Gebz:Vdraft KSNEO: verschil tussen versies
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Regel 6: | Regel 6: | ||
==Scenario Testscenario 1: uitgebreide problematiek == | ==Scenario Testscenario 1: uitgebreide problematiek == | ||
+ | === Documentgegevens === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Documentgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Identificatie | ||
+ | |style="background-color: white;"|0000 (in identificerend systeem: abc123) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Document datum | ||
+ | |style="background-color: white;"|22 sep 2021 08:48 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Set identificatie | ||
+ | |style="background-color: white;"|0000 (in identificerend systeem: abc123) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Versienummer | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Software naam | ||
+ | |style="background-color: white;"|InformatieSysteemX | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Verificatie zorgverlener | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Geverifieerd door zorgverlener? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Verificatie datum | ||
+ | |style="background-color: white;"|21 sep 2021 15:01 | ||
+ | |} | ||
=== Zorgaanbieder === | === Zorgaanbieder === | ||
Regel 16: | Regel 50: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgaanbieder identificatienummer | |colspan="2"|Zorgaanbieder identificatienummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgaanbieder identificatienummer | ||
+ | |style="background-color: white;"|0000 (in identificerend systeem: AGB-Z) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgaanbieder identificatienummer | ||
+ | |style="background-color: white;"|0000 (in identificerend systeem: URA) | ||
|} | |} | ||
− | === | + | === Zorgverlener === |
{| 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" | Zorgverlener |
|-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 27: | Regel 67: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Zorgverlener identificatienummer |
− | |style="background-color: white;"|1 | + | |style="background-color: white;"|0000 (in identificerend systeem: 2.16.528.1.1007.5.1) |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Naamgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="12"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Voornamen | ||
+ | |style="background-color: white;"|Hans Peter | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Initialen | ||
+ | |style="background-color: white;"|HP | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Roepnaam | ||
+ | |style="background-color: white;"|Hans | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Naamgebruik |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Geslachtsnaam |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Voorvoegsels |
− | |style="background-color: white;"| | + | |style="background-color: white;"|van den |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Achternaam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Akker |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslachtsnaam partner | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Achternaam partner |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Pieterse |
|} | |} | ||
− | === | + | === Vrouw === |
{| 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" | Vrouw |
|-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"|Demografische gegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="5"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Patient |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|000000000 (in identificerend systeem: BSN) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Geboortedatum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|11 mei 1993 |
+ | |} | ||
+ | === Zwangerschapsgegevens === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zwangerschapsgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Graviditeit |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Pariteit voor deze zwangerschap |
− | |style="background-color: white;"| | + | |style="background-color: white;"|0 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Complicaties tijdens zwangerschap | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="8"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Complicaties zwangerschap? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|koorts (code = '386661006' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verificatie status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Magnesiumsulfaat |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Antenatale steroiden gegeven? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
+ | |} | ||
+ | === Kind === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Kind | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="5" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Demografische gegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="9"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Patient | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="7"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999) |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Geboortedatum |
− | | | + | |style="background-color: white;"|7 maa 2020 12:13 |
− | | | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Geslacht |
+ | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Meerling indicator |
− | |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"|Rangnummer kind |
+ | |style="background-color: white;"|2 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Overlijdens indicator |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Bevallingsgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="9"| |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Zwangerschapsduur |
+ | |style="background-color: white;"|179 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Aantal geboren kinderen |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Type partus |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Primair (code = '177141003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Locatie partus |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zorgaanbieder | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="3"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Zorgaanbieder identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Organisatie naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|UMC Papendorp |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Ondersteuning opvang |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="7"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Verrichting |
|-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="3"| | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Verrichting |
|-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="3"| | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Opname gegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="37"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Opname |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="7"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Opname datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|7 maa 2020 13:30 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Ic opname? |
− | |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"| | + | |colspan="3"|Heropname? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Herkomst kind |
− | |style="background-color: white;"| | + | |style="background-color: white;"|In-hospital admission from obstetrical ward (procedure) (code = '59151000146103' in codeSystem 'SNOMED CT') |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Opname indicatie |
+ | |style="background-color: white;"|Finding of length of gestation (finding) (code = '366323009' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Ontslag datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|5 mei 2020 12:00 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Onderzoek | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="27"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Lichaamslengte |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Lengte waarde |
+ | |style="background-color: white;"|31 cm | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Lengte datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|7 maa 2020 13:20 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Lichaamsgewicht |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Gewicht waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|710 g |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Gewicht datum tijd |
− | |style="background-color: white;"|7 | + | |style="background-color: white;"|7 maa 2020 13:21 |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Lichaamstemperatuur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="5"| |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Temperatuur waarde |
+ | |style="background-color: white;"|37.4 graden celsius | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Temperatuur datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|7 maa 2020 13:22 |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Toelichting |
+ | |style="background-color: white;"|abc | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Temperatuur type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Rectale temperatuur (code = '307047009' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Schedelomvang |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Schedelomvang waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|22.5 cm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Schedelomvang datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|7 maa 2020 13:23 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Apgar score na 1 min | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |rowspan="2"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="2"|Apgar score totaal | ||
+ | |style="background-color: white;"|1 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Apgar score na 5 min |
|-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=" | + | |colspan="2"|Apgar score totaal |
− | |style="background-color: white;"| | + | |style="background-color: white;"|5 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Nsp h arterieel |
− | |style="background-color: white;"| | + | |style="background-color: white;"|7.05 ph |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Be |
− | |style="background-color: white;"| | + | |style="background-color: white;"|-12.0 mmol/l |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Problematiek kind | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="97"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Geboortetrauma |
|-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=" | + | |colspan="3"|Problemen aanwezig? |
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ademhalingsondersteuning | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="13"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Ademhalingsondersteuning? | ||
|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"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="4"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verrichting start datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|7 maa 2020 13:35 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verrichting eind datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|3 mei 2020 12:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Oxygen therapy using high flow oxygen nasal cannula (procedure) (code = '57485005:424226004=426854004' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Verrichting | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="4"| |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Verrichting start datum |
+ | |style="background-color: white;"|3 mei 2020 12:00 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verrichting eind datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|5 mei 2020 10:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="3"|O2 op dag 28? | |
− | + | |style="background-color: white;"|Ja | |
− | |colspan="3"| | ||
− | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Respiratoir |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="14"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Problemen aanwezig? |
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="4"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Respiratory distress syndrome in the newborn (disorder) (code = '46775006' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verificatie status |
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Aanvang | ||
+ | |style="background-color: white;"|Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Medicatie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Stimulatie ademhaling |
− | |style="background-color: white;"| | + | |style="background-color: white;"|COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Surfactant | ||
+ | |style="background-color: white;"|NATUURLIJKE FOSFOLIPIDEN - LONGSURFACTANTS (code = 'R07AA02' in codeSystem 'ATC-NL') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Medicatie |
|-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=" | + | |colspan="2"|Stimulatie ademhaling |
− | |style="background-color: white;"| | + | |style="background-color: white;"|DOXAPRAM (code = 'R07AB01' in codeSystem 'ATC-NL') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Circulatoir |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="9"| | |rowspan="9"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Probleem | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="3"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Patent ductus arteriosus (disorder) (code = '83330001' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verificatie status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Verrichting | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Drug therapy for patent ductus arteriosus (procedure) (code = '58801000146104' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Infectieus | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="13"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Problemen aanwezig? |
− | |||
− | |||
− | |||
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="9"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Suspected sepsis (situation) (code = '9331000146100' in codeSystem 'SNOMED CT') |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Probleem begin datum |
− | | | + | |style="background-color: white;"|8 maa 2020 |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Probleem eind datum |
+ | |style="background-color: white;"|11 maa 2020 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Verificatie status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Werk (code = '415684004' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Aanvang |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT') |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Microorganisme sepsis meningitis |
+ | |style="background-color: white;"|Other, specify (code = 'OTH' in codeSystem 'HL7 NullFlavor'): abc | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Problemen aanwezig? | + | |colspan="2"|Lijnsepsis? |
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Onset | ||
+ | |style="background-color: white;"|vroege neonatale periode (kwalificatiewaarde) (code = '303114002' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Antibiotica eerste 3 dagen? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Gastrointestinaal | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Verrichting | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Verrichting type | ||
+ | |style="background-color: white;"|Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Hematologisch | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Problemen aanwezig? | ||
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verrichting type |
|style="background-color: white;"|Transfusion for anemia (procedure) (code = '59071000146107' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Transfusion for anemia (procedure) (code = '59071000146107' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Metabool en endocrien |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="9"| | |rowspan="9"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Problemen aanwezig? |
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem naam |
|style="background-color: white;"|hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT') | |style="background-color: white;"|hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verificatie status |
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verrichting type |
|style="background-color: white;"|Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Neurologisch |
|-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=" | + | |colspan="3"|Problemen aanwezig? |
|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="5"| | + | |colspan="5"|Zintuigen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="11"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Retinopathy of prematurity stage 2 - intraretinal ridge (disorder) (code = '408848001' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verificatie status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Rop screening verricht? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Rop screening afgesloten? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Aabr verricht? |
|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="3"|Aabr afwijkend? |
|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="3"|Bera verricht? |
|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="5"| | + | |colspan="5"|Congenitale aandoeningen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3 | + | |colspan="3"|Problemen aanwezig? |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|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"|Ontslagoverplaatsing |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="15"| | |rowspan="15"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Nog opgenomen? |
|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"|Bestemming kind |
|style="background-color: white;"|Discharge to other hospital (procedure) (code = '115851000146108' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Discharge to other hospital (procedure) (code = '115851000146108' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Lichamelijk onderzoek |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="10"| | |rowspan="10"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Lichaamsgewicht |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Gewicht waarde |
|style="background-color: white;"|1740 gram | |style="background-color: white;"|1740 gram | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Gewicht datum tijd |
|style="background-color: white;"|5 mei 2020 09:00 | |style="background-color: white;"|5 mei 2020 09:00 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Schedelomvang |
|-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="2"|Schedelomvang meetmethode |
|style="background-color: white;"|Meten van schedelomvang m.b.v. meetlint (code = '31551000146109' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Meten van schedelomvang m.b.v. meetlint (code = '31551000146109' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Schedelomvang waarde |
|style="background-color: white;"|30 cm | |style="background-color: white;"|30 cm | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Schedelomvang datum tijd |
|style="background-color: white;"|5 mei 2020 09:01 | |style="background-color: white;"|5 mei 2020 09:01 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Voeding kind |
|style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') | |style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Mortaliteit |
|-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"|Overlijden lt12 uur na opname nicu? |
|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"|Overleden op verloskamer? |
|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"|Staken icbehandeling? |
|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"|Follow up |
|-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="5"|Na ontslag |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="6"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|O2 op dag 28? |
|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"|Gradatie bpd |
|style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') | |style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Zintuigen |
|-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=" | + | |colspan="2"|Problemen aanwezig? |
|style="background-color: white;"|NullFlavor: UNK | |style="background-color: white;"|NullFlavor: UNK | ||
+ | |} | ||
+ | ==Scenario Testscenario 2: geb.trauma + neurologisch + anat afw + overlijden == | ||
+ | |||
+ | === Documentgegevens === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Documentgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Identificatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|0000 (in identificerend systeem: abc123) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Document datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Set identificatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|0000 (in identificerend systeem: abc123) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Versienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Software naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|XIS |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Verificatie zorgverlener |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Geverifieerd door zorgverlener? |
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Verificatie datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
|} | |} | ||
− | |||
− | |||
=== Zorgaanbieder === | === Zorgaanbieder === | ||
Regel 597: | Regel 703: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgaanbieder identificatienummer | |colspan="2"|Zorgaanbieder identificatienummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) |
|} | |} | ||
− | === | + | === Zorgverlener === |
{| 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" | Zorgverlener |
|-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 608: | Regel 714: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Zorgverlener identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|0000 (in identificerend systeem: UZI Personen) |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Naamgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="8"| | |rowspan="8"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Voornamen |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Hans Paul |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Initialen |
+ | |style="background-color: white;"|H.P. | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Roepnaam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Hans |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Naamgebruik |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslachtsnaam | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Achternaam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Pieterse |
|} | |} | ||
− | === | + | === Vrouw === |
{| 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" | Vrouw |
|-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"|Demografische gegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="5"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Patient |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|(in identificerend systeem: BSN) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Geboortedatum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1994 |
+ | |} | ||
+ | === Zwangerschapsgegevens === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zwangerschapsgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Graviditeit |
− | |style="background-color: white;"| | + | |style="background-color: white;"|3 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Pariteit voor deze zwangerschap |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Complicaties tijdens zwangerschap | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="8"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Complicaties zwangerschap? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|hypertensieve aandoening (aandoening) (code = '38341003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verificatie status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Magnesiumsulfaat |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Antenatale steroiden gegeven? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|NullFlavor: NA |
+ | |} | ||
+ | === Kind === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Kind | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="6" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Demografische gegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="9"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Patient | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="7"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999) |
− | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
− | |colspan=" | + | |colspan="4"|Geboortedatum |
+ | |style="background-color: white;"|26 mei 2020 10:44 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Geslacht |
− | | | + | |style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') |
− | | | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Meerling indicator |
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Overlijdens indicator |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Datum overlijden |
+ | |style="background-color: white;"|26 mei 2020 21:00 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Bevallingsgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="9"| | |rowspan="9"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Zwangerschapsduur |
− | |style="background-color: white;"| | + | |style="background-color: white;"|254 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Aantal geboren kinderen |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Type partus |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Primair (code = '177141003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Locatie partus |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Zorgaanbieder | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="3"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Zorgaanbieder identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|234 (in identificerend systeem: AGB-Z) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Organisatie naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|UMC Papendorp |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Ondersteuning opvang |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="4"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Verrichting |
|-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=" | + | |colspan="4"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Opname gegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="28"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Opname |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="9"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Opname datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|26 mei 2020 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Ic opname? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Heropname? |
− | |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"|Herkomst kind |
+ | |style="background-color: white;"|In-hospital admission from obstetrical ward (procedure) (code = '59151000146103' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Opname indicatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Perinatal asphyxia (disorder) (code = '281578009' in codeSystem 'SNOMED CT') |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Opname indicatie |
+ | |style="background-color: white;"|Infant in poor condition at birth (finding) (code = '276707008' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Opname indicatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Congenital disease (disorder) (code = '66091009' in codeSystem 'SNOMED CT') |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Ontslag datum |
+ | |style="background-color: white;"|26 mei 2020 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Onderzoek |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="16"| |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Lichaamsgewicht |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Gewicht waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|3870 g |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Gewicht datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|26 mei 2020 11:01 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Lichaamstemperatuur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="4"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Temperatuur waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|36.1 graden celsius |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Temperatuur datum tijd |
+ | |style="background-color: white;"|26 mei 2020 11:02 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Temperatuur type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Rectale temperatuur (code = '307047009' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Apgar score na 1 min | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Apgar score totaal |
− | |style="background-color: white;"| | + | |style="background-color: white;"|0 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Apgar score na 5 min |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Apgar score totaal |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Problematiek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="68"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Geboortetrauma |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="6"| | |rowspan="6"| | ||
Regel 842: | Regel 962: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Probleem naam | |colspan="3"|Probleem naam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Spinal cord injury due to birth trauma (disorder) (code = '698500002' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verificatie status | |colspan="3"|Verificatie status | ||
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Ademhalingsondersteuning |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="7"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Ademhalingsondersteuning? |
|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"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting start datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|26 mei 2020 11:16 |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Verrichting type |
+ | |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|O2 op dag 28? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|NullFlavor: NA |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Respiratoir |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
Regel 875: | Regel 994: | ||
|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="6"| | + | |colspan="6"|Circulatoir |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="6"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Problemen aanwezig? | |colspan="4"|Problemen aanwezig? | ||
Regel 884: | Regel 1.003: | ||
|colspan="5"|Probleem | |colspan="5"|Probleem | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Probleem naam | |colspan="3"|Probleem naam | ||
− | |style="background-color: white;"|Neonatal | + | |style="background-color: white;"|Neonatal hypotension (disorder) (code = '276519002' in codeSystem 'SNOMED CT') |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verificatie status | |colspan="3"|Verificatie status | ||
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Infectieus |
|-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=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Gastrointestinaal |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Hematologisch |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Problemen aanwezig? |
− | |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"| | + | |colspan="6"|Metabool en endocrien |
|-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="4"|Problemen aanwezig? | |colspan="4"|Problemen aanwezig? | ||
− | + | |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="6"| | + | |colspan="6"|Neurologisch |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="17"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Problemen aanwezig? | |colspan="4"|Problemen aanwezig? | ||
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan | + | |rowspan="4"| |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Probleem naam |
+ | |style="background-color: white;"|Neonatal encephalopathy (disorder) (code = '95628005' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Ernst encefalopathie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ernstig (code = '24484000' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verificatie status |
|style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|asfyxie bij geboorte (code = '413654009' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verificatie status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Probleem |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Probleem naam |
+ | |style="background-color: white;"|Intraventricular (nontraumatic) hemorrhage, grade 2, of fetus and newborn (disorder) (code = '206396002' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming van hoofd (verrichting) (code = '241449005' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Zintuigen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|NullFlavor: UNK |
− | + | |-style="vertical-align:top; background-color: #E3E3E3;;" | |
− | + | |colspan="6"|Congenitale aandoeningen | |
− | |||
− | |||
− | |||
− | |||
− | |style=" | ||
− | |||
− | |colspan=" | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="8"| |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Aangeboren anatomische afwijkingen majorsyndromen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="5"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Overige congenitale afwijkingen zenuwstelsel (code = '09' in codeSystem '2.16.840.1.113883.2.4.4.13.8') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Verificatie status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="7"| | + | |colspan="7"|Ontslagoverplaatsing |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="5"|Nog opgenomen? |
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Voeding kind |
− | |style="background-color: white;"| | + | |style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Mortaliteit | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="5"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Overlijden lt12 uur na opname nicu? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Overleden op verloskamer? |
|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="5"|Oorzaak overlijden |
− | |style="background-color: white;"| | + | |style="background-color: white;"|multiorgaanfalen (aandoening) (code = '57653000' in codeSystem 'SNOMED CT') |
− | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
− | |colspan=" | + | |colspan="5"|Staken icbehandeling? |
+ | |style="background-color: white;"|Ja | ||
+ | |} | ||
+ | ==Scenario Testscenario 3: stofwisselingsziekte == | ||
+ | |||
+ | === Documentgegevens === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Documentgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Identificatie |
+ | |style="background-color: white;"|0000 (in identificerend systeem: abc123) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Document datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|22 sep 2021 09:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Set identificatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|0000 (in identificerend systeem: abc123) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Versienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|3 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Software naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|XIS |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Verificatie zorgverlener |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Geverifieerd door zorgverlener? |
|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"|Verificatie datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
+ | |} | ||
+ | === Zorgaanbieder === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgaanbieder | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Zorgaanbieder identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|0000 (in identificerend systeem: AGB-Z) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Zorgaanbieder identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|(in identificerend systeem: URA) |
+ | |} | ||
+ | === Zorgverlener === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zorgverlener | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Zorgverlener identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|0000 (in identificerend systeem: AGB-Z) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Naamgegevens |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Voornamen |
− | | | + | |style="background-color: white;"|Hans Peter |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Initialen |
+ | |style="background-color: white;"|HP | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Roepnaam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Hans |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Naamgebruik |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Geslachtsnaam |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Voorvoegsels |
− | |style="background-color: white;"| | + | |style="background-color: white;"|van de |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Achternaam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Velde |
− | | | + | |} |
− | |colspan=" | + | === Zwangerschapsgegevens === |
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschapsgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Graviditeit |
+ | |style="background-color: white;"|4 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Pariteit voor deze zwangerschap |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2 |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Complicaties tijdens zwangerschap |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="4"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Complicaties zwangerschap? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Antenatale steroiden gegeven? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Antenatale steroiden |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Complete steroid therapy for fetal lung maturation (procedure) (code = '255594003434601000124108' in codeSystem 'SNOMED CT') |
− | | | + | |} |
− | + | === Kind === | |
− | |style="background-color: white;"| | + | |
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Kind | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="6" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="7"| | + | |colspan="7"|Demografische gegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="7"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Patient |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Identificatienummer |
+ | |style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="4"|Geboortedatum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2 jul 2020 06:55 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslacht | ||
+ | |style="background-color: white;"|Ongedifferentieerd (code = 'UN' in codeSystem 'HL7 AdministrativeGender') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Overlijdens indicator |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="7"| | + | |colspan="7"|Bevallingsgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Zwangerschapsduur |
− | |style="background-color: white;"| | + | |style="background-color: white;"|215 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Aantal geboren kinderen |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Type partus |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Locatie partus |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="7"| | + | |colspan="7"|Opname gegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="29"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Opname | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="7"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Opname datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|16 sep 2020 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Ic opname? |
|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"|Heropname? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Herkomst kind |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Hospital admission from home or birth center (procedure) (code = '59141000146101' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Opname indicatie | ||
+ | |style="background-color: white;"|Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): vaccinatie onder observatie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Ontslag datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|16 sep 2020 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Onderzoek |
|-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"|Lichaamslengte |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Lengte waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|43 cm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Lengte datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|16 sep 2020 09:30 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Lichaamsgewicht | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="3"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Gewicht waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1800 g |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Gewicht datum tijd |
+ | |style="background-color: white;"|16 sep 2020 09:30 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Lichaamstemperatuur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Temperatuur waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|37.1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Temperatuur datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|16 sep 2020 09:30 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Schedelomvang | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Schedelomvang waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|31 centimeter |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Schedelomvang datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|16 sep 2020 09:32 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Nsp h arterieel |
− | |style="background-color: white;"| | + | |style="background-color: white;"|7.35 ph |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Be |
− | |style="background-color: white;"| | + | |style="background-color: white;"|0.0 mmol/l |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="7"| | + | |colspan="7"|Problematiek kind |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="10"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Congenitale aandoeningen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="8"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Stofwisselingsziekten | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="5"| |
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Probleem naam |
+ | |style="background-color: white;"|stoornis van mineraalstofwisseling (aandoening) (code = '45744005' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verificatie status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Differentiaal (code = '410590009' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="7"| | + | |colspan="7"|Ontslagoverplaatsing |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="5"| |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="5"|Nog opgenomen? |
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Bestemming kind |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Discharge to home (procedure) (code = '306689006' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Voeding kind |
− | |style="background-color: white;"| | + | |style="background-color: white;"|moedermelk (substantie) (code = '226789007' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Ondersteuning bij ontslag naar huis |
− | |style="background-color: white;"| | + | |style="background-color: white;"|monitoren met cardiotachometer (regime/therapie) (code = '63818009' in codeSystem 'SNOMED CT') |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Mortaliteit |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="4"| |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="5"|Overlijden lt12 uur na opname nicu? |
+ | |style="background-color: white;"|NullFlavor: NA | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Overleden op verloskamer? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Staken icbehandeling? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|NullFlavor: NA |
− | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |} |
− | |colspan=" | + | ==Scenario Testscenario 4: gastro + chirurgie == |
+ | |||
+ | === Documentgegevens === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Documentgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Identificatie | ||
+ | |style="background-color: white;"|0000 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Document datum |
+ | |style="background-color: white;"|22 sep 2021 10:00 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Set identificatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|0000 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Versienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Software naam |
+ | |style="background-color: white;"|InformatieSysteemX | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Verificatie zorgverlener |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Geverifieerd door zorgverlener? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|NullFlavor: NI |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Verificatie datum |
− | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |style="background-color: white;"| |
− | |colspan="4"| | + | |} |
− | |style="background-color: white;"| | + | === Zorgaanbieder === |
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgaanbieder | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgaanbieder identificatienummer | ||
+ | |style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) | ||
+ | |} | ||
+ | === Vrouw === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Vrouw | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Demografische gegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="5"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Patient | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="3"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|(in identificerend systeem: BSN) |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Geboortedatum | ||
+ | |style="background-color: white;"| | ||
+ | |} | ||
+ | === Zwangerschapsgegevens === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zwangerschapsgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Graviditeit | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Pariteit voor deze zwangerschap | ||
+ | |style="background-color: white;"|0 | ||
+ | |} | ||
+ | === Kind === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Kind | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="6" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Demografische gegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="9"| | |rowspan="9"| | ||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Patient |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="7"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999) |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortedatum | ||
+ | |style="background-color: white;"|13 aug 2020 13:00 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslacht | ||
+ | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Meerling indicator |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Rangnummer kind |
+ | |style="background-color: white;"|2 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Overlijdens indicator |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Bevallingsgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Zwangerschapsduur |
− | |style="background-color: white;"| | + | |style="background-color: white;"|236 dagen |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="5"|Aantal geboren kinderen |
+ | |style="background-color: white;"|2 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Type partus |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Locatie partus | ||
+ | |style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Ondersteuning opvang | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Verrichting |
|-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="4"| | + | |colspan="4"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Opname gegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="23"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Opname | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="11"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Opname datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|20 aug 2020 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Ic opname? |
|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"|Heropname? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Herkomst kind |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Hospital admission, transfer from other hospital or health care facility (procedure) (code = '4563007' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Zorgaanbieder |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Zorgaanbieder identificatienummer | ||
+ | |style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Organisatie naam | ||
+ | |style="background-color: white;"|AZ Papendorp | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Opname indicatie | ||
+ | |style="background-color: white;"|Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): abc | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Ontslag datum |
+ | |style="background-color: white;"|28 okt 2020 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Onderzoek |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="9"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Lichaamslengte |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Lengte waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|43 cm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Lengte datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|16 sep 2020 09:30 |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Lichaamsgewicht |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Gewicht waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1530 g |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Gewicht datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|20 aug 2020 09:30 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Problematiek kind |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="92"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Geboortetrauma |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Ademhalingsondersteuning |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="6"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Ademhalingsondersteuning? |
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 1.519: | Regel 1.660: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verrichting type | |colspan="3"|Verrichting type | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|O2 op dag 28? | ||
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Respiratoir |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="9"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Problemen aanwezig? | |colspan="4"|Problemen aanwezig? | ||
Regel 1.533: | Regel 1.677: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Probleem naam | |colspan="3"|Probleem naam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Bronchopulmonary dysplasia of newborn (disorder) (code = '67569000' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verificatie status | |colspan="3"|Verificatie status | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Medicatie |
|-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="3"| | + | |colspan="3"|Stimulatie ademhaling |
− | |style="background-color: white;"| | + | |style="background-color: white;"|COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL') |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Circulatoir |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="5"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Neonatal hypotension (disorder) (code = '276519002' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Infectieus |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="9"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Problemen aanwezig? | |colspan="4"|Problemen aanwezig? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Probleem | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="5"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|neonatale sepsis (aandoening) (code = '206376005' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Microorganisme sepsis meningitis |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Listeria monocytogenes (organism) (code = '36094007' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Lijnsepsis? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="3"|Onset |
− | |style="background-color: white;"|NullFlavor: | + | |style="background-color: white;"|late neonatale periode (kwalificatiewaarde) (code = '303115001' in codeSystem 'SNOMED CT') |
− | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
− | |colspan="6"| | + | |colspan="4"|Antibiotica eerste 3 dagen? |
+ | |style="background-color: white;"|NullFlavor: NA | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Infuus | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="7"| | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Infuuskatheter | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="5"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Medisch hulpmiddel |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Begin datum |
+ | |style="background-color: white;"|20 aug 2020 10:00 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Einddatum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|22 okt 2020 09:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Gastrointestinaal |
|-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=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Probleem | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |rowspan="3"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
− | + | |colspan="3"|Probleem naam | |
− | + | |style="background-color: white;"|Necrotizing enterocolitis in fetus OR newborn - Bell stage IIIA (disorder) (code = '21941000146103' in codeSystem 'SNOMED CT') | |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Verificatie status |
+ | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Verrichting |
|-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="3"| | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Laparotomy (procedure) (code = '86481000' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Hematologisch |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="5"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Transfusion for anemia (procedure) (code = '59071000146107' in codeSystem 'SNOMED CT') |
− | + | |-style="vertical-align:top; background-color: #E3E3E3;;" | |
− | + | |colspan="6"|Metabool en endocrien | |
− | |||
− | |||
− | |style=" | ||
− | |||
− | |colspan=" | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="16"| |
− | |style=" | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
− | + | |colspan="4"|Problemen aanwezig? | |
− | + | |style="background-color: white;"|Ja | |
− | |||
− | |||
− | |||
− | | | ||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Probleem |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem naam | ||
+ | |style="background-color: white;"|hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Verificatie status |
+ | |style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"|(in | + | |style="background-color: white;"|Hypoglycemia (disorder) (code = '302866003' in codeSystem 'SNOMED CT') |
− | | | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
− | = | + | |colspan="3"|Verificatie status |
− | + | |style="background-color: white;"|Differentiaal (code = '410590009' in codeSystem 'SNOMED CT') | |
− | + | |-style="vertical-align:top; background-color: #E3E3E3;;" | |
− | |style="background- | + | |colspan="5"|Verrichting |
− | |-style="background-color: # | ||
− | |colspan=" | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Verrichting |
|-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="3"| | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Intravenous infusion of glucose in hypoglycemia (procedure) (code = '109091000146105' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Zintuigen |
|-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=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|NullFlavor: NI |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Congenitale aandoeningen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="7"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Problemen aanwezig? |
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Chirurgische ingrepen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="4"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Verrichting |
|-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=" | + | |colspan="2"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Endoscopie van oesofagus (verrichting) (code = '49230008' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Ontslagoverplaatsing | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="10"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Nog opgenomen? |
− | |||
− | |||
− | |||
|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="5"|Bestemming kind |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Discharge to other location within hospital premises (procedure) (code = '115841000146105' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Lichamelijk onderzoek |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="5"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Lichaamsgewicht | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="3"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Gewicht waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2800 gram |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="3"|Gewicht datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|28 okt 2020 15:00 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Voeding kind | ||
+ | |style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Mortaliteit |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Overlijden lt12 uur na opname nicu? |
− | |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"|Overleden op verloskamer? |
− | |-style=" | + | |style="background-color: white;"|Nee |
− | |colspan=" | + | |} |
+ | ==Scenario Testscenario 5: zintuigen + FU == | ||
+ | |||
+ | === Documentgegevens === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Documentgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Identificatie |
+ | |style="background-color: white;"|0000 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Document datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|22 sep 2021 11:00 |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Set identificatie |
+ | |style="background-color: white;"|0000 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Versienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Software naam |
+ | |style="background-color: white;"|InformatieSysteemX | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Verificatie zorgverlener |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Geverifieerd door zorgverlener? |
− | |||
− | |||
− | |||
|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="2"|Verificatie datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|22 sep 2021 10:00 |
+ | |} | ||
+ | === Zorgaanbieder === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgaanbieder | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Zorgaanbieder identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
− | | | + | |} |
− | + | === Zwangerschapsgegevens === | |
− | |-style=" | + | |
− | | | + | {| class="wikitable" width="85%" |
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zwangerschapsgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Graviditeit |
− | |style="background-color: white;"| | + | |style="background-color: white;"|5 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Pariteit voor deze zwangerschap |
− | |style="background-color: white;"| | + | |style="background-color: white;"|4 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Complicaties tijdens zwangerschap | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="9"| |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Complicaties zwangerschap? |
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|preterm en prematuur gebroken vliezen (aandoening) (code = '312974005' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verificatie status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Magnesiumsulfaat |
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Antenatale steroiden gegeven? |
− | |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"| | + | |colspan="3"|Antenatale steroiden |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Complete steroid therapy for fetal lung maturation (procedure) (code = '255594003434601000124108' in codeSystem 'SNOMED CT') |
+ | |} | ||
+ | === Kind === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Kind | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="6" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Demografische gegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="8"| |
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Patient |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="6"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Identificatienummer | ||
+ | |style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Geboortedatum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2 feb 2020 14:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Geslacht |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor') |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Meerling indicator |
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Overlijdens indicator |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Bevallingsgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="4"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Zwangerschapsduur |
− | |style="background-color: white;"| | + | |style="background-color: white;"|177 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Type partus |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Sectio Caesarea (code = '11466000' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Locatie partus |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="7"| | + | |colspan="7"|Ondersteuning opvang |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="7"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Verrichting |
|-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="4"| | + | |colspan="4"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Opname gegevens |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="33"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Opname |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="7"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Opname datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2 feb 2020 14:30 |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Ic opname? |
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Heropname? |
− | |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"|Herkomst kind |
+ | |style="background-color: white;"|Hospital admission, transfer from other hospital or health care facility (procedure) (code = '4563007' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Opname indicatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Finding of length of gestation (finding) (code = '366323009' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Ontslag datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|17 jun 2020 12:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Onderzoek |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="23"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Lichaamsgewicht | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |rowspan="3"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="3"|Gewicht waarde | ||
+ | |style="background-color: white;"|710 g | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Gewicht datum tijd | ||
+ | |style="background-color: white;"|2 feb 2020 14:30 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Lichaamstemperatuur |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Temperatuur waarde |
+ | |style="background-color: white;"|36.7 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Temperatuur datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2 feb 2020 14:35 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Toelichting |
− | |style="background-color: white;"| | + | |style="background-color: white;"|geen bijzonderheden |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Temperatuur type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Orale temperatuur (onder de tong) (code = '415945006' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Schedelomvang |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Schedelomvang waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|25.5 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Schedelomvang datum tijd | ||
+ | |style="background-color: white;"|2 feb 2020 14:35 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Apgar score na 1 min |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Apgar score totaal |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Apgar score na 5 min |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Apgar score totaal |
+ | |style="background-color: white;"|4 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Nsp h arterieel |
− | |style="background-color: white;"| | + | |style="background-color: white;"|7.21 ph |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Be |
− | |style="background-color: white;"| | + | |style="background-color: white;"|-11 mmol/l |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Problematiek kind | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="124"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Geboortetrauma |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Ademhalingsondersteuning |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="15"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Ademhalingsondersteuning? |
|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"| | + | |colspan="5"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|toedienen van zuurstof via neusbril (verrichting) (code = '371907003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verrichting |
|-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=" | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Oxygen therapy using high flow oxygen nasal cannula (procedure) (code = '57485005:424226004=426854004' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Verrichting |
|-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="3"| | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Continuous positive airway pressure ventilation treatment (procedure) (code = '47545007' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |rowspan="2"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|Noninvasive ventilation (procedure) (code = '428311008' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|O2 op dag 28? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Respiratoir | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="21"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Probleem | |colspan="5"|Probleem | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="4"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Probleem naam | |colspan="3"|Probleem naam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Respiratory distress syndrome in the newborn (disorder) (code = '46775006' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem begin datum | ||
+ | |style="background-color: white;"|1 maa 2020 08:00 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Aanvang |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Probleem | |colspan="5"|Probleem | ||
Regel 2.041: | Regel 2.207: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Probleem naam | |colspan="3"|Probleem naam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Bronchopulmonary dysplasia of newborn - grade 3 (disorder) (code = '22041000146108' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |rowspan="2"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|Extracorporeal membrane oxygenation (procedure) (code = '233573008' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Medicatie |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Stimulatie ademhaling | ||
+ | |style="background-color: white;"|COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Surfactant |
− | | | + | |style="background-color: white;"|NATUURLIJKE FOSFOLIPIDEN - LONGSURFACTANTS (code = 'R07AA02' in codeSystem 'ATC-NL') |
− | | | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Systemische steroiden |
+ | |style="background-color: white;"|CORTICOSTEROIDEN VOOR SYSTEMISCH GEBRUIK - SYSTEMISCHE HORMOONPREPARATEN, EXCL GESLACHTSHORMONEN (code = 'H02' in codeSystem 'ATC-NL') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Medicatie |
|-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=" | + | |colspan="3"|Stimulatie ademhaling |
− | |style="background-color: white;"| | + | |style="background-color: white;"|DOXAPRAM (code = 'R07AB01' in codeSystem 'ATC-NL') |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Circulatoir |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
Regel 2.071: | Regel 2.243: | ||
|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"| | + | |colspan="5"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Low blood pressure (disorder) (code = '45007003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Infectieus |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="15"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Problemen aanwezig? | |colspan="4"|Problemen aanwezig? | ||
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="4"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|neonatale sepsis (aandoening) (code = '206376005' in codeSystem 'SNOMED CT') |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Lijnsepsis? |
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Onset |
− | |style="background-color: white;"| | + | |style="background-color: white;"|vroege neonatale periode (kwalificatiewaarde) (code = '303114002' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Probleem | |colspan="5"|Probleem | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Probleem naam | |colspan="3"|Probleem naam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|urineweginfectie (aandoening) (code = '68566005' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verificatie status | ||
+ | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Probleem | |colspan="5"|Probleem | ||
Regel 2.111: | Regel 2.285: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Probleem naam | |colspan="3"|Probleem naam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Neonatal pneumonia (disorder) (code = '233619008' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Antibiotica eerste 3 dagen? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Infuus |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="7"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Infuuskatheter | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="5"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Medisch hulpmiddel |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Begin datum |
+ | |style="background-color: white;"|2 feb 2020 17:00 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Einddatum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|5 maa 2020 08:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Gastrointestinaal |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="5"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Problemen aanwezig? | |colspan="4"|Problemen aanwezig? | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verrichting | |colspan="5"|Verrichting | ||
Regel 2.139: | Regel 2.320: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verrichting type | |colspan="3"|Verrichting type | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Hematologisch | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verrichting | |colspan="5"|Verrichting | ||
Regel 2.146: | Regel 2.334: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verrichting type | |colspan="3"|Verrichting type | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Treatment for trombocytopenia (procedure) (code = '59091000146106' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Metabool en endocrien |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="14"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Problemen aanwezig? | |colspan="4"|Problemen aanwezig? | ||
Regel 2.157: | Regel 2.345: | ||
|colspan="5"|Probleem | |colspan="5"|Probleem | ||
|-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="3"|Probleem naam | |colspan="3"|Probleem naam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Probleem | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Hypoglycemia (disorder) (code = '302866003' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Intravenous infusion of glucose in hypoglycemia (procedure) (code = '109091000146105' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Neurologisch |
|-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="4"|Problemen aanwezig? |
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming van hoofd (verrichting) (code = '241449005' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|'magnetic resonance imaging' van hoofd (verrichting) (code = '241601008' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Zintuigen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="15"| | |rowspan="15"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="5"|Probleem | |
− | |||
− | |||
− | |||
− | |colspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Plus disease (disorder) (code = '56341000146109' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Verificatie status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Rop screening verricht? |
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Rop screening afgesloten? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Aabr verricht? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Aabr afwijkend? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Bera verricht? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Bera |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Bera afwijkend? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Bera lateraliteit |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Links (code = '7771000' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="7"| | + | |colspan="7"|Ontslagoverplaatsing |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="15"| |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="5"|Nog opgenomen? | |
− | |||
− | |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="5"|Bestemming kind |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Discharge to other hospital (procedure) (code = '115851000146108' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Lichamelijk onderzoek |
|-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="5"|Lichaamsgewicht |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Gewicht waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|4 kg |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Gewicht datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|17 jun 2020 09:00 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Schedelomvang | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="4"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Schedelomvang meetmethode |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Meten van schedelomvang m.b.v. echografisch onderzoek (code = '31561000146107' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Schedelomvang waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|34.6 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Schedelomvang datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|16 jun 2020 10:20 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Voeding kind |
− | |style="background-color: white;"| | + | |style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Mortaliteit |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Overlijden lt12 uur na opname nicu? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Overleden op verloskamer? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
− | + | |-style="vertical-align:top; background-color: #E3E3E3;;" | |
− | + | |colspan="7"|Follow up | |
− | |||
− | |||
− | |||
− | |||
− | |style=" | ||
− | |||
− | |colspan=" | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="21"| |
− | |style=" | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
− | + | |colspan="6"|Na ontslag | |
− | + | |-style="vertical-align:top; background-color: #E3E3E3;;" | |
− | + | |rowspan="19"| | |
− | |||
− | |||
− | |-style="background-color: # | ||
− | | | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|O2 op dag 28? |
− | + | |style="background-color: white;"|Nee | |
− | |||
− | |||
− | |||
− | |||
− | |||
− | | | ||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Gradatie bpd |
+ | |style="background-color: white;"|Bronchopulmonary dysplasia of newborn - grade 1 (disorder) (code = '22021000146102' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Zintuigen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="15"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
− | + | |-style="vertical-align:top; background-color: #E3E3E3;;" | |
− | + | |colspan="4"|Probleem | |
− | + | |-style="vertical-align:top; background-color: #E3E3E3;;" | |
− | + | |rowspan="3"| | |
− | |style="background-color: # | ||
− | |-style="background-color: # | ||
− | | | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Plus disease (disorder) (code = '56341000146109' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verificatie status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Rop screening verricht? |
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="3"|Rop screening afgesloten? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
− | |} | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
− | === | + | |colspan="3"|Aabr verricht? |
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Aabr afwijkend? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Bera verricht? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Bera | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Bera afwijkend? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Bera lateraliteit | ||
+ | |style="background-color: white;"|Links (code = '7771000' in codeSystem 'SNOMED CT') | ||
+ | |} | ||
+ | ==Scenario Testscenario 6: overleden op verloskamer == | ||
+ | |||
+ | === Documentgegevens === | ||
{| 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" | Documentgegevens |
|-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"|Verificatie zorgverlener |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Geverifieerd door zorgverlener? |
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="2"|Verificatie datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
+ | |} | ||
+ | === Zorgaanbieder === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgaanbieder | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Zorgaanbieder identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
+ | |} | ||
+ | === Vrouw === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Vrouw | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Demografische gegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="5"| |
− | |style="background-color: | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="4"|Patient | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="3"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|000000000 (in identificerend systeem: BSN) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Geboortedatum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|12 dec 1991 |
− | | | + | |} |
− | |colspan=" | + | === Zwangerschapsgegevens === |
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschapsgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Graviditeit |
+ | |style="background-color: white;"|2 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Pariteit voor deze zwangerschap |
− | |||
− | |||
− | |||
|style="background-color: white;"|1 | |style="background-color: white;"|1 | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Complicaties tijdens zwangerschap |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Complicaties zwangerschap? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
+ | |} | ||
+ | === Kind === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Kind | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="5" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Demografische gegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="9"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Patient |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="7"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999) |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Geboortedatum |
+ | |style="background-color: white;"|27 nov 2020 13:20 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Geslacht |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') |
− | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
− | |colspan=" | + | |colspan="3"|Meerling indicator |
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Overlijdens indicator |
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Datum overlijden |
− | |style="background-color: white;"| | + | |style="background-color: white;"|27 nov 2020 19:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Bevallingsgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan | + | |rowspan="5"| |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Zwangerschapsduur |
+ | |style="background-color: white;"|266 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Aantal geboren kinderen |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Type partus |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Locatie partus |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Ondersteuning opvang |
|-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="5"| | + | |colspan="5"|Verrichting |
|-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="3"|Verrichting type |
− | + | |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | |
− | |||
− | |style="background-color: white;"| | ||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|mechanische thoraxcompressies (verrichting) (code = '33631000146101' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|injectie van adrenaline (verrichting) (code = '313191000' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Opname gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="21"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Opname | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Opname datum | ||
+ | |style="background-color: white;"|27 nov 2020 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Ic opname? | ||
+ | |style="background-color: white;"|NullFlavor: NA | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Heropname? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|NullFlavor: NA |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Ontslag datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|27 nov 2020 19:00 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Onderzoek |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="13"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Lichaamsgewicht |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Gewicht waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|3100 g |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="2"|Gewicht datum tijd |
− | |style="background-color: white;"|NullFlavor: | + | |style="background-color: white;"|27 nov 2020 13:30 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Apgar score na 1 min | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Apgar score totaal | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Apgar score na 5 min | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Apgar score totaal | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Nsp h arterieel | ||
+ | |style="background-color: white;"|7.13 ph | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Be | ||
+ | |style="background-color: white;"|-6.9 mmol/l | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Problematiek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="19"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ademhalingsondersteuning | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Ademhalingsondersteuning? | ||
+ | |style="background-color: white;"|NullFlavor: NI | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Circulatoir | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Infectieus | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Hematologisch | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zintuigen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Congenitale aandoeningen | |colspan="5"|Congenitale aandoeningen |
Huidige versie van 23 sep 2021 om 11:29
1 Addenda voor inhoudelijke gegevens Kernset Neonatologie 3.0
1.1 Scenario Testscenario 1: uitgebreide problematiek
1.1.1 Documentgegevens
Documentgegevens | |||
Gegevenselement | Waarde | ||
Identificatie | 0000 (in identificerend systeem: abc123) | ||
Document datum | 22 sep 2021 08:48 | ||
Set identificatie | 0000 (in identificerend systeem: abc123) | ||
Versienummer | 1 | ||
Software naam | InformatieSysteemX | ||
Verificatie zorgverlener | |||
Geverifieerd door zorgverlener? | Ja | ||
Verificatie datum | 21 sep 2021 15:01 |
1.1.2 Zorgaanbieder
Zorgaanbieder | ||
Gegevenselement | Waarde | |
Zorgaanbieder identificatienummer | 0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) | |
Zorgaanbieder identificatienummer | 0000 (in identificerend systeem: AGB-Z) | |
Zorgaanbieder identificatienummer | 0000 (in identificerend systeem: URA) |
1.1.3 Zorgverlener
Zorgverlener | ||||
Gegevenselement | Waarde | |||
Zorgverlener identificatienummer | 0000 (in identificerend systeem: 2.16.528.1.1007.5.1) | |||
Naamgegevens | ||||
Voornamen | Hans Peter | |||
Initialen | HP | |||
Roepnaam | Hans | |||
Naamgebruik | Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
Geslachtsnaam | ||||
Voorvoegsels | van den | |||
Achternaam | Akker | |||
Geslachtsnaam partner | ||||
Achternaam partner | Pieterse |
1.1.4 Vrouw
Vrouw | ||||
Gegevenselement | Waarde | |||
Demografische gegevens | ||||
Patient | ||||
Identificatienummer | 000000000 (in identificerend systeem: BSN) | |||
Geboortedatum | 11 mei 1993 |
1.1.5 Zwangerschapsgegevens
Zwangerschapsgegevens | ||||
Gegevenselement | Waarde | |||
Graviditeit | 1 | |||
Pariteit voor deze zwangerschap | 0 | |||
Complicaties tijdens zwangerschap | ||||
Complicaties zwangerschap? | Ja | |||
Probleem | ||||
Probleem naam | koorts (code = '386661006' in codeSystem 'SNOMED CT') | |||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||
Magnesiumsulfaat | Ja | |||
Antenatale steroiden gegeven? | Nee |
1.1.6 Kind
Kind | |||||
Gegevenselement | Waarde | ||||
Demografische gegevens | |||||
Patient | |||||
Identificatienummer | 123 (in identificerend systeem: 1.2.3.999) | ||||
Geboortedatum | 7 maa 2020 12:13 | ||||
Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
Meerling indicator | Ja | ||||
Rangnummer kind | 2 | ||||
Overlijdens indicator | Nee | ||||
Bevallingsgegevens | |||||
Zwangerschapsduur | 179 dagen | ||||
Aantal geboren kinderen | 2 | ||||
Type partus | Primair (code = '177141003' in codeSystem 'SNOMED CT') | ||||
Locatie partus | Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') | ||||
Zorgaanbieder | |||||
Zorgaanbieder identificatienummer | 0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) | ||||
Organisatie naam | UMC Papendorp | ||||
Ondersteuning opvang | |||||
Verrichting | |||||
Verrichting type | Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | ||||
Verrichting | |||||
Verrichting type | endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT') | ||||
Opname gegevens | |||||
Opname | |||||
Opname datum | 7 maa 2020 13:30 | ||||
Ic opname? | Ja | ||||
Heropname? | Nee | ||||
Herkomst kind | In-hospital admission from obstetrical ward (procedure) (code = '59151000146103' in codeSystem 'SNOMED CT') | ||||
Opname indicatie | Finding of length of gestation (finding) (code = '366323009' in codeSystem 'SNOMED CT') | ||||
Ontslag datum | 5 mei 2020 12:00 | ||||
Onderzoek | |||||
Lichaamslengte | |||||
Lengte waarde | 31 cm | ||||
Lengte datum tijd | 7 maa 2020 13:20 | ||||
Lichaamsgewicht | |||||
Gewicht waarde | 710 g | ||||
Gewicht datum tijd | 7 maa 2020 13:21 | ||||
Lichaamstemperatuur | |||||
Temperatuur waarde | 37.4 graden celsius | ||||
Temperatuur datum tijd | 7 maa 2020 13:22 | ||||
Toelichting | abc | ||||
Temperatuur type | Rectale temperatuur (code = '307047009' in codeSystem 'SNOMED CT') | ||||
Schedelomvang | |||||
Schedelomvang waarde | 22.5 cm | ||||
Schedelomvang datum tijd | 7 maa 2020 13:23 | ||||
Apgar score na 1 min | |||||
Apgar score totaal | 1 | ||||
Apgar score na 5 min | |||||
Apgar score totaal | 5 | ||||
Nsp h arterieel | 7.05 ph | ||||
Be | -12.0 mmol/l | ||||
Problematiek kind | |||||
Geboortetrauma | |||||
Problemen aanwezig? | Nee | ||||
Ademhalingsondersteuning | |||||
Ademhalingsondersteuning? | Ja | ||||
Verrichting | |||||
Verrichting start datum | 7 maa 2020 13:35 | ||||
Verrichting eind datum | 3 mei 2020 12:00 | ||||
Verrichting type | Oxygen therapy using high flow oxygen nasal cannula (procedure) (code = '57485005:424226004=426854004' in codeSystem 'SNOMED CT') | ||||
Verrichting | |||||
Verrichting start datum | 3 mei 2020 12:00 | ||||
Verrichting eind datum | 5 mei 2020 10:00 | ||||
Verrichting type | Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | ||||
O2 op dag 28? | Ja | ||||
Respiratoir | |||||
Problemen aanwezig? | Ja | ||||
Probleem | |||||
Probleem naam | Respiratory distress syndrome in the newborn (disorder) (code = '46775006' in codeSystem 'SNOMED CT') | ||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||||
Aanvang | Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT') | ||||
Medicatie | |||||
Stimulatie ademhaling | COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL') | ||||
Surfactant | NATUURLIJKE FOSFOLIPIDEN - LONGSURFACTANTS (code = 'R07AA02' in codeSystem 'ATC-NL') | ||||
Medicatie | |||||
Stimulatie ademhaling | DOXAPRAM (code = 'R07AB01' in codeSystem 'ATC-NL') | ||||
Circulatoir | |||||
Problemen aanwezig? | Ja | ||||
Probleem | |||||
Probleem naam | Patent ductus arteriosus (disorder) (code = '83330001' in codeSystem 'SNOMED CT') | ||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||||
Verrichting | |||||
Verrichting type | Drug therapy for patent ductus arteriosus (procedure) (code = '58801000146104' in codeSystem 'SNOMED CT') | ||||
Infectieus | |||||
Problemen aanwezig? | Ja | ||||
Probleem | |||||
Probleem naam | Suspected sepsis (situation) (code = '9331000146100' in codeSystem 'SNOMED CT') | ||||
Probleem begin datum | 8 maa 2020 | ||||
Probleem eind datum | 11 maa 2020 | ||||
Verificatie status | Werk (code = '415684004' in codeSystem 'SNOMED CT') | ||||
Aanvang | Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT') | ||||
Microorganisme sepsis meningitis | Other, specify (code = 'OTH' in codeSystem 'HL7 NullFlavor'): abc | ||||
Lijnsepsis? | Nee | ||||
Onset | vroege neonatale periode (kwalificatiewaarde) (code = '303114002' in codeSystem 'SNOMED CT') | ||||
Antibiotica eerste 3 dagen? | Ja | ||||
Gastrointestinaal | |||||
Problemen aanwezig? | Ja | ||||
Verrichting | |||||
Verrichting type | Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT') | ||||
Hematologisch | |||||
Problemen aanwezig? | Ja | ||||
Verrichting | |||||
Verrichting type | Transfusion for anemia (procedure) (code = '59071000146107' in codeSystem 'SNOMED CT') | ||||
Metabool en endocrien | |||||
Problemen aanwezig? | Ja | ||||
Probleem | |||||
Probleem naam | hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT') | ||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||||
Verrichting | |||||
Verrichting type | Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT') | ||||
Neurologisch | |||||
Problemen aanwezig? | Nee | ||||
Zintuigen | |||||
Problemen aanwezig? | Ja | ||||
Probleem | |||||
Probleem naam | Retinopathy of prematurity stage 2 - intraretinal ridge (disorder) (code = '408848001' in codeSystem 'SNOMED CT') | ||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||||
Rop screening verricht? | Ja | ||||
Rop screening afgesloten? | Ja | ||||
Aabr verricht? | Ja | ||||
Aabr afwijkend? | Ja | ||||
Bera verricht? | Nee | ||||
Congenitale aandoeningen | |||||
Problemen aanwezig? | Nee | ||||
Ontslagoverplaatsing | |||||
Nog opgenomen? | Nee | ||||
Bestemming kind | Discharge to other hospital (procedure) (code = '115851000146108' in codeSystem 'SNOMED CT') | ||||
Lichamelijk onderzoek | |||||
Lichaamsgewicht | |||||
Gewicht waarde | 1740 gram | ||||
Gewicht datum tijd | 5 mei 2020 09:00 | ||||
Schedelomvang | |||||
Schedelomvang meetmethode | Meten van schedelomvang m.b.v. meetlint (code = '31551000146109' in codeSystem 'SNOMED CT') | ||||
Schedelomvang waarde | 30 cm | ||||
Schedelomvang datum tijd | 5 mei 2020 09:01 | ||||
Voeding kind | niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') | ||||
Mortaliteit | |||||
Overlijden lt12 uur na opname nicu? | Nee | ||||
Overleden op verloskamer? | Nee | ||||
Staken icbehandeling? | Nee | ||||
Follow up | |||||
Na ontslag | |||||
O2 op dag 28? | Nee | ||||
Gradatie bpd | niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') | ||||
Zintuigen | |||||
Problemen aanwezig? | NullFlavor: UNK |
1.2 Scenario Testscenario 2: geb.trauma + neurologisch + anat afw + overlijden
1.2.1 Documentgegevens
Documentgegevens | |||
Gegevenselement | Waarde | ||
Identificatie | 0000 (in identificerend systeem: abc123) | ||
Document datum | |||
Set identificatie | 0000 (in identificerend systeem: abc123) | ||
Versienummer | 2 | ||
Software naam | XIS | ||
Verificatie zorgverlener | |||
Geverifieerd door zorgverlener? | Ja | ||
Verificatie datum |
1.2.2 Zorgaanbieder
Zorgaanbieder | ||
Gegevenselement | Waarde | |
Zorgaanbieder identificatienummer | 0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) |
1.2.3 Zorgverlener
Zorgverlener | ||||
Gegevenselement | Waarde | |||
Zorgverlener identificatienummer | 0000 (in identificerend systeem: UZI Personen) | |||
Naamgegevens | ||||
Voornamen | Hans Paul | |||
Initialen | H.P. | |||
Roepnaam | Hans | |||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
Geslachtsnaam | ||||
Achternaam | Pieterse |
1.2.4 Vrouw
Vrouw | ||||
Gegevenselement | Waarde | |||
Demografische gegevens | ||||
Patient | ||||
Identificatienummer | (in identificerend systeem: BSN) | |||
Geboortedatum | 1994 |
1.2.5 Zwangerschapsgegevens
Zwangerschapsgegevens | ||||
Gegevenselement | Waarde | |||
Graviditeit | 3 | |||
Pariteit voor deze zwangerschap | 2 | |||
Complicaties tijdens zwangerschap | ||||
Complicaties zwangerschap? | Ja | |||
Probleem | ||||
Probleem naam | hypertensieve aandoening (aandoening) (code = '38341003' in codeSystem 'SNOMED CT') | |||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||
Magnesiumsulfaat | Nee | |||
Antenatale steroiden gegeven? | NullFlavor: NA |
1.2.6 Kind
Kind | ||||||
Gegevenselement | Waarde | |||||
Demografische gegevens | ||||||
Patient | ||||||
Identificatienummer | 123 (in identificerend systeem: 1.2.3.999) | |||||
Geboortedatum | 26 mei 2020 10:44 | |||||
Geslacht | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |||||
Meerling indicator | Nee | |||||
Overlijdens indicator | Ja | |||||
Datum overlijden | 26 mei 2020 21:00 | |||||
Bevallingsgegevens | ||||||
Zwangerschapsduur | 254 dagen | |||||
Aantal geboren kinderen | 1 | |||||
Type partus | Primair (code = '177141003' in codeSystem 'SNOMED CT') | |||||
Locatie partus | Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') | |||||
Zorgaanbieder | ||||||
Zorgaanbieder identificatienummer | 234 (in identificerend systeem: AGB-Z) | |||||
Organisatie naam | UMC Papendorp | |||||
Ondersteuning opvang | ||||||
Verrichting | ||||||
Verrichting type | endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT') | |||||
Opname gegevens | ||||||
Opname | ||||||
Opname datum | 26 mei 2020 | |||||
Ic opname? | Ja | |||||
Heropname? | Nee | |||||
Herkomst kind | In-hospital admission from obstetrical ward (procedure) (code = '59151000146103' in codeSystem 'SNOMED CT') | |||||
Opname indicatie | Perinatal asphyxia (disorder) (code = '281578009' in codeSystem 'SNOMED CT') | |||||
Opname indicatie | Infant in poor condition at birth (finding) (code = '276707008' in codeSystem 'SNOMED CT') | |||||
Opname indicatie | Congenital disease (disorder) (code = '66091009' in codeSystem 'SNOMED CT') | |||||
Ontslag datum | 26 mei 2020 | |||||
Onderzoek | ||||||
Lichaamsgewicht | ||||||
Gewicht waarde | 3870 g | |||||
Gewicht datum tijd | 26 mei 2020 11:01 | |||||
Lichaamstemperatuur | ||||||
Temperatuur waarde | 36.1 graden celsius | |||||
Temperatuur datum tijd | 26 mei 2020 11:02 | |||||
Temperatuur type | Rectale temperatuur (code = '307047009' in codeSystem 'SNOMED CT') | |||||
Apgar score na 1 min | ||||||
Apgar score totaal | 0 | |||||
Apgar score na 5 min | ||||||
Apgar score totaal | 2 | |||||
Problematiek kind | ||||||
Geboortetrauma | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Spinal cord injury due to birth trauma (disorder) (code = '698500002' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Ademhalingsondersteuning | ||||||
Ademhalingsondersteuning? | Ja | |||||
Verrichting | ||||||
Verrichting start datum | 26 mei 2020 11:16 | |||||
Verrichting type | Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | |||||
O2 op dag 28? | NullFlavor: NA | |||||
Respiratoir | ||||||
Problemen aanwezig? | Nee | |||||
Circulatoir | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Neonatal hypotension (disorder) (code = '276519002' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Infectieus | ||||||
Problemen aanwezig? | Ja | |||||
Gastrointestinaal | ||||||
Problemen aanwezig? | Nee | |||||
Hematologisch | ||||||
Problemen aanwezig? | Ja | |||||
Metabool en endocrien | ||||||
Problemen aanwezig? | Nee | |||||
Neurologisch | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Neonatal encephalopathy (disorder) (code = '95628005' in codeSystem 'SNOMED CT') | |||||
Ernst encefalopathie | Ernstig (code = '24484000' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Probleem | ||||||
Probleem naam | asfyxie bij geboorte (code = '413654009' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Probleem | ||||||
Probleem naam | Intraventricular (nontraumatic) hemorrhage, grade 2, of fetus and newborn (disorder) (code = '206396002' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | echografische beeldvorming van hoofd (verrichting) (code = '241449005' in codeSystem 'SNOMED CT') | |||||
Zintuigen | ||||||
Problemen aanwezig? | NullFlavor: UNK | |||||
Congenitale aandoeningen | ||||||
Problemen aanwezig? | Ja | |||||
Aangeboren anatomische afwijkingen majorsyndromen | ||||||
Probleem | ||||||
Probleem naam | Overige congenitale afwijkingen zenuwstelsel (code = '09' in codeSystem '2.16.840.1.113883.2.4.4.13.8') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Ontslagoverplaatsing | ||||||
Nog opgenomen? | Nee | |||||
Voeding kind | niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') | |||||
Mortaliteit | ||||||
Overlijden lt12 uur na opname nicu? | Ja | |||||
Overleden op verloskamer? | Nee | |||||
Oorzaak overlijden | multiorgaanfalen (aandoening) (code = '57653000' in codeSystem 'SNOMED CT') | |||||
Staken icbehandeling? | Ja |
1.3 Scenario Testscenario 3: stofwisselingsziekte
1.3.1 Documentgegevens
Documentgegevens | |||
Gegevenselement | Waarde | ||
Identificatie | 0000 (in identificerend systeem: abc123) | ||
Document datum | 22 sep 2021 09:00 | ||
Set identificatie | 0000 (in identificerend systeem: abc123) | ||
Versienummer | 3 | ||
Software naam | XIS | ||
Verificatie zorgverlener | |||
Geverifieerd door zorgverlener? | Nee | ||
Verificatie datum |
1.3.2 Zorgaanbieder
Zorgaanbieder | ||
Gegevenselement | Waarde | |
Zorgaanbieder identificatienummer | 0000 (in identificerend systeem: AGB-Z) | |
Zorgaanbieder identificatienummer | (in identificerend systeem: URA) |
1.3.3 Zorgverlener
Zorgverlener | ||||
Gegevenselement | Waarde | |||
Zorgverlener identificatienummer | 0000 (in identificerend systeem: AGB-Z) | |||
Naamgegevens | ||||
Voornamen | Hans Peter | |||
Initialen | HP | |||
Roepnaam | Hans | |||
Naamgebruik | Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor') | |||
Geslachtsnaam | ||||
Voorvoegsels | van de | |||
Achternaam | Velde |
1.3.4 Zwangerschapsgegevens
Zwangerschapsgegevens | |||
Gegevenselement | Waarde | ||
Graviditeit | 4 | ||
Pariteit voor deze zwangerschap | 2 | ||
Complicaties tijdens zwangerschap | |||
Complicaties zwangerschap? | Ja | ||
Antenatale steroiden gegeven? | Ja | ||
Antenatale steroiden | Complete steroid therapy for fetal lung maturation (procedure) (code = '255594003434601000124108' in codeSystem 'SNOMED CT') |
1.3.5 Kind
Kind | ||||||
Gegevenselement | Waarde | |||||
Demografische gegevens | ||||||
Patient | ||||||
Identificatienummer | 123 (in identificerend systeem: 1.2.3.999) | |||||
Geboortedatum | 2 jul 2020 06:55 | |||||
Geslacht | Ongedifferentieerd (code = 'UN' in codeSystem 'HL7 AdministrativeGender') | |||||
Overlijdens indicator | Nee | |||||
Bevallingsgegevens | ||||||
Zwangerschapsduur | 215 dagen | |||||
Aantal geboren kinderen | 1 | |||||
Type partus | Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | |||||
Locatie partus | Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') | |||||
Opname gegevens | ||||||
Opname | ||||||
Opname datum | 16 sep 2020 | |||||
Ic opname? | Nee | |||||
Heropname? | Ja | |||||
Herkomst kind | Hospital admission from home or birth center (procedure) (code = '59141000146101' in codeSystem 'SNOMED CT') | |||||
Opname indicatie | Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): vaccinatie onder observatie | |||||
Ontslag datum | 16 sep 2020 | |||||
Onderzoek | ||||||
Lichaamslengte | ||||||
Lengte waarde | 43 cm | |||||
Lengte datum tijd | 16 sep 2020 09:30 | |||||
Lichaamsgewicht | ||||||
Gewicht waarde | 1800 g | |||||
Gewicht datum tijd | 16 sep 2020 09:30 | |||||
Lichaamstemperatuur | ||||||
Temperatuur waarde | 37.1 | |||||
Temperatuur datum tijd | 16 sep 2020 09:30 | |||||
Schedelomvang | ||||||
Schedelomvang waarde | 31 centimeter | |||||
Schedelomvang datum tijd | 16 sep 2020 09:32 | |||||
Nsp h arterieel | 7.35 ph | |||||
Be | 0.0 mmol/l | |||||
Problematiek kind | ||||||
Congenitale aandoeningen | ||||||
Problemen aanwezig? | Ja | |||||
Stofwisselingsziekten | ||||||
Probleem | ||||||
Probleem naam | stoornis van mineraalstofwisseling (aandoening) (code = '45744005' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Differentiaal (code = '410590009' in codeSystem 'SNOMED CT') | |||||
Ontslagoverplaatsing | ||||||
Nog opgenomen? | Nee | |||||
Bestemming kind | Discharge to home (procedure) (code = '306689006' in codeSystem 'SNOMED CT') | |||||
Voeding kind | moedermelk (substantie) (code = '226789007' in codeSystem 'SNOMED CT') | |||||
Ondersteuning bij ontslag naar huis | monitoren met cardiotachometer (regime/therapie) (code = '63818009' in codeSystem 'SNOMED CT') | |||||
Mortaliteit | ||||||
Overlijden lt12 uur na opname nicu? | NullFlavor: NA | |||||
Overleden op verloskamer? | Nee | |||||
Staken icbehandeling? | NullFlavor: NA |
1.4 Scenario Testscenario 4: gastro + chirurgie
1.4.1 Documentgegevens
Documentgegevens | |||
Gegevenselement | Waarde | ||
Identificatie | 0000 | ||
Document datum | 22 sep 2021 10:00 | ||
Set identificatie | 0000 | ||
Versienummer | 1 | ||
Software naam | InformatieSysteemX | ||
Verificatie zorgverlener | |||
Geverifieerd door zorgverlener? | NullFlavor: NI | ||
Verificatie datum |
1.4.2 Zorgaanbieder
Zorgaanbieder | ||
Gegevenselement | Waarde | |
Zorgaanbieder identificatienummer | 0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) |
1.4.3 Vrouw
Vrouw | ||||
Gegevenselement | Waarde | |||
Demografische gegevens | ||||
Patient | ||||
Identificatienummer | (in identificerend systeem: BSN) | |||
Geboortedatum |
1.4.4 Zwangerschapsgegevens
Zwangerschapsgegevens | ||
Gegevenselement | Waarde | |
Graviditeit | 1 | |
Pariteit voor deze zwangerschap | 0 |
1.4.5 Kind
Kind | ||||||
Gegevenselement | Waarde | |||||
Demografische gegevens | ||||||
Patient | ||||||
Identificatienummer | 123 (in identificerend systeem: 1.2.3.999) | |||||
Geboortedatum | 13 aug 2020 13:00 | |||||
Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |||||
Meerling indicator | Ja | |||||
Rangnummer kind | 2 | |||||
Overlijdens indicator | Nee | |||||
Bevallingsgegevens | ||||||
Zwangerschapsduur | 236 dagen | |||||
Aantal geboren kinderen | 2 | |||||
Type partus | Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | |||||
Locatie partus | Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') | |||||
Ondersteuning opvang | ||||||
Verrichting | ||||||
Verrichting type | Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | |||||
Opname gegevens | ||||||
Opname | ||||||
Opname datum | 20 aug 2020 | |||||
Ic opname? | Ja | |||||
Heropname? | Ja | |||||
Herkomst kind | Hospital admission, transfer from other hospital or health care facility (procedure) (code = '4563007' in codeSystem 'SNOMED CT') | |||||
Zorgaanbieder | ||||||
Zorgaanbieder identificatienummer | 0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) | |||||
Organisatie naam | AZ Papendorp | |||||
Opname indicatie | Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): abc | |||||
Ontslag datum | 28 okt 2020 | |||||
Onderzoek | ||||||
Lichaamslengte | ||||||
Lengte waarde | 43 cm | |||||
Lengte datum tijd | 16 sep 2020 09:30 | |||||
Lichaamsgewicht | ||||||
Gewicht waarde | 1530 g | |||||
Gewicht datum tijd | 20 aug 2020 09:30 | |||||
Problematiek kind | ||||||
Geboortetrauma | ||||||
Problemen aanwezig? | Nee | |||||
Ademhalingsondersteuning | ||||||
Ademhalingsondersteuning? | Ja | |||||
Verrichting | ||||||
Verrichting type | Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | |||||
O2 op dag 28? | Nee | |||||
Respiratoir | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Bronchopulmonary dysplasia of newborn (disorder) (code = '67569000' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Medicatie | ||||||
Stimulatie ademhaling | COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL') | |||||
Circulatoir | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Neonatal hypotension (disorder) (code = '276519002' in codeSystem 'SNOMED CT') | |||||
Infectieus | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | neonatale sepsis (aandoening) (code = '206376005' in codeSystem 'SNOMED CT') | |||||
Microorganisme sepsis meningitis | Listeria monocytogenes (organism) (code = '36094007' in codeSystem 'SNOMED CT') | |||||
Lijnsepsis? | Ja | |||||
Onset | late neonatale periode (kwalificatiewaarde) (code = '303115001' in codeSystem 'SNOMED CT') | |||||
Antibiotica eerste 3 dagen? | NullFlavor: NA | |||||
Infuus | ||||||
Infuuskatheter | ||||||
Medisch hulpmiddel | ||||||
Begin datum | 20 aug 2020 10:00 | |||||
Einddatum | 22 okt 2020 09:00 | |||||
Gastrointestinaal | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Necrotizing enterocolitis in fetus OR newborn - Bell stage IIIA (disorder) (code = '21941000146103' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | Laparotomy (procedure) (code = '86481000' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT') | |||||
Hematologisch | ||||||
Problemen aanwezig? | Ja | |||||
Verrichting | ||||||
Verrichting type | Transfusion for anemia (procedure) (code = '59071000146107' in codeSystem 'SNOMED CT') | |||||
Metabool en endocrien | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor') | |||||
Probleem | ||||||
Probleem naam | Hypoglycemia (disorder) (code = '302866003' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Differentiaal (code = '410590009' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | Intravenous infusion of glucose in hypoglycemia (procedure) (code = '109091000146105' in codeSystem 'SNOMED CT') | |||||
Zintuigen | ||||||
Problemen aanwezig? | NullFlavor: NI | |||||
Congenitale aandoeningen | ||||||
Problemen aanwezig? | Ja | |||||
Chirurgische ingrepen | ||||||
Verrichting | ||||||
Verrichting type | Endoscopie van oesofagus (verrichting) (code = '49230008' in codeSystem 'SNOMED CT') | |||||
Ontslagoverplaatsing | ||||||
Nog opgenomen? | Nee | |||||
Bestemming kind | Discharge to other location within hospital premises (procedure) (code = '115841000146105' in codeSystem 'SNOMED CT') | |||||
Lichamelijk onderzoek | ||||||
Lichaamsgewicht | ||||||
Gewicht waarde | 2800 gram | |||||
Gewicht datum tijd | 28 okt 2020 15:00 | |||||
Voeding kind | niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') | |||||
Mortaliteit | ||||||
Overlijden lt12 uur na opname nicu? | Nee | |||||
Overleden op verloskamer? | Nee |
1.5 Scenario Testscenario 5: zintuigen + FU
1.5.1 Documentgegevens
Documentgegevens | |||
Gegevenselement | Waarde | ||
Identificatie | 0000 | ||
Document datum | 22 sep 2021 11:00 | ||
Set identificatie | 0000 | ||
Versienummer | 1 | ||
Software naam | InformatieSysteemX | ||
Verificatie zorgverlener | |||
Geverifieerd door zorgverlener? | Ja | ||
Verificatie datum | 22 sep 2021 10:00 |
1.5.2 Zorgaanbieder
Zorgaanbieder | ||
Gegevenselement | Waarde | |
Zorgaanbieder identificatienummer |
1.5.3 Zwangerschapsgegevens
Zwangerschapsgegevens | ||||
Gegevenselement | Waarde | |||
Graviditeit | 5 | |||
Pariteit voor deze zwangerschap | 4 | |||
Complicaties tijdens zwangerschap | ||||
Complicaties zwangerschap? | Ja | |||
Probleem | ||||
Probleem naam | preterm en prematuur gebroken vliezen (aandoening) (code = '312974005' in codeSystem 'SNOMED CT') | |||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||
Magnesiumsulfaat | Ja | |||
Antenatale steroiden gegeven? | Ja | |||
Antenatale steroiden | Complete steroid therapy for fetal lung maturation (procedure) (code = '255594003434601000124108' in codeSystem 'SNOMED CT') |
1.5.4 Kind
Kind | ||||||
Gegevenselement | Waarde | |||||
Demografische gegevens | ||||||
Patient | ||||||
Identificatienummer | 123 (in identificerend systeem: 1.2.3.999) | |||||
Geboortedatum | 2 feb 2020 14:00 | |||||
Geslacht | Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor') | |||||
Meerling indicator | Nee | |||||
Overlijdens indicator | Nee | |||||
Bevallingsgegevens | ||||||
Zwangerschapsduur | 177 dagen | |||||
Type partus | Sectio Caesarea (code = '11466000' in codeSystem 'SNOMED CT') | |||||
Locatie partus | Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') | |||||
Ondersteuning opvang | ||||||
Verrichting | ||||||
Verrichting type | Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT') | |||||
Opname gegevens | ||||||
Opname | ||||||
Opname datum | 2 feb 2020 14:30 | |||||
Ic opname? | Ja | |||||
Heropname? | Nee | |||||
Herkomst kind | Hospital admission, transfer from other hospital or health care facility (procedure) (code = '4563007' in codeSystem 'SNOMED CT') | |||||
Opname indicatie | Finding of length of gestation (finding) (code = '366323009' in codeSystem 'SNOMED CT') | |||||
Ontslag datum | 17 jun 2020 12:00 | |||||
Onderzoek | ||||||
Lichaamsgewicht | ||||||
Gewicht waarde | 710 g | |||||
Gewicht datum tijd | 2 feb 2020 14:30 | |||||
Lichaamstemperatuur | ||||||
Temperatuur waarde | 36.7 | |||||
Temperatuur datum tijd | 2 feb 2020 14:35 | |||||
Toelichting | geen bijzonderheden | |||||
Temperatuur type | Orale temperatuur (onder de tong) (code = '415945006' in codeSystem 'SNOMED CT') | |||||
Schedelomvang | ||||||
Schedelomvang waarde | 25.5 | |||||
Schedelomvang datum tijd | 2 feb 2020 14:35 | |||||
Apgar score na 1 min | ||||||
Apgar score totaal | 1 | |||||
Apgar score na 5 min | ||||||
Apgar score totaal | 4 | |||||
Nsp h arterieel | 7.21 ph | |||||
Be | -11 mmol/l | |||||
Problematiek kind | ||||||
Geboortetrauma | ||||||
Problemen aanwezig? | Nee | |||||
Ademhalingsondersteuning | ||||||
Ademhalingsondersteuning? | Ja | |||||
Verrichting | ||||||
Verrichting type | toedienen van zuurstof via neusbril (verrichting) (code = '371907003' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | Oxygen therapy using high flow oxygen nasal cannula (procedure) (code = '57485005:424226004=426854004' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | Continuous positive airway pressure ventilation treatment (procedure) (code = '47545007' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | Noninvasive ventilation (procedure) (code = '428311008' in codeSystem 'SNOMED CT') | |||||
O2 op dag 28? | Ja | |||||
Respiratoir | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Respiratory distress syndrome in the newborn (disorder) (code = '46775006' in codeSystem 'SNOMED CT') | |||||
Probleem begin datum | 1 maa 2020 08:00 | |||||
Aanvang | Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT') | |||||
Probleem | ||||||
Probleem naam | Bronchopulmonary dysplasia of newborn - grade 3 (disorder) (code = '22041000146108' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | Extracorporeal membrane oxygenation (procedure) (code = '233573008' in codeSystem 'SNOMED CT') | |||||
Medicatie | ||||||
Stimulatie ademhaling | COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL') | |||||
Surfactant | NATUURLIJKE FOSFOLIPIDEN - LONGSURFACTANTS (code = 'R07AA02' in codeSystem 'ATC-NL') | |||||
Systemische steroiden | CORTICOSTEROIDEN VOOR SYSTEMISCH GEBRUIK - SYSTEMISCHE HORMOONPREPARATEN, EXCL GESLACHTSHORMONEN (code = 'H02' in codeSystem 'ATC-NL') | |||||
Medicatie | ||||||
Stimulatie ademhaling | DOXAPRAM (code = 'R07AB01' in codeSystem 'ATC-NL') | |||||
Circulatoir | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Low blood pressure (disorder) (code = '45007003' in codeSystem 'SNOMED CT') | |||||
Infectieus | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | neonatale sepsis (aandoening) (code = '206376005' in codeSystem 'SNOMED CT') | |||||
Lijnsepsis? | Nee | |||||
Onset | vroege neonatale periode (kwalificatiewaarde) (code = '303114002' in codeSystem 'SNOMED CT') | |||||
Probleem | ||||||
Probleem naam | urineweginfectie (aandoening) (code = '68566005' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Probleem | ||||||
Probleem naam | Neonatal pneumonia (disorder) (code = '233619008' in codeSystem 'SNOMED CT') | |||||
Antibiotica eerste 3 dagen? | Ja | |||||
Infuus | ||||||
Infuuskatheter | ||||||
Medisch hulpmiddel | ||||||
Begin datum | 2 feb 2020 17:00 | |||||
Einddatum | 5 maa 2020 08:00 | |||||
Gastrointestinaal | ||||||
Problemen aanwezig? | Ja | |||||
Verrichting | ||||||
Verrichting type | Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT') | |||||
Hematologisch | ||||||
Problemen aanwezig? | Ja | |||||
Verrichting | ||||||
Verrichting type | Treatment for trombocytopenia (procedure) (code = '59091000146106' in codeSystem 'SNOMED CT') | |||||
Metabool en endocrien | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT') | |||||
Probleem | ||||||
Probleem naam | Hypoglycemia (disorder) (code = '302866003' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | Intravenous infusion of glucose in hypoglycemia (procedure) (code = '109091000146105' in codeSystem 'SNOMED CT') | |||||
Neurologisch | ||||||
Problemen aanwezig? | Ja | |||||
Verrichting | ||||||
Verrichting type | echografische beeldvorming van hoofd (verrichting) (code = '241449005' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | 'magnetic resonance imaging' van hoofd (verrichting) (code = '241601008' in codeSystem 'SNOMED CT') | |||||
Zintuigen | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Plus disease (disorder) (code = '56341000146109' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Rop screening verricht? | Ja | |||||
Rop screening afgesloten? | Nee | |||||
Aabr verricht? | Ja | |||||
Aabr afwijkend? | Ja | |||||
Bera verricht? | Ja | |||||
Bera | ||||||
Bera afwijkend? | Ja | |||||
Bera lateraliteit | Links (code = '7771000' in codeSystem 'SNOMED CT') | |||||
Ontslagoverplaatsing | ||||||
Nog opgenomen? | Nee | |||||
Bestemming kind | Discharge to other hospital (procedure) (code = '115851000146108' in codeSystem 'SNOMED CT') | |||||
Lichamelijk onderzoek | ||||||
Lichaamsgewicht | ||||||
Gewicht waarde | 4 kg | |||||
Gewicht datum tijd | 17 jun 2020 09:00 | |||||
Schedelomvang | ||||||
Schedelomvang meetmethode | Meten van schedelomvang m.b.v. echografisch onderzoek (code = '31561000146107' in codeSystem 'SNOMED CT') | |||||
Schedelomvang waarde | 34.6 | |||||
Schedelomvang datum tijd | 16 jun 2020 10:20 | |||||
Voeding kind | niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') | |||||
Mortaliteit | ||||||
Overlijden lt12 uur na opname nicu? | Nee | |||||
Overleden op verloskamer? | Nee | |||||
Follow up | ||||||
Na ontslag | ||||||
O2 op dag 28? | Nee | |||||
Gradatie bpd | Bronchopulmonary dysplasia of newborn - grade 1 (disorder) (code = '22021000146102' in codeSystem 'SNOMED CT') | |||||
Zintuigen | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Plus disease (disorder) (code = '56341000146109' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Rop screening verricht? | Ja | |||||
Rop screening afgesloten? | Ja | |||||
Aabr verricht? | Ja | |||||
Aabr afwijkend? | Ja | |||||
Bera verricht? | Ja | |||||
Bera | ||||||
Bera afwijkend? | Ja | |||||
Bera lateraliteit | Links (code = '7771000' in codeSystem 'SNOMED CT') |
1.6 Scenario Testscenario 6: overleden op verloskamer
1.6.1 Documentgegevens
Documentgegevens | |||
Gegevenselement | Waarde | ||
Verificatie zorgverlener | |||
Geverifieerd door zorgverlener? | Ja | ||
Verificatie datum |
1.6.2 Zorgaanbieder
Zorgaanbieder | ||
Gegevenselement | Waarde | |
Zorgaanbieder identificatienummer |
1.6.3 Vrouw
Vrouw | ||||
Gegevenselement | Waarde | |||
Demografische gegevens | ||||
Patient | ||||
Identificatienummer | 000000000 (in identificerend systeem: BSN) | |||
Geboortedatum | 12 dec 1991 |
1.6.4 Zwangerschapsgegevens
Zwangerschapsgegevens | |||
Gegevenselement | Waarde | ||
Graviditeit | 2 | ||
Pariteit voor deze zwangerschap | 1 | ||
Complicaties tijdens zwangerschap | |||
Complicaties zwangerschap? | Nee |
1.6.5 Kind
Kind | |||||
Gegevenselement | Waarde | ||||
Demografische gegevens | |||||
Patient | |||||
Identificatienummer | 123 (in identificerend systeem: 1.2.3.999) | ||||
Geboortedatum | 27 nov 2020 13:20 | ||||
Geslacht | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | ||||
Meerling indicator | Nee | ||||
Overlijdens indicator | Ja | ||||
Datum overlijden | 27 nov 2020 19:00 | ||||
Bevallingsgegevens | |||||
Zwangerschapsduur | 266 dagen | ||||
Aantal geboren kinderen | 1 | ||||
Type partus | Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | ||||
Locatie partus | Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') | ||||
Ondersteuning opvang | |||||
Verrichting | |||||
Verrichting type | Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | ||||
Verrichting | |||||
Verrichting type | mechanische thoraxcompressies (verrichting) (code = '33631000146101' in codeSystem 'SNOMED CT') | ||||
Verrichting | |||||
Verrichting type | injectie van adrenaline (verrichting) (code = '313191000' in codeSystem 'SNOMED CT') | ||||
Opname gegevens | |||||
Opname | |||||
Opname datum | 27 nov 2020 | ||||
Ic opname? | NullFlavor: NA | ||||
Heropname? | NullFlavor: NA | ||||
Ontslag datum | 27 nov 2020 19:00 | ||||
Onderzoek | |||||
Lichaamsgewicht | |||||
Gewicht waarde | 3100 g | ||||
Gewicht datum tijd | 27 nov 2020 13:30 | ||||
Apgar score na 1 min | |||||
Apgar score totaal | 1 | ||||
Apgar score na 5 min | |||||
Apgar score totaal | 1 | ||||
Nsp h arterieel | 7.13 ph | ||||
Be | -6.9 mmol/l | ||||
Problematiek kind | |||||
Ademhalingsondersteuning | |||||
Ademhalingsondersteuning? | NullFlavor: NI | ||||
Circulatoir | |||||
Problemen aanwezig? | Nee | ||||
Infectieus | |||||
Problemen aanwezig? | Nee | ||||
Hematologisch | |||||
Problemen aanwezig? | Nee | ||||
Zintuigen | |||||
Problemen aanwezig? | Nee | ||||
Congenitale aandoeningen | |||||
Problemen aanwezig? | Nee | ||||
Mortaliteit | |||||
Overlijden lt12 uur na opname nicu? | NullFlavor: NA | ||||
Overleden op verloskamer? | Ja | ||||
Oorzaak overlijden | ernstige asfyxie bij geboorte (aandoening) (code = '57284007' in codeSystem 'SNOMED CT') | ||||
Staken icbehandeling? | NullFlavor: NA |