Gebz:Vdraft AddendaKwalificatieKernsetGeboortezorg23: verschil tussen versies

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Regel 16: Regel 16:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Burgerservicenummer
 
|colspan="2"|Burgerservicenummer
|style="background-color: white;"|
+
|style="background-color: white;"|999910413
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Lokale persoonsidentificatie
 
|colspan="2"|Lokale persoonsidentificatie
|style="background-color: white;"|
+
|style="background-color: white;"|000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Geboortedatum
 
|colspan="2"|Geboortedatum
|style="background-color: white;"|
+
|style="background-color: white;"|1976-05-02
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Adres - postcode
 
|colspan="2"|Adres - postcode
|style="background-color: white;"|
+
|style="background-color: white;"|4563 AB
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Etniciteit
 
|colspan="2"|Etniciteit
|style="background-color: white;"|
+
|style="background-color: white;"|Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Lengte gemeten
 
|colspan="2"|Lengte gemeten
|style="background-color: white;"|
+
|style="background-color: white;"|170 cm
 
|}<section end=999910413 />
 
|}<section end=999910413 />
 
=== Anamnese ===
 
=== Anamnese ===
 
<section begin=anamnese_999910413 />
 
<section begin=anamnese_999910413 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Anamnese
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Anamnese
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Onder behandeling geweest?
+
|colspan="3"|Onder behandeling geweest?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Algemene anamnese
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Cardiovasculaire aandoening
 +
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Oncologische aandoening
 +
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Infectieziekte
 +
|style="background-color: white;"|Herpes (code = '23513009' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Algemene anamnese
+
|colspan="2"|Type operatie
|style="background-color: white;"|
+
|style="background-color: white;"|Orthopedisch (code = '112697007' in codeSystem 'Snomed CT')
 
|}<section end=anamnese_999910413 />
 
|}<section end=anamnese_999910413 />
 
=== Zorgverlening ===
 
=== Zorgverlening ===
Regel 58: Regel 71:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Datum start zorgverantwoordelijkheid
 
|colspan="2"|Datum start zorgverantwoordelijkheid
|style="background-color: white;"|
+
|style="background-color: white;"|2014-03-01T00:00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Datum einde zorgverantwoordelijkheid
 
|colspan="2"|Datum einde zorgverantwoordelijkheid
|style="background-color: white;"|
+
|style="background-color: white;"|2014-11-12T00:00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Conclusie risicostatus na intake
 
|colspan="2"|Conclusie risicostatus na intake
|style="background-color: white;"|
+
|style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
 
|}<section end=zorgverlening_999910413 />
 
|}<section end=zorgverlening_999910413 />
 
=== Zorgverlenerzorginstelling ===
 
=== Zorgverlenerzorginstelling ===
Regel 97: Regel 110:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Zorginstelling lvrid
 
|colspan="2"|Zorginstelling lvrid
|style="background-color: white;"|
+
|style="background-color: white;"|1808
 
|}<section end=zorgverlenerzorginstelling_999910413 />
 
|}<section end=zorgverlenerzorginstelling_999910413 />
 
=== Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
 
=== Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
 
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 />
 
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="5" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Wijze einde zwangerschap
+
|colspan="5"|Wijze einde zwangerschap
|style="background-color: white;"|
+
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Definitieve a terme datum
 +
|style="background-color: white;"|2011-12-01
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Irregulaire antistoffen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Eerdere bevalling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="12"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Placenta - geboorte placenta
 +
|style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Hoeveelheid bloedverlies
 +
|style="background-color: white;"|550 ml
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Vorige uitkomst per kind - vorige baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Demografische gegevens - geboortedatum
 +
|style="background-color: white;"|2011-12-08T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Kindspecifieke gegevens vorige uitkomsten
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Type partus
 +
|style="background-color: white;"|Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Definitieve a terme datum
+
|colspan="2"|Percentiel van het geboortegewicht
|style="background-color: white;"|
+
|style="background-color: white;"|50 ≤ P < 90 (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.50')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Irregulaire antistoffen?
+
|colspan="2"|Apgarscore na 5 min
|style="background-color: white;"|
+
|style="background-color: white;"|8
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Eerdere bevalling
+
|colspan="2"|Congenitale afwijkingen?
|style="background-color: white;"|
+
|style="background-color: white;"|Nee
 
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 />
 
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 />
 
=== Zwangerschap ===
 
=== Zwangerschap ===
 
<section begin=zwangerschap_999910413 />
 
<section begin=zwangerschap_999910413 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zwangerschap
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Zwangerschap
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Dossiernummer
+
|colspan="3"|Dossiernummer
 
|style="background-color: white;"|
 
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Graviditeit
+
|colspan="3"|Graviditeit
|style="background-color: white;"|
+
|style="background-color: white;"|2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pariteit voor deze zwangerschap
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Definitieve a terme datum
 +
|style="background-color: white;"|2014-10-09
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voornemens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie
 +
|style="background-color: white;"|Thuis (code = '169813005' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Prenatale controle
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum controle
 +
|style="background-color: white;"|2014-03-02T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zwangerschapsduur
 +
|style="background-color: white;"|59 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Leven voelen
 +
|style="background-color: white;"|goed (code = '289431008' in codeSystem 'Snomed CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Rookgedrag
 +
|style="background-color: white;"|niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Alcoholgebruik
 +
|style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Drugsgebruik?
 +
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Pariteit voor deze zwangerschap
+
|colspan="2"|Gewicht gemeten
|style="background-color: white;"|
+
|style="background-color: white;"|70 kg
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Diagnose
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Definitieve a terme datum
+
|rowspan="4"|
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Voornemens
+
|colspan="2"|Datum
|style="background-color: white;"|
+
|style="background-color: white;"|2014-03-02T00:00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Prenatale controle
+
|colspan="2"|Zwangerschapsduur
|style="background-color: white;"|
+
|style="background-color: white;"|59 dagen
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Diagnose
+
|colspan="2"|Infectie
|style="background-color: white;"|
+
|style="background-color: white;"|Urineweg infectie (code = '307534009' in codeSystem 'Snomed CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Maternale sterfte?
+
|colspan="3"|Maternale sterfte?
|style="background-color: white;"|
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Wijze einde zwangerschap
+
|colspan="3"|Wijze einde zwangerschap
|style="background-color: white;"|
+
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 
|}<section end=zwangerschap_999910413 />
 
|}<section end=zwangerschap_999910413 />
 
=== Bevalling ===
 
=== Bevalling ===
 
<section begin=bevalling_999910413 />
 
<section begin=bevalling_999910413 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Bevalling
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Bevalling
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Partusnummer
+
|colspan="3"|Partusnummer
|style="background-color: white;"|
+
|style="background-color: white;"|000000
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Aantal geboren kinderen
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Risicostatus voor baring
 +
|style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Interventies begin baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Interventie begin baring
 +
|style="background-color: white;"|Strippen (code = '236960006' in codeSystem 'Snomed CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Aantal geboren kinderen
+
|colspan="2"|Indicatie interventie begin baring
|style="background-color: white;"|
+
|style="background-color: white;"|wens patiënt (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Risicostatus voor baring
+
|colspan="3"|Wijze waarop de baring begon
|style="background-color: white;"|
+
|style="background-color: white;"|Interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Interventies begin baring
+
|colspan="3"|Tijdstip begin actieve ontsluiting
|style="background-color: white;"|
+
|style="background-color: white;"|2014-10-08T14:30:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Medicatie nageboortetijdperk groep
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Wijze waarop de baring begon
+
|rowspan="3"|
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Tijdstip begin actieve ontsluiting
+
|colspan="2"|Medicatie nageboortetijdperk?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Medicatie nageboortetijdperk groep
+
|colspan="2"|Soort medicatie nageboortetijdperk
|style="background-color: white;"|
+
|style="background-color: white;"|Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Placenta - geboorte placenta
+
|colspan="3"|Placenta - geboorte placenta
|style="background-color: white;"|
+
|style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Hoeveelheid bloedverlies
+
|colspan="3"|Hoeveelheid bloedverlies
|style="background-color: white;"|
+
|style="background-color: white;"|615 ml
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Conditie perineum postpartum
+
|colspan="3"|Conditie perineum postpartum
|style="background-color: white;"|
+
|style="background-color: white;"|1e graads perineumruptuur (code = '199916005' in codeSystem 'Snomed CT')
 
|}<section end=bevalling_999910413 />
 
|}<section end=bevalling_999910413 />
 
=== Uitkomst per kind ===
 
=== Uitkomst per kind ===
 
<section begin=uitkomst_per_kind_999910413 />
 
<section begin=uitkomst_per_kind_999910413 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Uitkomst per kind
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Uitkomst per kind
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="5" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Baring
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Baring
+
|rowspan="34"|
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Werkelijke plaats baring type locatie
 +
|style="background-color: white;"|Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Demografische gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="10"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Identificaties kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Bsn kind
 +
|style="background-color: white;"|999910383
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Geslacht medische observatie
 +
|style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Geboortedatum
 +
|style="background-color: white;"|2014-10-08T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Rangnummer kind
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Perinatale sterfte groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Perinatale sterfte?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Kindspecifieke maternale gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Tijdstip breken vliezen
 +
|style="background-color: white;"|2014-10-08T09:15:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Kleur en consistentie vruchtwater
 +
|style="background-color: white;"|Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Tijdstip actief meepersen
 +
|style="background-color: white;"|2014-10-08T12:13:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Episiotomie?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Ruggeprik gewenst niet gekregen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pijnbestrijding?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Sedatie?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Kindspecifieke uitkomstgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="11"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Type partus
 +
|style="background-color: white;"|Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Ligging bij geboorte
 +
|style="background-color: white;"|Achterhoofd-achter (code = '37235006' in codeSystem 'Snomed CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Aanpakker kind - rol aanpakker kind
 +
|style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Supervisor - rol supervisor
 +
|style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Lichamelijk onderzoek kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Geboortegewicht
 +
|style="background-color: white;"|3450 gram
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Congenitale afwijkingen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Problematiek kind?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Kinderarts betrokken?
 +
|style="background-color: white;"|Nee
 
|}<section end=uitkomst_per_kind_999910413 />
 
|}<section end=uitkomst_per_kind_999910413 />
 
=== Medisch onderzoek ===
 
=== Medisch onderzoek ===
 
<section begin=medisch_onderzoek_999910413 />
 
<section begin=medisch_onderzoek_999910413 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Medisch onderzoek
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Medisch onderzoek
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
+
|rowspan="2"|
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Irregulaire antistoffen?
 +
|style="background-color: white;"|Nee
 
|}<section end=medisch_onderzoek_999910413 />
 
|}<section end=medisch_onderzoek_999910413 />
 
=== Postnatale fase ===
 
=== Postnatale fase ===
 
<section begin=postnatale_fase_999910413 />
 
<section begin=postnatale_fase_999910413 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Postnatale fase
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Postnatale fase
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="4" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Kindspecifieke gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voeding kind groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voeding kind datum
 +
|style="background-color: white;"|2014-10-12
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Substantie voeding kind
 +
|style="background-color: white;"|borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Kindspecifieke gegevens
+
|colspan="2"|Substantie voeding kind
|style="background-color: white;"|
+
|style="background-color: white;"|kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')
 
|}<section end=postnatale_fase_999910413 />
 
|}<section end=postnatale_fase_999910413 />
 
==Scenario 2. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)==
 
==Scenario 2. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)==
Regel 241: Regel 440:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Burgerservicenummer
 
|colspan="2"|Burgerservicenummer
|style="background-color: white;"|
+
|style="background-color: white;"|961921821
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Lokale persoonsidentificatie
 
|colspan="2"|Lokale persoonsidentificatie
|style="background-color: white;"|
+
|style="background-color: white;"|* (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Geboortedatum
 
|colspan="2"|Geboortedatum
|style="background-color: white;"|
+
|style="background-color: white;"|1974-09-11
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Adres - postcode
 
|colspan="2"|Adres - postcode
|style="background-color: white;"|
+
|style="background-color: white;"|5689 CZ
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Etniciteit
 
|colspan="2"|Etniciteit
|style="background-color: white;"|
+
|style="background-color: white;"|Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Lengte gemeten
 
|colspan="2"|Lengte gemeten
|style="background-color: white;"|
+
|style="background-color: white;"|184 cm
 
|}<section end=961921821 />
 
|}<section end=961921821 />
 
=== Anamnese ===
 
=== Anamnese ===
Regel 268: Regel 467:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Onder behandeling geweest?
 
|colspan="2"|Onder behandeling geweest?
|style="background-color: white;"|
+
|style="background-color: white;"|Nee
 
|}<section end=anamnese_961921821 />
 
|}<section end=anamnese_961921821 />
 
=== Zorgverlening ===
 
=== Zorgverlening ===
 
<section begin=zorgverlening_961921821 />
 
<section begin=zorgverlening_961921821 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgverlening
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Zorgverlening
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="6" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Datum start zorgverantwoordelijkheid
+
|colspan="6"|Datum start zorgverantwoordelijkheid
|style="background-color: white;"|
+
|style="background-color: white;"|2018-08-28
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Datum einde zorgverantwoordelijkheid
 +
|style="background-color: white;"|2018-11-28
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Conclusie risicostatus na intake
 +
|style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Verwijsdetails
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="20"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Datum verwijzing
 +
|style="background-color: white;"|2014-05-06T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Verwijzing van
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Zorginstelling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Zorgaanbieder identificatie nummer
 +
|style="background-color: white;"|1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Verwijzing naar
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Zorginstelling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Specialisme
 +
|style="background-color: white;"|Gynaecoloog 2e lijn (code = '02' in codeSystem 'Specialisme, specifiek voor perinatologie.')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Redenen van verwijzing
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Datum einde zorgverantwoordelijkheid
+
|rowspan="6"|
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="5"|Van 1e naar 2e lijn
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
+
|rowspan="4"|
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="4"|Zwangerschap
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
+
|rowspan="2"|
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Conclusie risicostatus na intake
+
|colspan="2"|Hypertensieve aandoening
|style="background-color: white;"|
+
|style="background-color: white;"|Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Verwijsdetails
+
|colspan="5"|Perinatale periode
|style="background-color: white;"|
+
|style="background-color: white;"|voor 28e week (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52')
 
|}<section end=zorgverlening_961921821 />
 
|}<section end=zorgverlening_961921821 />
 
=== Zorgverlenerzorginstelling ===
 
=== Zorgverlenerzorginstelling ===
Regel 307: Regel 550:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Zorginstelling lvrid
 
|colspan="2"|Zorginstelling lvrid
|style="background-color: white;"|
+
|style="background-color: white;"|1504
 
|}<section end=zorgverlenerzorginstelling_961921821 />
 
|}<section end=zorgverlenerzorginstelling_961921821 />
 
=== Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
 
=== Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
 
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
 
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Wijze einde zwangerschap
+
|colspan="3"|Wijze einde zwangerschap
|style="background-color: white;"|
+
|style="background-color: white;"|Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Definitieve a terme datum
 +
|style="background-color: white;"|2013-06-05
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Diagnose
 +
|-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"|Definitieve a terme datum
+
|colspan="2"|Bloedverlies?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Diagnose
+
|colspan="2"|Hyperemesis gravidarum?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Irregulaire antistoffen?
+
|colspan="3"|Irregulaire antistoffen?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
 
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
 
=== Zwangerschap ===
 
=== Zwangerschap ===
 
<section begin=zwangerschap_961921821 />
 
<section begin=zwangerschap_961921821 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zwangerschap
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Zwangerschap
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Dossiernummer
+
|colspan="3"|Dossiernummer
 
|style="background-color: white;"|
 
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Graviditeit
+
|colspan="3"|Graviditeit
|style="background-color: white;"|
+
|style="background-color: white;"|2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pariteit voor deze zwangerschap
 +
|style="background-color: white;"|0
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Definitieve a terme datum
 +
|style="background-color: white;"|2014-09-08
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voornemens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie
 +
|style="background-color: white;"|Nog niet bepaald (code = '05' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Prenatale controle
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum controle
 +
|style="background-color: white;"|2014-05-06T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zwangerschapsduur
 +
|style="background-color: white;"|155 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Leven voelen
 +
|style="background-color: white;"|Weak fetal movements (finding) (code = '276372004' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Rookgedrag
 +
|style="background-color: white;"|gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Alcoholgebruik
 +
|style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Drugsgebruik?
 +
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Pariteit voor deze zwangerschap
+
|colspan="2"|Gewicht gemeten
|style="background-color: white;"|
+
|style="background-color: white;"|85 kg
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Diagnose
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Definitieve a terme datum
+
|rowspan="4"|
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Voornemens
+
|colspan="2"|Datum
|style="background-color: white;"|
+
|style="background-color: white;"|2014-05-06T00:00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Prenatale controle
+
|colspan="2"|Zwangerschapsduur
|style="background-color: white;"|
+
|style="background-color: white;"|155 dagen
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Diagnose
+
|colspan="2"|Hypertensieve aandoening
|style="background-color: white;"|
+
|style="background-color: white;"|Pregnancy-induced hypertension (disorder) (code = '48194001' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Maternale sterfte?
+
|colspan="3"|Maternale sterfte?
|style="background-color: white;"|
+
|style="background-color: white;"|Nee
 
|}<section end=zwangerschap_961921821 />
 
|}<section end=zwangerschap_961921821 />
 
==Scenario 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)==
 
==Scenario 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)==
Regel 373: Regel 659:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Burgerservicenummer
 
|colspan="2"|Burgerservicenummer
|style="background-color: white;"|
+
|style="background-color: white;"|961921821
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Lokale persoonsidentificatie
 
|colspan="2"|Lokale persoonsidentificatie
|style="background-color: white;"|
+
|style="background-color: white;"|* (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Geboortedatum
 
|colspan="2"|Geboortedatum
|style="background-color: white;"|
+
|style="background-color: white;"|1974-09-11
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Adres - postcode
 
|colspan="2"|Adres - postcode
|style="background-color: white;"|
+
|style="background-color: white;"|5689 CZ
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Etniciteit
 
|colspan="2"|Etniciteit
|style="background-color: white;"|
+
|style="background-color: white;"|Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Lengte gemeten
 
|colspan="2"|Lengte gemeten
|style="background-color: white;"|
+
|style="background-color: white;"|184 cm
 
|}<section end=961921821 />
 
|}<section end=961921821 />
 
=== Anamnese ===
 
=== Anamnese ===
Regel 400: Regel 686:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Onder behandeling geweest?
 
|colspan="2"|Onder behandeling geweest?
|style="background-color: white;"|
+
|style="background-color: white;"|Nee
 
|}<section end=anamnese_961921821 />
 
|}<section end=anamnese_961921821 />
 
=== Zorgverlening ===
 
=== Zorgverlening ===
 
<section begin=zorgverlening_961921821 />
 
<section begin=zorgverlening_961921821 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgverlening
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Zorgverlening
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="6" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Datum start zorgverantwoordelijkheid
+
|colspan="6"|Datum start zorgverantwoordelijkheid
|style="background-color: white;"|
+
|style="background-color: white;"|2014-05-12T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Datum einde zorgverantwoordelijkheid
 +
|style="background-color: white;"|2014-10-09T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Verwijsdetails
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="18"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Verwijzing van
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Zorginstelling
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Datum einde zorgverantwoordelijkheid
+
|rowspan="2"|
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
+
|colspan="3"|Zorgaanbieder identificatie nummer
|style="background-color: white;"|
+
|style="background-color: white;"|1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="6"|Verwijzing naar
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
+
|rowspan="4"|
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="5"|Zorginstelling
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
+
|rowspan="2"|
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
+
|colspan="3"|Zorgaanbieder identificatie nummer
|style="background-color: white;"|
+
|style="background-color: white;"|0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="6"|Redenen van verwijzing
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
+
|rowspan="6"|
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="5"|Van 1e naar 2e lijn
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
+
|rowspan="4"|
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="4"|Zwangerschap
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
+
|rowspan="2"|
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Verwijsdetails
+
|colspan="2"|Hypertensieve aandoening
|style="background-color: white;"|
+
|style="background-color: white;"|Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT')
 
|}<section end=zorgverlening_961921821 />
 
|}<section end=zorgverlening_961921821 />
 
=== Zorgverlenerzorginstelling ===
 
=== Zorgverlenerzorginstelling ===
Regel 451: Regel 775:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Zorginstelling lvrid
 
|colspan="2"|Zorginstelling lvrid
|style="background-color: white;"|
+
|style="background-color: white;"|0003
 
|}<section end=zorgverlenerzorginstelling_961921821 />
 
|}<section end=zorgverlenerzorginstelling_961921821 />
 
=== Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
 
=== Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
 
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
 
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Wijze einde zwangerschap
+
|colspan="3"|Wijze einde zwangerschap
|style="background-color: white;"|
+
|style="background-color: white;"|Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Definitieve a terme datum
 +
|style="background-color: white;"|2013-06-05
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Diagnose
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Gynaecologische aandoening
 +
|style="background-color: white;"|Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Definitieve a terme datum
+
|colspan="2"|Bloedverlies?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Diagnose
+
|colspan="2"|Hyperemesis gravidarum?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Irregulaire antistoffen?
+
|colspan="3"|Irregulaire antistoffen?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
 
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
 
=== Zwangerschap ===
 
=== Zwangerschap ===
 
<section begin=zwangerschap_961921821 />
 
<section begin=zwangerschap_961921821 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zwangerschap
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Zwangerschap
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Dossiernummer
+
|colspan="3"|Dossiernummer
 
|style="background-color: white;"|
 
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Graviditeit
+
|colspan="3"|Graviditeit
|style="background-color: white;"|
+
|style="background-color: white;"|2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pariteit voor deze zwangerschap
 +
|style="background-color: white;"|0
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Definitieve a terme datum
 +
|style="background-color: white;"|2014-09-08
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voornemens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="1"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Prenatale controle
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum controle
 +
|style="background-color: white;"|2014-05-12T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zwangerschapsduur
 +
|style="background-color: white;"|161 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Leven voelen
 +
|style="background-color: white;"|Reduced fetal movement (finding) (code = '276369006' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Rookgedrag
 +
|style="background-color: white;"|gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Alcoholgebruik
 +
|style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Drugsgebruik?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Gewicht gemeten
 +
|style="background-color: white;"|85 kg
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Diagnose
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Pariteit voor deze zwangerschap
+
|colspan="2"|Datum
|style="background-color: white;"|
+
|style="background-color: white;"|2014-05-12T00:00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Definitieve a terme datum
+
|colspan="2"|Zwangerschapsduur
|style="background-color: white;"|
+
|style="background-color: white;"|161 dagen
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Voornemens
+
|colspan="2"|Gynaecologische aandoening
|style="background-color: white;"|
+
|style="background-color: white;"|Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Prenatale controle
+
|colspan="2"|Partiele mola?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Diagnose
+
|colspan="2"|Hypertensieve aandoening
|style="background-color: white;"|
+
|style="background-color: white;"|Pre-eclampsia (disorder) (code = '398254007' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Maternale sterfte?
+
|colspan="3"|Maternale sterfte?
|style="background-color: white;"|
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Wijze einde zwangerschap
+
|colspan="3"|Wijze einde zwangerschap
|style="background-color: white;"|
+
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 
|}<section end=zwangerschap_961921821 />
 
|}<section end=zwangerschap_961921821 />
 
=== Bevalling ===
 
=== Bevalling ===
 
<section begin=bevalling_961921821 />
 
<section begin=bevalling_961921821 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Bevalling
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Bevalling
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Partusnummer
+
|colspan="3"|Partusnummer
|style="background-color: white;"|
+
|style="background-color: white;"|000000
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Aantal geboren kinderen
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Risicostatus voor baring
 +
|style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Interventies begin baring
 +
|-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"|Aantal geboren kinderen
+
|colspan="2"|Interventie begin baring
|style="background-color: white;"|
+
|style="background-color: white;"|Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Risicostatus voor baring
+
|colspan="2"|Indicatie interventie begin baring
|style="background-color: white;"|
+
|style="background-color: white;"|acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Interventies begin baring
+
|colspan="3"|Wijze waarop de baring begon
|style="background-color: white;"|
+
|style="background-color: white;"|interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Wijze waarop de baring begon
+
|colspan="3"|Tijdstip begin actieve ontsluiting
|style="background-color: white;"|
+
|style="background-color: white;"|2014-08-30T14:09:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Medicatie nageboortetijdperk groep
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Tijdstip begin actieve ontsluiting
+
|rowspan="2"|
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Medicatie nageboortetijdperk groep
+
|colspan="2"|Medicatie nageboortetijdperk?
|style="background-color: white;"|
+
|style="background-color: white;"|UNK
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Placenta - geboorte placenta
+
|colspan="3"|Placenta - geboorte placenta
|style="background-color: white;"|
+
|style="background-color: white;"|placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Hoeveelheid bloedverlies
+
|colspan="3"|Hoeveelheid bloedverlies
|style="background-color: white;"|
+
|style="background-color: white;"|980 ml
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Conditie perineum postpartum
+
|colspan="3"|Conditie perineum postpartum
|style="background-color: white;"|
+
|style="background-color: white;"|Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96')
 
|}<section end=bevalling_961921821 />
 
|}<section end=bevalling_961921821 />
 
=== Uitkomst per kind ===
 
=== Uitkomst per kind ===
 
<section begin=uitkomst_per_kind_961921821 />
 
<section begin=uitkomst_per_kind_961921821 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Uitkomst per kind
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Uitkomst per kind
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="6" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="51"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Werkelijke plaats baring type locatie
 +
|style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Ziekenhuis baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ziekenhuisnummer lvrid
 +
|style="background-color: white;"|0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Demografische gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="10"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Identificaties kind
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Baring
+
|rowspan="2"|
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Bsn kind
 +
|style="background-color: white;"|951847624
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geslacht medische observatie
 +
|style="background-color: white;"|mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geboortedatum
 +
|style="background-color: white;"|2014-09-01T02:34:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Rangnummer kind
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Perinatale sterfte groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Perinatale sterfte?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Kindspecifieke maternale gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="12"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Tijdstip breken vliezen
 +
|style="background-color: white;"|2014-08-30T23:04:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Kleur en consistentie vruchtwater
 +
|style="background-color: white;"|geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ruggeprik gewenst niet gekregen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Pijnbestrijding?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Pijnbestrijding
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Methode
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Methode
 +
|style="background-color: white;"|Epidural anesthesia (procedure) (code = '18946005' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Periode
 +
|style="background-color: white;"|tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Sedatie?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Kindspecifieke uitkomstgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="21"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Type partus
 +
|style="background-color: white;"|Cesarean section (procedure) (code = '11466000' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ligging bij geboorte
 +
|style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Aanpakker kind - rol aanpakker kind
 +
|style="background-color: white;"|gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Supervisor - rol supervisor
 +
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Sectio caesarea group
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Indicatie primaire sectio
 +
|style="background-color: white;"|Suspected fetal distress (situation) (code = '444433005:246090004=130955003' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Indicatie primaire sectio
 +
|style="background-color: white;"|Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Lichamelijk onderzoek kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Geboortegewicht
 +
|style="background-color: white;"|3620 gram
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Congenitale afwijkingen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problematiek kind?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Kinderarts betrokken?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Betrokkenheid kinderarts
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Datum betrokkenheid
 +
|style="background-color: white;"|2014-09-01T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Reden betrokkenheid
 +
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Type betrokkenheid
 +
|style="background-color: white;"|consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Zorginstelling lvrid
 +
|style="background-color: white;"|0003
 
|}<section end=uitkomst_per_kind_961921821 />
 
|}<section end=uitkomst_per_kind_961921821 />
 
=== Medisch onderzoek ===
 
=== Medisch onderzoek ===
 
<section begin=medisch_onderzoek_961921821 />
 
<section begin=medisch_onderzoek_961921821 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Medisch onderzoek
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Medisch onderzoek
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Irregulaire antistoffen?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
+
|colspan="2"|Welke irregulaire antistoffen vrouw aanwezig
|style="background-color: white;"|
+
|style="background-color: white;"|Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96')
 
|}<section end=medisch_onderzoek_961921821 />
 
|}<section end=medisch_onderzoek_961921821 />
 
=== Postnatale fase ===
 
=== Postnatale fase ===
 
<section begin=postnatale_fase_961921821 />
 
<section begin=postnatale_fase_961921821 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Postnatale fase
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Postnatale fase
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="4" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Diagnoseinterventie postpartum
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Diagnoseinterventie postpartum
+
|rowspan="3"|
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Datum
 +
|style="background-color: white;"|2014-09-03T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pathologie vrouw
 +
|style="background-color: white;"|Urinary tract infectious disease (disorder) (code = '68566005' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Kindspecifieke gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voeding kind groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voeding kind datum
 +
|style="background-color: white;"|2014-10-07
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Kindspecifieke gegevens
+
|colspan="2"|Substantie voeding kind
|style="background-color: white;"|
+
|style="background-color: white;"|kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')
 
|}<section end=postnatale_fase_961921821 />
 
|}<section end=postnatale_fase_961921821 />
 
==Scenario 3. zorg volledig in 2e lijn, meerling, 1 kind overleden (voor vrouw met BSN: 895623146)==
 
==Scenario 3. zorg volledig in 2e lijn, meerling, 1 kind overleden (voor vrouw met BSN: 895623146)==
Regel 598: Regel 1.136:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Burgerservicenummer
 
|colspan="2"|Burgerservicenummer
|style="background-color: white;"|
+
|style="background-color: white;"|895623146
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Lokale persoonsidentificatie
 
|colspan="2"|Lokale persoonsidentificatie
|style="background-color: white;"|
+
|style="background-color: white;"|000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Geboortedatum
 
|colspan="2"|Geboortedatum
|style="background-color: white;"|
+
|style="background-color: white;"|1985-08-05
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Adres - postcode
 
|colspan="2"|Adres - postcode
|style="background-color: white;"|
+
|style="background-color: white;"|5421 JG
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Etniciteit
 
|colspan="2"|Etniciteit
|style="background-color: white;"|
+
|style="background-color: white;"|Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Lengte gemeten
 
|colspan="2"|Lengte gemeten
|style="background-color: white;"|
+
|style="background-color: white;"|167 cm
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Vrouwelijke genitale verminking?
 
|colspan="2"|Vrouwelijke genitale verminking?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Type vrouwelijke genitale verminking
 
|colspan="2"|Type vrouwelijke genitale verminking
|style="background-color: white;"|
+
|style="background-color: white;"|Female genital mutilation type 2 (disorder) (code = '130621000119105' in codeSystem '2.16.840.1.113883.6.96')
 
|}<section end=895623146 />
 
|}<section end=895623146 />
 
=== Anamnese ===
 
=== Anamnese ===
 
<section begin=anamnese_895623146 />
 
<section begin=anamnese_895623146 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Anamnese
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Anamnese
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Onder behandeling geweest?
+
|colspan="3"|Onder behandeling geweest?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Algemene anamnese
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Cardiovasculaire aandoening
 +
|style="background-color: white;"|Cardiac arrhythmia (disorder) (code = '698247007' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Schildklier aandoening
 +
|style="background-color: white;"|Hyperthyroidism (disorder) (code = '34486009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Anemie
 +
|style="background-color: white;"|Iron deficiency anemia (disorder) (code = '87522002' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Bloedtransfusie?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Algemene anamnese
+
|colspan="2"|Type operatie
|style="background-color: white;"|
+
|style="background-color: white;"|Operation on heart (procedure) (code = '64915003' in codeSystem '2.16.840.1.113883.6.96')
 
|}<section end=anamnese_895623146 />
 
|}<section end=anamnese_895623146 />
 
=== Zorgverlening ===
 
=== Zorgverlening ===
Regel 646: Regel 1.200:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Datum start zorgverantwoordelijkheid
 
|colspan="2"|Datum start zorgverantwoordelijkheid
|style="background-color: white;"|
+
|style="background-color: white;"|2014-03-10T00:00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Datum einde zorgverantwoordelijkheid
 
|colspan="2"|Datum einde zorgverantwoordelijkheid
|style="background-color: white;"|
+
|style="background-color: white;"|2014-11-03T00:00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Conclusie risicostatus na intake
 
|colspan="2"|Conclusie risicostatus na intake
|style="background-color: white;"|
+
|style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
 
|}<section end=zorgverlening_895623146 />
 
|}<section end=zorgverlening_895623146 />
 
=== Zorgverlenerzorginstelling ===
 
=== Zorgverlenerzorginstelling ===
Regel 688: Regel 1.242:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Zorginstelling lvrid
 
|colspan="2"|Zorginstelling lvrid
|style="background-color: white;"|
+
|style="background-color: white;"|9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 
|}<section end=zorgverlenerzorginstelling_895623146 />
 
|}<section end=zorgverlenerzorginstelling_895623146 />
 
=== Zwangerschap ===
 
=== Zwangerschap ===
 
<section begin=zwangerschap_895623146 />
 
<section begin=zwangerschap_895623146 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zwangerschap
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Zwangerschap
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Dossiernummer
+
|colspan="3"|Dossiernummer
 
|style="background-color: white;"|
 
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Graviditeit
+
|colspan="3"|Graviditeit
|style="background-color: white;"|
+
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pariteit voor deze zwangerschap
 +
|style="background-color: white;"|0
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Definitieve a terme datum
 +
|style="background-color: white;"|2014-09-22
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voornemens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie
 +
|style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Prenatale controle
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum controle
 +
|style="background-color: white;"|2014-05-21T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zwangerschapsduur
 +
|style="background-color: white;"|156 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Leven voelen
 +
|style="background-color: white;"|Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Rookgedrag
 +
|style="background-color: white;"|niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Alcoholgebruik
 +
|style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Drugsgebruik?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Gewicht gemeten
 +
|style="background-color: white;"|67 kg
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Diagnose
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum
 +
|style="background-color: white;"|2014-05-21T00:00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Pariteit voor deze zwangerschap
+
|colspan="2"|Zwangerschapsduur
|style="background-color: white;"|
+
|style="background-color: white;"|156 dagen
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Definitieve a terme datum
+
|colspan="2"|Bloedverlies?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Voornemens
+
|colspan="2"|Infectie
|style="background-color: white;"|
+
|style="background-color: white;"|Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Prenatale controle
+
|colspan="2"|Afwijkende groei foetus
|style="background-color: white;"|
+
|style="background-color: white;"|Small for gestational age fetus (disorder) (code = '267258002' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Diagnose
+
|colspan="2"|Abruptio placentae?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Maternale sterfte?
+
|colspan="3"|Maternale sterfte?
|style="background-color: white;"|
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Wijze einde zwangerschap
+
|colspan="3"|Wijze einde zwangerschap
|style="background-color: white;"|
+
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 
|}<section end=zwangerschap_895623146 />
 
|}<section end=zwangerschap_895623146 />
 
=== Bevalling ===
 
=== Bevalling ===
 
<section begin=bevalling_895623146 />
 
<section begin=bevalling_895623146 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Bevalling
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Bevalling
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Partusnummer
+
|colspan="3"|Partusnummer
|style="background-color: white;"|
+
|style="background-color: white;"|000000
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Diagnose bevalling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Pprom?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Verdenking foetale nood?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Diagnose bevalling
+
|colspan="3"|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="2"|Aantal geboren kinderen
+
|colspan="3"|Risicostatus voor baring
|style="background-color: white;"|
+
|style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Risicostatus voor baring
+
|colspan="3"|Wijze waarop de baring begon
|style="background-color: white;"|
+
|style="background-color: white;"|spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Wijze waarop de baring begon
+
|colspan="3"|Tijdstip begin actieve ontsluiting
|style="background-color: white;"|
+
|style="background-color: white;"|2014-08-27T22:09:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Medicatie nageboortetijdperk groep
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Tijdstip begin actieve ontsluiting
+
|rowspan="2"|
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Medicatie nageboortetijdperk groep
+
|colspan="2"|Medicatie nageboortetijdperk?
|style="background-color: white;"|
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Placenta - geboorte placenta
+
|colspan="3"|Placenta - geboorte placenta
|style="background-color: white;"|
+
|style="background-color: white;"|controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Hoeveelheid bloedverlies
+
|colspan="3"|Hoeveelheid bloedverlies
|style="background-color: white;"|
+
|style="background-color: white;"|1740 ml
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Conditie perineum postpartum
+
|colspan="3"|Conditie perineum postpartum
|style="background-color: white;"|
+
|style="background-color: white;"|Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96')
 
|}<section end=bevalling_895623146 />
 
|}<section end=bevalling_895623146 />
 
=== Uitkomst per kind ===
 
=== Uitkomst per kind ===
 
<section begin=uitkomst_per_kind_895623146 />
 
<section begin=uitkomst_per_kind_895623146 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Uitkomst per kind
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="8" | Uitkomst per kind
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="7" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="8"|Baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="59"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Werkelijke plaats baring type locatie
 +
|style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Ziekenhuis baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ziekenhuisnummer lvrid
 +
|style="background-color: white;"|9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Demografische gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="10"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Identificaties kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Bsn kind
 +
|style="background-color: white;"|847035116
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Geslacht medische observatie
 +
|style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Geboortedatum
 +
|style="background-color: white;"|2014-08-28T06:30:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Rangnummer kind
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Perinatale sterfte groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Perinatale sterfte?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Kindspecifieke maternale gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="19"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Tijdstip breken vliezen
 +
|style="background-color: white;"|2014-08-27T22:09:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Kleur en consistentie vruchtwater
 +
|style="background-color: white;"|kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Tijdstip actief meepersen
 +
|style="background-color: white;"|2014-08-27T23:49:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Episiotomie?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Locatie episiotomie
 +
|style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ruggeprik gewenst niet gekregen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Pijnbestrijding?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Pijnbestrijding
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Methode
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Methode
 +
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Overig middel
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Middel
 +
|style="background-color: white;"|Administration of morphinomimetic analgesic (procedure) (code = '52685006:363701004=404642006' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Toediening
 +
|style="background-color: white;"|Administration of substance via intravenous route (procedure) (code = '431215000' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Periode
 +
|style="background-color: white;"|tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Sedatie?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Kindspecifieke uitkomstgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="22"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Type partus
 +
|style="background-color: white;"|Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ligging bij geboorte
 +
|style="background-color: white;"|Face presentation (finding) (code = '21882006' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Aanpakker kind - rol aanpakker kind
 +
|style="background-color: white;"|arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Supervisor - rol supervisor
 +
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Vaginale kunstverlossing groep
 +
|-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"|Baring
+
|colspan="4"|Vaginale kunstverlossing
|style="background-color: white;"|
+
|style="background-color: white;"|Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Succes vaginale kunstverlossing?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Lichamelijk onderzoek kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geboortegewicht
 +
|style="background-color: white;"|2040 gram
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Congenitale afwijkingen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Problematiek kind?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Problematiek kind
 +
|style="background-color: white;"|Birth trauma of fetus (disorder) (code = '56110009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Kinderarts betrokken?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Betrokkenheid kinderarts
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Datum betrokkenheid
 +
|style="background-color: white;"|2014-08-28T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Reden betrokkenheid
 +
|style="background-color: white;"|Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Type betrokkenheid
 +
|style="background-color: white;"|consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Zorginstelling lvrid
 +
|style="background-color: white;"|9999
 
|}<section end=uitkomst_per_kind_895623146 />
 
|}<section end=uitkomst_per_kind_895623146 />
 
=== Uitkomst per kind ===
 
=== Uitkomst per kind ===
 
<section begin=uitkomst_per_kind_895623146 />
 
<section begin=uitkomst_per_kind_895623146 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Uitkomst per kind
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="8" | Uitkomst per kind
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="7" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="8"|Baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="71"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Werkelijke plaats baring type locatie
 +
|style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Ziekenhuis baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ziekenhuisnummer lvrid
 +
|style="background-color: white;"|9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Demografische gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="12"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Identificaties kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Bsn kind
 +
|style="background-color: white;"|847035128
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Geslacht medische observatie
 +
|style="background-color: white;"|mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Geboortedatum
 +
|style="background-color: white;"|2014-08-28T07:02:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Rangnummer kind
 +
|style="background-color: white;"|2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Perinatale sterfte groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Perinatale sterfte?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Fase perinatale sterfte
 +
|style="background-color: white;"|Newborn death (event) (code = '276506001' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Datumtijd vaststelling perinatale sterfte
 +
|style="background-color: white;"|2014-08-28T08:10:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Kindspecifieke maternale gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="19"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Tijdstip breken vliezen
 +
|style="background-color: white;"|2014-08-27T23:13:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Kleur en consistentie vruchtwater
 +
|style="background-color: white;"|kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Tijdstip actief meepersen
 +
|style="background-color: white;"|2014-08-28T06:45:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Episiotomie?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Locatie episiotomie
 +
|style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ruggeprik gewenst niet gekregen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Pijnbestrijding?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Pijnbestrijding
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Methode
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Methode
 +
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Overig middel
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Middel
 +
|style="background-color: white;"|Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Toediening
 +
|style="background-color: white;"|Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Periode
 +
|style="background-color: white;"|tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Sedatie?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Kindspecifieke uitkomstgegevens
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Baring
+
|rowspan="32"|
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Type partus
 +
|style="background-color: white;"|Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ligging bij geboorte
 +
|style="background-color: white;"|Complete breech presentation (finding) (code = '49168004' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Aanpakker kind - rol aanpakker kind
 +
|style="background-color: white;"|arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Supervisor - rol supervisor
 +
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Vaginale kunstverlossing groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Vaginale kunstverlossing
 +
|style="background-color: white;"|Total breech extraction (procedure) (code = '416055001' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Succes vaginale kunstverlossing?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Overige interventies
 +
|style="background-color: white;"|Maneuvers for delivery in shoulder dystocia (procedure) (code = '237008007' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Lichamelijk onderzoek kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geboortegewicht
 +
|style="background-color: white;"|1580 gram
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Congenitale afwijkingen?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Congenitale afwijkingen groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Specificatie congenitale afwijking groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Specificatie congenitale afwijking
 +
|style="background-color: white;"|Spina bifida occulta (disorder) (code = '76916001' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Specificatie congenitale afwijking groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Specificatie congenitale afwijking
 +
|style="background-color: white;"|Multiple congenital cardiac defects (disorder) (code = '94702005' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Chromosomale afwijkingen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Problematiek kind?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Problematiek kind
 +
|style="background-color: white;"|Subdural intracranial hemorrhage due to birth trauma (disorder) (code = '126941005' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Kinderarts betrokken?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Betrokkenheid kinderarts
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Datum betrokkenheid
 +
|style="background-color: white;"|2014-08-28T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Reden betrokkenheid
 +
|style="background-color: white;"|Finding of neonatal condition (finding) (code = '364737004' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Type betrokkenheid
 +
|style="background-color: white;"|overdracht (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Zorginstelling lvrid
 +
|style="background-color: white;"|0001
 
|}<section end=uitkomst_per_kind_895623146 />
 
|}<section end=uitkomst_per_kind_895623146 />
 
=== Medisch onderzoek ===
 
=== Medisch onderzoek ===
 
<section begin=medisch_onderzoek_895623146 />
 
<section begin=medisch_onderzoek_895623146 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Medisch onderzoek
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Medisch onderzoek
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
+
|rowspan="2"|
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Irregulaire antistoffen?
 +
|style="background-color: white;"|Nee
 
|}<section end=medisch_onderzoek_895623146 />
 
|}<section end=medisch_onderzoek_895623146 />
 
=== Postnatale fase ===
 
=== Postnatale fase ===
 
<section begin=postnatale_fase_895623146 />
 
<section begin=postnatale_fase_895623146 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Postnatale fase
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Postnatale fase
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="4" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Kindspecifieke gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Rangnummer kind
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voeding kind groep
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Kindspecifieke gegevens
+
|rowspan="3"|
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voeding kind datum
 +
|style="background-color: white;"|2014-09-03
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Substantie voeding kind
 +
|style="background-color: white;"|borstmelk (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')
 
|}<section end=postnatale_fase_895623146 />
 
|}<section end=postnatale_fase_895623146 />
 
==Scenario 4. 1e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)==
 
==Scenario 4. 1e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)==
Regel 823: Regel 1.783:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Burgerservicenummer
 
|colspan="2"|Burgerservicenummer
|style="background-color: white;"|
+
|style="background-color: white;"|850810711
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Lokale persoonsidentificatie
 
|colspan="2"|Lokale persoonsidentificatie
|style="background-color: white;"|
+
|style="background-color: white;"|* (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Geboortedatum
 
|colspan="2"|Geboortedatum
|style="background-color: white;"|
+
|style="background-color: white;"|1987-08-06
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Adres - postcode
 
|colspan="2"|Adres - postcode
|style="background-color: white;"|
+
|style="background-color: white;"|4589 BA
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Etniciteit
 
|colspan="2"|Etniciteit
|style="background-color: white;"|
+
|style="background-color: white;"|Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Lengte gemeten
 
|colspan="2"|Lengte gemeten
|style="background-color: white;"|
+
|style="background-color: white;"|162 cm
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Vrouwelijke genitale verminking?
 
|colspan="2"|Vrouwelijke genitale verminking?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Type vrouwelijke genitale verminking
 
|colspan="2"|Type vrouwelijke genitale verminking
|style="background-color: white;"|
+
|style="background-color: white;"|Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96')
 
|}<section end=850810711 />
 
|}<section end=850810711 />
 
=== Anamnese ===
 
=== Anamnese ===
 
<section begin=anamnese_850810711 />
 
<section begin=anamnese_850810711 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Anamnese
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Anamnese
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Onder behandeling geweest?
+
|colspan="3"|Onder behandeling geweest?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Algemene anamnese
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Autoimmuun aandoening
 +
|style="background-color: white;"|Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Urogenitale aandoening
 +
|style="background-color: white;"|Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Diabetes mellitus?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Mdl aandoening
 +
|style="background-color: white;"|Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Longaandoening
 +
|style="background-color: white;"|Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Type operatie
 +
|style="background-color: white;"|Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Type operatie
 +
|style="background-color: white;"|Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Algemene anamnese
+
|colspan="2"|Type operatie
|style="background-color: white;"|
+
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 
|}<section end=anamnese_850810711 />
 
|}<section end=anamnese_850810711 />
 
=== Zorgverlening ===
 
=== Zorgverlening ===
 
<section begin=zorgverlening_850810711 />
 
<section begin=zorgverlening_850810711 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgverlening
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Zorgverlening
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="5" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Datum start zorgverantwoordelijkheid
+
|colspan="5"|Datum start zorgverantwoordelijkheid
|style="background-color: white;"|
+
|style="background-color: white;"|2014-08-07T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Datum einde zorgverantwoordelijkheid
 +
|style="background-color: white;"|2014-09-15T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Conclusie risicostatus na intake
 +
|style="background-color: white;"|3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Verwijsdetails
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="15"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verwijzing van
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Zorginstelling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorgaanbieder identificatie nummer
 +
|style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verwijzing naar
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Datum einde zorgverantwoordelijkheid
+
|rowspan="4"|
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="4"|Zorginstelling
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
+
|rowspan="2"|
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
+
|colspan="2"|Zorgaanbieder identificatie nummer
|style="background-color: white;"|
+
|style="background-color: white;"|1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="5"|Redenen van verwijzing
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Conclusie risicostatus na intake
+
|rowspan="1"|
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="5"|Redenen van verwijzing
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Verwijsdetails
+
|rowspan="1"|
|style="background-color: white;"|
 
 
|}<section end=zorgverlening_850810711 />
 
|}<section end=zorgverlening_850810711 />
 
=== Zorgverlenerzorginstelling ===
 
=== Zorgverlenerzorginstelling ===
Regel 898: Regel 1.914:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Zorginstelling lvrid
 
|colspan="2"|Zorginstelling lvrid
|style="background-color: white;"|
+
|style="background-color: white;"|1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 
|}<section end=zorgverlenerzorginstelling_850810711 />
 
|}<section end=zorgverlenerzorginstelling_850810711 />
 
=== Zwangerschap ===
 
=== Zwangerschap ===
Regel 913: Regel 1.929:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Graviditeit
 
|colspan="2"|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="2"|Pariteit voor deze zwangerschap
 
|colspan="2"|Pariteit voor deze zwangerschap
|style="background-color: white;"|
+
|style="background-color: white;"|0
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Definitieve a terme datum
 
|colspan="2"|Definitieve a terme datum
|style="background-color: white;"|
+
|style="background-color: white;"|2014-08-18
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Maternale sterfte?
 
|colspan="2"|Maternale sterfte?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Wijze einde zwangerschap
 
|colspan="2"|Wijze einde zwangerschap
|style="background-color: white;"|
+
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 
|}<section end=zwangerschap_850810711 />
 
|}<section end=zwangerschap_850810711 />
 
=== Bevalling ===
 
=== Bevalling ===
 
<section begin=bevalling_850810711 />
 
<section begin=bevalling_850810711 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Bevalling
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Bevalling
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Aantal geboren kinderen
+
|colspan="3"|Aantal geboren kinderen
|style="background-color: white;"|
+
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Risicostatus voor baring
 +
|style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Wijze waarop de baring begon
 +
|style="background-color: white;"|spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Risicostatus voor baring
+
|colspan="3"|Tijdstip begin actieve ontsluiting
|style="background-color: white;"|
+
|style="background-color: white;"|2014-08-03T21:09:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Medicatie nageboortetijdperk groep
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Wijze waarop de baring begon
+
|rowspan="3"|
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Tijdstip begin actieve ontsluiting
+
|colspan="2"|Medicatie nageboortetijdperk?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Medicatie nageboortetijdperk groep
+
|colspan="2"|Soort medicatie nageboortetijdperk
|style="background-color: white;"|
+
|style="background-color: white;"|Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Placenta - geboorte placenta
+
|colspan="3"|Placenta - geboorte placenta
|style="background-color: white;"|
+
|style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Hoeveelheid bloedverlies
+
|colspan="3"|Hoeveelheid bloedverlies
|style="background-color: white;"|
+
|style="background-color: white;"|1120 ml
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Conditie perineum postpartum
+
|colspan="3"|Conditie perineum postpartum
|style="background-color: white;"|
+
|style="background-color: white;"|Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96')
 
|}<section end=bevalling_850810711 />
 
|}<section end=bevalling_850810711 />
 
=== Uitkomst per kind ===
 
=== Uitkomst per kind ===
 
<section begin=uitkomst_per_kind_850810711 />
 
<section begin=uitkomst_per_kind_850810711 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Uitkomst per kind
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="8" | Uitkomst per kind
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="7" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="8"|Baring
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Baring
+
|rowspan="58"|
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Werkelijke plaats baring type locatie
 +
|style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Ziekenhuis baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ziekenhuisnummer lvrid
 +
|style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Demografische gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="10"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Identificaties kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Bsn kind
 +
|style="background-color: white;"|840736526
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Geslacht medische observatie
 +
|style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Geboortedatum
 +
|style="background-color: white;"|2014-08-04T23:35:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Rangnummer kind
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Perinatale sterfte groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Perinatale sterfte?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Kindspecifieke maternale gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="19"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Tijdstip breken vliezen
 +
|style="background-color: white;"|2014-08-03T07:04:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Kleur en consistentie vruchtwater
 +
|style="background-color: white;"|bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Tijdstip actief meepersen
 +
|style="background-color: white;"|2014-08-04T22:15:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Episiotomie?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Locatie episiotomie
 +
|style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ruggeprik gewenst niet gekregen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Pijnbestrijding?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Pijnbestrijding
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Methode
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Methode
 +
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Overig middel
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Middel
 +
|style="background-color: white;"|Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Toediening
 +
|style="background-color: white;"|Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Periode
 +
|style="background-color: white;"|tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Sedatie?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Kindspecifieke uitkomstgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="21"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Type partus
 +
|style="background-color: white;"|Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ligging bij geboorte
 +
|style="background-color: white;"|Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Aanpakker kind - rol aanpakker kind
 +
|style="background-color: white;"|co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Supervisor - rol supervisor
 +
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Vaginale kunstverlossing groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Vaginale kunstverlossing
 +
|style="background-color: white;"|Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Succes vaginale kunstverlossing?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Lichamelijk onderzoek kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geboortegewicht
 +
|style="background-color: white;"|4205 gram
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Congenitale afwijkingen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Problematiek kind?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Kinderarts betrokken?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Betrokkenheid kinderarts
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Datum betrokkenheid
 +
|style="background-color: white;"|2014-08-04T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Reden betrokkenheid
 +
|style="background-color: white;"|Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Type betrokkenheid
 +
|style="background-color: white;"|consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Zorginstelling lvrid
 +
|style="background-color: white;"|0010
 
|}<section end=uitkomst_per_kind_850810711 />
 
|}<section end=uitkomst_per_kind_850810711 />
 
=== Postnatale fase ===
 
=== Postnatale fase ===
 
<section begin=postnatale_fase_850810711 />
 
<section begin=postnatale_fase_850810711 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Postnatale fase
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Postnatale fase
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="4" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Diagnoseinterventie postpartum
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Datum
 +
|style="background-color: white;"|2014-08-08T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pathologie vrouw
 +
|style="background-color: white;"|Embolism (disorder) (code = '414086009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Diagnoseinterventie postpartum
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Datum
 +
|style="background-color: white;"|2014-08-08T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pathologie vrouw
 +
|style="background-color: white;"|Episiotomy infection (disorder) (code = '300927001' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Kindspecifieke gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voeding kind groep
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Diagnoseinterventie postpartum
+
|rowspan="3"|
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Diagnoseinterventie postpartum
+
|colspan="2"|Voeding kind datum
|style="background-color: white;"|
+
|style="background-color: white;"|2014-09-15
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Kindspecifieke gegevens
+
|colspan="2"|Substantie voeding kind
|style="background-color: white;"|
+
|style="background-color: white;"|kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')
 
|}<section end=postnatale_fase_850810711 />
 
|}<section end=postnatale_fase_850810711 />
 
==Scenario 4. 2e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)==
 
==Scenario 4. 2e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)==
Regel 1.000: Regel 2.196:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Burgerservicenummer
 
|colspan="2"|Burgerservicenummer
|style="background-color: white;"|
+
|style="background-color: white;"|850810711
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Lokale persoonsidentificatie
 
|colspan="2"|Lokale persoonsidentificatie
|style="background-color: white;"|
+
|style="background-color: white;"|* (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Geboortedatum
 
|colspan="2"|Geboortedatum
|style="background-color: white;"|
+
|style="background-color: white;"|1987-08-06
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Adres - postcode
 
|colspan="2"|Adres - postcode
|style="background-color: white;"|
+
|style="background-color: white;"|4589 BA
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Etniciteit
 
|colspan="2"|Etniciteit
|style="background-color: white;"|
+
|style="background-color: white;"|Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Lengte gemeten
 
|colspan="2"|Lengte gemeten
|style="background-color: white;"|
+
|style="background-color: white;"|162 cm
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Vrouwelijke genitale verminking?
 
|colspan="2"|Vrouwelijke genitale verminking?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Type vrouwelijke genitale verminking
 
|colspan="2"|Type vrouwelijke genitale verminking
|style="background-color: white;"|
+
|style="background-color: white;"|Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96')
 
|}<section end=850810711 />
 
|}<section end=850810711 />
 
=== Anamnese ===
 
=== Anamnese ===
 
<section begin=anamnese_850810711 />
 
<section begin=anamnese_850810711 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Anamnese
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Anamnese
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Onder behandeling geweest?
+
|colspan="3"|Onder behandeling geweest?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Algemene anamnese
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Autoimmuun aandoening
 +
|style="background-color: white;"|Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Urogenitale aandoening
 +
|style="background-color: white;"|Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Diabetes mellitus?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Mdl aandoening
 +
|style="background-color: white;"|Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Longaandoening
 +
|style="background-color: white;"|Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Type operatie
 +
|style="background-color: white;"|Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Type operatie
 +
|style="background-color: white;"|Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Algemene anamnese
+
|colspan="2"|Type operatie
|style="background-color: white;"|
+
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 
|}<section end=anamnese_850810711 />
 
|}<section end=anamnese_850810711 />
 
=== Zorgverlening ===
 
=== Zorgverlening ===
 
<section begin=zorgverlening_850810711 />
 
<section begin=zorgverlening_850810711 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgverlening
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Zorgverlening
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="5" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Datum start zorgverantwoordelijkheid
+
|colspan="5"|Datum start zorgverantwoordelijkheid
|style="background-color: white;"|
+
|style="background-color: white;"|2014-02-03T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Datum einde zorgverantwoordelijkheid
 +
|style="background-color: white;"|2014-08-06T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Conclusie risicostatus na intake
 +
|style="background-color: white;"|3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Verwijsdetails
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="15"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Datum einde zorgverantwoordelijkheid
+
|colspan="4"|Datum verwijzing
|style="background-color: white;"|
+
|style="background-color: white;"|2014-08-06T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verwijzing van
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
+
|rowspan="4"|
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="4"|Zorginstelling
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
+
|rowspan="2"|
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
+
|colspan="2"|Zorgaanbieder identificatie nummer
|style="background-color: white;"|
+
|style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="5"|Verwijzing naar
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
+
|rowspan="4"|
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="4"|Zorginstelling
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
+
|rowspan="2"|
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
+
|colspan="2"|Zorgaanbieder identificatie nummer
|style="background-color: white;"|
+
|style="background-color: white;"|1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;
 +
|colspan="5"|Redenen van verwijzing
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Conclusie risicostatus na intake
+
|rowspan="1"|
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Verwijsdetails
+
|colspan="4"|Perinatale periode
|style="background-color: white;"|
+
|style="background-color: white;"|2e t/m 7e dag (code = '92' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52')
 
|}<section end=zorgverlening_850810711 />
 
|}<section end=zorgverlening_850810711 />
 
=== Zorgverlenerzorginstelling ===
 
=== Zorgverlenerzorginstelling ===
Regel 1.087: Regel 2.341:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Zorginstelling lvrid
 
|colspan="2"|Zorginstelling lvrid
|style="background-color: white;"|
+
|style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 
|}<section end=zorgverlenerzorginstelling_850810711 />
 
|}<section end=zorgverlenerzorginstelling_850810711 />
 
=== Zwangerschap ===
 
=== Zwangerschap ===
 
<section begin=zwangerschap_850810711 />
 
<section begin=zwangerschap_850810711 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zwangerschap
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Zwangerschap
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Dossiernummer
+
|colspan="3"|Dossiernummer
 
|style="background-color: white;"|
 
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Graviditeit
+
|colspan="3"|Graviditeit
|style="background-color: white;"|
+
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pariteit voor deze zwangerschap
 +
|style="background-color: white;"|0
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Definitieve a terme datum
 +
|style="background-color: white;"|2014-08-18
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voornemens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie
 +
|style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Prenatale controle
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum controle
 +
|style="background-color: white;"|2014-05-07T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zwangerschapsduur
 +
|style="background-color: white;"|149 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Leven voelen
 +
|style="background-color: white;"|Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Rookgedrag
 +
|style="background-color: white;"|niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Alcoholgebruik
 +
|style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Drugsgebruik?
 +
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Pariteit voor deze zwangerschap
+
|colspan="2"|Gewicht gemeten
|style="background-color: white;"|
+
|style="background-color: white;"|82 kg
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Diagnose
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Definitieve a terme datum
+
|rowspan="4"|
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Voornemens
+
|colspan="2"|Datum
|style="background-color: white;"|
+
|style="background-color: white;"|2014-05-07T00:00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Prenatale controle
+
|colspan="2"|Zwangerschapsduur
|style="background-color: white;"|
+
|style="background-color: white;"|149 dagen
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Diagnose
+
|colspan="2"|Infectie
|style="background-color: white;"|
+
|style="background-color: white;"|Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Maternale sterfte?
+
|colspan="3"|Maternale sterfte?
|style="background-color: white;"|
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Wijze einde zwangerschap
+
|colspan="3"|Wijze einde zwangerschap
|style="background-color: white;"|
+
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 
|}<section end=zwangerschap_850810711 />
 
|}<section end=zwangerschap_850810711 />
 
=== Bevalling ===
 
=== Bevalling ===
 
<section begin=bevalling_850810711 />
 
<section begin=bevalling_850810711 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Bevalling
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Bevalling
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Diagnose bevalling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Niet vorderende ontsluiting?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Diagnose bevalling
+
|colspan="2"|Niet vorderende uitdrijving?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Aantal geboren kinderen
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Risicostatus voor baring
 +
|style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Aantal geboren kinderen
+
|colspan="3"|Wijze waarop de baring begon
|style="background-color: white;"|
+
|style="background-color: white;"|spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Risicostatus voor baring
+
|colspan="3"|Tijdstip begin actieve ontsluiting
|style="background-color: white;"|
+
|style="background-color: white;"|2014-08-03T21:09:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Medicatie nageboortetijdperk groep
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Wijze waarop de baring begon
+
|rowspan="3"|
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Tijdstip begin actieve ontsluiting
+
|colspan="2"|Medicatie nageboortetijdperk?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Medicatie nageboortetijdperk groep
+
|colspan="2"|Soort medicatie nageboortetijdperk
|style="background-color: white;"|
+
|style="background-color: white;"|Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Placenta - geboorte placenta
+
|colspan="3"|Placenta - geboorte placenta
|style="background-color: white;"|
+
|style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Hoeveelheid bloedverlies
+
|colspan="3"|Hoeveelheid bloedverlies
|style="background-color: white;"|
+
|style="background-color: white;"|1120 ml
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Conditie perineum postpartum
+
|colspan="3"|Conditie perineum postpartum
|style="background-color: white;"|
+
|style="background-color: white;"|Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96')
 
|}<section end=bevalling_850810711 />
 
|}<section end=bevalling_850810711 />
 
=== Uitkomst per kind ===
 
=== Uitkomst per kind ===
 
<section begin=uitkomst_per_kind_850810711 />
 
<section begin=uitkomst_per_kind_850810711 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Uitkomst per kind
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="8" | Uitkomst per kind
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="7" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="8"|Baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="58"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Werkelijke plaats baring type locatie
 +
|style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Ziekenhuis baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Baring
+
|colspan="5"|Ziekenhuisnummer lvrid
|style="background-color: white;"|
+
|style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Demografische gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="10"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Identificaties kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Bsn kind
 +
|style="background-color: white;"|840736526
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Geslacht medische observatie
 +
|style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Geboortedatum
 +
|style="background-color: white;"|2014-08-04T23:35:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Rangnummer kind
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Perinatale sterfte groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Perinatale sterfte?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Kindspecifieke maternale gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="19"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Tijdstip breken vliezen
 +
|style="background-color: white;"|2014-08-03T07:04:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Kleur en consistentie vruchtwater
 +
|style="background-color: white;"|bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Tijdstip actief meepersen
 +
|style="background-color: white;"|2014-08-04T22:15:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Episiotomie?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Locatie episiotomie
 +
|style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ruggeprik gewenst niet gekregen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Pijnbestrijding?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Pijnbestrijding
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Methode
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Methode
 +
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Overig middel
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Middel
 +
|style="background-color: white;"|Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Toediening
 +
|style="background-color: white;"|Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Periode
 +
|style="background-color: white;"|tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Sedatie?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Kindspecifieke uitkomstgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="21"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Type partus
 +
|style="background-color: white;"|Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ligging bij geboorte
 +
|style="background-color: white;"|Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Aanpakker kind - rol aanpakker kind
 +
|style="background-color: white;"|co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Supervisor - rol supervisor
 +
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Vaginale kunstverlossing groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Vaginale kunstverlossing
 +
|style="background-color: white;"|Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Succes vaginale kunstverlossing?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Lichamelijk onderzoek kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geboortegewicht
 +
|style="background-color: white;"|4205 gram
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Congenitale afwijkingen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Problematiek kind?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Kinderarts betrokken?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Betrokkenheid kinderarts
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Datum betrokkenheid
 +
|style="background-color: white;"|2014-08-04T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Reden betrokkenheid
 +
|style="background-color: white;"|Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Type betrokkenheid
 +
|style="background-color: white;"|consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Zorginstelling lvrid
 +
|style="background-color: white;"|0010
 
|}<section end=uitkomst_per_kind_850810711 />
 
|}<section end=uitkomst_per_kind_850810711 />
 
=== Medisch onderzoek ===
 
=== Medisch onderzoek ===
 
<section begin=medisch_onderzoek_850810711 />
 
<section begin=medisch_onderzoek_850810711 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Medisch onderzoek
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Medisch onderzoek
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
+
|colspan="2"|Irregulaire antistoffen?
|style="background-color: white;"|
+
|style="background-color: white;"|Nee
 
|}<section end=medisch_onderzoek_850810711 />
 
|}<section end=medisch_onderzoek_850810711 />
 
==Scenario 5. zorg volledig 2e lijn, vrouw overleden (voor vrouw met BSN: 912345676)==
 
==Scenario 5. zorg volledig 2e lijn, vrouw overleden (voor vrouw met BSN: 912345676)==
Regel 1.195: Regel 2.651:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Burgerservicenummer
 
|colspan="2"|Burgerservicenummer
|style="background-color: white;"|
+
|style="background-color: white;"|912345676
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Lokale persoonsidentificatie
 
|colspan="2"|Lokale persoonsidentificatie
|style="background-color: white;"|
+
|style="background-color: white;"|* (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Geboortedatum
 
|colspan="2"|Geboortedatum
|style="background-color: white;"|
+
|style="background-color: white;"|1993-03-04
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Adres - postcode
 
|colspan="2"|Adres - postcode
|style="background-color: white;"|
+
|style="background-color: white;"|9562 GF
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Etniciteit
 
|colspan="2"|Etniciteit
|style="background-color: white;"|
+
|style="background-color: white;"|Latijns Amerikaans (code = '14' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Lengte gemeten
 
|colspan="2"|Lengte gemeten
|style="background-color: white;"|
+
|style="background-color: white;"|186 cm
 
|}<section end=912345676 />
 
|}<section end=912345676 />
 
=== Anamnese ===
 
=== Anamnese ===
 
<section begin=anamnese_912345676 />
 
<section begin=anamnese_912345676 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Anamnese
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Anamnese
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Onder behandeling geweest?
+
|colspan="3"|Onder behandeling geweest?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Algemene anamnese
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Cardiovasculaire aandoening
 +
|style="background-color: white;"|Hypertensive disorder, systemic arterial (disorder) (code = '38341003' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Diabetes mellitus?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Neurologische aandoening
 +
|style="background-color: white;"|Epilepsy (disorder) (code = '84757009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Longaandoening
 +
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Orthopedische afwijking
 +
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Type stollingsprobleem
 +
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Algemene anamnese
+
|colspan="2"|Psychiatrie?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|}<section end=anamnese_912345676 />
 
|}<section end=anamnese_912345676 />
 
=== Zorgverlening ===
 
=== Zorgverlening ===
Regel 1.237: Regel 2.715:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Datum start zorgverantwoordelijkheid
 
|colspan="2"|Datum start zorgverantwoordelijkheid
|style="background-color: white;"|
+
|style="background-color: white;"|2013-12-09T00:00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Datum einde zorgverantwoordelijkheid
 
|colspan="2"|Datum einde zorgverantwoordelijkheid
|style="background-color: white;"|
+
|style="background-color: white;"|2014-08-04T00:00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
|style="background-color: white;"|
+
|style="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Conclusie risicostatus na intake
 
|colspan="2"|Conclusie risicostatus na intake
|style="background-color: white;"|
+
|style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
 
|}<section end=zorgverlening_912345676 />
 
|}<section end=zorgverlening_912345676 />
 
=== Zorgverlenerzorginstelling ===
 
=== Zorgverlenerzorginstelling ===
Regel 1.279: Regel 2.757:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Zorginstelling lvrid
 
|colspan="2"|Zorginstelling lvrid
|style="background-color: white;"|
+
|style="background-color: white;"|0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 
|}<section end=zorgverlenerzorginstelling_912345676 />
 
|}<section end=zorgverlenerzorginstelling_912345676 />
 
=== Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
 
=== Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
 
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 />
 
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="5" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Wijze einde zwangerschap
+
|colspan="5"|Wijze einde zwangerschap
|style="background-color: white;"|
+
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Definitieve a terme datum
 +
|style="background-color: white;"|2012-06-05
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Diagnose
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Infectie
 +
|style="background-color: white;"|Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Zwangerschapscholestase?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Afwijkende groei foetus
 +
|style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Irregulaire antistoffen?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Eerdere bevalling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="11"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Placenta - geboorte placenta
 +
|style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Vorige uitkomst per kind - vorige baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Demografische gegevens - geboortedatum
 +
|style="background-color: white;"|2012-06-09T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Kindspecifieke gegevens vorige uitkomsten
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Definitieve a terme datum
+
|colspan="2"|Type partus
|style="background-color: white;"|
+
|style="background-color: white;"|Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Diagnose
+
|colspan="2"|Percentiel van het geboortegewicht
|style="background-color: white;"|
+
|style="background-color: white;"|10 ≤ P < 50 (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.50')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Irregulaire antistoffen?
+
|colspan="2"|Apgarscore na 5 min
|style="background-color: white;"|
+
|style="background-color: white;"|10
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Eerdere bevalling
+
|colspan="2"|Congenitale afwijkingen?
|style="background-color: white;"|
+
|style="background-color: white;"|Nee
 
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 />
 
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 />
 
=== Zwangerschap ===
 
=== Zwangerschap ===
 
<section begin=zwangerschap_912345676 />
 
<section begin=zwangerschap_912345676 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zwangerschap
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Zwangerschap
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Dossiernummer
+
|colspan="3"|Dossiernummer
 
|style="background-color: white;"|
 
|style="background-color: white;"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Graviditeit
+
|colspan="3"|Graviditeit
|style="background-color: white;"|
+
|style="background-color: white;"|2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pariteit voor deze zwangerschap
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Definitieve a terme datum
 +
|style="background-color: white;"|2014-07-22
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voornemens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie
 +
|style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Prenatale controle
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum controle
 +
|style="background-color: white;"|2014-01-09T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zwangerschapsduur
 +
|style="background-color: white;"|86 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Leven voelen
 +
|style="background-color: white;"|Fetal movements absent (context-dependent category) (code = '289432001' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Rookgedrag
 +
|style="background-color: white;"|gestopt tijdens huidige zwangerschap (code = '6' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Alcoholgebruik
 +
|style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Drugsgebruik?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Gewicht gemeten
 +
|style="background-color: white;"|89 kg
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Diagnose
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Pariteit voor deze zwangerschap
+
|rowspan="5"|
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Definitieve a terme datum
+
|colspan="2"|Datum
|style="background-color: white;"|
+
|style="background-color: white;"|2014-01-09T00:00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Voornemens
+
|colspan="2"|Zwangerschapsduur
|style="background-color: white;"|
+
|style="background-color: white;"|86 dagen
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Prenatale controle
+
|colspan="2"|Afwijkende groei foetus
|style="background-color: white;"|
+
|style="background-color: white;"|Large-for-dates fetus (disorder) (code = '199616008' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Diagnose
+
|colspan="2"|Abruptio placentae?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Intrauteriene behandeling
+
|colspan="3"|Intrauteriene behandeling
|style="background-color: white;"|
+
|style="background-color: white;"|Selective destruction of fetus (procedure) (code = '265633004' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Maternale sterfte?
+
|colspan="3"|Maternale sterfte?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Wijze einde zwangerschap
+
|colspan="3"|Wijze einde zwangerschap
|style="background-color: white;"|
+
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 
|}<section end=zwangerschap_912345676 />
 
|}<section end=zwangerschap_912345676 />
 
=== Bevalling ===
 
=== Bevalling ===
 
<section begin=bevalling_912345676 />
 
<section begin=bevalling_912345676 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Bevalling
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Bevalling
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Partusnummer
+
|colspan="3"|Partusnummer
|style="background-color: white;"|
+
|style="background-color: white;"|000000
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Aantal geboren kinderen
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Risicostatus voor baring
 +
|style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Interventies begin baring
 +
|-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"|Aantal geboren kinderen
+
|colspan="2"|Interventie begin baring
|style="background-color: white;"|
+
|style="background-color: white;"|Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Risicostatus voor baring
+
|colspan="2"|Indicatie interventie begin baring
|style="background-color: white;"|
+
|style="background-color: white;"|acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Interventies begin baring
+
|colspan="3"|Wijze waarop de baring begon
|style="background-color: white;"|
+
|style="background-color: white;"|interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Medicatie nageboortetijdperk groep
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Wijze waarop de baring begon
+
|rowspan="2"|
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Medicatie nageboortetijdperk groep
+
|colspan="2"|Medicatie nageboortetijdperk?
|style="background-color: white;"|
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Placenta - geboorte placenta
+
|colspan="3"|Placenta - geboorte placenta
|style="background-color: white;"|
+
|style="background-color: white;"|placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Hoeveelheid bloedverlies
+
|colspan="3"|Hoeveelheid bloedverlies
|style="background-color: white;"|
+
|style="background-color: white;"|1500 ml
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Conditie perineum postpartum
+
|colspan="3"|Conditie perineum postpartum
|style="background-color: white;"|
+
|style="background-color: white;"|Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96')
 
|}<section end=bevalling_912345676 />
 
|}<section end=bevalling_912345676 />
 
=== Uitkomst per kind ===
 
=== Uitkomst per kind ===
 
<section begin=uitkomst_per_kind_912345676 />
 
<section begin=uitkomst_per_kind_912345676 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Uitkomst per kind
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Uitkomst per kind
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="6" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="58"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Werkelijke plaats baring type locatie
 +
|style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Ziekenhuis baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ziekenhuisnummer lvrid
 +
|style="background-color: white;"|0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Demografische gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="10"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Identificaties kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Bsn kind
 +
|style="background-color: white;"|528741913
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geslacht medische observatie
 +
|style="background-color: white;"|twijfelachtig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geboortedatum
 +
|style="background-color: white;"|2014-07-24T02:30:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Rangnummer kind
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Perinatale sterfte groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Perinatale sterfte?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Kindspecifieke maternale gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="12"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Kleur en consistentie vruchtwater
 +
|style="background-color: white;"|meconium (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Episiotomie?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ruggeprik gewenst niet gekregen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Pijnbestrijding?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Pijnbestrijding
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Methode
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Methode
 +
|style="background-color: white;"|General anesthesia (procedure) (code = '50697003' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Periode
 +
|style="background-color: white;"|tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Sedatie?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Kindspecifieke uitkomstgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="28"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Type partus
 +
|style="background-color: white;"|Emergency cesarian section (procedure) (code = '274130007' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ligging bij geboorte
 +
|style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Aanpakker kind - rol aanpakker kind
 +
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Supervisor - rol supervisor
 +
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Vaginale kunstverlossing groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Vaginale kunstverlossing
 +
|style="background-color: white;"|Delivery by vacuum extraction (procedure) (code = '61586001' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Succes vaginale kunstverlossing?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Sectio caesarea group
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Beslismoment sectio caesarea
 +
|style="background-color: white;"|tijdens uitdrijving besloten (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.5')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Indicatie secundaire sectio
 +
|style="background-color: white;"|Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Lichamelijk onderzoek kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Geboortegewicht
 +
|style="background-color: white;"|3750 gram
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Baring
+
|colspan="4"|Congenitale afwijkingen?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Congenitale afwijkingen groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Specificatie congenitale afwijking groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="1"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Chromosomale afwijkingen?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Specificatie chromosomale afwijking groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Specificatie chromosomale afwijking
 +
|style="background-color: white;"|Complete trisomy 21 syndrome (disorder) (code = '41040004' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problematiek kind?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problematiek kind
 +
|style="background-color: white;"|Congenital hearing disorder (disorder) (code = '95827002' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Kinderarts betrokken?
 +
|style="background-color: white;"|Nee
 
|}<section end=uitkomst_per_kind_912345676 />
 
|}<section end=uitkomst_per_kind_912345676 />
 
=== Medisch onderzoek ===
 
=== Medisch onderzoek ===
 
<section begin=medisch_onderzoek_912345676 />
 
<section begin=medisch_onderzoek_912345676 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Medisch onderzoek
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Medisch onderzoek
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
 +
|-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"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
+
|colspan="2"|Irregulaire antistoffen?
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Welke irregulaire antistoffen vrouw aanwezig
 +
|style="background-color: white;"|Kell (code = '405844003' in codeSystem '2.16.840.1.113883.6.96')
 
|}<section end=medisch_onderzoek_912345676 />
 
|}<section end=medisch_onderzoek_912345676 />
 
=== Postnatale fase ===
 
=== Postnatale fase ===
 
<section begin=postnatale_fase_912345676 />
 
<section begin=postnatale_fase_912345676 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Postnatale fase
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Postnatale fase
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
|colspan="2" width="25%"| Gegevenselement
+
|colspan="4" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Diagnoseinterventie postpartum
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Datum
 +
|style="background-color: white;"|2014-07-24T00:00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pathologie vrouw
 +
|style="background-color: white;"|Postpartum deep phlebothrombosis (disorder) (code = '56272000' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Kindspecifieke gegevens
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Diagnoseinterventie postpartum
+
|rowspan="5"|
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voeding kind groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voeding kind datum
 +
|style="background-color: white;"|2014-07-24
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
|colspan="2"|Kindspecifieke gegevens
+
|colspan="2"|Substantie voeding kind
|style="background-color: white;"|
+
|style="background-color: white;"|kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')
 
|}<section end=postnatale_fase_912345676 />
 
|}<section end=postnatale_fase_912345676 />

Versie van 25 jan 2019 14:10

{{#customtitle:Kernset Geboortezorg 2.3 - inhoud kwalificatie}}

Naar nictiz.nl

1 Addenda voor inhoudelijke gegevens Kernset Geboortezorg 2.3

1.1 Scenario 1. Zorg volledig 1e lijn, herpes, strippen, gezonde eenling (voor vrouw met BSN: 999910413)

Vrouw
Gegevenselement Waarde
Burgerservicenummer 999910413
Lokale persoonsidentificatie 000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
Geboortedatum 1976-05-02
Adres - postcode 4563 AB
Etniciteit Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
Lengte gemeten 170 cm

1.1.1 Anamnese

Anamnese
Gegevenselement Waarde
Onder behandeling geweest? Ja
Algemene anamnese
Cardiovasculaire aandoening Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Oncologische aandoening Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Infectieziekte Herpes (code = '23513009' in codeSystem '2.16.840.1.113883.6.96')
Type operatie Orthopedisch (code = '112697007' in codeSystem 'Snomed CT')

1.1.2 Zorgverlening

Zorgverlening
Gegevenselement Waarde
Datum start zorgverantwoordelijkheid 2014-03-01T00:00:00
Datum einde zorgverantwoordelijkheid 2014-11-12T00:00:00
Eindverantwoordelijk in welke perinatale periode? start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Conclusie risicostatus na intake 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26')

1.1.3 Zorgverlenerzorginstelling

Zorgverlenerzorginstelling
Gegevenselement Waarde
Zorginstelling lvrid 1808

1.1.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap

Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Gegevenselement Waarde
Wijze einde zwangerschap Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
Definitieve a terme datum 2011-12-01
Irregulaire antistoffen? Nee
Eerdere bevalling
Placenta - geboorte placenta Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
Hoeveelheid bloedverlies 550 ml
Vorige uitkomst per kind - vorige baring
Demografische gegevens - geboortedatum 2011-12-08T00:00:00
Kindspecifieke gegevens vorige uitkomsten
Type partus Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT')
Percentiel van het geboortegewicht 50 ≤ P < 90 (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.50')
Apgarscore na 5 min 8
Congenitale afwijkingen? Nee

1.1.5 Zwangerschap

Zwangerschap
Gegevenselement Waarde
Dossiernummer
Graviditeit 2
Pariteit voor deze zwangerschap 1
Definitieve a terme datum 2014-10-09
Voornemens
Voorgenomen plaats baring tijdens zwangerschap type locatie Thuis (code = '169813005' in codeSystem '2.16.840.1.113883.6.96')
Prenatale controle
Datum controle 2014-03-02T00:00:00
Zwangerschapsduur 59 dagen
Leven voelen goed (code = '289431008' in codeSystem 'Snomed CT')
Rookgedrag niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
Alcoholgebruik geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
Drugsgebruik? Nee
Gewicht gemeten 70 kg
Diagnose
Datum 2014-03-02T00:00:00
Zwangerschapsduur 59 dagen
Infectie Urineweg infectie (code = '307534009' in codeSystem 'Snomed CT')
Maternale sterfte? Nee
Wijze einde zwangerschap Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')

1.1.6 Bevalling

Bevalling
Gegevenselement Waarde
Partusnummer 000000
Aantal geboren kinderen 1
Risicostatus voor baring 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
Interventies begin baring
Interventie begin baring Strippen (code = '236960006' in codeSystem 'Snomed CT')
Indicatie interventie begin baring wens patiënt (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7')
Wijze waarop de baring begon Interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
Tijdstip begin actieve ontsluiting 2014-10-08T14:30:00
Medicatie nageboortetijdperk groep
Medicatie nageboortetijdperk? Ja
Soort medicatie nageboortetijdperk Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73')
Placenta - geboorte placenta Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
Hoeveelheid bloedverlies 615 ml
Conditie perineum postpartum 1e graads perineumruptuur (code = '199916005' in codeSystem 'Snomed CT')

1.1.7 Uitkomst per kind

Uitkomst per kind
Gegevenselement Waarde
Baring
Werkelijke plaats baring type locatie Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7')
Demografische gegevens
Identificaties kind
Bsn kind 999910383
Geslacht medische observatie vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
Geboortedatum 2014-10-08T00:00:00
Rangnummer kind 1
Perinatale sterfte groep
Perinatale sterfte? Nee
Kindspecifieke maternale gegevens
Tijdstip breken vliezen 2014-10-08T09:15:00
Kleur en consistentie vruchtwater Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
Tijdstip actief meepersen 2014-10-08T12:13:00
Episiotomie? Nee
Ruggeprik gewenst niet gekregen? Nee
Pijnbestrijding? Nee
Sedatie? Nee
Kindspecifieke uitkomstgegevens
Type partus Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT')
Ligging bij geboorte Achterhoofd-achter (code = '37235006' in codeSystem 'Snomed CT')
Aanpakker kind - rol aanpakker kind 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
Supervisor - rol supervisor 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
Lichamelijk onderzoek kind
Geboortegewicht 3450 gram
Congenitale afwijkingen? Nee
Problematiek kind? Nee
Kinderarts betrokken? Nee

1.1.8 Medisch onderzoek

Medisch onderzoek
Gegevenselement Waarde
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
Irregulaire antistoffen? Nee

1.1.9 Postnatale fase

Postnatale fase
Gegevenselement Waarde
Kindspecifieke gegevens
Voeding kind groep
Voeding kind datum 2014-10-12
Substantie voeding kind borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')
Substantie voeding kind kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')

1.2 Scenario 2. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)

Vrouw
Gegevenselement Waarde
Burgerservicenummer 961921821
Lokale persoonsidentificatie * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
Geboortedatum 1974-09-11
Adres - postcode 5689 CZ
Etniciteit Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
Lengte gemeten 184 cm

1.2.1 Anamnese

Anamnese
Gegevenselement Waarde
Onder behandeling geweest? Nee

1.2.2 Zorgverlening

Zorgverlening
Gegevenselement Waarde
Datum start zorgverantwoordelijkheid 2018-08-28
Datum einde zorgverantwoordelijkheid 2018-11-28
Eindverantwoordelijk in welke perinatale periode? start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Conclusie risicostatus na intake 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
Verwijsdetails
Datum verwijzing 2014-05-06T00:00:00
Verwijzing van
Zorginstelling
Zorgaanbieder identificatie nummer 1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Verwijzing naar
Zorginstelling
Specialisme Gynaecoloog 2e lijn (code = '02' in codeSystem 'Specialisme, specifiek voor perinatologie.')
Redenen van verwijzing
Van 1e naar 2e lijn
Zwangerschap
Hypertensieve aandoening Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT')
Perinatale periode voor 28e week (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52')

1.2.3 Zorgverlenerzorginstelling

Zorgverlenerzorginstelling
Gegevenselement Waarde
Zorginstelling lvrid 1504

1.2.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap

Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Gegevenselement Waarde
Wijze einde zwangerschap Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
Definitieve a terme datum 2013-06-05
Diagnose
Bloedverlies? Ja
Hyperemesis gravidarum? Ja
Irregulaire antistoffen? Ja

1.2.5 Zwangerschap

Zwangerschap
Gegevenselement Waarde
Dossiernummer
Graviditeit 2
Pariteit voor deze zwangerschap 0
Definitieve a terme datum 2014-09-08
Voornemens
Voorgenomen plaats baring tijdens zwangerschap type locatie Nog niet bepaald (code = '05' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7')
Prenatale controle
Datum controle 2014-05-06T00:00:00
Zwangerschapsduur 155 dagen
Leven voelen Weak fetal movements (finding) (code = '276372004' in codeSystem '2.16.840.1.113883.6.96')
Rookgedrag gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
Alcoholgebruik geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
Drugsgebruik? Nee
Gewicht gemeten 85 kg
Diagnose
Datum 2014-05-06T00:00:00
Zwangerschapsduur 155 dagen
Hypertensieve aandoening Pregnancy-induced hypertension (disorder) (code = '48194001' in codeSystem '2.16.840.1.113883.6.96')
Maternale sterfte? Nee

1.3 Scenario 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)

Vrouw
Gegevenselement Waarde
Burgerservicenummer 961921821
Lokale persoonsidentificatie * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
Geboortedatum 1974-09-11
Adres - postcode 5689 CZ
Etniciteit Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
Lengte gemeten 184 cm

1.3.1 Anamnese

Anamnese
Gegevenselement Waarde
Onder behandeling geweest? Nee

1.3.2 Zorgverlening

Zorgverlening
Gegevenselement Waarde
Datum start zorgverantwoordelijkheid 2014-05-12T00:00:00
Datum einde zorgverantwoordelijkheid 2014-10-09T00:00:00
Eindverantwoordelijk in welke perinatale periode? zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Verwijsdetails
Verwijzing van
Zorginstelling
Zorgaanbieder identificatie nummer 1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Verwijzing naar
Zorginstelling
Zorgaanbieder identificatie nummer 0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Redenen van verwijzing
Van 1e naar 2e lijn
Zwangerschap
Hypertensieve aandoening Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT')

1.3.3 Zorgverlenerzorginstelling

Zorgverlenerzorginstelling
Gegevenselement Waarde
Zorginstelling lvrid 0003

1.3.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap

Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Gegevenselement Waarde
Wijze einde zwangerschap Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
Definitieve a terme datum 2013-06-05
Diagnose
Gynaecologische aandoening Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96')
Bloedverlies? Ja
Hyperemesis gravidarum? Ja
Irregulaire antistoffen? Ja

1.3.5 Zwangerschap

Zwangerschap
Gegevenselement Waarde
Dossiernummer
Graviditeit 2
Pariteit voor deze zwangerschap 0
Definitieve a terme datum 2014-09-08
Voornemens
Prenatale controle
Datum controle 2014-05-12T00:00:00
Zwangerschapsduur 161 dagen
Leven voelen Reduced fetal movement (finding) (code = '276369006' in codeSystem '2.16.840.1.113883.6.96')
Rookgedrag gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
Alcoholgebruik geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
Drugsgebruik? Nee
Gewicht gemeten 85 kg
Diagnose
Datum 2014-05-12T00:00:00
Zwangerschapsduur 161 dagen
Gynaecologische aandoening Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96')
Partiele mola? Ja
Hypertensieve aandoening Pre-eclampsia (disorder) (code = '398254007' in codeSystem '2.16.840.1.113883.6.96')
Maternale sterfte? Nee
Wijze einde zwangerschap Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')

1.3.6 Bevalling

Bevalling
Gegevenselement Waarde
Partusnummer 000000
Aantal geboren kinderen 1
Risicostatus voor baring 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
Interventies begin baring
Interventie begin baring Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96')
Indicatie interventie begin baring acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7')
Wijze waarop de baring begon interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
Tijdstip begin actieve ontsluiting 2014-08-30T14:09:00
Medicatie nageboortetijdperk groep
Medicatie nageboortetijdperk? UNK
Placenta - geboorte placenta placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
Hoeveelheid bloedverlies 980 ml
Conditie perineum postpartum Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96')

1.3.7 Uitkomst per kind

Uitkomst per kind
Gegevenselement Waarde
Baring
Werkelijke plaats baring type locatie Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
Ziekenhuis baring
Ziekenhuisnummer lvrid 0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Demografische gegevens
Identificaties kind
Bsn kind 951847624
Geslacht medische observatie mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
Geboortedatum 2014-09-01T02:34:00
Rangnummer kind 1
Perinatale sterfte groep
Perinatale sterfte? Nee
Kindspecifieke maternale gegevens
Tijdstip breken vliezen 2014-08-30T23:04:00
Kleur en consistentie vruchtwater geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008')
Ruggeprik gewenst niet gekregen? Nee
Pijnbestrijding? Ja
Pijnbestrijding
Methode
Methode Epidural anesthesia (procedure) (code = '18946005' in codeSystem '2.16.840.1.113883.6.96')
Periode tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
Sedatie? Ja
Kindspecifieke uitkomstgegevens
Type partus Cesarean section (procedure) (code = '11466000' in codeSystem 'SNOMED CT')
Ligging bij geboorte Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008')
Aanpakker kind - rol aanpakker kind gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
Supervisor - rol supervisor gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
Sectio caesarea group
Indicatie primaire sectio Suspected fetal distress (situation) (code = '444433005:246090004=130955003' in codeSystem '2.16.840.1.113883.6.96')
Indicatie primaire sectio Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96')
Lichamelijk onderzoek kind
Geboortegewicht 3620 gram
Congenitale afwijkingen? Nee
Problematiek kind? Nee
Kinderarts betrokken? Ja
Betrokkenheid kinderarts
Datum betrokkenheid 2014-09-01T00:00:00
Reden betrokkenheid Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Type betrokkenheid consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
Zorginstelling lvrid 0003

1.3.8 Medisch onderzoek

Medisch onderzoek
Gegevenselement Waarde
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
Irregulaire antistoffen? Ja
Welke irregulaire antistoffen vrouw aanwezig Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96')

1.3.9 Postnatale fase

Postnatale fase
Gegevenselement Waarde
Diagnoseinterventie postpartum
Datum 2014-09-03T00:00:00
Pathologie vrouw Urinary tract infectious disease (disorder) (code = '68566005' in codeSystem '2.16.840.1.113883.6.96')
Kindspecifieke gegevens
Voeding kind groep
Voeding kind datum 2014-10-07
Substantie voeding kind kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')

1.4 Scenario 3. zorg volledig in 2e lijn, meerling, 1 kind overleden (voor vrouw met BSN: 895623146)

Vrouw
Gegevenselement Waarde
Burgerservicenummer 895623146
Lokale persoonsidentificatie 000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
Geboortedatum 1985-08-05
Adres - postcode 5421 JG
Etniciteit Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
Lengte gemeten 167 cm
Vrouwelijke genitale verminking? Ja
Type vrouwelijke genitale verminking Female genital mutilation type 2 (disorder) (code = '130621000119105' in codeSystem '2.16.840.1.113883.6.96')

1.4.1 Anamnese

Anamnese
Gegevenselement Waarde
Onder behandeling geweest? Ja
Algemene anamnese
Cardiovasculaire aandoening Cardiac arrhythmia (disorder) (code = '698247007' in codeSystem '2.16.840.1.113883.6.96')
Schildklier aandoening Hyperthyroidism (disorder) (code = '34486009' in codeSystem '2.16.840.1.113883.6.96')
Anemie Iron deficiency anemia (disorder) (code = '87522002' in codeSystem '2.16.840.1.113883.6.96')
Bloedtransfusie? Ja
Type operatie Operation on heart (procedure) (code = '64915003' in codeSystem '2.16.840.1.113883.6.96')

1.4.2 Zorgverlening

Zorgverlening
Gegevenselement Waarde
Datum start zorgverantwoordelijkheid 2014-03-10T00:00:00
Datum einde zorgverantwoordelijkheid 2014-11-03T00:00:00
Eindverantwoordelijk in welke perinatale periode? start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Conclusie risicostatus na intake 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26')

1.4.3 Zorgverlenerzorginstelling

Zorgverlenerzorginstelling
Gegevenselement Waarde
Zorginstelling lvrid 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)

1.4.4 Zwangerschap

Zwangerschap
Gegevenselement Waarde
Dossiernummer
Graviditeit 1
Pariteit voor deze zwangerschap 0
Definitieve a terme datum 2014-09-22
Voornemens
Voorgenomen plaats baring tijdens zwangerschap type locatie Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
Prenatale controle
Datum controle 2014-05-21T00:00:00
Zwangerschapsduur 156 dagen
Leven voelen Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96')
Rookgedrag niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
Alcoholgebruik geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
Drugsgebruik? Nee
Gewicht gemeten 67 kg
Diagnose
Datum 2014-05-21T00:00:00
Zwangerschapsduur 156 dagen
Bloedverlies? Ja
Infectie Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96')
Afwijkende groei foetus Small for gestational age fetus (disorder) (code = '267258002' in codeSystem '2.16.840.1.113883.6.96')
Abruptio placentae? Ja
Maternale sterfte? Nee
Wijze einde zwangerschap Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')

1.4.5 Bevalling

Bevalling
Gegevenselement Waarde
Partusnummer 000000
Diagnose bevalling
Pprom? Ja
Verdenking foetale nood? Ja
Aantal geboren kinderen 2
Risicostatus voor baring 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
Wijze waarop de baring begon spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
Tijdstip begin actieve ontsluiting 2014-08-27T22:09:00
Medicatie nageboortetijdperk groep
Medicatie nageboortetijdperk? Nee
Placenta - geboorte placenta controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
Hoeveelheid bloedverlies 1740 ml
Conditie perineum postpartum Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96')

1.4.6 Uitkomst per kind

Uitkomst per kind
Gegevenselement Waarde
Baring
Werkelijke plaats baring type locatie Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
Ziekenhuis baring
Ziekenhuisnummer lvrid 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Demografische gegevens
Identificaties kind
Bsn kind 847035116
Geslacht medische observatie vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
Geboortedatum 2014-08-28T06:30:00
Rangnummer kind 1
Perinatale sterfte groep
Perinatale sterfte? Nee
Kindspecifieke maternale gegevens
Tijdstip breken vliezen 2014-08-27T22:09:00
Kleur en consistentie vruchtwater kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
Tijdstip actief meepersen 2014-08-27T23:49:00
Episiotomie? Ja
Locatie episiotomie mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60')
Ruggeprik gewenst niet gekregen? Nee
Pijnbestrijding? Ja
Pijnbestrijding
Methode
Methode Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Overig middel
Middel Administration of morphinomimetic analgesic (procedure) (code = '52685006:363701004=404642006' in codeSystem '2.16.840.1.113883.6.96')
Toediening Administration of substance via intravenous route (procedure) (code = '431215000' in codeSystem '2.16.840.1.113883.6.96')
Periode tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
Sedatie? Nee
Kindspecifieke uitkomstgegevens
Type partus Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
Ligging bij geboorte Face presentation (finding) (code = '21882006' in codeSystem '2.16.840.1.113883.6.96')
Aanpakker kind - rol aanpakker kind arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
Supervisor - rol supervisor gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
Vaginale kunstverlossing groep
Vaginale kunstverlossing Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96')
Succes vaginale kunstverlossing? Ja
Lichamelijk onderzoek kind
Geboortegewicht 2040 gram
Congenitale afwijkingen? Nee
Problematiek kind? Ja
Problematiek kind Birth trauma of fetus (disorder) (code = '56110009' in codeSystem '2.16.840.1.113883.6.96')
Kinderarts betrokken? Ja
Betrokkenheid kinderarts
Datum betrokkenheid 2014-08-28T00:00:00
Reden betrokkenheid Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96')
Type betrokkenheid consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
Zorginstelling lvrid 9999

1.4.7 Uitkomst per kind

Uitkomst per kind
Gegevenselement Waarde
Baring
Werkelijke plaats baring type locatie Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
Ziekenhuis baring
Ziekenhuisnummer lvrid 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Demografische gegevens
Identificaties kind
Bsn kind 847035128
Geslacht medische observatie mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
Geboortedatum 2014-08-28T07:02:00
Rangnummer kind 2
Perinatale sterfte groep
Perinatale sterfte? Ja
Fase perinatale sterfte Newborn death (event) (code = '276506001' in codeSystem '2.16.840.1.113883.6.96')
Datumtijd vaststelling perinatale sterfte 2014-08-28T08:10:00
Kindspecifieke maternale gegevens
Tijdstip breken vliezen 2014-08-27T23:13:00
Kleur en consistentie vruchtwater kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
Tijdstip actief meepersen 2014-08-28T06:45:00
Episiotomie? Ja
Locatie episiotomie mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60')
Ruggeprik gewenst niet gekregen? Nee
Pijnbestrijding? Ja
Pijnbestrijding
Methode
Methode Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Overig middel
Middel Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96')
Toediening Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96')
Periode tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
Sedatie? Nee
Kindspecifieke uitkomstgegevens
Type partus Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
Ligging bij geboorte Complete breech presentation (finding) (code = '49168004' in codeSystem '2.16.840.1.113883.6.96')
Aanpakker kind - rol aanpakker kind arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
Supervisor - rol supervisor gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
Vaginale kunstverlossing groep
Vaginale kunstverlossing Total breech extraction (procedure) (code = '416055001' in codeSystem '2.16.840.1.113883.6.96')
Succes vaginale kunstverlossing? Ja
Overige interventies Maneuvers for delivery in shoulder dystocia (procedure) (code = '237008007' in codeSystem '2.16.840.1.113883.6.96')
Lichamelijk onderzoek kind
Geboortegewicht 1580 gram
Congenitale afwijkingen? Ja
Congenitale afwijkingen groep
Specificatie congenitale afwijking groep
Specificatie congenitale afwijking Spina bifida occulta (disorder) (code = '76916001' in codeSystem '2.16.840.1.113883.6.96')
Specificatie congenitale afwijking groep
Specificatie congenitale afwijking Multiple congenital cardiac defects (disorder) (code = '94702005' in codeSystem '2.16.840.1.113883.6.96')
Chromosomale afwijkingen? Nee
Problematiek kind? Ja
Problematiek kind Subdural intracranial hemorrhage due to birth trauma (disorder) (code = '126941005' in codeSystem '2.16.840.1.113883.6.96')
Kinderarts betrokken? Ja
Betrokkenheid kinderarts
Datum betrokkenheid 2014-08-28T00:00:00
Reden betrokkenheid Finding of neonatal condition (finding) (code = '364737004' in codeSystem '2.16.840.1.113883.6.96')
Type betrokkenheid overdracht (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
Zorginstelling lvrid 0001

1.4.8 Medisch onderzoek

Medisch onderzoek
Gegevenselement Waarde
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
Irregulaire antistoffen? Nee

1.4.9 Postnatale fase

Postnatale fase
Gegevenselement Waarde
Kindspecifieke gegevens
Rangnummer kind 1
Voeding kind groep
Voeding kind datum 2014-09-03
Substantie voeding kind borstmelk (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')

1.5 Scenario 4. 1e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)

Vrouw
Gegevenselement Waarde
Burgerservicenummer 850810711
Lokale persoonsidentificatie * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
Geboortedatum 1987-08-06
Adres - postcode 4589 BA
Etniciteit Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
Lengte gemeten 162 cm
Vrouwelijke genitale verminking? Ja
Type vrouwelijke genitale verminking Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96')

1.5.1 Anamnese

Anamnese
Gegevenselement Waarde
Onder behandeling geweest? Ja
Algemene anamnese
Autoimmuun aandoening Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96')
Urogenitale aandoening Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96')
Diabetes mellitus? Ja
Mdl aandoening Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96')
Longaandoening Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96')
Type operatie Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96')
Type operatie Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96')
Type operatie Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')

1.5.2 Zorgverlening

Zorgverlening
Gegevenselement Waarde
Datum start zorgverantwoordelijkheid 2014-08-07T00:00:00
Datum einde zorgverantwoordelijkheid 2014-09-15T00:00:00
Eindverantwoordelijk in welke perinatale periode? 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Conclusie risicostatus na intake 3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
Verwijsdetails
Verwijzing van
Zorginstelling
Zorgaanbieder identificatie nummer 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Verwijzing naar
Zorginstelling
Zorgaanbieder identificatie nummer 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Redenen van verwijzing
Redenen van verwijzing

1.5.3 Zorgverlenerzorginstelling

Zorgverlenerzorginstelling
Gegevenselement Waarde
Zorginstelling lvrid 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)

1.5.4 Zwangerschap

Zwangerschap
Gegevenselement Waarde
Dossiernummer
Graviditeit 1
Pariteit voor deze zwangerschap 0
Definitieve a terme datum 2014-08-18
Maternale sterfte? Ja
Wijze einde zwangerschap Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')

1.5.5 Bevalling

Bevalling
Gegevenselement Waarde
Aantal geboren kinderen 1
Risicostatus voor baring 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
Wijze waarop de baring begon spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
Tijdstip begin actieve ontsluiting 2014-08-03T21:09:00
Medicatie nageboortetijdperk groep
Medicatie nageboortetijdperk? Ja
Soort medicatie nageboortetijdperk Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73')
Placenta - geboorte placenta spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
Hoeveelheid bloedverlies 1120 ml
Conditie perineum postpartum Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96')

1.5.6 Uitkomst per kind

Uitkomst per kind
Gegevenselement Waarde
Baring
Werkelijke plaats baring type locatie Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
Ziekenhuis baring
Ziekenhuisnummer lvrid 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Demografische gegevens
Identificaties kind
Bsn kind 840736526
Geslacht medische observatie vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
Geboortedatum 2014-08-04T23:35:00
Rangnummer kind 1
Perinatale sterfte groep
Perinatale sterfte? Nee
Kindspecifieke maternale gegevens
Tijdstip breken vliezen 2014-08-03T07:04:00
Kleur en consistentie vruchtwater bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
Tijdstip actief meepersen 2014-08-04T22:15:00
Episiotomie? Ja
Locatie episiotomie mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60')
Ruggeprik gewenst niet gekregen? Nee
Pijnbestrijding? Ja
Pijnbestrijding
Methode
Methode Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Overig middel
Middel Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96')
Toediening Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96')
Periode tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
Sedatie? Nee
Kindspecifieke uitkomstgegevens
Type partus Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
Ligging bij geboorte Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96')
Aanpakker kind - rol aanpakker kind co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
Supervisor - rol supervisor gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
Vaginale kunstverlossing groep
Vaginale kunstverlossing Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96')
Succes vaginale kunstverlossing? Ja
Lichamelijk onderzoek kind
Geboortegewicht 4205 gram
Congenitale afwijkingen? Nee
Problematiek kind? Nee
Kinderarts betrokken? Ja
Betrokkenheid kinderarts
Datum betrokkenheid 2014-08-04T00:00:00
Reden betrokkenheid Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96')
Type betrokkenheid consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
Zorginstelling lvrid 0010

1.5.7 Postnatale fase

Postnatale fase
Gegevenselement Waarde
Diagnoseinterventie postpartum
Datum 2014-08-08T00:00:00
Pathologie vrouw Embolism (disorder) (code = '414086009' in codeSystem '2.16.840.1.113883.6.96')
Diagnoseinterventie postpartum
Datum 2014-08-08T00:00:00
Pathologie vrouw Episiotomy infection (disorder) (code = '300927001' in codeSystem '2.16.840.1.113883.6.96')
Kindspecifieke gegevens
Voeding kind groep
Voeding kind datum 2014-09-15
Substantie voeding kind kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')

1.6 Scenario 4. 2e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)

Vrouw
Gegevenselement Waarde
Burgerservicenummer 850810711
Lokale persoonsidentificatie * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
Geboortedatum 1987-08-06
Adres - postcode 4589 BA
Etniciteit Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
Lengte gemeten 162 cm
Vrouwelijke genitale verminking? Ja
Type vrouwelijke genitale verminking Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96')

1.6.1 Anamnese

Anamnese
Gegevenselement Waarde
Onder behandeling geweest? Ja
Algemene anamnese
Autoimmuun aandoening Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96')
Urogenitale aandoening Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96')
Diabetes mellitus? Ja
Mdl aandoening Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96')
Longaandoening Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96')
Type operatie Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96')
Type operatie Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96')
Type operatie Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')

1.6.2 Zorgverlening

Zorgverlening
Gegevenselement Waarde
Datum start zorgverantwoordelijkheid 2014-02-03T00:00:00
Datum einde zorgverantwoordelijkheid 2014-08-06T00:00:00
Eindverantwoordelijk in welke perinatale periode? zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Conclusie risicostatus na intake 3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
Verwijsdetails
Datum verwijzing 2014-08-06T00:00:00
Verwijzing van
Zorginstelling
Zorgaanbieder identificatie nummer 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Verwijzing naar
Zorginstelling
Zorgaanbieder identificatie nummer 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Redenen van verwijzing
Perinatale periode 2e t/m 7e dag (code = '92' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52')

1.6.3 Zorgverlenerzorginstelling

Zorgverlenerzorginstelling
Gegevenselement Waarde
Zorginstelling lvrid 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)

1.6.4 Zwangerschap

Zwangerschap
Gegevenselement Waarde
Dossiernummer
Graviditeit 1
Pariteit voor deze zwangerschap 0
Definitieve a terme datum 2014-08-18
Voornemens
Voorgenomen plaats baring tijdens zwangerschap type locatie Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
Prenatale controle
Datum controle 2014-05-07T00:00:00
Zwangerschapsduur 149 dagen
Leven voelen Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96')
Rookgedrag niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
Alcoholgebruik geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
Drugsgebruik? Nee
Gewicht gemeten 82 kg
Diagnose
Datum 2014-05-07T00:00:00
Zwangerschapsduur 149 dagen
Infectie Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96')
Maternale sterfte? Nee
Wijze einde zwangerschap Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')

1.6.5 Bevalling

Bevalling
Gegevenselement Waarde
Diagnose bevalling
Niet vorderende ontsluiting? Ja
Niet vorderende uitdrijving? Ja
Aantal geboren kinderen 1
Risicostatus voor baring 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
Wijze waarop de baring begon spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
Tijdstip begin actieve ontsluiting 2014-08-03T21:09:00
Medicatie nageboortetijdperk groep
Medicatie nageboortetijdperk? Ja
Soort medicatie nageboortetijdperk Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73')
Placenta - geboorte placenta spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
Hoeveelheid bloedverlies 1120 ml
Conditie perineum postpartum Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96')

1.6.6 Uitkomst per kind

Uitkomst per kind
Gegevenselement Waarde
Baring
Werkelijke plaats baring type locatie Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
Ziekenhuis baring
Ziekenhuisnummer lvrid 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Demografische gegevens
Identificaties kind
Bsn kind 840736526
Geslacht medische observatie vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
Geboortedatum 2014-08-04T23:35:00
Rangnummer kind 1
Perinatale sterfte groep
Perinatale sterfte? Nee
Kindspecifieke maternale gegevens
Tijdstip breken vliezen 2014-08-03T07:04:00
Kleur en consistentie vruchtwater bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
Tijdstip actief meepersen 2014-08-04T22:15:00
Episiotomie? Ja
Locatie episiotomie mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60')
Ruggeprik gewenst niet gekregen? Nee
Pijnbestrijding? Ja
Pijnbestrijding
Methode
Methode Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Overig middel
Middel Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96')
Toediening Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96')
Periode tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
Sedatie? Nee
Kindspecifieke uitkomstgegevens
Type partus Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
Ligging bij geboorte Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96')
Aanpakker kind - rol aanpakker kind co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
Supervisor - rol supervisor gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
Vaginale kunstverlossing groep
Vaginale kunstverlossing Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96')
Succes vaginale kunstverlossing? Ja
Lichamelijk onderzoek kind
Geboortegewicht 4205 gram
Congenitale afwijkingen? Nee
Problematiek kind? Nee
Kinderarts betrokken? Ja
Betrokkenheid kinderarts
Datum betrokkenheid 2014-08-04T00:00:00
Reden betrokkenheid Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96')
Type betrokkenheid consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
Zorginstelling lvrid 0010

1.6.7 Medisch onderzoek

Medisch onderzoek
Gegevenselement Waarde
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
Irregulaire antistoffen? Nee

1.7 Scenario 5. zorg volledig 2e lijn, vrouw overleden (voor vrouw met BSN: 912345676)

Vrouw
Gegevenselement Waarde
Burgerservicenummer 912345676
Lokale persoonsidentificatie * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
Geboortedatum 1993-03-04
Adres - postcode 9562 GF
Etniciteit Latijns Amerikaans (code = '14' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
Lengte gemeten 186 cm

1.7.1 Anamnese

Anamnese
Gegevenselement Waarde
Onder behandeling geweest? Ja
Algemene anamnese
Cardiovasculaire aandoening Hypertensive disorder, systemic arterial (disorder) (code = '38341003' in codeSystem '2.16.840.1.113883.6.96')
Diabetes mellitus? Ja
Neurologische aandoening Epilepsy (disorder) (code = '84757009' in codeSystem '2.16.840.1.113883.6.96')
Longaandoening Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Orthopedische afwijking Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Type stollingsprobleem Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Psychiatrie? Ja

1.7.2 Zorgverlening

Zorgverlening
Gegevenselement Waarde
Datum start zorgverantwoordelijkheid 2013-12-09T00:00:00
Datum einde zorgverantwoordelijkheid 2014-08-04T00:00:00
Eindverantwoordelijk in welke perinatale periode? start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Conclusie risicostatus na intake 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26')

1.7.3 Zorgverlenerzorginstelling

Zorgverlenerzorginstelling
Gegevenselement Waarde
Zorginstelling lvrid 0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)

1.7.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap

Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Gegevenselement Waarde
Wijze einde zwangerschap Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
Definitieve a terme datum 2012-06-05
Diagnose
Infectie Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96')
Zwangerschapscholestase? Ja
Afwijkende groei foetus Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008')
Irregulaire antistoffen? Ja
Eerdere bevalling
Placenta - geboorte placenta spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
Vorige uitkomst per kind - vorige baring
Demografische gegevens - geboortedatum 2012-06-09T00:00:00
Kindspecifieke gegevens vorige uitkomsten
Type partus Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
Percentiel van het geboortegewicht 10 ≤ P < 50 (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.50')
Apgarscore na 5 min 10
Congenitale afwijkingen? Nee

1.7.5 Zwangerschap

Zwangerschap
Gegevenselement Waarde
Dossiernummer
Graviditeit 2
Pariteit voor deze zwangerschap 1
Definitieve a terme datum 2014-07-22
Voornemens
Voorgenomen plaats baring tijdens zwangerschap type locatie Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008')
Prenatale controle
Datum controle 2014-01-09T00:00:00
Zwangerschapsduur 86 dagen
Leven voelen Fetal movements absent (context-dependent category) (code = '289432001' in codeSystem '2.16.840.1.113883.6.96')
Rookgedrag gestopt tijdens huidige zwangerschap (code = '6' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
Alcoholgebruik geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
Drugsgebruik? Ja
Gewicht gemeten 89 kg
Diagnose
Datum 2014-01-09T00:00:00
Zwangerschapsduur 86 dagen
Afwijkende groei foetus Large-for-dates fetus (disorder) (code = '199616008' in codeSystem '2.16.840.1.113883.6.96')
Abruptio placentae? Ja
Intrauteriene behandeling Selective destruction of fetus (procedure) (code = '265633004' in codeSystem '2.16.840.1.113883.6.96')
Maternale sterfte? Ja
Wijze einde zwangerschap Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')

1.7.6 Bevalling

Bevalling
Gegevenselement Waarde
Partusnummer 000000
Aantal geboren kinderen 1
Risicostatus voor baring 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
Interventies begin baring
Interventie begin baring Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96')
Indicatie interventie begin baring acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7')
Wijze waarop de baring begon interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
Medicatie nageboortetijdperk groep
Medicatie nageboortetijdperk? Nee
Placenta - geboorte placenta placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
Hoeveelheid bloedverlies 1500 ml
Conditie perineum postpartum Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96')

1.7.7 Uitkomst per kind

Uitkomst per kind
Gegevenselement Waarde
Baring
Werkelijke plaats baring type locatie Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
Ziekenhuis baring
Ziekenhuisnummer lvrid 0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Demografische gegevens
Identificaties kind
Bsn kind 528741913
Geslacht medische observatie twijfelachtig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
Geboortedatum 2014-07-24T02:30:00
Rangnummer kind 1
Perinatale sterfte groep
Perinatale sterfte? Nee
Kindspecifieke maternale gegevens
Kleur en consistentie vruchtwater meconium (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
Episiotomie? Nee
Ruggeprik gewenst niet gekregen? Nee
Pijnbestrijding? Ja
Pijnbestrijding
Methode
Methode General anesthesia (procedure) (code = '50697003' in codeSystem '2.16.840.1.113883.6.96')
Periode tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
Sedatie? Ja
Kindspecifieke uitkomstgegevens
Type partus Emergency cesarian section (procedure) (code = '274130007' in codeSystem 'SNOMED CT')
Ligging bij geboorte Onbekend (code = 'UNK' in codeSystem '2.16.840.1.113883.5.1008')
Aanpakker kind - rol aanpakker kind gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
Supervisor - rol supervisor gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
Vaginale kunstverlossing groep
Vaginale kunstverlossing Delivery by vacuum extraction (procedure) (code = '61586001' in codeSystem '2.16.840.1.113883.6.96')
Succes vaginale kunstverlossing? Nee
Sectio caesarea group
Beslismoment sectio caesarea tijdens uitdrijving besloten (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.5')
Indicatie secundaire sectio Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96')
Lichamelijk onderzoek kind
Geboortegewicht 3750 gram
Congenitale afwijkingen? Ja
Congenitale afwijkingen groep
Specificatie congenitale afwijking groep
Chromosomale afwijkingen? Ja
Specificatie chromosomale afwijking groep
Specificatie chromosomale afwijking Complete trisomy 21 syndrome (disorder) (code = '41040004' in codeSystem '2.16.840.1.113883.6.96')
Problematiek kind? Ja
Problematiek kind Congenital hearing disorder (disorder) (code = '95827002' in codeSystem '2.16.840.1.113883.6.96')
Kinderarts betrokken? Nee

1.7.8 Medisch onderzoek

Medisch onderzoek
Gegevenselement Waarde
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
Irregulaire antistoffen? Ja
Welke irregulaire antistoffen vrouw aanwezig Kell (code = '405844003' in codeSystem '2.16.840.1.113883.6.96')

1.7.9 Postnatale fase

Postnatale fase
Gegevenselement Waarde
Diagnoseinterventie postpartum
Datum 2014-07-24T00:00:00
Pathologie vrouw Postpartum deep phlebothrombosis (disorder) (code = '56272000' in codeSystem '2.16.840.1.113883.6.96')
Kindspecifieke gegevens
Voeding kind groep
Voeding kind datum 2014-07-24
Substantie voeding kind kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')