Gebz:Vdraft AddendaKwalificatieKernsetGeboortezorg23 Dekkingsgraad: verschil tussen versies
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| Regel 494: | Regel 494: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Geboorte placenta | |colspan="5"|Geboorte placenta | ||
| − | |style="background-color: white;"|(code = '' in codeSystem '') - (code = '' in codeSystem '') - (code = '' in codeSystem '') - (code = '' in codeSystem ' | + | |style="background-color: white;"| - - - - - - - Thuis (code = '169813005' in codeSystem '2.16.840.1.113883.6.96') - - - goed (code = '289431008' in codeSystem 'Snomed CT') - niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') - - - - - Urineweg infectie (code = '307534009' in codeSystem 'Snomed CT') - Strippen (code = '236960006' in codeSystem 'Snomed CT') - wens patiënt (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') - - Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') - Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') - - - - - - - - - - voor 28e week (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') - - - - - - Nog niet bepaald (code = '05' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') - - - Weak fetal movements (finding) (code = '276372004' in codeSystem '2.16.840.1.113883.6.96') - gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') - - - - - Pregnancy-induced hypertension (disorder) (code = '48194001' in codeSystem '2.16.840.1.113883.6.96') - - - - - - - Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') - - - - - Reduced fetal movement (finding) (code = '276369006' in codeSystem '2.16.840.1.113883.6.96') - gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') - - - - - Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') - - Pre-eclampsia (disorder) (code = '398254007' in codeSystem '2.16.840.1.113883.6.96') - Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96') - acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') - - placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - - - - - - - Urinary tract infectious disease (disorder) (code = '68566005' in codeSystem '2.16.840.1.113883.6.96') - - - - - - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - - - Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96') - niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') - - - - - - Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') - Small for gestational age fetus (disorder) (code = '267258002' in codeSystem '2.16.840.1.113883.6.96') - - - - - controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - - - - - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - - - - - - - - - - - - - - - - - Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') - spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - - - - - - Embolism (disorder) (code = '414086009' in codeSystem '2.16.840.1.113883.6.96') - - Episiotomy infection (disorder) (code = '300927001' in codeSystem '2.16.840.1.113883.6.96') - - - - - - 2e t/m 7e dag (code = '92' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') - - - - - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - - - Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96') - niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') - - - - - Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') - - - - Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') - spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - - - - - - - - - - Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') - - Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') - - - Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') - - - Fetal movements absent (context-dependent category) (code = '289432001' in codeSystem '2.16.840.1.113883.6.96') - gestopt tijdens huidige zwangerschap (code = '6' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') - - - - - Large-for-dates fetus (disorder) (code = '199616008' in codeSystem '2.16.840.1.113883.6.96') - - Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96') - acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') - - placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - - - - - - - Postpartum deep phlebothrombosis (disorder) (code = '56272000' in codeSystem '2.16.840.1.113883.6.96') - |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Hoeveelheid bloedverlies | |colspan="6"|Hoeveelheid bloedverlies | ||
| Regel 848: | Regel 848: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Methode | |colspan="3"|Methode | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| - - - - 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - - - - Gynaecoloog 2e lijn (code = '02' in codeSystem 'Specialisme, specifiek voor perinatologie.') - - - - - - - - tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - Suspected fetal distress (situation) (code = '444433005:246090004=130955003' in codeSystem '2.16.840.1.113883.6.96') - Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') - - - Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') - - - Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96') - - - - tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') - - - - Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') - consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') - - - - Newborn death (event) (code = '276506001' in codeSystem '2.16.840.1.113883.6.96') - - - tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - Total breech extraction (procedure) (code = '416055001' in codeSystem '2.16.840.1.113883.6.96') - - - - - - - Finding of neonatal condition (finding) (code = '364737004' in codeSystem '2.16.840.1.113883.6.96') - overdracht (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.17') - - - - - - - - tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') - - - - Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') - consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') - - - - - - - tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') - - - - Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') - consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') - - - - - - - - tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - Delivery by vacuum extraction (procedure) (code = '61586001' in codeSystem '2.16.840.1.113883.6.96') - - tijdens uitdrijving besloten (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.5') - Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') - - - - - - Kell (code = '405844003' in codeSystem '2.16.840.1.113883.6.96') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Overig middel | |colspan="4"|Overig middel | ||
| Regel 984: | Regel 984: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Welke irregulaire antistoffen vrouw aanwezig | |colspan="2"|Welke irregulaire antistoffen vrouw aanwezig | ||
| − | |style="background-color: white;"| | + | |style="background-color: white;"| - - Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96') - - - - Kell (code = '405844003' in codeSystem '2.16.840.1.113883.6.96') |
|}<section end=medisch_onderzoek_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 /> | |}<section end=medisch_onderzoek_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 /> | ||
=== Postnatale fase === | === Postnatale fase === | ||
Versie van 27 jan 2019 16:19
{{#customtitle:Kernset Geboortezorg 2.3 - dekkingsgraad scenario's}}
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Deze pagina is nog in bewerking |
1 Dekkingsgraad scenario's voor Kernset Geboortezorg 2.3
1.1 Scenario (voor vrouw met BSN: 999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676)
| Vrouw | ||
| Gegevenselement | Waarde | |
| Burgerservicenummer | 999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 | |
| Lokale persoonsidentificatie | 000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) - * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) - * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) - 000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) - * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) - * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) - * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) | |
| Geboortedatum | 2 mei 1976 - 11 sep 1974 - 11 sep 1974 - 5 aug 1985 - 6 aug 1987 - 6 aug 1987 - 4 mrt 1993 | |
| Adres - postcode | 4563 AB - 5689 CZ - 5689 CZ - 5421 JG - 4589 BA - 4589 BA - 9562 GF | |
| Etniciteit | Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28') - Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') - Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') - Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') - Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') - Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') - Latijns Amerikaans (code = '14' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | |
| Lengte gemeten | 170 cm - 184 cm - 184 cm - 167 cm - 162 cm - 162 cm - 186 cm | |
| Vrouwelijke genitale verminking? | Ja - Ja - Ja | |
| Type vrouwelijke genitale verminking | Female genital mutilation type 2 (disorder) (code = '130621000119105' in codeSystem '2.16.840.1.113883.6.96') - Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96') - Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96') | |
1.1.1 Anamnese
| Anamnese | |||
| Gegevenselement | Waarde | ||
| Onder behandeling geweest? | Ja - Nee - Nee - Ja - Ja - Ja - Ja | ||
| Algemene anamnese | |||
| Autoimmuun aandoening | Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96') - Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96') | ||
| Cardiovasculaire aandoening | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - Cardiac arrhythmia (disorder) (code = '698247007' in codeSystem '2.16.840.1.113883.6.96') - Hypertensive disorder, systemic arterial (disorder) (code = '38341003' in codeSystem '2.16.840.1.113883.6.96') | ||
| Urogenitale aandoening | Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96') - Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96') | ||
| Oncologische aandoening | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
| Schildklier aandoening | Hyperthyroidism (disorder) (code = '34486009' in codeSystem '2.16.840.1.113883.6.96') | ||
| Diabetes mellitus? | Ja - Ja - Ja | ||
| Neurologische aandoening | Epilepsy (disorder) (code = '84757009' in codeSystem '2.16.840.1.113883.6.96') | ||
| Infectieziekte | Herpes (code = '23513009' in codeSystem '2.16.840.1.113883.6.96') | ||
| Mdl aandoening | Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96') - Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96') | ||
| Anemie | Iron deficiency anemia (disorder) (code = '87522002' in codeSystem '2.16.840.1.113883.6.96') | ||
| Longaandoening | Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96') - Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96') - Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
| Gynaecologische aandoening | |||
| Orthopedische afwijking | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
| Bloedtransfusie? | Ja | ||
| Transfusiereactie? | |||
| Type operatie | Orthopedisch (code = '112697007' in codeSystem 'Snomed CT') - Operation on heart (procedure) (code = '64915003' in codeSystem '2.16.840.1.113883.6.96') - Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96') - Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96') - Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96') - Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96') - Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
| Type stollingsprobleem | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | ||
| Psychiatrie? | Ja | ||
| Overige aandoening? | |||
| Overige aandoening | |||
1.1.2 Zorgverlening
| Zorgverlening | |||||||
| Gegevenselement | Waarde | ||||||
| Datum start zorgverantwoordelijkheid | 1 mrt 2014 00:00 - 28 aug 2018 - 12 mei 2014 00:00 - 10 mrt 2014 00:00 - 7 aug 2014 00:00 - 3 feb 2014 00:00 - 9 dec 2013 00:00 | ||||||
| Datum einde zorgverantwoordelijkheid | 12 nov 2014 00:00 - 28 nov 2018 - 9 okt 2014 00:00 - 3 nov 2014 00:00 - 15 sep 2014 00:00 - 6 aug 2014 00:00 - 4 aug 2014 00:00 | ||||||
| Eindverantwoordelijk in welke perinatale periode? | start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | ||||||
| Conclusie risicostatus na intake | 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') - 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') - 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') - 3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26') - 3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26') - 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | ||||||
| Verwijsdetails | |||||||
| Datum verwijzing | 6 mei 2014 00:00 - 6 aug 2014 00:00 | ||||||
| Verwijzing van | |||||||
| Zorginstelling | |||||||
| Zorgaanbieder identificatie nummer | 1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||||
| Specialisme | Gynaecoloog 2e lijn (code = '02' in codeSystem 'Specialisme, specifiek voor perinatologie.') | ||||||
| Verwijzing naar | |||||||
| Zorginstelling | |||||||
| Zorgaanbieder identificatie nummer | 1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||||
| Specialisme | Gynaecoloog 2e lijn (code = '02' in codeSystem 'Specialisme, specifiek voor perinatologie.') | ||||||
| Type verwijzing | |||||||
| Redenen van verwijzing | |||||||
| Van 1e naar 2e lijn | |||||||
| Algemene anamnese | |||||||
| Autoimmuun aandoening | |||||||
| Cardiovasculaire aandoening | |||||||
| Urogenitale aandoening | |||||||
| Oncologische aandoening | |||||||
| Schildklier aandoening | |||||||
| Diabetes mellitus? | |||||||
| Neurologische aandoening | |||||||
| Infectieziekte | |||||||
| Mdl aandoening | |||||||
| Anemie | |||||||
| Longaandoening | |||||||
| Gynaecologische aandoening | |||||||
| Orthopedische afwijking | |||||||
| Bloedtransfusie? | |||||||
| Transfusiereactie? | |||||||
| Type operatie | |||||||
| Type stollingsprobleem | |||||||
| Psychiatrie? | |||||||
| Overige aandoening? | |||||||
| Obstetrische anamnese | |||||||
| Gynaecologische aandoening | |||||||
| Bloedverlies? | |||||||
| Partiele mola? | |||||||
| Cervixinsufficientie? | |||||||
| Infectie | |||||||
| Hyperemesis gravidarum? | |||||||
| Hypertensieve aandoening | Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT') - Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT') | ||||||
| Zwangerschapscholestase? | |||||||
| Diabetes gravidarum met insuline? | |||||||
| Afwijkende groei foetus | |||||||
| Dreigende partus immaturus? | |||||||
| Dreigende partus prematurus? | |||||||
| Abruptio placentae? | |||||||
| Fluxus postpartum? | |||||||
| Zwangerschap | |||||||
| Gynaecologische aandoening | |||||||
| Bloedverlies? | |||||||
| Partiele mola? | |||||||
| Cervixinsufficientie? | |||||||
| Infectie | |||||||
| Hyperemesis gravidarum? | |||||||
| Hypertensieve aandoening | Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT') - Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT') | ||||||
| Zwangerschapscholestase? | |||||||
| Diabetes gravidarum met insuline? | |||||||
| Afwijkende groei foetus | |||||||
| Dreigende partus immaturus? | |||||||
| Dreigende partus prematurus? | |||||||
| Abruptio placentae? | |||||||
| Navelstrengprolaps? | |||||||
| Liggingsafwijking | |||||||
| Intrauteriene vruchtdood | |||||||
| Vermoeden intrauteriene vruchtdood? | |||||||
| Einde zwangerschap | |||||||
| Bevalling | |||||||
| Pprom? | |||||||
| Prom? | |||||||
| Koorts? | |||||||
| Niet vorderende ontsluiting? | |||||||
| Niet vorderende uitdrijving? | |||||||
| Verdenking foetale nood? | |||||||
| Intrauteriene vruchtdood | |||||||
| Vermoeden intrauteriene vruchtdood? | |||||||
| Vastzittende placenta? | |||||||
| Conditie perineum postpartum | |||||||
| Fluxus postpartum? | |||||||
| Postnatale fase | |||||||
| Pathologie vrouw | |||||||
| Overig | |||||||
| Van 2e naar 3e lijn | |||||||
| Van 2e naar 1e lijn | |||||||
| Van 3e naar 2e lijn | |||||||
| Perinatale periode | voor 28e week (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') - 2e t/m 7e dag (code = '92' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') | ||||||
1.1.3 Zorgverlenerzorginstelling
| Zorgverlenerzorginstelling | |||
| Gegevenselement | Waarde | ||
| Zorginstelling | |||
| Zorginstelling agbid | |||
| Zorginstelling lvrid | 1808 - 1504 - 0003 - 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||
1.1.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
| Obstetrische anamnese gegroepeerd per voorgaande zwangerschap | |||||||
| Gegevenselement | Waarde | ||||||
| Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | ||||||
| Definitieve a terme datum | 1 dec 2011 - 9 okt 2014 - 5 jun 2013 - 8 sep 2014 - 5 jun 2013 - 8 sep 2014 - 22 sep 2014 - 18 aug 2014 - 18 aug 2014 - 5 jun 2012 - 22 jul 2014 | ||||||
| Diagnose | |||||||
| Gynaecologische aandoening | Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') - Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Bloedverlies? | Ja - Ja - Ja | ||||||
| Cervixinsufficientie? | |||||||
| Infectie | Urineweg infectie (code = '307534009' in codeSystem 'Snomed CT') - Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') - Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') - Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Hyperemesis gravidarum? | Ja - Ja | ||||||
| Hypertensieve aandoening | Pregnancy-induced hypertension (disorder) (code = '48194001' in codeSystem '2.16.840.1.113883.6.96') - Pre-eclampsia (disorder) (code = '398254007' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Zwangerschapscholestase? | Ja | ||||||
| Diabetes gravidarum met insuline? | |||||||
| Afwijkende groei foetus | Small for gestational age fetus (disorder) (code = '267258002' in codeSystem '2.16.840.1.113883.6.96') - Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') - Large-for-dates fetus (disorder) (code = '199616008' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Dreigende partus immaturus? | |||||||
| Dreigende partus prematurus? | |||||||
| Abruptio placentae? | Ja - Ja | ||||||
| Irregulaire antistoffen? | Nee - Ja - Ja - Ja | ||||||
| Eerdere bevalling | |||||||
| Placenta | |||||||
| Geboorte placenta | - - - - - - - Thuis (code = '169813005' in codeSystem '2.16.840.1.113883.6.96') - - - goed (code = '289431008' in codeSystem 'Snomed CT') - niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') - - - - - Urineweg infectie (code = '307534009' in codeSystem 'Snomed CT') - Strippen (code = '236960006' in codeSystem 'Snomed CT') - wens patiënt (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') - - Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') - Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') - - - - - - - - - - voor 28e week (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') - - - - - - Nog niet bepaald (code = '05' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') - - - Weak fetal movements (finding) (code = '276372004' in codeSystem '2.16.840.1.113883.6.96') - gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') - - - - - Pregnancy-induced hypertension (disorder) (code = '48194001' in codeSystem '2.16.840.1.113883.6.96') - - - - - - - Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') - - - - - Reduced fetal movement (finding) (code = '276369006' in codeSystem '2.16.840.1.113883.6.96') - gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') - - - - - Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') - - Pre-eclampsia (disorder) (code = '398254007' in codeSystem '2.16.840.1.113883.6.96') - Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96') - acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') - - placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - - - - - - - Urinary tract infectious disease (disorder) (code = '68566005' in codeSystem '2.16.840.1.113883.6.96') - - - - - - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - - - Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96') - niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') - - - - - - Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') - Small for gestational age fetus (disorder) (code = '267258002' in codeSystem '2.16.840.1.113883.6.96') - - - - - controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - - - - - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - - - - - - - - - - - - - - - - - Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') - spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - - - - - - Embolism (disorder) (code = '414086009' in codeSystem '2.16.840.1.113883.6.96') - - Episiotomy infection (disorder) (code = '300927001' in codeSystem '2.16.840.1.113883.6.96') - - - - - - 2e t/m 7e dag (code = '92' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') - - - - - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - - - Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96') - niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') - - - - - Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') - - - - Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') - spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - - - - - - - - - - Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') - - Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') - - - Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') - - - Fetal movements absent (context-dependent category) (code = '289432001' in codeSystem '2.16.840.1.113883.6.96') - gestopt tijdens huidige zwangerschap (code = '6' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') - - - - - Large-for-dates fetus (disorder) (code = '199616008' in codeSystem '2.16.840.1.113883.6.96') - - Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96') - acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') - - placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - - - - - - - Postpartum deep phlebothrombosis (disorder) (code = '56272000' in codeSystem '2.16.840.1.113883.6.96') - | ||||||
| Hoeveelheid bloedverlies | 2014-03-01T00:00:00 - 2014-11-12T00:00:00 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 1 - - 999910413 - 000000 - 1976-05-02 - - 6 - - 170 cm - 1 - 2011-12-01 - False - - 0cbda760-1fdd-11e9-b56e-0800200c9a66 - 2 - 1 - 2014-10-09 - - - - False - 1 - 000000 - 1 - 1 - - 3 - 2014-10-08T14:30:00 - - - 615 ml - 2 - - - - 2018-08-28 - 2018-11-28 - 1 - 2 - 1 - - - 961921821 - * - 1974-09-11 - - 3 - - 184 cm - 2 - 2013-06-05 - - True - 5460cff0-2089-11e9-b56e-0800200c9a66 - 2 - 0 - 2014-09-08 - - - - False - 2014-05-12T00:00:00 - 2014-10-09T00:00:00 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - - - 961921821 - * - 1974-09-11 - - 3 - - 184 cm - 2 - 2013-06-05 - - True - C2204d20-209a-11e9-b56e-0800200c9a66 - 2 - 0 - 2014-09-08 - - - - False - 1 - 000000 - 1 - 2 - - 3 - 2014-08-30T14:09:00 - - - 980 ml - 1 - - - - - 2014-03-10T00:00:00 - 2014-11-03T00:00:00 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 3 - - 895623146 - 000000 - 1985-08-05 - - 5 - - 167 cm - True - 2 - Ad9c3280-209d-11e9-b56e-0800200c9a66 - 1 - 0 - 2014-09-22 - - - - False - 1 - 000000 - - 2 - 2 - 2 - 2014-08-27T22:09:00 - - - 1740 ml - 9 - - - - - 2014-08-07T00:00:00 - 2014-09-15T00:00:00 - 7 - 8 - 5 - - - 850810711 - * - 1987-08-06 - - 5 - - 162 cm - True - 1 - 05e54070-209f-11e9-b56e-0800200c9a66 - 1 - 0 - 2014-08-18 - True - 1 - 1 - 2 - 2 - 2014-08-03T21:09:00 - - - 1120 ml - 4 - - - - - 2014-02-03T00:00:00 - 2014-08-06T00:00:00 - 2 - 3 - 4 - 5 - 6 - 7 - 5 - - - 850810711 - * - 1987-08-06 - - 5 - - 162 cm - True - 1 - E1691540-209f-11e9-b56e-0800200c9a66 - 1 - 0 - 2014-08-18 - - - - False - 1 - - 1 - 2 - 2 - 2014-08-03T21:09:00 - - - 1120 ml - 4 - - - 2013-12-09T00:00:00 - 2014-08-04T00:00:00 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 3 - - 912345676 - * - 1993-03-04 - - 1 - - 186 cm - 1 - 2012-06-05 - - True - - 68a34ee0-20a0-11e9-b56e-0800200c9a66 - 2 - 1 - 2014-07-22 - - - - 2 - True - 1 - 000000 - 1 - 2 - - 3 - - - 1500 ml - 1 - - - - | ||||||
| Vorige uitkomst per kind | |||||||
| Vorige baring | |||||||
| Geboortedatum | |||||||
| Kindspecifieke gegevens vorige uitkomsten | |||||||
| Type partus | Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT') - Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') | ||||||
| Percentiel van het geboortegewicht | 50 ≤ P < 90 (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.50') - 10 ≤ P < 50 (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.50') | ||||||
| Apgarscore na 5 min | 8 - 10 | ||||||
| Congenitale afwijkingen? | Nee - Nee | ||||||
| Congenitale afwijkingen groep | |||||||
| Chromosomale afwijkingen? | |||||||
1.1.5 Zwangerschap
| Zwangerschap | ||||
| Gegevenselement | Waarde | |||
| Graviditeit | 2 - 2 - 2 - 1 - 1 - 1 - 2 | |||
| Pariteit voor deze zwangerschap | 1 - 0 - 0 - 0 - 0 - 0 - 1 | |||
| Definitieve a terme datum | 1 dec 2011 - 9 okt 2014 - 5 jun 2013 - 8 sep 2014 - 5 jun 2013 - 8 sep 2014 - 22 sep 2014 - 18 aug 2014 - 18 aug 2014 - 5 jun 2012 - 22 jul 2014 | |||
| Voornemens | ||||
| Voorgenomen plaats baring tijdens zwangerschap type locatie | Thuis (code = '169813005' in codeSystem '2.16.840.1.113883.6.96') - Nog niet bepaald (code = '05' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') | |||
| Prenatale controle | ||||
| Datum controle | 2 mrt 2014 00:00 - 6 mei 2014 00:00 - 12 mei 2014 00:00 - 21 mei 2014 00:00 - 7 mei 2014 00:00 - 9 jan 2014 00:00 | |||
| Zwangerschapsduur | 59 dagen - 59 dagen - 155 dagen - 155 dagen - 161 dagen - 161 dagen - 156 dagen - 156 dagen - 149 dagen - 149 dagen - 86 dagen - 86 dagen | |||
| Leven voelen | goed (code = '289431008' in codeSystem 'Snomed CT') - Weak fetal movements (finding) (code = '276372004' in codeSystem '2.16.840.1.113883.6.96') - Reduced fetal movement (finding) (code = '276369006' in codeSystem '2.16.840.1.113883.6.96') - Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96') - Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96') - Fetal movements absent (context-dependent category) (code = '289432001' in codeSystem '2.16.840.1.113883.6.96') | |||
| Rookgedrag | niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - gestopt tijdens huidige zwangerschap (code = '6' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | |||
| Alcoholgebruik | geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') - geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') - geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') - geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') - geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') - geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59') | |||
| Drugsgebruik? | Nee - Nee - Nee - Nee - Nee - Ja | |||
| Gewicht gemeten | 70 kg - 85 kg - 85 kg - 67 kg - 82 kg - 89 kg | |||
| Diagnose | ||||
| Datum | 2 mrt 2014 00:00 - 6 mei 2014 00:00 - 12 mei 2014 00:00 - 3 sep 2014 00:00 - 21 mei 2014 00:00 - 8 aug 2014 00:00 - 8 aug 2014 00:00 - 7 mei 2014 00:00 - 9 jan 2014 00:00 - 24 jul 2014 00:00 | |||
| Zwangerschapsduur | 59 dagen - 59 dagen - 155 dagen - 155 dagen - 161 dagen - 161 dagen - 156 dagen - 156 dagen - 149 dagen - 149 dagen - 86 dagen - 86 dagen | |||
| Gynaecologische aandoening | Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') - Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') | |||
| Bloedverlies? | Ja - Ja - Ja | |||
| Partiele mola? | Ja | |||
| Cervixinsufficientie? | ||||
| Infectie | Urineweg infectie (code = '307534009' in codeSystem 'Snomed CT') - Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') - Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') - Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') | |||
| Hyperemesis gravidarum? | Ja - Ja | |||
| Hypertensieve aandoening | Pregnancy-induced hypertension (disorder) (code = '48194001' in codeSystem '2.16.840.1.113883.6.96') - Pre-eclampsia (disorder) (code = '398254007' in codeSystem '2.16.840.1.113883.6.96') | |||
| Zwangerschapscholestase? | Ja | |||
| Diabetes gravidarum met insuline? | ||||
| Afwijkende groei foetus | Small for gestational age fetus (disorder) (code = '267258002' in codeSystem '2.16.840.1.113883.6.96') - Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') - Large-for-dates fetus (disorder) (code = '199616008' in codeSystem '2.16.840.1.113883.6.96') | |||
| Dreigende partus immaturus? | ||||
| Dreigende partus prematurus? | ||||
| Abruptio placentae? | Ja - Ja | |||
| Navelstrengprolaps? | ||||
| Liggingsafwijking | ||||
| Intrauteriene vruchtdood | ||||
| Vermoeden intrauteriene vruchtdood? | ||||
| Vermoeden iuvd op basis van | ||||
| Intrauteriene behandeling | Selective destruction of fetus (procedure) (code = '265633004' in codeSystem '2.16.840.1.113883.6.96') | |||
| Maternale sterfte? | Nee - Nee - Nee - Nee - Ja - Nee - Ja | |||
| Wijze einde zwangerschap | Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | |||
1.1.6 Bevalling
| Bevalling | ||||
| Gegevenselement | Waarde | |||
| Partusnummer | 000000 - 000000 - 000000 - 000000 | |||
| Diagnose bevalling | ||||
| Pprom? | Ja | |||
| Prom? | ||||
| Koorts? | ||||
| Niet vorderende ontsluiting? | Ja | |||
| Niet vorderende uitdrijving? | Ja | |||
| Verdenking foetale nood? | Ja | |||
| Intrauteriene vruchtdood | ||||
| Vermoeden intrauteriene vruchtdood? | ||||
| Vermoeden iuvd op basis van | ||||
| Vastzittende placenta? | ||||
| Fluxus postpartum? | ||||
| Aantal geboren kinderen | 1 - 1 - 2 - 1 - 1 - 1 | |||
| Risicostatus voor baring | 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') - 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') - 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') - 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') - 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') - 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | |||
| Interventies begin baring | ||||
| Interventie begin baring | Strippen (code = '236960006' in codeSystem 'Snomed CT') - Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96') - Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96') | |||
| Indicatie interventie begin baring | wens patiënt (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') - acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') - 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') - interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') - spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') - spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') - spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') - 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 | 8 okt 2014 14:30 - 30 aug 2014 14:09 - 27 aug 2014 22:09 - 3 aug 2014 21:09 - 3 aug 2014 21:09 | |||
| Medicatie nageboortetijdperk groep | ||||
| Medicatie nageboortetijdperk? | Ja - UNK - Nee - Ja - Ja - Nee | |||
| Soort medicatie nageboortetijdperk | Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') - Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') - Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') | |||
| Placenta | ||||
| Geboorte placenta | Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | |||
| Hoeveelheid bloedverlies | 615 ml - 980 ml - 1740 ml - 1120 ml - 1120 ml - 1500 ml | |||
| Conditie perineum postpartum | 1e graads perineumruptuur (code = '199916005' in codeSystem 'Snomed CT') - Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') - Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96') - Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') - Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') - Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') | |||
1.1.7 Uitkomst per kind
| Uitkomst per kind | |||||||
| Gegevenselement | Waarde | ||||||
| Baring | |||||||
| Werkelijke plaats baring type locatie | Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Ziekenhuis baring | |||||||
| Ziekenhuisnummer lvrid | 0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | ||||||
| Demografische gegevens | |||||||
| Identificaties kind | |||||||
| Bsn kind | 999910383 - 951847624 - 847035116 - 847035128 - 840736526 - 840736526 - 528741913 | ||||||
| Geslacht medische observatie | vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') - mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21') - vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') - mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21') - vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') - vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') - twijfelachtig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | ||||||
| Geboortedatum | 8 okt 2014 00:00 - 1 sep 2014 02:34 - 28 aug 2014 06:30 - 28 aug 2014 07:02 - 4 aug 2014 23:35 - 4 aug 2014 23:35 - 24 jul 2014 02:30 | ||||||
| Rangnummer kind | 1808 - 4563 AB - true - - - 550 - - 1 - 2014-03-02T00:00:00 - 59 - 1 - 1 - 1 - false - 70 - 2014-03-02T00:00:00 - 59 - 2 - 1 - 11 - true - 1 - 1 - 2 - - - - - - 2014-05-06T00:00:00 - - - - 3 - 1504 - 5689 CZ - false - true - true - 4 - 2014-05-06T00:00:00 - 155 - 2 - 5 - 1 - false - 85 - 2014-05-06T00:00:00 - 155 - 1 - - - - 0003 - 5689 CZ - false - 1 - true - true - 2014-05-12T00:00:00 - 161 - 3 - 5 - 1 - false - 85 - 2014-05-12T00:00:00 - 161 - 1 - true - 2 - 7 - 2 - UNK - 4 - 3 - - - - - - 2014-09-03T00:00:00 - 16 - - 9999 - 5421 JG - true - - 3 - 2014-05-21T00:00:00 - 156 - 1 - 1 - 1 - false - 67 - 2014-05-21T00:00:00 - 156 - true - 2 - 2 - true - true - true - false - 2 - 3 - - - - - 3 - - - - - - 1 - - - - - - 1410 - 4589 BA - true - - true - 2 - 1 - 3 - - - - - 2014-08-08T00:00:00 - 10 - 2014-08-08T00:00:00 - 17 - - 2014-08-06T00:00:00 - - - - 14 - 0010 - 4589 BA - true - - 3 - 2014-05-07T00:00:00 - 149 - 1 - 1 - 1 - false - 82 - 2014-05-07T00:00:00 - 149 - 2 - true - true - true - 2 - 1 - 3 - - - - - - 0179 - 9562 GF - true - - 2 - true - 3 - - - 7 - 2014-01-09T00:00:00 - 86 - 4 - 6 - 1 - true - 89 - 2014-01-09T00:00:00 - 86 - 1 - true - 7 - 2 - false - 4 - 3 - - - - - - 2014-07-24T00:00:00 - 6 - | ||||||
| Perinatale sterfte groep | |||||||
| Perinatale sterfte? | Nee - Nee - Nee - Ja - Nee - Nee - Nee | ||||||
| Fase perinatale sterfte | Newborn death (event) (code = '276506001' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Datumtijd vaststelling perinatale sterfte | 28 aug 2014 08:10 | ||||||
| Kindspecifieke maternale gegevens | |||||||
| Bijstimulatie toegediend? | |||||||
| Tijdstip breken vliezen | 8 okt 2014 09:15 - 30 aug 2014 23:04 - 27 aug 2014 22:09 - 27 aug 2014 23:13 - 3 aug 2014 07:04 - 3 aug 2014 07:04 | ||||||
| Kleur en consistentie vruchtwater | Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') - geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') - kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') - kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') - bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18') - bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18') - meconium (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | ||||||
| Tijdstip actief meepersen | 8 okt 2014 12:13 - 27 aug 2014 23:49 - 28 aug 2014 06:45 - 4 aug 2014 22:15 - 4 aug 2014 22:15 | ||||||
| Episiotomie? | Nee - Ja - Ja - Ja - Ja - Nee | ||||||
| Indicatie episiotomie | |||||||
| Locatie episiotomie | mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') - mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') - mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') - mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | ||||||
| Ruggeprik gewenst niet gekregen? | Nee - Nee - Nee - Nee - Nee - Nee - Nee | ||||||
| Pijnbestrijding? | Nee - Ja - Ja - Ja - Ja - Ja - Ja | ||||||
| Pijnbestrijding | |||||||
| Methode | |||||||
| Methode | - - - - 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - - - - Gynaecoloog 2e lijn (code = '02' in codeSystem 'Specialisme, specifiek voor perinatologie.') - - - - - - - - tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - Suspected fetal distress (situation) (code = '444433005:246090004=130955003' in codeSystem '2.16.840.1.113883.6.96') - Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') - - - Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') - - - Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96') - - - - tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') - - - - Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') - consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') - - - - Newborn death (event) (code = '276506001' in codeSystem '2.16.840.1.113883.6.96') - - - tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - Total breech extraction (procedure) (code = '416055001' in codeSystem '2.16.840.1.113883.6.96') - - - - - - - Finding of neonatal condition (finding) (code = '364737004' in codeSystem '2.16.840.1.113883.6.96') - overdracht (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.17') - - - - - - - - tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') - - - - Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') - consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') - - - - - - - tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') - - - - Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') - consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') - - - - - - - - tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - Delivery by vacuum extraction (procedure) (code = '61586001' in codeSystem '2.16.840.1.113883.6.96') - - tijdens uitdrijving besloten (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.5') - Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') - - - - - - Kell (code = '405844003' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Overig middel | |||||||
| Middel | Administration of morphinomimetic analgesic (procedure) (code = '52685006:363701004=404642006' in codeSystem '2.16.840.1.113883.6.96') - Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96') - Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96') - Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Toediening | Administration of substance via intravenous route (procedure) (code = '431215000' in codeSystem '2.16.840.1.113883.6.96') - Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96') - Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96') - Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Periode | tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | ||||||
| Sedatie? | Nee - Ja - Nee - Nee - Nee - Nee - Ja | ||||||
| Kindspecifieke uitkomstgegevens | |||||||
| Type partus | Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT') - Cesarean section (procedure) (code = '11466000' in codeSystem 'SNOMED CT') - Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') - Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') - Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') - Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') - Emergency cesarian section (procedure) (code = '274130007' in codeSystem 'SNOMED CT') | ||||||
| Ligging bij geboorte | Achterhoofd-achter (code = '37235006' in codeSystem 'Snomed CT') - Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') - Face presentation (finding) (code = '21882006' in codeSystem '2.16.840.1.113883.6.96') - Complete breech presentation (finding) (code = '49168004' in codeSystem '2.16.840.1.113883.6.96') - Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') - Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') - Onbekend (code = 'UNK' in codeSystem '2.16.840.1.113883.5.1008') | ||||||
| Aanpakker kind - rol aanpakker kind | 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||||||
| Supervisor - rol supervisor | 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | ||||||
| Vaginale kunstverlossing groep | |||||||
| Vaginale kunstverlossing | Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') - Total breech extraction (procedure) (code = '416055001' in codeSystem '2.16.840.1.113883.6.96') - Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') - Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') - Delivery by vacuum extraction (procedure) (code = '61586001' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Succes vaginale kunstverlossing? | Ja - Ja - Ja - Ja - Nee | ||||||
| Sectio caesarea group | |||||||
| Beslismoment sectio caesarea | tijdens uitdrijving besloten (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.5') | ||||||
| Indicatie primaire sectio | Suspected fetal distress (situation) (code = '444433005:246090004=130955003' in codeSystem '2.16.840.1.113883.6.96') - Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Indicatie secundaire sectio | Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Overige interventies | Maneuvers for delivery in shoulder dystocia (procedure) (code = '237008007' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Lichamelijk onderzoek kind | |||||||
| Apgarscore na 5 min | |||||||
| Geboortegewicht | 3450 gram - 3620 gram - 2040 gram - 1580 gram - 4205 gram - 4205 gram - 3750 gram | ||||||
| Congenitale afwijkingen? | Nee - Nee - Nee - Ja - Nee - Nee - Ja | ||||||
| Congenitale afwijkingen groep | |||||||
| Specificatie congenitale afwijking groep | |||||||
| Specificatie congenitale afwijking | Spina bifida occulta (disorder) (code = '76916001' in codeSystem '2.16.840.1.113883.6.96') - Multiple congenital cardiac defects (disorder) (code = '94702005' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Chromosomale afwijkingen? | Nee - Ja | ||||||
| Specificatie chromosomale afwijking groep | |||||||
| Specificatie chromosomale afwijking | Complete trisomy 21 syndrome (disorder) (code = '41040004' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Problematiek kind? | Nee - Nee - Ja - Ja - Nee - Nee - Ja | ||||||
| Problematiek kind | Birth trauma of fetus (disorder) (code = '56110009' in codeSystem '2.16.840.1.113883.6.96') - Subdural intracranial hemorrhage due to birth trauma (disorder) (code = '126941005' in codeSystem '2.16.840.1.113883.6.96') - Congenital hearing disorder (disorder) (code = '95827002' in codeSystem '2.16.840.1.113883.6.96') | ||||||
| Kinderarts betrokken? | Nee - Ja - Ja - Ja - Ja - Ja - Nee | ||||||
| Betrokkenheid kinderarts | |||||||
| Datum betrokkenheid | 1 sep 2014 00:00 - 28 aug 2014 00:00 - 28 aug 2014 00:00 - 4 aug 2014 00:00 - 4 aug 2014 00:00 | ||||||
| Reden betrokkenheid | Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') - Finding of neonatal condition (finding) (code = '364737004' in codeSystem '2.16.840.1.113883.6.96') - Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') - 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') - consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') - overdracht (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.17') - consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') - consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | ||||||
| Zorginstelling lvrid | 0003 - 9999 - 0001 - 0010 - 0010 | ||||||
1.1.8 Medisch onderzoek
| Medisch onderzoek | |||
| Gegevenselement | Waarde | ||
| Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | |||
| Irregulaire antistoffen? | Nee - Ja - 1 - Nee - Nee - Ja - 4 | ||
| Welke irregulaire antistoffen vrouw aanwezig | - - Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96') - - - - Kell (code = '405844003' in codeSystem '2.16.840.1.113883.6.96') | ||
1.1.9 Postnatale fase
| Postnatale fase | ||||
| Gegevenselement | Waarde | |||
| Diagnoseinterventie postpartum | ||||
| Datum | 2 mrt 2014 00:00 - 6 mei 2014 00:00 - 12 mei 2014 00:00 - 3 sep 2014 00:00 - 21 mei 2014 00:00 - 8 aug 2014 00:00 - 8 aug 2014 00:00 - 7 mei 2014 00:00 - 9 jan 2014 00:00 - 24 jul 2014 00:00 | |||
| Pathologie vrouw | Urinary tract infectious disease (disorder) (code = '68566005' in codeSystem '2.16.840.1.113883.6.96') - Embolism (disorder) (code = '414086009' in codeSystem '2.16.840.1.113883.6.96') - Episiotomy infection (disorder) (code = '300927001' in codeSystem '2.16.840.1.113883.6.96') - Postpartum deep phlebothrombosis (disorder) (code = '56272000' in codeSystem '2.16.840.1.113883.6.96') | |||
| Kindspecifieke gegevens | ||||
| Rangnummer kind | 1 | |||
| Voeding kind groep | ||||
| Voeding kind datum | 12 okt 2014 - 7 okt 2014 - 3 sep 2014 - 15 sep 2014 - 24 jul 2014 | |||
| Substantie voeding kind | borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') - kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') - kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') - borstmelk (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') - kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') - kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | |||