ||||||
Datum betrokkenheid | 1 sep 2014 | |||||
Reden betrokkenheid | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | |||||
Type betrokkenheid | consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | |||||
Zorginstelling lvrid | 0003 |
1.3.8 Medisch onderzoek
Medisch onderzoek | |||
Gegevenselement | Waarde | ||
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
Irregulaire antistoffen? | Ja | ||
Welke irregulaire antistoffen vrouw aanwezig | Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96') |
1.3.9 Postnatale fase
Postnatale fase | ||||
Gegevenselement | Waarde | |||
Diagnose postpartum | ||||
Datum | 3 sep 2014 | |||
Pathologie vrouw? | Ja | |||
Pathologie vrouw | Urinary tract infectious disease (disorder) (code = '68566005' in codeSystem '2.16.840.1.113883.6.96') | |||
Kindspecifieke kraamzorggegevens | ||||
Voeding kind groep | ||||
Voeding kind datum | 7 okt 2014 | |||
Substantie voeding kind | kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
1.4 Scenario 3. zorg volledig in 2e lijn, meerling, 1 kind overleden (voor vrouw met BSN: 895623146)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 895623146 | |
Lokale persoonsidentificatie | 000000 | |
Geboortedatum | 5 aug 1985 | |
Adres - postcode | 5421 JG | |
Etniciteit | Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 167 cm | |
Vrouwelijke genitale verminking? | Ja | |
Type vrouwelijke genitale verminking | Female genital mutilation type 2 (disorder) (code = '130621000119105' in codeSystem '2.16.840.1.113883.6.96') |
1.4.1 Anamnese
Anamnese | |||
Gegevenselement | Waarde | ||
Onder behandeling geweest? | Ja | ||
Algemene anamnese | |||
Cardiovasculaire aandoening? | Ja | ||
Cardiovasculaire aandoening | Cardiac arrhythmia (disorder) (code = '698247007' in codeSystem '2.16.840.1.113883.6.96') | ||
Schildklier aandoening? | Ja | ||
Schildklier aandoening | Hyperthyroidism (disorder) (code = '34486009' in codeSystem '2.16.840.1.113883.6.96') | ||
Anemie? | Ja | ||
Anemie | Iron deficiency anemia (disorder) (code = '87522002' in codeSystem '2.16.840.1.113883.6.96') | ||
Bloedtransfusie? | Ja | ||
Operatie? | Ja | ||
Type operatie | Operation on heart (procedure) (code = '64915003' in codeSystem '2.16.840.1.113883.6.96') |
1.4.2 Zorgverlening
Zorgverlening | ||
Gegevenselement | Waarde | |
Datum start zorgverantwoordelijkheid | 10 mrt 2014 | |
Datum einde zorgverantwoordelijkheid | 3 nov 2014 | |
Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Conclusie risicostatus na intake | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | |
Is er sprake van overdracht aan? | Nee |
1.4.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | ||
Gegevenselement | Waarde | |
Zorginstelling lvrid | 9999 |
1.4.4 Zwangerschap
Zwangerschap | |||
Gegevenselement | Waarde | ||
Graviditeit | 1 | ||
Pariteit voor deze zwangerschap | 0 | ||
Definitieve a terme datum | 22 sep 2014 | ||
Voornemens | |||
Voorgenomen plaats baring tijdens zwangerschap type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||
Prenatale controle | |||
Datum controle | 21 mei 2014 | ||
Zwangerschapsduur | 156 dagen | ||
Leven voelen | Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96') | ||
Rookgedrag | niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
Drugsgebruik? | Nee | ||
Gewicht gemeten | 67 kg | ||
Diagnose | |||
Datum | 21 mei 2014 | ||
Zwangerschapsduur | 156 dagen | ||
Bloedverlies? | Ja | ||
Infectie | Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | ||
Afwijkende groei foetus | Small for gestational age fetus (disorder) (code = '267258002' in codeSystem '2.16.840.1.113883.6.96') | ||
Abruptio placentae? | Ja | ||
Maternale sterfte? | Nee | ||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.4.5 Bevalling
Bevalling | |||
Gegevenselement | Waarde | ||
Partusnummer | 000000 | ||
Diagnose bevalling | |||
Pprom? | Ja | ||
Verdenking foetale nood? | Ja | ||
Aantal geboren kinderen | 2 | ||
Risicostatus voor baring | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
Wijze waarop de baring begon | spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
Tijdstip begin actieve ontsluiting | 27 aug 2014 | ||
Bijstimulatie toegediend? | Ja | ||
Medicatie nageboortetijdperk groep | |||
Medicatie nageboortetijdperk? | Nee | ||
Placenta - geboorte placenta | controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
Hoeveelheid bloedverlies | 1740 ml | ||
Conditie perineum postpartum | Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96') |
1.4.6 Uitkomst per kind
Uitkomst per kind | |||||||
Gegevenselement | Waarde | ||||||
Baring | |||||||
Werkelijke plaats baring type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Ziekenhuis baring | |||||||
Ziekenhuisnummer lvrid | 9999 | ||||||
Demografische gegevens - geboortedatum | 28 aug 2014 | ||||||
Kindspecifieke maternale gegevens | |||||||
Tijdstip breken vliezen | 27 aug 2014 | ||||||
Kleur en consistentie vruchtwater | kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
Tijdstip actief meepersen | 27 aug 2014 | ||||||
Episiotomie? | Ja | ||||||
Locatie episiotomie | mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||||||
Ruggeprik gewenst niet gekregen? | Nee | ||||||
Pijnbestrijding? | Ja | ||||||
Pijnbestrijding | |||||||
Methode | |||||||
Methode | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||||||
Overig middel | |||||||
Middel | Administration of morphinomimetic analgesic (procedure) (code = '52685006:363701004=404642006' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Toediening | Administration of substance via intravenous route (procedure) (code = '431215000' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Periode | tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||||||
Sedatie? | Nee | ||||||
Kindspecifieke uitkomstgegevens | |||||||
Type partus | Assisted delivery of fetus (finding) (code = '8561000146109' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Apgarscore na 5 min | 7 | ||||||
Ligging bij geboorte | Face presentation (finding) (code = '21882006' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Aanpakker kind - rol aanpakker kind | arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||||||
Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||||||
Vaginale kunstverlossing groep | |||||||
Vaginale kunstverlossing | Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Succes vaginale kunstverlossing? | Ja | ||||||
Lichamelijk onderzoek kind - geboortegewicht | 2040 gram | ||||||
Congenitale afwijkingen? | Nee | ||||||
Problematiek kind? | Ja | ||||||
Problematiek kind | Birth trauma of fetus (disorder) (code = '56110009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Kinderarts betrokken? | Ja | ||||||
Betrokkenheid kinderarts | |||||||
Datum betrokkenheid | 28 aug 2014 | ||||||
Reden betrokkenheid | Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Type betrokkenheid | consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
Zorginstelling lvrid | 9999 |
1.4.7 Uitkomst per kind
Uitkomst per kind | |||||||
Gegevenselement | Waarde | ||||||
Baring | |||||||
Werkelijke plaats baring type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Ziekenhuis baring | |||||||
Ziekenhuisnummer lvrid | 9999 | ||||||
Demografische gegevens - geboortedatum | 28 aug 2014 | ||||||
Kindspecifieke maternale gegevens | |||||||
Tijdstip breken vliezen | 27 aug 2014 | ||||||
Kleur en consistentie vruchtwater | kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
Tijdstip actief meepersen | 28 aug 2014 | ||||||
Episiotomie? | Ja | ||||||
Locatie episiotomie | mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||||||
Ruggeprik gewenst niet gekregen? | Nee | ||||||
Pijnbestrijding? | Ja | ||||||
Pijnbestrijding | |||||||
Methode | |||||||
Methode | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||||||
Overig middel | |||||||
Middel | Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Toediening | Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Periode | tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||||||
Sedatie? | Nee | ||||||
Kindspecifieke uitkomstgegevens | |||||||
Type partus | Assisted delivery of fetus (finding) (code = '8561000146109' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Apgarscore na 5 min | 4 | ||||||
Ligging bij geboorte | Complete breech presentation (finding) (code = '49168004' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Aanpakker kind - rol aanpakker kind | arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||||||
Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||||||
Vaginale kunstverlossing groep | |||||||
Vaginale kunstverlossing | Total breech extraction (procedure) (code = '416055001' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Succes vaginale kunstverlossing? | Ja | ||||||
Overige interventies | Maneuvers for delivery in shoulder dystocia (procedure) (code = '237008007' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Lichamelijk onderzoek kind - geboortegewicht | 1580 gram | ||||||
Congenitale afwijkingen? | Ja | ||||||
Congenitale afwijkingen groep | |||||||
Specificatie congenitale afwijking groep | |||||||
Specificatie congenitale afwijking | Spina bifida occulta (disorder) (code = '76916001' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Specificatie congenitale afwijking groep | |||||||
Specificatie congenitale afwijking | Multiple congenital cardiac defects (disorder) (code = '94702005' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Chromosomale afwijkingen? | Nee | ||||||
Problematiek kind? | Ja | ||||||
Problematiek kind | Subdural intracranial hemorrhage due to birth trauma (disorder) (code = '126941005' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Kinderarts betrokken? | Ja | ||||||
Betrokkenheid kinderarts | |||||||
Datum betrokkenheid | 28 aug 2014 | ||||||
Reden betrokkenheid | Finding of neonatal condition (finding) (code = '364737004' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Type betrokkenheid | overdracht (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
Zorginstelling lvrid | 0001 |
1.4.8 Medisch onderzoek
Medisch onderzoek | |||
Gegevenselement | Waarde | ||
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
Irregulaire antistoffen? | Nee |
1.4.9 Postnatale fase
Postnatale fase | ||||
Gegevenselement | Waarde | |||
Kindspecifieke gegevens | ||||
Voeding kind groep | ||||
Voeding kind datum | 3 sep 2014 | |||
Substantie voeding kind | borstmelk (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
1.5 Scenario 4. 1e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 850810711 | |
Lokale persoonsidentificatie | * | |
Geboortedatum | 6 aug 1987 | |
Adres - postcode | 4589 BA | |
Etniciteit | Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 162 cm | |
Vrouwelijke genitale verminking? | Ja | |
Type vrouwelijke genitale verminking | Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96') |
1.5.1 Anamnese
Anamnese | |||
Gegevenselement | Waarde | ||
Onder behandeling geweest? | Ja | ||
Algemene anamnese | |||
Autoimmuun aandoening? | Ja | ||
Autoimmuun aandoening | Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96') | ||
Urogenitale aandoening? | Ja | ||
Urogenitale aandoening | Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96') | ||
Diabetes mellitus? | Ja | ||
Mdl aandoening? | Ja | ||
Mdl aandoening | Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96') | ||
Longaandoening? | Ja | ||
Longaandoening | Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96') | ||
Operatie? | Ja | ||
Type operatie | Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96') | ||
Type operatie | Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96') | ||
Type operatie | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') |
1.5.2 Zorgverlening
Zorgverlening | ||||
Gegevenselement | Waarde | |||
Datum start zorgverantwoordelijkheid | 7 aug 2014 | |||
Datum einde zorgverantwoordelijkheid | 15 sep 2014 | |||
Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
Eindverantwoordelijk in welke perinatale periode? | follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
Conclusie risicostatus na intake | 3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | |||
Zorgverzoekdetails | ||||
Overname van zorginstelling | ||||
Overname van zorginstelling id | 0010 | |||
Redenen van overname | ||||
Reden van overname lijst prn | Uitbesteding zorg 2e lijn overige redenen (code = '8240' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.1') | |||
Reden van overname lijst prn | Overige niet medische indicaties vrouw en kind (code = '8499' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.1') | |||
Is er sprake van overdracht aan? | Nee |
1.5.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | ||
Gegevenselement | Waarde | |
Zorginstelling lvrid | 1410 |
1.5.4 Zwangerschap
Zwangerschap | ||
Gegevenselement | Waarde | |
Graviditeit | 1 | |
Pariteit voor deze zwangerschap | 0 | |
Definitieve a terme datum | 18 aug 2014 | |
Maternale sterfte? | Ja | |
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.5.5 Bevalling
Bevalling | |||
Gegevenselement | Waarde | ||
Aantal geboren kinderen | 1 | ||
Risicostatus voor baring | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
Wijze waarop de baring begon | spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
Tijdstip begin actieve ontsluiting | 3 aug 2014 | ||
Bijstimulatie toegediend? | Nee | ||
Medicatie nageboortetijdperk groep | |||
Medicatie nageboortetijdperk? | Ja | ||
Soort medicatie nageboortetijdperk | Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') | ||
Placenta - geboorte placenta | spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
Hoeveelheid bloedverlies | 1120 ml | ||
Conditie perineum postpartum | Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') |
1.5.6 Uitkomst per kind
Uitkomst per kind | |||||||
Gegevenselement | Waarde | ||||||
Baring | |||||||
Werkelijke plaats baring type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Ziekenhuis baring | |||||||
Ziekenhuisnummer lvrid | 0010 | ||||||
Demografische gegevens - geboortedatum | 4 aug 2014 | ||||||
Kindspecifieke maternale gegevens | |||||||
Tijdstip breken vliezen | 3 aug 2014 | ||||||
Kleur en consistentie vruchtwater | bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
Tijdstip actief meepersen | 4 aug 2014 | ||||||
Episiotomie? | Ja | ||||||
Locatie episiotomie | mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||||||
Ruggeprik gewenst niet gekregen? | Nee | ||||||
Pijnbestrijding? | Ja | ||||||
Pijnbestrijding | |||||||
Methode | |||||||
Methode | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||||||
Overig middel | |||||||
Middel | Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Toediening | Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Periode | tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||||||
Sedatie? | Nee | ||||||
Kindspecifieke uitkomstgegevens | |||||||
Type partus | Assisted delivery of fetus (finding) (code = '8561000146109' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Apgarscore na 5 min | 9 | ||||||
Ligging bij geboorte | Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Aanpakker kind - rol aanpakker kind | co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||||||
Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||||||
Vaginale kunstverlossing groep | |||||||
Vaginale kunstverlossing | Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Succes vaginale kunstverlossing? | Ja | ||||||
Lichamelijk onderzoek kind - geboortegewicht | 4205 gram | ||||||
Congenitale afwijkingen? | Nee | ||||||
Problematiek kind? | Nee | ||||||
Kinderarts betrokken? | Ja | ||||||
Betrokkenheid kinderarts | |||||||
Datum betrokkenheid | 4 aug 2014 | ||||||
Reden betrokkenheid | Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Type betrokkenheid | consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
Zorginstelling lvrid | 0010 |
1.5.7 Postnatale fase
Postnatale fase | ||||
Gegevenselement | Waarde | |||
Diagnose postpartum | ||||
Datum | 8 aug 2014 | |||
Pathologie vrouw? | Ja | |||
Pathologie vrouw | Embolism (disorder) (code = '414086009' in codeSystem '2.16.840.1.113883.6.96') | |||
Diagnose postpartum | ||||
Datum | 8 aug 2014 | |||
Pathologie vrouw? | Ja | |||
Pathologie vrouw | Episiotomy infection (disorder) (code = '300927001' in codeSystem '2.16.840.1.113883.6.96') | |||
Kindspecifieke gegevens | ||||
Voeding kind groep | ||||
Voeding kind datum | 15 sep 2014 | |||
Substantie voeding kind | kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
1.6 Scenario 4. 2e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 850810711 | |
Lokale persoonsidentificatie | * | |
Geboortedatum | 6 aug 1987 | |
Adres - postcode | 4589 BA | |
Etniciteit | Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 162 cm | |
Vrouwelijke genitale verminking? | Ja | |
Type vrouwelijke genitale verminking | Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96') |
1.6.1 Anamnese
Anamnese | |||
Gegevenselement | Waarde | ||
Onder behandeling geweest? | Ja | ||
Algemene anamnese | |||
Autoimmuun aandoening? | Ja | ||
Autoimmuun aandoening | Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96') | ||
Urogenitale aandoening? | Ja | ||
Urogenitale aandoening | Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96') | ||
Diabetes mellitus? | Ja | ||
Mdl aandoening? | Ja | ||
Mdl aandoening | Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96') | ||
Longaandoening? | Ja | ||
Longaandoening | Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96') | ||
Operatie? | Ja | ||
Type operatie | Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96') | ||
Type operatie | Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96') | ||
Type operatie | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') |
1.6.2 Zorgverlening
Zorgverlening | ||||
Gegevenselement | Waarde | |||
Datum start zorgverantwoordelijkheid | 3 feb 2014 | |||
Datum einde zorgverantwoordelijkheid | 6 aug 2014 | |||
Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |||
Conclusie risicostatus na intake | 3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | |||
Is er sprake van overdracht aan? | Ja | |||
Overdrachtdetails | ||||
Datum van overdracht | 6 aug 2014 | |||
Overdracht aan zorginstelling id | 1410 | |||
Perinatale periode van overdracht | 2e t/m 7e dag (code = '92' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') | |||
Redenen van overdracht aan | ||||
Reden overdracht aan lijst prn | anders (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') |
1.6.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | ||
Gegevenselement | Waarde | |
Zorginstelling lvrid | 0010 |
1.6.4 Zwangerschap
Zwangerschap | |||
Gegevenselement | Waarde | ||
Graviditeit | 1 | ||
Pariteit voor deze zwangerschap | 0 | ||
Definitieve a terme datum | 18 aug 2014 | ||
Voornemens | |||
Voorgenomen plaats baring tijdens zwangerschap type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||
Prenatale controle | |||
Datum controle | 7 mei 2014 | ||
Zwangerschapsduur | 149 dagen | ||
Leven voelen | Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96') | ||
Rookgedrag | niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
Drugsgebruik? | Nee | ||
Gewicht gemeten | 82 kg | ||
Diagnose | |||
Datum | 7 mei 2014 | ||
Zwangerschapsduur | 149 dagen | ||
Infectie | Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | ||
Maternale sterfte? | Nee | ||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.6.5 Bevalling
Bevalling | |||
Gegevenselement | Waarde | ||
Diagnose bevalling | |||
Niet vorderende ontsluiting? | Ja | ||
Niet vorderende uitdrijving? | Ja | ||
Aantal geboren kinderen | 1 | ||
Risicostatus voor baring | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
Wijze waarop de baring begon | spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
Tijdstip begin actieve ontsluiting | 3 aug 2014 | ||
Bijstimulatie toegediend? | Nee | ||
Medicatie nageboortetijdperk groep | |||
Medicatie nageboortetijdperk? | Ja | ||
Soort medicatie nageboortetijdperk | Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') | ||
Placenta - geboorte placenta | spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
Hoeveelheid bloedverlies | 1120 ml | ||
Conditie perineum postpartum | Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') |
1.6.6 Uitkomst per kind
Uitkomst per kind | |||||||
Gegevenselement | Waarde | ||||||
Baring | |||||||
Werkelijke plaats baring type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Ziekenhuis baring | |||||||
Ziekenhuisnummer lvrid | 0010 | ||||||
Demografische gegevens - geboortedatum | 4 aug 2014 | ||||||
Kindspecifieke maternale gegevens | |||||||
Tijdstip breken vliezen | 3 aug 2014 | ||||||
Kleur en consistentie vruchtwater | bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
Tijdstip actief meepersen | 4 aug 2014 | ||||||
Episiotomie? | Ja | ||||||
Locatie episiotomie | mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||||||
Ruggeprik gewenst niet gekregen? | Nee | ||||||
Pijnbestrijding? | Ja | ||||||
Pijnbestrijding | |||||||
Methode | |||||||
Methode | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||||||
Overig middel | |||||||
Middel | Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Toediening | Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Periode | tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||||||
Sedatie? | Nee | ||||||
Kindspecifieke uitkomstgegevens | |||||||
Type partus | Assisted delivery of fetus (finding) (code = '8561000146109' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Apgarscore na 5 min | 9 | ||||||
Ligging bij geboorte | Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Aanpakker kind - rol aanpakker kind | co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | ||||||
Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||||||
Vaginale kunstverlossing groep | |||||||
Vaginale kunstverlossing | Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Succes vaginale kunstverlossing? | Ja | ||||||
Lichamelijk onderzoek kind - geboortegewicht | 4205 gram | ||||||
Congenitale afwijkingen? | Nee | ||||||
Problematiek kind? | Nee | ||||||
Kinderarts betrokken? | Ja | ||||||
Betrokkenheid kinderarts | |||||||
Datum betrokkenheid | 4 aug 2014 | ||||||
Reden betrokkenheid | Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') | ||||||
Type betrokkenheid | consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
Zorginstelling lvrid | 0010 |
1.6.7 Medisch onderzoek
Medisch onderzoek | |||
Gegevenselement | Waarde | ||
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
Irregulaire antistoffen? | Nee |
1.7 Scenario 5. zorg volledig 2e lijn, vrouw overleden (voor vrouw met BSN: 912345676)
Vrouw | ||
Gegevenselement | Waarde | |
Burgerservicenummer | 912345676 | |
Lokale persoonsidentificatie | * | |
Geboortedatum | 4 mrt 1993 | |
Adres - postcode | 9562 GF | |
Etniciteit | Latijns Amerikaans (code = '14' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
Lengte gemeten | 186 cm |
1.7.1 Anamnese
Anamnese | |||
Gegevenselement | Waarde | ||
Onder behandeling geweest? | Ja | ||
Algemene anamnese | |||
Cardiovasculaire aandoening? | Ja | ||
Cardiovasculaire aandoening | Hypertensive disorder, systemic arterial (disorder) (code = '38341003' in codeSystem '2.16.840.1.113883.6.96') | ||
Diabetes mellitus? | Ja | ||
Neurologische aandoening? | Ja | ||
Neurologische aandoening | Epilepsy (disorder) (code = '84757009' in codeSystem '2.16.840.1.113883.6.96') | ||
Longaandoening? | Ja | ||
Longaandoening | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
Orthopedische afwijking? | Ja | ||
Orthopedische afwijking | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
Stollingsprobleem? | Ja | ||
Type stollingsprobleem | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
Psychiatrie? | Ja |
1.7.2 Zorgverlening
Zorgverlening | ||
Gegevenselement | Waarde | |
Datum start zorgverantwoordelijkheid | 9 dec 2013 | |
Datum einde zorgverantwoordelijkheid | 4 aug 2014 | |
Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Eindverantwoordelijk in welke perinatale periode? | follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | |
Conclusie risicostatus na intake | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | |
Is er sprake van overdracht aan? | Nee |
1.7.3 Zorgverlenerzorginstelling
Zorgverlenerzorginstelling | ||
Gegevenselement | Waarde | |
Zorginstelling lvrid | 0179 |
1.7.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||||
Gegevenselement | Waarde | ||||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||||
Definitieve a terme datum | 5 jun 2012 | ||||
Diagnose | |||||
Infectie | Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | ||||
Zwangerschapscholestase? | Ja | ||||
Afwijkende groei foetus | Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | ||||
Irregulaire antistoffen? | Ja | ||||
Eerdere bevalling | |||||
Placenta - geboorte placenta | spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||||
Vorige uitkomst per kind - vorige baring | |||||
Demografische gegevens - geboortedatum | 9 jun 2012 | ||||
Kindspecifieke gegevens vorige uitkomsten | |||||
Type partus | Assisted delivery of fetus (finding) (code = '8561000146109' in codeSystem '2.16.840.1.113883.6.96') | ||||
Percentiel van het geboortegewicht | 10 ≤ P < 50 (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.50') | ||||
Apgarscore na 5 min | 10 | ||||
Congenitale afwijkingen? | Nee |
1.7.5 Zwangerschap
Zwangerschap | |||
Gegevenselement | Waarde | ||
Graviditeit | 2 | ||
Pariteit voor deze zwangerschap | 1 | ||
Definitieve a terme datum | 22 jul 2014 | ||
Voornemens | |||
Voorgenomen plaats baring tijdens zwangerschap type locatie | Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | ||
Prenatale controle | |||
Datum controle | 9 jan 2014 | ||
Zwangerschapsduur | 86 dagen | ||
Leven voelen | Fetal movements absent (context-dependent category) (code = '289432001' in codeSystem '2.16.840.1.113883.6.96') | ||
Rookgedrag | gestopt tijdens huidige zwangerschap (code = '6' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
Drugsgebruik? | Ja | ||
Gewicht gemeten | 89 kg | ||
Diagnose | |||
Datum | 9 jan 2014 | ||
Zwangerschapsduur | 86 dagen | ||
Afwijkende groei foetus | Large-for-dates fetus (disorder) (code = '199616008' in codeSystem '2.16.840.1.113883.6.96') | ||
Abruptio placentae? | Ja | ||
Intrauteriene behandeling | Selective destruction of fetus (procedure) (code = '265633004' in codeSystem '2.16.840.1.113883.6.96') | ||
Maternale sterfte? | Ja | ||
Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
1.7.6 Bevalling
Bevalling | |||
Gegevenselement | Waarde | ||
Partusnummer | 000000 | ||
Aantal geboren kinderen | 1 | ||
Risicostatus voor baring | 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
Wijze waarop de baring begon | interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
Interventies begin baring groep | |||
Interventie begin baring | Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96') | ||
Indicatie interventie begin baring | acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | ||
Bijstimulatie toegediend? | Nee | ||
Medicatie nageboortetijdperk groep | |||
Medicatie nageboortetijdperk? | Nee | ||
Placenta - geboorte placenta | placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
Hoeveelheid bloedverlies | 1500 ml | ||
Conditie perineum postpartum | Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') |
1.7.7 Uitkomst per kind
Uitkomst per kind | ||||||
Gegevenselement | Waarde | |||||
Baring | ||||||
Werkelijke plaats baring type locatie | Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | |||||
Ziekenhuis baring | ||||||
Ziekenhuisnummer lvrid | 0179 | |||||
Demografische gegevens - geboortedatum | 24 jul 2014 | |||||
Kindspecifieke maternale gegevens | ||||||
Kleur en consistentie vruchtwater | meconium (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | |||||
Episiotomie? | Nee | |||||
Ruggeprik gewenst niet gekregen? | Nee | |||||
Pijnbestrijding? | Ja | |||||
Pijnbestrijding | ||||||
Methode | ||||||
Methode | General anesthesia (procedure) (code = '50697003' in codeSystem '2.16.840.1.113883.6.96') | |||||
Periode | tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | |||||
Sedatie? | Ja | |||||
Kindspecifieke uitkomstgegevens | ||||||
Type partus | Delivery by emergency cesarean section (finding) (code = '200149009' in codeSystem '2.16.840.1.113883.6.96') | |||||
Apgarscore na 5 min | 9 | |||||
Ligging bij geboorte | Onbekend (code = 'UNK' in codeSystem '2.16.840.1.113883.5.1008') | |||||
Aanpakker kind - rol aanpakker kind | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | |||||
Supervisor - rol supervisor | gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | |||||
Vaginale kunstverlossing groep | ||||||
Vaginale kunstverlossing | Delivery by vacuum extraction (procedure) (code = '61586001' in codeSystem '2.16.840.1.113883.6.96') | |||||
Succes vaginale kunstverlossing? | Nee | |||||
Sectio caesarea group | ||||||
Beslismoment sectio caesarea | tijdens uitdrijving besloten (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.5') | |||||
Indicatie sectio caesarea | Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') | |||||
Lichamelijk onderzoek kind - geboortegewicht | 3750 gram | |||||
Congenitale afwijkingen? | Ja | |||||
Congenitale afwijkingen groep | ||||||
Specificatie congenitale afwijking groep | ||||||
Chromosomale afwijkingen? | Ja | |||||
Specificatie chromosomale afwijking groep | ||||||
Specificatie chromosomale afwijking | Complete trisomy 21 syndrome (disorder) (code = '41040004' in codeSystem '2.16.840.1.113883.6.96') | |||||
Problematiek kind? | Ja | |||||
Problematiek kind | Congenital hearing disorder (disorder) (code = '95827002' in codeSystem '2.16.840.1.113883.6.96') | |||||
Kinderarts betrokken? | Nee |
1.7.8 Medisch onderzoek
Medisch onderzoek | |||
Gegevenselement | Waarde | ||
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
Irregulaire antistoffen? | Ja | ||
Welke irregulaire antistoffen vrouw aanwezig | Kell (code = '405844003' in codeSystem '2.16.840.1.113883.6.96') |
1.7.9 Postnatale fase
Postnatale fase | ||||
Gegevenselement | Waarde | |||
Diagnose postpartum | ||||
Datum | 24 jul 2014 | |||
Pathologie vrouw? | Ja | |||
Pathologie vrouw | Postpartum deep phlebothrombosis (disorder) (code = '56272000' in codeSystem '2.16.840.1.113883.6.96') | |||
Kindspecifieke gegevens | ||||
Voeding kind groep | ||||
Voeding kind datum | 24 jul 2014 | |||
Substantie voeding kind | kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |