Gebz:Vdraft AddendaKwalificatieKernsetGeboortezorg23 Dekkingsgraad: verschil tussen versies
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| Regel 24: | Regel 24: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Burgerservicenummer | |colspan="2"|Burgerservicenummer | ||
|style="background-color: white;"|999910413 | |style="background-color: white;"|999910413 - 961921821 - 895623146 - 850810711 - 912345676 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lokale persoonsidentificatie | |colspan="2"|Lokale persoonsidentificatie | ||
|style="background-color: white;"|000000 | |style="background-color: white;"|000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) - * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Geboortedatum | |colspan="2"|Geboortedatum | ||
|style="background-color: white;"|2 mei 1976 | |style="background-color: white;"|2 mei 1976 - 11 sep 1974 - 5 aug 1985 - 6 aug 1987 - 4 mrt 1993 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Adres - postcode | |colspan="2"|Adres - postcode | ||
|style="background-color: white;"|4563 AB | |style="background-color: white;"|4563 AB - 5689 CZ - 5421 JG - 4589 BA - 9562 GF | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Etniciteit | |colspan="2"|Etniciteit | ||
|style="background-color: white;"|Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28') - Kaukasisch (code = '12 | |style="background-color: white;"|Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28') - Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') - Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') - Latijns Amerikaans (code = '14' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lengte gemeten | |colspan="2"|Lengte gemeten | ||
|style="background-color: white;"|170 | |style="background-color: white;"|170 cm - 184 cm - 167 cm - 162 cm - 186 cm | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Vrouwelijke genitale verminking? | |colspan="2"|Vrouwelijke genitale verminking? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Type vrouwelijke genitale verminking | |colspan="2"|Type vrouwelijke genitale verminking | ||
|style="background-color: white;"|Female genital mutilation type 2 (disorder) (code = '130621000119105 | |style="background-color: white;"|Female genital mutilation type 2 (disorder) (code = '130621000119105' in codeSystem '2.16.840.1.113883.6.96') - Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 /> | |}<section end=999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 /> | ||
=== Anamnese === | === Anamnese === | ||
| Regel 57: | Regel 57: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Onder behandeling geweest? | |colspan="3"|Onder behandeling geweest? | ||
|style="background-color: white;"|Ja - Nee | |style="background-color: white;"|Ja - Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Algemene anamnese | |colspan="4"|Algemene anamnese | ||
| Regel 64: | Regel 64: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Autoimmuun aandoening | |colspan="2"|Autoimmuun aandoening | ||
|style="background-color: white;"| | |style="background-color: white;"|Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Cardiovasculaire aandoening | |colspan="2"|Cardiovasculaire aandoening | ||
| Regel 70: | Regel 70: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Urogenitale aandoening | |colspan="2"|Urogenitale aandoening | ||
|style="background-color: white;"| | |style="background-color: white;"|Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Oncologische aandoening | |colspan="2"|Oncologische aandoening | ||
| Regel 79: | Regel 79: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Diabetes mellitus? | |colspan="2"|Diabetes mellitus? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Neurologische aandoening | |colspan="2"|Neurologische aandoening | ||
| Regel 88: | Regel 88: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Mdl aandoening | |colspan="2"|Mdl aandoening | ||
|style="background-color: white;"| | |style="background-color: white;"|Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Anemie | |colspan="2"|Anemie | ||
| Regel 94: | Regel 94: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Longaandoening | |colspan="2"|Longaandoening | ||
|style="background-color: white;"| | |style="background-color: white;"|Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96') - Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Gynaecologische aandoening | |colspan="2"|Gynaecologische aandoening | ||
| Regel 109: | Regel 109: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Type operatie | |colspan="2"|Type operatie | ||
|style="background-color: white;"|Orthopedisch (code = '112697007' in codeSystem 'Snomed CT') - Operation on heart (procedure) (code = '64915003 | |style="background-color: white;"|Orthopedisch (code = '112697007' in codeSystem 'Snomed CT') - Operation on heart (procedure) (code = '64915003' in codeSystem '2.16.840.1.113883.6.96') - Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96') - Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Type stollingsprobleem | |colspan="2"|Type stollingsprobleem | ||
| Regel 139: | Regel 139: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Eindverantwoordelijk in welke perinatale periode? | |colspan="7"|Eindverantwoordelijk in welke perinatale periode? | ||
|style="background-color: white;"| | |style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Conclusie risicostatus na intake | |colspan="7"|Conclusie risicostatus na intake | ||
|style="background-color: white;"| | |style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') - 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') - 3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="8"|Verwijsdetails | |colspan="8"|Verwijsdetails | ||
| Regel 160: | Regel 160: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorgaanbieder identificatie nummer | |colspan="4"|Zorgaanbieder identificatie nummer | ||
|style="background-color: white;"|1504 | |style="background-color: white;"|1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Specialisme | |colspan="4"|Specialisme | ||
| Regel 174: | Regel 174: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorgaanbieder identificatie nummer | |colspan="4"|Zorgaanbieder identificatie nummer | ||
|style="background-color: white;"|0003 | |style="background-color: white;"|0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Specialisme | |colspan="4"|Specialisme | ||
| Regel 445: | Regel 445: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Wijze einde zwangerschap | |colspan="7"|Wijze einde zwangerschap | ||
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Miskraam (code = '2 | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Definitieve a terme datum | |colspan="7"|Definitieve a terme datum | ||
|style="background-color: white;"|1 dec 2011 | |style="background-color: white;"|1 dec 2011 - 5 jun 2013 - 5 jun 2012 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="8"|Diagnose | |colspan="8"|Diagnose | ||
| Regel 458: | Regel 458: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Bloedverlies? | |colspan="6"|Bloedverlies? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Cervixinsufficientie? | |colspan="6"|Cervixinsufficientie? | ||
| Regel 467: | Regel 467: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Hyperemesis gravidarum? | |colspan="6"|Hyperemesis gravidarum? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Hypertensieve aandoening | |colspan="6"|Hypertensieve aandoening | ||
| Regel 491: | Regel 491: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Irregulaire antistoffen? | |colspan="7"|Irregulaire antistoffen? | ||
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee - Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="8"|Eerdere bevalling | |colspan="8"|Eerdere bevalling | ||
| Regel 502: | Regel 502: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Geboorte placenta | |colspan="5"|Geboorte placenta | ||
|style="background-color: white;"|Spontaan | |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="6"|Hoeveelheid bloedverlies | |colspan="6"|Hoeveelheid bloedverlies | ||
| Regel 532: | Regel 532: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Congenitale afwijkingen? | |colspan="3"|Congenitale afwijkingen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Congenitale afwijkingen groep | |colspan="4"|Congenitale afwijkingen groep | ||
| Regel 551: | Regel 551: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Graviditeit | |colspan="4"|Graviditeit | ||
|style="background-color: white;"| | |style="background-color: white;"|2 - 1 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Pariteit voor deze zwangerschap | |colspan="4"|Pariteit voor deze zwangerschap | ||
|style="background-color: white;"|1 - 0 | |style="background-color: white;"|1 - 0 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Definitieve a terme datum | |colspan="4"|Definitieve a terme datum | ||
|style="background-color: white;"|9 okt | |style="background-color: white;"|9 okt 2014 - 8 sep 2014 - 22 sep 2014 - 18 aug 2014 - 22 jul 2014 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Voornemens | |colspan="5"|Voornemens | ||
| Regel 564: | Regel 564: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Voorgenomen plaats baring tijdens zwangerschap type locatie | |colspan="3"|Voorgenomen plaats baring tijdens zwangerschap type locatie | ||
|style="background-color: white;"|Thuis (code = '169813005' in codeSystem '2.16.840.1.113883.6.96') - Nog niet bepaald (code = '05' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7 | |style="background-color: white;"|Thuis (code = '169813005' in codeSystem '2.16.840.1.113883.6.96') - Nog niet bepaald (code = '05' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - 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="5"|Prenatale controle | |colspan="5"|Prenatale controle | ||
| Regel 577: | Regel 577: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Leven voelen | |colspan="3"|Leven voelen | ||
|style="background-color: white;"|goed (code = '289431008' in codeSystem 'Snomed CT') - Weak fetal movements (finding) (code = '276372004' in codeSystem '2.16.840.1.113883.6.96') - Reduced fetal movement (finding) (code = '276369006 | |style="background-color: white;"|goed (code = '289431008' in codeSystem 'Snomed CT') - Weak fetal movements (finding) (code = '276372004' in codeSystem '2.16.840.1.113883.6.96') - Reduced fetal movement (finding) (code = '276369006' in codeSystem '2.16.840.1.113883.6.96') - Fetal movements absent (context-dependent category) (code = '289432001' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Rookgedrag | |colspan="3"|Rookgedrag | ||
|style="background-color: white;"|niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - gestopt vóór huidige zwangerschap (code = '5 | |style="background-color: white;"|niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - gestopt tijdens huidige zwangerschap (code = '6' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Alcoholgebruik | |colspan="3"|Alcoholgebruik | ||
|style="background-color: white;"| | |style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Drugsgebruik? | |colspan="3"|Drugsgebruik? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee - Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Gewicht gemeten | |colspan="3"|Gewicht gemeten | ||
|style="background-color: white;"|70 | |style="background-color: white;"|70 kg - 85 kg - 67 kg - 82 kg - 89 kg | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Diagnose | |colspan="5"|Diagnose | ||
| Regel 614: | Regel 614: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Infectie | |colspan="3"|Infectie | ||
|style="background-color: white;"|Urineweg infectie (code = '307534009' in codeSystem 'Snomed CT | |style="background-color: white;"|Urineweg infectie (code = '307534009' in codeSystem 'Snomed CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Hyperemesis gravidarum? | |colspan="3"|Hyperemesis gravidarum? | ||
| Regel 638: | Regel 638: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Abruptio placentae? | |colspan="3"|Abruptio placentae? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Navelstrengprolaps? | |colspan="3"|Navelstrengprolaps? | ||
| Regel 660: | Regel 660: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Maternale sterfte? | |colspan="4"|Maternale sterfte? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee - Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Wijze einde zwangerschap | |colspan="4"|Wijze einde zwangerschap | ||
|style="background-color: white;"| | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||
|}<section end=zwangerschap_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 /> | |}<section end=zwangerschap_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 /> | ||
=== Bevalling === | === Bevalling === | ||
| Regel 675: | Regel 675: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Partusnummer | |colspan="4"|Partusnummer | ||
|style="background-color: white;"| | |style="background-color: white;"|000000 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Diagnose bevalling | |colspan="5"|Diagnose bevalling | ||
| Regel 716: | Regel 716: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Aantal geboren kinderen | |colspan="4"|Aantal geboren kinderen | ||
|style="background-color: white;"| | |style="background-color: white;"|1 - 2 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Risicostatus voor baring | |colspan="4"|Risicostatus voor baring | ||
|style="background-color: white;"|1e lijn (VIL A) (code = '1 | |style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') - 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Interventies begin baring | |colspan="5"|Interventies begin baring | ||
| Regel 726: | Regel 726: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Interventie begin baring | |colspan="3"|Interventie begin baring | ||
|style="background-color: white;"|Strippen (code = '236960006' in codeSystem 'Snomed CT | |style="background-color: white;"|Strippen (code = '236960006' in codeSystem 'Snomed CT') - Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Indicatie interventie begin baring | |colspan="3"|Indicatie interventie begin baring | ||
|style="background-color: white;"|wens patiënt (code = '7 | |style="background-color: white;"|wens patiënt (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') - acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Wijze waarop de baring begon | |colspan="4"|Wijze waarop de baring begon | ||
|style="background-color: white;"|Interventie om baring op gang te brengen (code = '3 | |style="background-color: white;"|Interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') - spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Tijdstip begin actieve ontsluiting | |colspan="4"|Tijdstip begin actieve ontsluiting | ||
|style="background-color: white;"|8 okt 2014 14:30 - 30 aug 2014 14:09 - 27 aug 2014 22 | |style="background-color: white;"|8 okt 2014 14:30 - 30 aug 2014 14:09 - 27 aug 2014 22:09 - 3 aug 2014 21:09 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Medicatie nageboortetijdperk groep | |colspan="5"|Medicatie nageboortetijdperk groep | ||
| Regel 742: | Regel 742: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Medicatie nageboortetijdperk? | |colspan="3"|Medicatie nageboortetijdperk? | ||
|style="background-color: white;"|Ja - UNK | |style="background-color: white;"|Ja - UNK - Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Soort medicatie nageboortetijdperk | |colspan="3"|Soort medicatie nageboortetijdperk | ||
|style="background-color: white;"|Oxytocine (code = 'H01BB02 | |style="background-color: white;"|Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') - 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="5"|Placenta | |colspan="5"|Placenta | ||
| Regel 752: | Regel 752: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Geboorte placenta | |colspan="3"|Geboorte placenta | ||
|style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - controlled cord traction (code = '2 | |style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Hoeveelheid bloedverlies | |colspan="4"|Hoeveelheid bloedverlies | ||
|style="background-color: white;"|615 ml - 980 ml - 1740 | |style="background-color: white;"|615 ml - 980 ml - 1740 ml - 1120 ml - 1500 ml | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Conditie perineum postpartum | |colspan="4"|Conditie perineum postpartum | ||
|style="background-color: white;"|1e graads perineumruptuur (code = '199916005' in codeSystem 'Snomed CT') - Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') - Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96') - Third degree perineal tear during delivery - delivered (disorder) (code = '199930000 | |style="background-color: white;"|1e graads perineumruptuur (code = '199916005' in codeSystem 'Snomed CT') - Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') - Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96') - Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') | ||
|}<section end=bevalling_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 /> | |}<section end=bevalling_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 /> | ||
=== Uitkomst per kind === | === Uitkomst per kind === | ||
| Regel 774: | Regel 774: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Werkelijke plaats baring type locatie | |colspan="6"|Werkelijke plaats baring type locatie | ||
|style="background-color: white;"|Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7 | |style="background-color: white;"|Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Ziekenhuis baring | |colspan="7"|Ziekenhuis baring | ||
| Regel 781: | Regel 781: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Ziekenhuisnummer lvrid | |colspan="5"|Ziekenhuisnummer lvrid | ||
|style="background-color: white;"|0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 9999 | |style="background-color: white;"|0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Demografische gegevens | |colspan="7"|Demografische gegevens | ||
| Regel 792: | Regel 792: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Bsn kind | |colspan="4"|Bsn kind | ||
|style="background-color: white;"|999910383 - 951847624 - 847035116 - 847035128 | |style="background-color: white;"|999910383 - 951847624 - 847035116 - 847035128 - 840736526 - 528741913 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Geslacht medische observatie | |colspan="5"|Geslacht medische observatie | ||
|style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') - mannelijk (code = '1 | |style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') - mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21') - twijfelachtig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Geboortedatum | |colspan="5"|Geboortedatum | ||
|style="background-color: white;"|8 okt 2014 00:00 - 1 sep 2014 02:34 - 28 aug 2014 06:30 - 28 aug 2014 07:02 | |style="background-color: white;"|8 okt 2014 00:00 - 1 sep 2014 02:34 - 28 aug 2014 06:30 - 28 aug 2014 07:02 - 4 aug 2014 23:35 - 24 jul 2014 02:30 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Rangnummer kind | |colspan="5"|Rangnummer kind | ||
|style="background-color: white;"| | |style="background-color: white;"|1 - 2 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Perinatale sterfte groep | |colspan="6"|Perinatale sterfte groep | ||
| Regel 808: | Regel 808: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Perinatale sterfte? | |colspan="4"|Perinatale sterfte? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee - Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Fase perinatale sterfte | |colspan="4"|Fase perinatale sterfte | ||
| Regel 824: | Regel 824: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Tijdstip breken vliezen | |colspan="5"|Tijdstip breken vliezen | ||
|style="background-color: white;"|8 okt 2014 09:15 - 30 aug 2014 23:04 - 27 aug 2014 22:09 - 27 aug 2014 23:13 | |style="background-color: white;"|8 okt 2014 09:15 - 30 aug 2014 23:04 - 27 aug 2014 22:09 - 27 aug 2014 23:13 - 3 aug 2014 07:04 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Kleur en consistentie vruchtwater | |colspan="5"|Kleur en consistentie vruchtwater | ||
|style="background-color: white;"|Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') - geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008 | |style="background-color: white;"|Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') - geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') - bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18') - meconium (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Tijdstip actief meepersen | |colspan="5"|Tijdstip actief meepersen | ||
|style="background-color: white;"|8 okt 2014 12:13 - 27 aug 2014 23:49 - 28 aug 2014 06:45 | |style="background-color: white;"|8 okt 2014 12:13 - 27 aug 2014 23:49 - 28 aug 2014 06:45 - 4 aug 2014 22:15 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Episiotomie? | |colspan="5"|Episiotomie? | ||
|style="background-color: white;"|Nee - Ja | |style="background-color: white;"|Nee - Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Indicatie episiotomie | |colspan="5"|Indicatie episiotomie | ||
| Regel 839: | Regel 839: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Locatie episiotomie | |colspan="5"|Locatie episiotomie | ||
|style="background-color: white;"| | |style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Ruggeprik gewenst niet gekregen? | |colspan="5"|Ruggeprik gewenst niet gekregen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Pijnbestrijding? | |colspan="5"|Pijnbestrijding? | ||
|style="background-color: white;"|Nee | |style="background-color: white;"|Nee - Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Pijnbestrijding | |colspan="6"|Pijnbestrijding | ||
| Regel 856: | Regel 856: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Methode | |colspan="3"|Methode | ||
|style="background-color: white;"|Epidural anesthesia (procedure) (code = '18946005' in codeSystem '2.16.840.1.113883.6.96 | |style="background-color: white;"|Epidural anesthesia (procedure) (code = '18946005' in codeSystem '2.16.840.1.113883.6.96') - Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - General anesthesia (procedure) (code = '50697003' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Overig middel | |colspan="4"|Overig middel | ||
| Regel 863: | Regel 863: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Middel | |colspan="2"|Middel | ||
|style="background-color: white;"|Administration of morphinomimetic analgesic (procedure) (code = '52685006:363701004=404642006 | |style="background-color: white;"|Administration of morphinomimetic analgesic (procedure) (code = '52685006:363701004=404642006' in codeSystem '2.16.840.1.113883.6.96') - Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' 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"|Toediening | |colspan="2"|Toediening | ||
|style="background-color: white;"|Administration of substance via intravenous route (procedure) (code = '431215000 | |style="background-color: white;"|Administration of substance via intravenous route (procedure) (code = '431215000' in codeSystem '2.16.840.1.113883.6.96') - Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Periode | |colspan="4"|Periode | ||
|style="background-color: white;"|tijdens sectio (code = 'Sectio | |style="background-color: white;"|tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Sedatie? | |colspan="5"|Sedatie? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee - Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Kindspecifieke uitkomstgegevens | |colspan="7"|Kindspecifieke uitkomstgegevens | ||
| Regel 879: | Regel 879: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Type partus | |colspan="5"|Type partus | ||
|style="background-color: white;"|Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT') - Cesarean section (procedure) (code = '11466000 | |style="background-color: white;"|Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT') - Cesarean section (procedure) (code = '11466000' in codeSystem 'SNOMED CT') - Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') - Emergency cesarian section (procedure) (code = '274130007' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Ligging bij geboorte | |colspan="5"|Ligging bij geboorte | ||
|style="background-color: white;"|Achterhoofd-achter (code = '37235006' in codeSystem 'Snomed CT') - Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') - Face presentation (finding) (code = '21882006' in codeSystem '2.16.840.1.113883.6.96') - Complete breech presentation (finding) (code = '49168004 | |style="background-color: white;"|Achterhoofd-achter (code = '37235006' in codeSystem 'Snomed CT') - Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') - Face presentation (finding) (code = '21882006' in codeSystem '2.16.840.1.113883.6.96') - Complete breech presentation (finding) (code = '49168004' in codeSystem '2.16.840.1.113883.6.96') - Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') - 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="5"|Aanpakker kind - rol aanpakker kind | |colspan="5"|Aanpakker kind - rol aanpakker kind | ||
|style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - arts-assistent (code = '24 | |style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Supervisor - rol supervisor | |colspan="5"|Supervisor - rol supervisor | ||
|style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59 | |style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Vaginale kunstverlossing groep | |colspan="6"|Vaginale kunstverlossing groep | ||
| Regel 895: | Regel 895: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Vaginale kunstverlossing | |colspan="4"|Vaginale kunstverlossing | ||
|style="background-color: white;"|Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') - Total breech extraction (procedure) (code = '416055001 | |style="background-color: white;"|Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') - Total breech extraction (procedure) (code = '416055001' in codeSystem '2.16.840.1.113883.6.96') - Delivery by vacuum extraction (procedure) (code = '61586001' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Succes vaginale kunstverlossing? | |colspan="4"|Succes vaginale kunstverlossing? | ||
|style="background-color: white;"| | |style="background-color: white;"|Ja - Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Sectio caesarea group | |colspan="6"|Sectio caesarea group | ||
| Regel 924: | Regel 924: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geboortegewicht | |colspan="4"|Geboortegewicht | ||
|style="background-color: white;"|3450 gram - 3620 gram - 2040 gram - 1580 | |style="background-color: white;"|3450 gram - 3620 gram - 2040 gram - 1580 gram - 4205 gram - 3750 gram | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Congenitale afwijkingen? | |colspan="5"|Congenitale afwijkingen? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee - Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Congenitale afwijkingen groep | |colspan="6"|Congenitale afwijkingen groep | ||
| Regel 951: | Regel 951: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Problematiek kind? | |colspan="5"|Problematiek kind? | ||
|style="background-color: white;"| | |style="background-color: white;"|Nee - Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Problematiek kind | |colspan="5"|Problematiek kind | ||
| Regel 957: | Regel 957: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Kinderarts betrokken? | |colspan="5"|Kinderarts betrokken? | ||
|style="background-color: white;"|Nee - Ja | |style="background-color: white;"|Nee - Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Betrokkenheid kinderarts | |colspan="6"|Betrokkenheid kinderarts | ||
| Regel 964: | Regel 964: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Datum betrokkenheid | |colspan="4"|Datum betrokkenheid | ||
|style="background-color: white;"|1 sep 2014 00:00 - 28 | |style="background-color: white;"|1 sep 2014 00:00 - 28 aug 2014 00:00 - 4 aug 2014 00:00 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Reden betrokkenheid | |colspan="4"|Reden betrokkenheid | ||
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') - Finding of neonatal condition (finding) (code = '364737004 | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') - Finding of neonatal condition (finding) (code = '364737004' in codeSystem '2.16.840.1.113883.6.96') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Type betrokkenheid | |colspan="4"|Type betrokkenheid | ||
|style="background-color: white;"| | |style="background-color: white;"|consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') - overdracht (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorginstelling lvrid | |colspan="4"|Zorginstelling lvrid | ||
|style="background-color: white;"|0003 - 9999 - 0001 | |style="background-color: white;"|0003 - 9999 - 0001 - 0010 | ||
|}<section end=uitkomst_per_kind_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 /> | |}<section end=uitkomst_per_kind_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 /> | ||
=== Medisch onderzoek === | === Medisch onderzoek === | ||
| Regel 989: | Regel 989: | ||
|-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;"| | |style="background-color: white;"|Nee - Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Welke irregulaire antistoffen vrouw aanwezig | |colspan="2"|Welke irregulaire antistoffen vrouw aanwezig | ||
| Regel 1.008: | Regel 1.008: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Datum | |colspan="3"|Datum | ||
|style="background-color: white;"|3 sep | |style="background-color: white;"|3 sep 2014 00:00 - 8 aug 2014 00:00 - 24 jul 2014 00:00 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Pathologie vrouw | |colspan="3"|Pathologie vrouw | ||
| Regel 1.028: | Regel 1.028: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Substantie voeding kind | |colspan="2"|Substantie voeding kind | ||
|style="background-color: white;"|borstvoeding (code = '1 | |style="background-color: white;"|borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') - kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | ||
|}<section end=postnatale_fase_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 /> | |}<section end=postnatale_fase_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 /> | ||
[[Categorie:Kwalificatie]] | [[Categorie:Kwalificatie]] | ||
Versie van 28 jan 2019 19:09
{{#customtitle:Kernset Geboortezorg 2.3 - dekkingsgraad scenario's}} __NUMBEREDHEADINGS__
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Dekkingsgraad scenario's voor Kernset Geboortezorg 2.3
De volgende scenario's zijn meegenomen:
- 1. Zorg volledig 1e lijn, herpes, strippen, gezonde eenling (id: scenario1-23)
- 2. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling(id: scenario2_1elijn-23)
- 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling(id: scenario2_2elijn-23)
- 3. zorg volledig in 2e lijn, meerling, 1 kind overleden(id: scenario3-23)
- 4. 1e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden(id: scenario4_1elijn-23)
- 4. 2e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden(id: scenario4_2elijn-23)
- 5. zorg volledig 2e lijn, vrouw overleden(id: scenario5-23)
Scenario (voor vrouw met BSN: 999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676)
| Vrouw | ||
| Gegevenselement | Waarde | |
| Burgerservicenummer | 999910413 - 961921821 - 895623146 - 850810711 - 912345676 | |
| Lokale persoonsidentificatie | 000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) - * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) | |
| Geboortedatum | 2 mei 1976 - 11 sep 1974 - 5 aug 1985 - 6 aug 1987 - 4 mrt 1993 | |
| Adres - postcode | 4563 AB - 5689 CZ - 5421 JG - 4589 BA - 9562 GF | |
| Etniciteit | Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28') - Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') - Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') - Latijns Amerikaans (code = '14' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
| Lengte gemeten | 170 cm - 184 cm - 167 cm - 162 cm - 186 cm | |
| 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') - Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96') | |
Anamnese
| Anamnese | |||
| Gegevenselement | Waarde | ||
| Onder behandeling geweest? | Ja - Nee | ||
| Algemene anamnese | |||
| Autoimmuun aandoening | Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96') | ||
| Cardiovasculaire aandoening | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - Cardiac arrhythmia (disorder) (code = '698247007' in codeSystem '2.16.840.1.113883.6.96') - Hypertensive disorder, systemic arterial (disorder) (code = '38341003' in codeSystem '2.16.840.1.113883.6.96') | ||
| Urogenitale aandoening | Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96') | ||
| Oncologische aandoening | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
| Schildklier aandoening | Hyperthyroidism (disorder) (code = '34486009' in codeSystem '2.16.840.1.113883.6.96') | ||
| Diabetes mellitus? | Ja | ||
| Neurologische aandoening | Epilepsy (disorder) (code = '84757009' in codeSystem '2.16.840.1.113883.6.96') | ||
| Infectieziekte | Herpes (code = '23513009' in codeSystem '2.16.840.1.113883.6.96') | ||
| Mdl aandoening | Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96') | ||
| Anemie | Iron deficiency anemia (disorder) (code = '87522002' in codeSystem '2.16.840.1.113883.6.96') | ||
| Longaandoening | Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96') - Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
| Gynaecologische aandoening | |||
| Orthopedische afwijking | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
| Bloedtransfusie? | Ja | ||
| Transfusiereactie? | |||
| Type operatie | Orthopedisch (code = '112697007' in codeSystem 'Snomed CT') - Operation on heart (procedure) (code = '64915003' in codeSystem '2.16.840.1.113883.6.96') - Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96') - Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
| Type stollingsprobleem | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
| Psychiatrie? | Ja | ||
| Overige aandoening? | |||
| Overige aandoening | |||
Zorgverlening
| Zorgverlening | |||||||
| Gegevenselement | Waarde | ||||||
| Datum start zorgverantwoordelijkheid | 1 mrt 2014 00:00 - 28 aug 2018 - 12 mei 2014 00:00 - 10 mrt 2014 00:00 - 7 aug 2014 00:00 - 3 feb 2014 00:00 - 9 dec 2013 00:00 | ||||||
| Datum einde zorgverantwoordelijkheid | 12 nov 2014 00:00 - 28 nov 2018 - 9 okt 2014 00:00 - 3 nov 2014 00:00 - 15 sep 2014 00:00 - 6 aug 2014 00:00 - 4 aug 2014 00:00 | ||||||
| Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||||||
| Conclusie risicostatus na intake | 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') - 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') - 3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | ||||||
| Verwijsdetails | |||||||
| Datum verwijzing | 6 mei 2014 00:00 - 6 aug 2014 00:00 | ||||||
| Verwijzing van | |||||||
| Zorginstelling | |||||||
| Zorgaanbieder identificatie nummer | 1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||||
| Specialisme | |||||||
| Verwijzing naar | |||||||
| Zorginstelling | |||||||
| Zorgaanbieder identificatie nummer | 0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||||
| Specialisme | Gynaecoloog 2e lijn (code = '02' in codeSystem 'Specialisme, specifiek voor perinatologie.') | ||||||
| Type verwijzing | |||||||
| Redenen van verwijzing | |||||||
| Van 1e naar 2e lijn | |||||||
| Algemene anamnese | |||||||
| Autoimmuun aandoening | |||||||
| Cardiovasculaire aandoening | |||||||
| Urogenitale aandoening | |||||||
| Oncologische aandoening | |||||||
| Schildklier aandoening | |||||||
| Diabetes mellitus? | |||||||
| Neurologische aandoening | |||||||
| Infectieziekte | |||||||
| Mdl aandoening | |||||||
| Anemie | |||||||
| Longaandoening | |||||||
| Gynaecologische aandoening | |||||||
| Orthopedische afwijking | |||||||
| Bloedtransfusie? | |||||||
| Transfusiereactie? | |||||||
| Type operatie | |||||||
| Type stollingsprobleem | |||||||
| Psychiatrie? | |||||||
| Overige aandoening? | |||||||
| Obstetrische anamnese | |||||||
| Gynaecologische aandoening | |||||||
| Bloedverlies? | |||||||
| Partiele mola? | |||||||
| Cervixinsufficientie? | |||||||
| Infectie | |||||||
| Hyperemesis gravidarum? | |||||||
| Hypertensieve aandoening | |||||||
| Zwangerschapscholestase? | |||||||
| Diabetes gravidarum met insuline? | |||||||
| Afwijkende groei foetus | |||||||
| Dreigende partus immaturus? | |||||||
| Dreigende partus prematurus? | |||||||
| Abruptio placentae? | |||||||
| Fluxus postpartum? | |||||||
| Zwangerschap | |||||||
| Gynaecologische aandoening | |||||||
| Bloedverlies? | |||||||
| Partiele mola? | |||||||
| Cervixinsufficientie? | |||||||
| Infectie | |||||||
| Hyperemesis gravidarum? | |||||||
| Hypertensieve aandoening | Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT') - Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT') | ||||||
| Zwangerschapscholestase? | |||||||
| Diabetes gravidarum met insuline? | |||||||
| Afwijkende groei foetus | |||||||
| Dreigende partus immaturus? | |||||||
| Dreigende partus prematurus? | |||||||
| Abruptio placentae? | |||||||
| Navelstrengprolaps? | |||||||
| Liggingsafwijking | |||||||
| Intrauteriene vruchtdood | |||||||
| Vermoeden intrauteriene vruchtdood? | |||||||
| Einde zwangerschap | |||||||
| Bevalling | |||||||
| Pprom? | |||||||
| Prom? | |||||||
| Koorts? | |||||||
| Niet vorderende ontsluiting? | |||||||
| Niet vorderende uitdrijving? | |||||||
| Verdenking foetale nood? | |||||||
| Intrauteriene vruchtdood | |||||||
| Vermoeden intrauteriene vruchtdood? | |||||||
| Vastzittende placenta? | |||||||
| Conditie perineum postpartum | |||||||
| Fluxus postpartum? | |||||||
| Postnatale fase | |||||||
| Pathologie vrouw | |||||||
| Overig | |||||||
| Van 2e naar 3e lijn | |||||||
| Van 2e naar 1e lijn | |||||||
| Van 3e naar 2e lijn | |||||||
| Perinatale periode | voor 28e week (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') - 2e t/m 7e dag (code = '92' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') | ||||||
Zorgverlenerzorginstelling
| Zorgverlenerzorginstelling | |||
| Gegevenselement | Waarde | ||
| Zorginstelling | |||
| Zorginstelling agbid | |||
| Zorginstelling lvrid | 1808 - 1504 - 0003 - 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
| Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||||||
| Gegevenselement | Waarde | ||||||
| Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||||||
| Definitieve a terme datum | 1 dec 2011 - 5 jun 2013 - 5 jun 2012 | ||||||
| Diagnose | |||||||
| Gynaecologische aandoening | Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Bloedverlies? | Ja | ||||||
| Cervixinsufficientie? | |||||||
| Infectie | Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Hyperemesis gravidarum? | Ja | ||||||
| Hypertensieve aandoening | |||||||
| Zwangerschapscholestase? | Ja | ||||||
| Diabetes gravidarum met insuline? | |||||||
| Afwijkende groei foetus | Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | ||||||
| Dreigende partus immaturus? | |||||||
| Dreigende partus prematurus? | |||||||
| Abruptio placentae? | |||||||
| Irregulaire antistoffen? | Nee - Ja | ||||||
| Eerdere bevalling | |||||||
| Placenta | |||||||
| Geboorte placenta | Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | ||||||
| Hoeveelheid bloedverlies | 550 ml | ||||||
| Vorige uitkomst per kind | |||||||
| Vorige baring | |||||||
| Geboortedatum | 8 dec 2011 00:00 - 9 jun 2012 00:00 | ||||||
| Kindspecifieke gegevens vorige uitkomsten | |||||||
| Type partus | Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT') - Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') | ||||||
| Percentiel van het geboortegewicht | 50 ≤ P < 90 (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.50') - 10 ≤ P < 50 (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.50') | ||||||
| Apgarscore na 5 min | 8 - 10 | ||||||
| Congenitale afwijkingen? | Nee | ||||||
| Congenitale afwijkingen groep | |||||||
| Chromosomale afwijkingen? | |||||||
Zwangerschap
| Zwangerschap | ||||
| Gegevenselement | Waarde | |||
| Graviditeit | 2 - 1 | |||
| Pariteit voor deze zwangerschap | 1 - 0 | |||
| Definitieve a terme datum | 9 okt 2014 - 8 sep 2014 - 22 sep 2014 - 18 aug 2014 - 22 jul 2014 | |||
| Voornemens | ||||
| Voorgenomen plaats baring tijdens zwangerschap type locatie | Thuis (code = '169813005' in codeSystem '2.16.840.1.113883.6.96') - Nog niet bepaald (code = '05' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | |||
| Prenatale controle | ||||
| Datum controle | 2 mrt 2014 00:00 - 6 mei 2014 00:00 - 12 mei 2014 00:00 - 21 mei 2014 00:00 - 7 mei 2014 00:00 - 9 jan 2014 00:00 | |||
| Zwangerschapsduur | 59 dagen - 155 dagen - 161 dagen - 156 dagen - 149 dagen - 86 dagen | |||
| Leven voelen | goed (code = '289431008' in codeSystem 'Snomed CT') - Weak fetal movements (finding) (code = '276372004' in codeSystem '2.16.840.1.113883.6.96') - Reduced fetal movement (finding) (code = '276369006' in codeSystem '2.16.840.1.113883.6.96') - Fetal movements absent (context-dependent category) (code = '289432001' 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') - gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - gestopt tijdens huidige zwangerschap (code = '6' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | |||
| Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | |||
| Drugsgebruik? | Nee - Ja | |||
| Gewicht gemeten | 70 kg - 85 kg - 67 kg - 82 kg - 89 kg | |||
| Diagnose | ||||
| Datum | 2 mrt 2014 00:00 - 6 mei 2014 00:00 - 12 mei 2014 00:00 - 21 mei 2014 00:00 - 7 mei 2014 00:00 - 9 jan 2014 00:00 | |||
| Zwangerschapsduur | 59 dagen - 155 dagen - 161 dagen - 156 dagen - 149 dagen - 86 dagen | |||
| Gynaecologische aandoening | Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') | |||
| Bloedverlies? | Ja | |||
| Partiele mola? | Ja | |||
| Cervixinsufficientie? | ||||
| Infectie | Urineweg infectie (code = '307534009' in codeSystem 'Snomed CT') | |||
| Hyperemesis gravidarum? | ||||
| Hypertensieve aandoening | Pregnancy-induced hypertension (disorder) (code = '48194001' in codeSystem '2.16.840.1.113883.6.96') - Pre-eclampsia (disorder) (code = '398254007' in codeSystem '2.16.840.1.113883.6.96') | |||
| Zwangerschapscholestase? | ||||
| Diabetes gravidarum met insuline? | ||||
| Afwijkende groei foetus | Small for gestational age fetus (disorder) (code = '267258002' in codeSystem '2.16.840.1.113883.6.96') - Large-for-dates fetus (disorder) (code = '199616008' in codeSystem '2.16.840.1.113883.6.96') | |||
| Dreigende partus immaturus? | ||||
| Dreigende partus prematurus? | ||||
| Abruptio placentae? | Ja | |||
| Navelstrengprolaps? | ||||
| Liggingsafwijking | ||||
| Intrauteriene vruchtdood | ||||
| Vermoeden intrauteriene vruchtdood? | ||||
| Vermoeden iuvd op basis van | ||||
| Intrauteriene behandeling | Selective destruction of fetus (procedure) (code = '265633004' in codeSystem '2.16.840.1.113883.6.96') | |||
| Maternale sterfte? | Nee - Ja | |||
| Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |||
Bevalling
| Bevalling | ||||
| Gegevenselement | Waarde | |||
| Partusnummer | 000000 | |||
| Diagnose bevalling | ||||
| Pprom? | Ja | |||
| Prom? | ||||
| Koorts? | ||||
| Niet vorderende ontsluiting? | Ja | |||
| Niet vorderende uitdrijving? | Ja | |||
| Verdenking foetale nood? | Ja | |||
| Intrauteriene vruchtdood | ||||
| Vermoeden intrauteriene vruchtdood? | ||||
| Vermoeden iuvd op basis van | ||||
| Vastzittende placenta? | ||||
| Fluxus postpartum? | ||||
| Aantal geboren kinderen | 1 - 2 | |||
| Risicostatus voor baring | 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') - 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | |||
| Interventies begin baring | ||||
| Interventie begin baring | Strippen (code = '236960006' in codeSystem 'Snomed CT') - Elective caesarean section (procedure) (code = '177141003' 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') - acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | |||
| Wijze waarop de baring begon | Interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') - spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | |||
| Tijdstip begin actieve ontsluiting | 8 okt 2014 14:30 - 30 aug 2014 14:09 - 27 aug 2014 22:09 - 3 aug 2014 21:09 | |||
| Medicatie nageboortetijdperk groep | ||||
| Medicatie nageboortetijdperk? | Ja - UNK - Nee | |||
| Soort medicatie nageboortetijdperk | Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') - 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') - placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | |||
| Hoeveelheid bloedverlies | 615 ml - 980 ml - 1740 ml - 1120 ml - 1500 ml | |||
| Conditie perineum postpartum | 1e graads perineumruptuur (code = '199916005' in codeSystem 'Snomed CT') - Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') - Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96') - Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') | |||
Uitkomst per kind
| Uitkomst per kind | |||||||
| Gegevenselement | Waarde | ||||||
| Baring | |||||||
| Werkelijke plaats baring type locatie | Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Ziekenhuis baring | |||||||
| Ziekenhuisnummer lvrid | 0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||||
| Demografische gegevens | |||||||
| Identificaties kind | |||||||
| Bsn kind | 999910383 - 951847624 - 847035116 - 847035128 - 840736526 - 528741913 | ||||||
| Geslacht medische observatie | vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') - mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21') - twijfelachtig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||||||
| Geboortedatum | 8 okt 2014 00:00 - 1 sep 2014 02:34 - 28 aug 2014 06:30 - 28 aug 2014 07:02 - 4 aug 2014 23:35 - 24 jul 2014 02:30 | ||||||
| Rangnummer kind | 1 - 2 | ||||||
| Perinatale sterfte groep | |||||||
| Perinatale sterfte? | Nee - Ja | ||||||
| Fase perinatale sterfte | Newborn death (event) (code = '276506001' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Datumtijd vaststelling perinatale sterfte | 28 aug 2014 08:10 | ||||||
| Kindspecifieke maternale gegevens | |||||||
| Bijstimulatie toegediend? | |||||||
| Tijdstip breken vliezen | 8 okt 2014 09:15 - 30 aug 2014 23:04 - 27 aug 2014 22:09 - 27 aug 2014 23:13 - 3 aug 2014 07:04 | ||||||
| Kleur en consistentie vruchtwater | Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') - geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') - bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18') - meconium (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
| Tijdstip actief meepersen | 8 okt 2014 12:13 - 27 aug 2014 23:49 - 28 aug 2014 06:45 - 4 aug 2014 22:15 | ||||||
| Episiotomie? | Nee - Ja | ||||||
| Indicatie episiotomie | |||||||
| 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? | Nee - Ja | ||||||
| Pijnbestrijding | |||||||
| Methode | |||||||
| Methode | Epidural anesthesia (procedure) (code = '18946005' in codeSystem '2.16.840.1.113883.6.96') - Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - General anesthesia (procedure) (code = '50697003' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Overig middel | |||||||
| Middel | Administration of morphinomimetic analgesic (procedure) (code = '52685006:363701004=404642006' in codeSystem '2.16.840.1.113883.6.96') - Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' 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') - Inhalational analgesia (procedure) (code = '241717009' 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') - tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||||||
| Sedatie? | Nee - Ja | ||||||
| Kindspecifieke uitkomstgegevens | |||||||
| Type partus | Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT') - Cesarean section (procedure) (code = '11466000' in codeSystem 'SNOMED CT') - Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') - Emergency cesarian section (procedure) (code = '274130007' in codeSystem 'SNOMED CT') | ||||||
| Ligging bij geboorte | Achterhoofd-achter (code = '37235006' in codeSystem 'Snomed CT') - Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') - Face presentation (finding) (code = '21882006' in codeSystem '2.16.840.1.113883.6.96') - Complete breech presentation (finding) (code = '49168004' in codeSystem '2.16.840.1.113883.6.96') - Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') - Onbekend (code = 'UNK' in codeSystem '2.16.840.1.113883.5.1008') | ||||||
| Aanpakker kind - rol aanpakker kind | 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||||||
| Supervisor - rol supervisor | 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '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') - Total breech extraction (procedure) (code = '416055001' in codeSystem '2.16.840.1.113883.6.96') - Delivery by vacuum extraction (procedure) (code = '61586001' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Succes vaginale kunstverlossing? | Ja - 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 primaire sectio | Suspected fetal distress (situation) (code = '444433005:246090004=130955003' in codeSystem '2.16.840.1.113883.6.96') - Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Indicatie secundaire sectio | Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Overige interventies | Maneuvers for delivery in shoulder dystocia (procedure) (code = '237008007' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Lichamelijk onderzoek kind | |||||||
| Apgarscore na 5 min | |||||||
| Geboortegewicht | 3450 gram - 3620 gram - 2040 gram - 1580 gram - 4205 gram - 3750 gram | ||||||
| Congenitale afwijkingen? | Nee - 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') - Multiple congenital cardiac defects (disorder) (code = '94702005' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Chromosomale afwijkingen? | Nee - 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? | Nee - Ja | ||||||
| Problematiek kind | Birth trauma of fetus (disorder) (code = '56110009' in codeSystem '2.16.840.1.113883.6.96') - Subdural intracranial hemorrhage due to birth trauma (disorder) (code = '126941005' in codeSystem '2.16.840.1.113883.6.96') - Congenital hearing disorder (disorder) (code = '95827002' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Kinderarts betrokken? | Nee - Ja | ||||||
| Betrokkenheid kinderarts | |||||||
| Datum betrokkenheid | 1 sep 2014 00:00 - 28 aug 2014 00:00 - 4 aug 2014 00:00 | ||||||
| Reden betrokkenheid | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') - Finding of neonatal condition (finding) (code = '364737004' 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') - overdracht (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
| Zorginstelling lvrid | 0003 - 9999 - 0001 - 0010 | ||||||
Medisch onderzoek
| Medisch onderzoek | |||
| Gegevenselement | Waarde | ||
| Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
| Irregulaire antistoffen? | Nee - Ja | ||
| Welke irregulaire antistoffen vrouw aanwezig | Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96') - Kell (code = '405844003' in codeSystem '2.16.840.1.113883.6.96') | ||
Postnatale fase
| Postnatale fase | ||||
| Gegevenselement | Waarde | |||
| Diagnoseinterventie postpartum | ||||
| Datum | 3 sep 2014 00:00 - 8 aug 2014 00:00 - 24 jul 2014 00:00 | |||
| Pathologie vrouw | Urinary tract infectious disease (disorder) (code = '68566005' in codeSystem '2.16.840.1.113883.6.96') - Embolism (disorder) (code = '414086009' in codeSystem '2.16.840.1.113883.6.96') - Episiotomy infection (disorder) (code = '300927001' in codeSystem '2.16.840.1.113883.6.96') - Postpartum deep phlebothrombosis (disorder) (code = '56272000' in codeSystem '2.16.840.1.113883.6.96') | |||
| Kindspecifieke gegevens | ||||
| Rangnummer kind | 1 | |||
| Voeding kind groep | ||||
| Voeding kind datum | 12 okt 2014 - 7 okt 2014 - 3 sep 2014 - 15 sep 2014 - 24 jul 2014 | |||
| Substantie voeding kind | borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') - kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | |||