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=" | |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=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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"| | |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=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Wijze einde zwangerschap | ||
|style="background-color: white;"| | |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"| | |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"| | |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"| | |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=" | |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=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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"| | |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"| | |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;;" | ||
| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |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"| | |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"| | |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=" | |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=" | |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=" | |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=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |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"| | |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=" | |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=" | |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;;" | ||
| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |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"| | |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=" | |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=" | |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=" | |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=" | |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=" | |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"| | |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=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="2"| | ||
|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=" | |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=" | |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"| | |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=" | |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=" | |colspan="6" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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;;" | ||
| | |rowspan="6"| | ||
|style="background-color: | |-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;;" | ||
| | |rowspan="4"| | ||
|style="background-color: | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zwangerschap | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |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=" | |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=" | |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=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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"| | |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"| | |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=" | |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=" | |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=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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"| | |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"| | |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;;" | ||
| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |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"| | |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"| | |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=" | |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=" | |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=" | |colspan="6" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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;;" | ||
| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Zorgaanbieder identificatie nummer | ||
|style="background-color: | |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;;" | ||
| | |rowspan="4"| | ||
|style="background-color: | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Zorginstelling | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="3"|Zorgaanbieder identificatie nummer | ||
|style="background-color: | |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;;" | ||
| | |rowspan="6"| | ||
|style="background-color: | |-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;;" | ||
| | |rowspan="4"| | ||
|style="background-color: | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zwangerschap | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |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=" | |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=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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"| | |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"| | |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=" | |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=" | |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=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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"| | |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"| | |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"| | |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"| | |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"| | |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"| | |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=" | |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=" | |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=" | |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=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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"| | |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"| | |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=" | |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=" | |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;;" | ||
| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Medicatie nageboortetijdperk | |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=" | |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=" | |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=" | |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=" | |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=" | |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"| | |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=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|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"| | |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=" | |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=" | |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"| | |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"| | |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=" | |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=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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"| | |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=" | |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=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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"| | |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"| | |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"| | |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"| | |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"| | |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"| | |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=" | |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=" | |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=" | |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=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |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=" | |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=" | |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=" | |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=" | |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;;" | ||
| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Medicatie nageboortetijdperk | |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=" | |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=" | |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=" | |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=" | |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=" | |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"| | |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=" | |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=" | |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"| | |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=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="2"| | ||
|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=" | |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=" | |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"| | |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=" | |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=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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"| | |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=" | |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=" | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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;;" | ||
| | |rowspan="4"| | ||
|style="background-color: | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorginstelling | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Zorgaanbieder identificatie nummer | ||
|style="background-color: | |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;;" | ||
| | |rowspan="1"| | ||
|style="background-color: | |-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;;" | ||
| | |rowspan="1"| | ||
|}<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=" | |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=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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=" | |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;;" | ||
| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |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"| | |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=" | |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=" | |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=" | |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=" | |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=" | |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"| | |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=" | |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=" | |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;;" | ||
| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |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"| | |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=" | |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=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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"| | |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=" | |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=" | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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=" | |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;;" | ||
| | |rowspan="4"| | ||
|style="background-color: | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorginstelling | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Zorgaanbieder identificatie nummer | ||
|style="background-color: | |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;;" | ||
| | |rowspan="4"| | ||
|style="background-color: | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorginstelling | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |colspan="2"|Zorgaanbieder identificatie nummer | ||
|style="background-color: | |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;;" | ||
| | |rowspan="1"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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=" | |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=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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"| | |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"| | |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;;" | ||
| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |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"| | |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"| | |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=" | |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=" | |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=" | |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=" | |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"| | |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=" | |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=" | |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;;" | ||
| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |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"| | |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=" | |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=" | |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=" | |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=" | |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=" | |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"| | |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=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|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"| | |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=" | |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=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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"| | |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=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="5" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |colspan="5"|Wijze einde zwangerschap | ||
|style="background-color: white;"| | |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"| | |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"| | |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"| | |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"| | |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=" | |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=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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"| | |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;;" | ||
| | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"| | |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"| | |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"| | |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"| | |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=" | |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=" | |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=" | |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=" | |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=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan=" | |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"| | |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"| | |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=" | |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;;" | ||
| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Medicatie nageboortetijdperk | |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=" | |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=" | |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=" | |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=" | |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=" | |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"| | |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=" | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan=" | |colspan="3" width="25%"| Gegevenselement | ||
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |||
|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"| | |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=" | |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=" | |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"| | |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"| | |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}} __NUMBEREDHEADINGS__
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Addenda voor inhoudelijke gegevens Kernset Geboortezorg 2.3
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 | |
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') | ||
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') | |
Zorgverlenerzorginstelling
| Zorgverlenerzorginstelling | ||
| Gegevenselement | Waarde | |
| Zorginstelling lvrid | 1808 | |
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 | ||||
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') | ||
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') | ||
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 | ||||
Medisch onderzoek
| Medisch onderzoek | |||
| Gegevenselement | Waarde | ||
| Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
| Irregulaire antistoffen? | Nee | ||
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') | |||
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 | |
Anamnese
| Anamnese | ||
| Gegevenselement | Waarde | |
| Onder behandeling geweest? | Nee | |
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') | |||||
Zorgverlenerzorginstelling
| Zorgverlenerzorginstelling | ||
| Gegevenselement | Waarde | |
| Zorginstelling lvrid | 1504 | |
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 | ||
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 | ||
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 | |
Anamnese
| Anamnese | ||
| Gegevenselement | Waarde | |
| Onder behandeling geweest? | Nee | |
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') | |||||
Zorgverlenerzorginstelling
| Zorgverlenerzorginstelling | ||
| Gegevenselement | Waarde | |
| Zorginstelling lvrid | 0003 | |
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 | ||
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') | ||
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') | ||
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 | |||||
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') | ||
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') | |||
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') | |
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') | ||
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') | |
Zorgverlenerzorginstelling
| Zorgverlenerzorginstelling | ||
| Gegevenselement | Waarde | |
| Zorginstelling lvrid | 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | |
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') | ||
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') | ||
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 | ||||||
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 | ||||||
Medisch onderzoek
| Medisch onderzoek | |||
| Gegevenselement | Waarde | ||
| Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
| Irregulaire antistoffen? | Nee | ||
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') | |||
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') | |
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') | ||
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 | |||||
Zorgverlenerzorginstelling
| Zorgverlenerzorginstelling | ||
| Gegevenselement | Waarde | |
| Zorginstelling lvrid | 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | |
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') | |
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') | ||
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 | ||||||
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') | |||
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') | |
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') | ||
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') | ||||
Zorgverlenerzorginstelling
| Zorgverlenerzorginstelling | ||
| Gegevenselement | Waarde | |
| Zorginstelling lvrid | 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | |
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') | ||
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') | ||
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 | ||||||
Medisch onderzoek
| Medisch onderzoek | |||
| Gegevenselement | Waarde | ||
| Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
| Irregulaire antistoffen? | Nee | ||
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 | |
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 | ||
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') | |
Zorgverlenerzorginstelling
| Zorgverlenerzorginstelling | ||
| Gegevenselement | Waarde | |
| Zorginstelling lvrid | 0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | |
Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
| Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||||
| Gegevenselement | Waarde | ||||
| Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||||
| 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 | ||||
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') | ||
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') | ||
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 | |||||
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') | ||
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') | |||