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| Regel 1: |
Regel 1: |
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| {{#customtitle:Kernset Geboortezorg 2.3 - inhoud kwalificatie}} | | {{#customtitle:Kernset Geboortezorg 2.3 - dekkingsgraad scenario's}} |
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| =Addenda voor inhoudelijke gegevens Kernset Geboortezorg 2.3= | | =Dekkingsgraad scenario's voor Kernset Geboortezorg 2.3= |
| ==Scenario 1. Zorg volledig 1e lijn, herpes, strippen, gezonde eenling (voor vrouw met BSN: 999910413)==
| | De volgende scenario's zijn meegenomen: |
| <section begin=999910413 /> | | * 1. Zorg volledig 1e lijn, herpes, strippen, gezonde eenling (id: scenario1-23) |
| | * 2. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling(id: scenario2_1elijn-23) |
| | * 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling(id: scenario2_2elijn-23) |
| | * 3. zorg volledig in 2e lijn, meerling, 1 kind overleden(id: scenario3-23) |
| | * 4. 1e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden(id: scenario4_1elijn-23) |
| | * 4. 2e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden(id: scenario4_2elijn-23) |
| | * 5. zorg volledig 2e lijn, vrouw overleden(id: scenario5-23) |
| | * 6. 2e lijn(id: scenario6-23) |
| | Zie voor de inhoud van deze scenario's: [[Gebz:Vdraft_AddendaKwalificatieKernsetGeboortezorg23]]. Onderstaande tabel toont de unieke waarden voor ieder veld. Lege velden worden niet geraakt door de meegenomen bovenstaande scenario's. |
| | ==Scenario (voor vrouw met BSN: 999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020)== |
| | <section begin=999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 /> |
| {| class="wikitable" width="85%" | | {| class="wikitable" width="85%" |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw |
| Regel 16: |
Regel 26: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Burgerservicenummer | | |colspan="2"|Burgerservicenummer |
| |style="background-color: white;"|999910413 | | |style="background-color: white;"|999910413 - 961921821 - 895623146 - 850810711 - 912345676 - 100202020 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Lokale persoonsidentificatie | | |colspan="2"|Lokale persoonsidentificatie |
| |style="background-color: white;"|000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) | | |style="background-color: white;"|000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) - * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) - 987654321 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Geboortedatum | | |colspan="2"|Geboortedatum |
| |style="background-color: white;"|2 may 1976 | | |style="background-color: white;"|2 mei 1976 - 11 sep 1974 - 5 aug 1985 - 6 aug 1987 - 4 mrt 1993 - 1 jan 1989 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Adres - postcode | | |colspan="2"|Adres - postcode |
| |style="background-color: white;"|4563 AB | | |style="background-color: white;"|4563 AB - 5689 CZ - 5421 JG - 4589 BA - 9562 GF - 1234 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;"|Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28') | | |style="background-color: white;"|Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28') - Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') - Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') - Latijns Amerikaans (code = '14' in codeSystem '2.16.840.1.113883.2.4.4.13.28') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Lengte gemeten | | |colspan="2"|Lengte gemeten |
| |style="background-color: white;"|170 cm | | |style="background-color: white;"|170 cm - 184 cm - 167 cm - 162 cm - 186 cm - 172 cm |
| |}<section end=999910413 /> | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| | |colspan="2"|Vrouwelijke genitale verminking? |
| | |style="background-color: white;"|Ja - Nee |
| | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| | |colspan="2"|Type vrouwelijke genitale verminking |
| | |style="background-color: white;"|Female genital mutilation type 2 (disorder) (code = '130621000119105' in codeSystem '2.16.840.1.113883.6.96') - Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96') |
| | |}<section end=999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 /> |
| === Anamnese === | | === Anamnese === |
| <section begin=anamnese_999910413 /> | | <section begin=anamnese_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 /> |
| {| class="wikitable" width="85%" | | {| class="wikitable" width="85%" |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese |
| Regel 43: |
Regel 59: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Onder behandeling geweest? | | |colspan="3"|Onder behandeling geweest? |
| |style="background-color: white;"|Ja | | |style="background-color: white;"|Ja - Nee |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Algemene anamnese | | |colspan="4"|Algemene anamnese |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="5"| | | |rowspan="21"| |
| | |-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;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Cardiovasculaire aandoening | | |colspan="2"|Cardiovasculaire aandoening |
| |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | | |style="background-color: white;"|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') |
| | |-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') - Pyelonefritis (code = '45816000' in codeSystem 'Snomed CT') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Oncologische aandoening | | |colspan="2"|Oncologische aandoening |
| |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | | |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"|Infectieziekte | | |colspan="2"|Schildklier aandoening |
| |style="background-color: white;"|Herpes (code = '23513009' in codeSystem '2.16.840.1.113883.6.96') | | |style="background-color: white;"|Hyperthyroidism (disorder) (code = '34486009' in codeSystem '2.16.840.1.113883.6.96') - Hypothyreoidie (code = '40930008' in codeSystem 'Snomed CT') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Type operatie | | |colspan="2"|Diabetes mellitus? |
| |style="background-color: white;"|Orthopedisch (code = '112697007' in codeSystem 'Snomed CT') | | |style="background-color: white;"|Ja - Nee |
| |}<section end=anamnese_999910413 />
| |
| === Zorgverlening ===
| |
| <section begin=zorgverlening_999910413 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlening
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Datum start zorgverantwoordelijkheid | | |colspan="2"|Neurologische aandoening |
| |style="background-color: white;"|1 mar 2014 00:00 | | |style="background-color: white;"|Epilepsy (disorder) (code = '84757009' in codeSystem '2.16.840.1.113883.6.96') - Hernia nuclei pulposi (code = '84857004' in codeSystem 'Snomed CT') - Overig, niet nader omschreven 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"|Datum einde zorgverantwoordelijkheid | | |colspan="2"|Infectieziekte |
| |style="background-color: white;"|12 nov 2014 00:00 | | |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"|Eindverantwoordelijk in welke perinatale periode? | | |colspan="2"|Mdl aandoening |
| |style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | | |style="background-color: white;"|Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96') - M. Crohn (code = '34000006' in codeSystem 'Snomed CT') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | | |colspan="2"|Anemie |
| |style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | | |style="background-color: white;"|Iron deficiency anemia (disorder) (code = '87522002' in codeSystem '2.16.840.1.113883.6.96') - IJzergebrek (code = '87522002' in codeSystem 'Snomed CT') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | | |colspan="2"|Longaandoening |
| |style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | | |style="background-color: white;"|Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96') - Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | | |colspan="2"|Gynaecologische aandoening |
| |style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | | |colspan="2"|Orthopedische afwijking |
| |style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') | | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - Trauma bekken (code = '282771003' in codeSystem 'Snomed CT') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | | |colspan="2"|Bloedtransfusie? |
| |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="background-color: white;"|Ja - Nee |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Eindverantwoordelijk in welke perinatale periode? | | |colspan="2"|Transfusiereactie? |
| |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="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Conclusie risicostatus na intake | | |colspan="2"|Type operatie |
| |style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') | | |style="background-color: white;"|Orthopedisch (code = '112697007' in codeSystem 'Snomed CT') - Operation on heart (procedure) (code = '64915003' in codeSystem '2.16.840.1.113883.6.96') - Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96') - Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - Sectio (code = '11466000' in codeSystem 'Snomed CT') - Rug (code = '129152004:260686004=129284003' in codeSystem '2.16.840.1.113883.6.96') |
| |}<section end=zorgverlening_999910413 />
| |
| === Zorgverlenerzorginstelling ===
| |
| <section begin=zorgverlenerzorginstelling_999910413 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Zorginstelling lvrid | | |colspan="2"|Type stollingsprobleem |
| |style="background-color: white;"|1808 | | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') |
| |}<section end=zorgverlenerzorginstelling_999910413 />
| |
| === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
| |
| <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="5" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Wijze einde zwangerschap | | |colspan="2"|Psychiatrie? |
| |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | | |style="background-color: white;"|Ja - Nee |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Definitieve a terme datum | | |colspan="2"|Overige aandoening? |
| |style="background-color: white;"|1 dec 2011
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Irregulaire antistoffen?
| |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Nee |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Eerdere bevalling
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="12"|
| | |colspan="2"|Overige aandoening |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| | |style="background-color: white;"| |
| |colspan="4"|Placenta - geboorte placenta | | |}<section end=anamnese_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 /> |
| |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;"|8 dec 2011 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;;"
| |
| |colspan="2"|Percentiel van het geboortegewicht
| |
| |style="background-color: white;"|p50 tot p90 (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.50')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Apgarscore na 5 min
| |
| |style="background-color: white;"|8
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Congenitale afwijkingen?
| |
| |style="background-color: white;"|Nee
| |
| |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 /> | |
| === Zwangerschap ===
| |
| <section begin=zwangerschap_999910413 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Dossiernummer
| |
| |style="background-color: white;"|0cbda760-1fdd-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Graviditeit
| |
| |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;"|9 oct 2014
| |
| |-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;"|2 mar 2014 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;;"
| |
| |colspan="2"|Gewicht gemeten
| |
| |style="background-color: white;"|70 kg
| |
| |-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"|Datum
| |
| |style="background-color: white;"|2 mar 2014 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"|Infectie
| |
| |style="background-color: white;"|Urineweg infectie (code = '307534009' in codeSystem 'Snomed CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Maternale sterfte?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Wijze einde zwangerschap
| |
| |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
| |
| |}<section end=zwangerschap_999910413 />
| |
| === Bevalling ===
| |
| <section begin=bevalling_999910413 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Partusnummer
| |
| |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;;"
| |
| |colspan="2"|Indicatie interventie begin baring
| |
| |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;;"
| |
| |colspan="3"|Wijze waarop de baring begon
| |
| |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="3"|Tijdstip begin actieve ontsluiting
| |
| |style="background-color: white;"|8 oct 2014 14:30
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Medicatie nageboortetijdperk groep
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Medicatie nageboortetijdperk?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Soort medicatie nageboortetijdperk
| |
| |style="background-color: white;"|Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|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="3"|Hoeveelheid bloedverlies
| |
| |style="background-color: white;"|615 ml
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Conditie perineum postpartum
| |
| |style="background-color: white;"|1e graads perineumruptuur (code = '199916005' in codeSystem 'Snomed CT')
| |
| |}<section end=bevalling_999910413 />
| |
| === Uitkomst per kind ===
| |
| <section begin=uitkomst_per_kind_999910413 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="5" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Baring
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="34"|
| |
| |-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;"|8 oct 2014 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;"|8 oct 2014 09:15
| |
| |-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;"|8 oct 2014 12:13
| |
| |-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 />
| |
| === Medisch onderzoek ===
| |
| <section begin=medisch_onderzoek_999910413 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || 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;;"
| |
| |colspan="2"|Irregulaire antistoffen?
| |
| |style="background-color: white;"|Nee
| |
| |}<section end=medisch_onderzoek_999910413 />
| |
| === Postnatale fase ===
| |
| <section begin=postnatale_fase_999910413 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || 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;"|12 oct 2014
| |
| |-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;;"
| |
| |colspan="2"|Substantie voeding kind
| |
| |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 />
| |
| ==Scenario 2. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)==
| |
| <section begin=961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Burgerservicenummer
| |
| |style="background-color: white;"|961921821
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Lokale persoonsidentificatie
| |
| |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;;"
| |
| |colspan="2"|Geboortedatum
| |
| |style="background-color: white;"|11 sep 1974
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Adres - postcode
| |
| |style="background-color: white;"|5689 CZ
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Etniciteit
| |
| |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;;"
| |
| |colspan="2"|Lengte gemeten
| |
| |style="background-color: white;"|184 cm
| |
| |}<section end=961921821 />
| |
| === Anamnese ===
| |
| <section begin=anamnese_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Anamnese
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Onder behandeling geweest?
| |
| |style="background-color: white;"|Nee
| |
| |}<section end=anamnese_961921821 />
| |
| === Zorgverlening === | | === Zorgverlening === |
| <section begin=zorgverlening_961921821 /> | | <section begin=zorgverlening_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 /> |
| {| class="wikitable" width="85%" | | {| class="wikitable" width="85%" |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Zorgverlening | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Zorgverlening |
| |-style="background-color: #1F497D;; color: white; text-align:left;" | | |-style="background-color: #1F497D;; color: white; text-align:left;" |
| |colspan="6" width="25%"| Gegevenselement | | |colspan="7" width="25%"| Gegevenselement |
| || Waarde | | || Waarde |
|
| |
|
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="6"|Datum start zorgverantwoordelijkheid | | |colspan="7"|Datum start zorgverantwoordelijkheid |
| |style="background-color: white;"|28 aug 2018 | | |style="background-color: white;"|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 - 1 mrt 2019 00:00 |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Datum einde zorgverantwoordelijkheid
| |
| |style="background-color: white;"|28 nov 2018
| |
| |-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;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="20"| | | |colspan="7"|Datum einde zorgverantwoordelijkheid |
| | |style="background-color: white;"|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 - 15 okt 2019 00:00 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Datum verwijzing | | |colspan="7"|Eindverantwoordelijk in welke perinatale periode? |
| |style="background-color: white;"|6 may 2014 00:00 | | |style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Verwijzing van
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="4"| | | |colspan="7"|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') - 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') - 3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Zorginstelling | | |colspan="8"|Verwijsdetails |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="2"| | | |rowspan="99"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Zorgaanbieder identificatie nummer | | |colspan="6"|Datum verwijzing |
| |style="background-color: white;"|1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | | |style="background-color: white;"|6 mei 2014 00:00 - 6 aug 2014 00:00 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="6"|Verwijzing naar | | |colspan="7"|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"|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;;"
| |
| |rowspan="6"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Van 1e naar 2e lijn
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Zwangerschap
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Hypertensieve aandoening
| |
| |style="background-color: white;"|Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Perinatale periode
| |
| |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 />
| |
| === Zorgverlenerzorginstelling ===
| |
| <section begin=zorgverlenerzorginstelling_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorginstelling lvrid
| |
| |style="background-color: white;"|1504
| |
| |}<section end=zorgverlenerzorginstelling_961921821 />
| |
| === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
| |
| <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Wijze einde zwangerschap
| |
| |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;"|5 jun 2013
| |
| |-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;;"
| |
| |colspan="2"|Bloedverlies?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Hyperemesis gravidarum?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Irregulaire antistoffen?
| |
| |style="background-color: white;"|Ja
| |
| |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
| |
| === Zwangerschap ===
| |
| <section begin=zwangerschap_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Dossiernummer
| |
| |style="background-color: white;"|5460cff0-2089-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Graviditeit
| |
| |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;"|8 sep 2014
| |
| |-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;"|6 may 2014 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;;"
| |
| |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="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Datum
| |
| |style="background-color: white;"|6 may 2014 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"|Hypertensieve aandoening
| |
| |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;;"
| |
| |colspan="3"|Maternale sterfte?
| |
| |style="background-color: white;"|Nee
| |
| |}<section end=zwangerschap_961921821 />
| |
| ==Scenario 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)==
| |
| <section begin=961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Burgerservicenummer
| |
| |style="background-color: white;"|961921821
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Lokale persoonsidentificatie
| |
| |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;;"
| |
| |colspan="2"|Geboortedatum
| |
| |style="background-color: white;"|11 sep 1974
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Adres - postcode
| |
| |style="background-color: white;"|5689 CZ
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Etniciteit
| |
| |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;;"
| |
| |colspan="2"|Lengte gemeten
| |
| |style="background-color: white;"|184 cm
| |
| |}<section end=961921821 />
| |
| === Anamnese ===
| |
| <section begin=anamnese_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Anamnese
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Onder behandeling geweest?
| |
| |style="background-color: white;"|Nee
| |
| |}<section end=anamnese_961921821 />
| |
| === Zorgverlening ===
| |
| <section begin=zorgverlening_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Zorgverlening
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="6" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Datum start zorgverantwoordelijkheid
| |
| |style="background-color: white;"|12 may 2014 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Datum einde zorgverantwoordelijkheid
| |
| |style="background-color: white;"|9 oct 2014 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;;"
| |
| |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"|Zorgaanbieder identificatie nummer
| |
| |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;;"
| |
| |rowspan="6"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Van 1e naar 2e lijn
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Zwangerschap
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Hypertensieve aandoening
| |
| |style="background-color: white;"|Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT')
| |
| |}<section end=zorgverlening_961921821 />
| |
| === Zorgverlenerzorginstelling ===
| |
| <section begin=zorgverlenerzorginstelling_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorginstelling lvrid
| |
| |style="background-color: white;"|0003
| |
| |}<section end=zorgverlenerzorginstelling_961921821 />
| |
| === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
| |
| <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Wijze einde zwangerschap
| |
| |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;"|5 jun 2013
| |
| |-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;;"
| |
| |colspan="2"|Bloedverlies?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Hyperemesis gravidarum?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Irregulaire antistoffen?
| |
| |style="background-color: white;"|Ja
| |
| |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
| |
| === Zwangerschap ===
| |
| <section begin=zwangerschap_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Dossiernummer
| |
| |style="background-color: white;"|c2204d20-209a-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Graviditeit
| |
| |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;"|8 sep 2014
| |
| |-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;"|12 may 2014 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;;"
| |
| |colspan="2"|Datum
| |
| |style="background-color: white;"|12 may 2014 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"|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;;"
| |
| |colspan="2"|Partiele mola?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Hypertensieve aandoening
| |
| |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;;"
| |
| |colspan="3"|Maternale sterfte?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Wijze einde zwangerschap
| |
| |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
| |
| |}<section end=zwangerschap_961921821 />
| |
| === Bevalling ===
| |
| <section begin=bevalling_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Partusnummer
| |
| |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;;"
| |
| |colspan="2"|Interventie begin baring
| |
| |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;;"
| |
| |colspan="2"|Indicatie interventie begin baring
| |
| |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;;"
| |
| |colspan="3"|Wijze waarop de baring begon
| |
| |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="3"|Tijdstip begin actieve ontsluiting
| |
| |style="background-color: white;"|30 aug 2014 14:09
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Medicatie nageboortetijdperk groep
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Medicatie nageboortetijdperk?
| |
| |style="background-color: white;"|UNK
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Placenta - geboorte placenta
| |
| |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;;"
| |
| |colspan="3"|Hoeveelheid bloedverlies
| |
| |style="background-color: white;"|980 ml
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Conditie perineum postpartum
| |
| |style="background-color: white;"|Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96')
| |
| |}<section end=bevalling_961921821 />
| |
| === Uitkomst per kind ===
| |
| <section begin=uitkomst_per_kind_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="6" width="25%"| Gegevenselement
| |
| || 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;;"
| |
| |rowspan="2"|
| |
| |-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;"|1 sep 2014 02:34
| |
| |-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;"|30 aug 2014 23:04
| |
| |-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;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="5"| | | |rowspan="5"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Methode | | |colspan="6"|Zorginstelling |
| |-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;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="3"| | | |rowspan="3"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Indicatie primaire sectio | | |colspan="4"|Zorgaanbieder identificatie nummer |
| |style="background-color: white;"|Suspected fetal distress (situation) (code = '444433005:246090004=130955003' in codeSystem '2.16.840.1.113883.6.96') | | |style="background-color: white;"|1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Indicatie primaire sectio
| | |colspan="4"|Specialisme |
| |style="background-color: white;"|Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96')
| | |style="background-color: white;"| |
| |-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;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Betrokkenheid kinderarts | | |colspan="7"|Verwijzing naar |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Datum betrokkenheid
| |
| |style="background-color: white;"|1 sep 2014 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 />
| |
| === Medisch onderzoek ===
| |
| <section begin=medisch_onderzoek_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || 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;;"
| |
| |colspan="2"|Welke irregulaire antistoffen vrouw aanwezig
| |
| |style="background-color: white;"|Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96')
| |
| |}<section end=medisch_onderzoek_961921821 />
| |
| === Postnatale fase ===
| |
| <section begin=postnatale_fase_961921821 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || 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;"|3 sep 2014 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;"|7 oct 2014
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Substantie voeding kind
| |
| |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 />
| |
| ==Scenario 3. zorg volledig in 2e lijn, meerling, 1 kind overleden (voor vrouw met BSN: 895623146)==
| |
| <section begin=895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Burgerservicenummer
| |
| |style="background-color: white;"|895623146
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Lokale persoonsidentificatie
| |
| |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;;"
| |
| |colspan="2"|Geboortedatum
| |
| |style="background-color: white;"|5 aug 1985
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Adres - postcode
| |
| |style="background-color: white;"|5421 JG
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Etniciteit
| |
| |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;;"
| |
| |colspan="2"|Lengte gemeten
| |
| |style="background-color: white;"|167 cm
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Vrouwelijke genitale verminking?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Type vrouwelijke genitale verminking
| |
| |style="background-color: white;"|Female genital mutilation type 2 (disorder) (code = '130621000119105' in codeSystem '2.16.840.1.113883.6.96')
| |
| |}<section end=895623146 />
| |
| === Anamnese ===
| |
| <section begin=anamnese_895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Onder behandeling geweest?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Algemene anamnese
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="6"| | | |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;;"
| |
| |colspan="2"|Type operatie
| |
| |style="background-color: white;"|Operation on heart (procedure) (code = '64915003' in codeSystem '2.16.840.1.113883.6.96')
| |
| |}<section end=anamnese_895623146 />
| |
| === Zorgverlening ===
| |
| <section begin=zorgverlening_895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlening
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Datum start zorgverantwoordelijkheid
| |
| |style="background-color: white;"|10 mar 2014 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Datum einde zorgverantwoordelijkheid
| |
| |style="background-color: white;"|3 nov 2014 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|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="2"|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="2"|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="2"|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="2"|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="2"|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="2"|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="2"|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="2"|Conclusie risicostatus na intake
| |
| |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 />
| |
| === Zorgverlenerzorginstelling ===
| |
| <section begin=zorgverlenerzorginstelling_895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorginstelling lvrid
| |
| |style="background-color: white;"|9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
| |
| |}<section end=zorgverlenerzorginstelling_895623146 />
| |
| === Zwangerschap ===
| |
| <section begin=zwangerschap_895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Dossiernummer
| |
| |style="background-color: white;"|ad9c3280-209d-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Graviditeit
| |
| |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;"|22 sep 2014
| |
| |-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;"|21 may 2014 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;"|21 may 2014 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"|Bloedverlies?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|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="2"|Afwijkende groei foetus
| |
| |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;;"
| |
| |colspan="2"|Abruptio placentae?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Maternale sterfte?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Wijze einde zwangerschap
| |
| |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
| |
| |}<section end=zwangerschap_895623146 />
| |
| === Bevalling ===
| |
| <section begin=bevalling_895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Partusnummer
| |
| |style="background-color: white;"|000000
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Diagnose bevalling | | |colspan="6"|Zorginstelling |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="3"| | | |rowspan="3"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Pprom? | | |colspan="4"|Zorgaanbieder identificatie nummer |
| |style="background-color: white;"|Ja | | |style="background-color: white;"|0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Verdenking foetale nood? | | |colspan="4"|Specialisme |
| |style="background-color: white;"|Ja | | |style="background-color: white;"|Gynaecoloog 2e lijn (code = '02' in codeSystem 'Specialisme, specifiek voor perinatologie.') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Aantal geboren kinderen | | |colspan="5"|Type verwijzing |
| |style="background-color: white;"|2 | | |style="background-color: white;"| |
| |-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;;"
| |
| |colspan="3"|Tijdstip begin actieve ontsluiting
| |
| |style="background-color: white;"|27 aug 2014 22:09
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Medicatie nageboortetijdperk groep | | |colspan="7"|Redenen van verwijzing |
| |-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? | | |rowspan="82"| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Placenta - geboorte placenta
| |
| |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;;"
| |
| |colspan="3"|Hoeveelheid bloedverlies
| |
| |style="background-color: white;"|1740 ml
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Conditie perineum postpartum
| |
| |style="background-color: white;"|Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96')
| |
| |}<section end=bevalling_895623146 />
| |
| === Uitkomst per kind ===
| |
| <section begin=uitkomst_per_kind_895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="7" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="8"|Baring | | |colspan="6"|Van 1e naar 2e lijn |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="59"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="6"|Werkelijke plaats baring type locatie | | |rowspan="77"| |
| |style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="7"|Ziekenhuis baring | | |colspan="5"|Algemene anamnese |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="2"| | | |rowspan="20"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Ziekenhuisnummer lvrid | | |colspan="3"|Autoimmuun aandoening |
| |style="background-color: white;"|9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Demografische gegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="10"| | | |colspan="3"|Cardiovasculaire aandoening |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |style="background-color: white;"| |
| |colspan="6"|Identificaties kind
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="2"| | | |colspan="3"|Urogenitale aandoening |
| | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Bsn kind | | |colspan="3"|Oncologische aandoening |
| |style="background-color: white;"|847035116 | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Geslacht medische observatie | | |colspan="3"|Schildklier aandoening |
| |style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Geboortedatum | | |colspan="3"|Diabetes mellitus? |
| |style="background-color: white;"|28 aug 2014 06:30 | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Rangnummer kind | | |colspan="3"|Neurologische aandoening |
| |style="background-color: white;"|1 | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Perinatale sterfte groep
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="2"| | | |colspan="3"|Infectieziekte |
| | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Perinatale sterfte? | | |colspan="3"|Mdl aandoening |
| |style="background-color: white;"|Nee | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Kindspecifieke maternale gegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="19"| | | |colspan="3"|Anemie |
| | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Tijdstip breken vliezen | | |colspan="3"|Longaandoening |
| |style="background-color: white;"|27 aug 2014 22:09 | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Kleur en consistentie vruchtwater | | |colspan="3"|Gynaecologische aandoening |
| |style="background-color: white;"|kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Tijdstip actief meepersen | | |colspan="3"|Orthopedische afwijking |
| |style="background-color: white;"|27 aug 2014 23:49 | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Episiotomie? | | |colspan="3"|Bloedtransfusie? |
| |style="background-color: white;"|Ja | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Locatie episiotomie | | |colspan="3"|Transfusiereactie? |
| |style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Ruggeprik gewenst niet gekregen? | | |colspan="3"|Type operatie |
| |style="background-color: white;"|Nee | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Pijnbestrijding? | | |colspan="3"|Type stollingsprobleem |
| |style="background-color: white;"|Ja | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Pijnbestrijding
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="9"| | | |colspan="3"|Psychiatrie? |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |style="background-color: white;"| |
| |colspan="5"|Methode
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="6"|
| | |colspan="3"|Overige aandoening? |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| | |style="background-color: white;"| |
| |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;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Overig middel | | |colspan="5"|Obstetrische anamnese |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="3"| | | |rowspan="15"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Middel | | |colspan="3"|Gynaecologische aandoening |
| |style="background-color: white;"|Administration of morphinomimetic analgesic (procedure) (code = '52685006:363701004=404642006' in codeSystem '2.16.840.1.113883.6.96') | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Toediening | | |colspan="3"|Bloedverlies? |
| |style="background-color: white;"|Administration of substance via intravenous route (procedure) (code = '431215000' in codeSystem '2.16.840.1.113883.6.96') | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Periode | | |colspan="3"|Partiele mola? |
| |style="background-color: white;"|tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Sedatie? | | |colspan="3"|Cervixinsufficientie? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"| |
| |-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;;" |
| |rowspan="22"| | | |colspan="3"|Infectie |
| | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Type partus | | |colspan="3"|Hyperemesis gravidarum? |
| |style="background-color: white;"|Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Ligging bij geboorte | | |colspan="3"|Hypertensieve aandoening |
| |style="background-color: white;"|Face presentation (finding) (code = '21882006' in codeSystem '2.16.840.1.113883.6.96') | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Aanpakker kind - rol aanpakker kind | | |colspan="3"|Zwangerschapscholestase? |
| |style="background-color: white;"|arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Supervisor - rol supervisor | | |colspan="3"|Diabetes gravidarum met insuline? |
| |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Vaginale kunstverlossing groep
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="3"| | | |colspan="3"|Afwijkende groei foetus |
| | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Vaginale kunstverlossing | | |colspan="3"|Dreigende partus immaturus? |
| |style="background-color: white;"|Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Succes vaginale kunstverlossing? | | |colspan="3"|Dreigende partus prematurus? |
| |style="background-color: white;"|Ja | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Lichamelijk onderzoek kind
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="2"| | | |colspan="3"|Abruptio placentae? |
| | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Geboortegewicht | | |colspan="3"|Fluxus postpartum? |
| |style="background-color: white;"|2040 gram
| | |style="background-color: white;"| |
| |-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;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="6"|Betrokkenheid kinderarts
| | |colspan="5"|Zwangerschap |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Datum betrokkenheid
| |
| |style="background-color: white;"|28 aug 2014 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 />
| |
| === Uitkomst per kind ===
| |
| <section begin=uitkomst_per_kind_895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="7" width="25%"| Gegevenselement
| |
| || 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;"|28 aug 2014 07:02
| |
| |-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;"|28 aug 2014 08:10
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Kindspecifieke maternale gegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="19"| | | |rowspan="19"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Tijdstip breken vliezen | | |colspan="3"|Gynaecologische aandoening |
| |style="background-color: white;"|27 aug 2014 23:13 | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Kleur en consistentie vruchtwater | | |colspan="3"|Bloedverlies? |
| |style="background-color: white;"|kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Tijdstip actief meepersen | | |colspan="3"|Partiele mola? |
| |style="background-color: white;"|28 aug 2014 06:45 | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Episiotomie? | | |colspan="3"|Cervixinsufficientie? |
| |style="background-color: white;"|Ja | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Locatie episiotomie | | |colspan="3"|Infectie |
| |style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60') | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Ruggeprik gewenst niet gekregen? | | |colspan="3"|Hyperemesis gravidarum? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Pijnbestrijding? | | |colspan="3"|Hypertensieve aandoening |
| |style="background-color: white;"|Ja | | |style="background-color: white;"|Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT') - Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT') |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Pijnbestrijding
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="9"| | | |colspan="3"|Zwangerschapscholestase? |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |style="background-color: white;"| |
| |colspan="5"|Methode
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="6"| | | |colspan="3"|Diabetes gravidarum met insuline? |
| | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Methode | | |colspan="3"|Afwijkende groei foetus |
| |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Overig middel
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="3"| | | |colspan="3"|Dreigende partus immaturus? |
| | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Middel | | |colspan="3"|Dreigende partus prematurus? |
| |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="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Toediening | | |colspan="3"|Abruptio placentae? |
| |style="background-color: white;"|Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96') | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Periode | | |colspan="3"|Navelstrengprolaps? |
| |style="background-color: white;"|tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Sedatie? | | |colspan="3"|Liggingsafwijking |
| |style="background-color: white;"|Nee | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="7"|Kindspecifieke uitkomstgegevens
| | |colspan="4"|Intrauteriene vruchtdood |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="32"|
| |
| |-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;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="2"| | | |rowspan="2"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Geboortegewicht | | |colspan="2"|Vermoeden intrauteriene vruchtdood? |
| |style="background-color: white;"|1580 gram | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Congenitale afwijkingen? | | |colspan="4"|Einde zwangerschap |
| |style="background-color: white;"|Ja | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="6"|Congenitale afwijkingen groep | | |colspan="5"|Bevalling |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="8"| | | |rowspan="13"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Specificatie congenitale afwijking groep
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="2"| | | |colspan="3"|Pprom? |
| | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Specificatie congenitale afwijking | | |colspan="3"|Prom? |
| |style="background-color: white;"|Spina bifida occulta (disorder) (code = '76916001' in codeSystem '2.16.840.1.113883.6.96') | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Specificatie congenitale afwijking groep
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="2"| | | |colspan="3"|Koorts? |
| | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Specificatie congenitale afwijking | | |colspan="3"|Niet vorderende ontsluiting? |
| |style="background-color: white;"|Multiple congenital cardiac defects (disorder) (code = '94702005' in codeSystem '2.16.840.1.113883.6.96') | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Chromosomale afwijkingen? | | |colspan="3"|Niet vorderende uitdrijving? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Problematiek kind? | | |colspan="3"|Verdenking foetale nood? |
| |style="background-color: white;"|Ja | | |style="background-color: white;"| |
| |-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;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="6"|Betrokkenheid kinderarts
| | |colspan="4"|Intrauteriene vruchtdood |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Datum betrokkenheid
| |
| |style="background-color: white;"|28 aug 2014 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 />
| |
| === Medisch onderzoek ===
| |
| <section begin=medisch_onderzoek_895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || 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"| | | |rowspan="2"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Irregulaire antistoffen? | | |colspan="2"|Vermoeden intrauteriene vruchtdood? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"| |
| |}<section end=medisch_onderzoek_895623146 />
| |
| === Postnatale fase ===
| |
| <section begin=postnatale_fase_895623146 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-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;;" |
| |rowspan="6"|
| | |colspan="3"|Vastzittende placenta? |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Rangnummer kind | |
| |style="background-color: white;"| | | |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;"|3 sep 2014
| |
| |-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 />
| |
| ==Scenario 4. 1e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)==
| |
| <section begin=850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Burgerservicenummer
| |
| |style="background-color: white;"|850810711
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Lokale persoonsidentificatie
| |
| |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;;"
| |
| |colspan="2"|Geboortedatum
| |
| |style="background-color: white;"|6 aug 1987
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Adres - postcode
| |
| |style="background-color: white;"|4589 BA
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Etniciteit
| |
| |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;;"
| |
| |colspan="2"|Lengte gemeten
| |
| |style="background-color: white;"|162 cm
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Vrouwelijke genitale verminking?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Type vrouwelijke genitale verminking
| |
| |style="background-color: white;"|Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96')
| |
| |}<section end=850810711 />
| |
| === Anamnese ===
| |
| <section begin=anamnese_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Onder behandeling geweest?
| |
| |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;;"
| |
| |colspan="2"|Type operatie
| |
| |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
| |
| |}<section end=anamnese_850810711 />
| |
| === Zorgverlening ===
| |
| <section begin=zorgverlening_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Zorgverlening
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="5" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Datum start zorgverantwoordelijkheid
| |
| |style="background-color: white;"|7 aug 2014 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Datum einde zorgverantwoordelijkheid
| |
| |style="background-color: white;"|15 sep 2014 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;;"
| |
| |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;"|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;;"
| |
| |rowspan="1"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Redenen van verwijzing
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="1"|
| |
| |}<section end=zorgverlening_850810711 />
| |
| === Zorgverlenerzorginstelling ===
| |
| <section begin=zorgverlenerzorginstelling_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorginstelling lvrid
| |
| |style="background-color: white;"|1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
| |
| |}<section end=zorgverlenerzorginstelling_850810711 />
| |
| === Zwangerschap ===
| |
| <section begin=zwangerschap_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zwangerschap
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Dossiernummer
| |
| |style="background-color: white;"|05e54070-209f-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Graviditeit
| |
| |style="background-color: white;"|1
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Pariteit voor deze zwangerschap
| |
| |style="background-color: white;"|0
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Definitieve a terme datum
| |
| |style="background-color: white;"|18 aug 2014
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Maternale sterfte?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Wijze einde zwangerschap
| |
| |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
| |
| |}<section end=zwangerschap_850810711 />
| |
| === Bevalling ===
| |
| <section begin=bevalling_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-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="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;;"
| |
| |colspan="3"|Tijdstip begin actieve ontsluiting
| |
| |style="background-color: white;"|3 aug 2014 21:09
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Medicatie nageboortetijdperk groep
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Medicatie nageboortetijdperk?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Soort medicatie nageboortetijdperk
| |
| |style="background-color: white;"|Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|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="3"|Hoeveelheid bloedverlies
| |
| |style="background-color: white;"|1120 ml
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Conditie perineum postpartum | | |colspan="3"|Conditie perineum postpartum |
| |style="background-color: white;"|Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') | | |style="background-color: white;"| |
| |}<section end=bevalling_850810711 />
| |
| === Uitkomst per kind ===
| |
| <section begin=uitkomst_per_kind_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="7" width="25%"| Gegevenselement
| |
| || 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;;" |
| |rowspan="58"|
| | |colspan="3"|Fluxus postpartum? |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| | |style="background-color: white;"| |
| |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;"|4 aug 2014 23:35
| |
| |-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;"|3 aug 2014 07:04
| |
| |-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;"|4 aug 2014 22:15
| |
| |-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;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="6"|Lichamelijk onderzoek kind | | |colspan="5"|Postnatale fase |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="2"| | | |rowspan="2"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |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;"|4 aug 2014 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 />
| |
| === Postnatale fase ===
| |
| <section begin=postnatale_fase_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || 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;"|8 aug 2014 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Pathologie vrouw | | |colspan="3"|Pathologie vrouw |
| |style="background-color: white;"|Embolism (disorder) (code = '414086009' in codeSystem '2.16.840.1.113883.6.96') | | |style="background-color: white;"| |
| |-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;;" |
| |rowspan="3"| | | |colspan="4"|Overig |
| | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Datum | | |colspan="5"|Van 2e naar 3e lijn |
| |style="background-color: white;"|8 aug 2014 00:00 | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Pathologie vrouw | | |colspan="5"|Van 2e naar 1e lijn |
| |style="background-color: white;"|Episiotomy infection (disorder) (code = '300927001' in codeSystem '2.16.840.1.113883.6.96') | | |style="background-color: white;"| |
| |-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;;" |
| |rowspan="5"| | | |colspan="5"|Van 3e naar 2e lijn |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |style="background-color: white;"| |
| |colspan="4"|Voeding kind groep
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="3"|
| | |colspan="6"|Perinatale periode |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| | |style="background-color: white;"|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') |
| |colspan="2"|Voeding kind datum | | |}<section end=zorgverlening_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 /> |
| |style="background-color: white;"|15 sep 2014 | | === Zorgverlenerzorginstelling === |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| | <section begin=zorgverlenerzorginstelling_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 /> |
| |colspan="2"|Substantie voeding kind
| |
| |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 /> | |
| ==Scenario 4. 2e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)== | |
| <section begin=850810711 /> | |
| {| class="wikitable" width="85%" | | {| class="wikitable" width="85%" |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw
| | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zorgverlenerzorginstelling |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Burgerservicenummer
| |
| |style="background-color: white;"|850810711
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Lokale persoonsidentificatie
| |
| |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;;"
| |
| |colspan="2"|Geboortedatum
| |
| |style="background-color: white;"|6 aug 1987
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Adres - postcode
| |
| |style="background-color: white;"|4589 BA
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Etniciteit
| |
| |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;;"
| |
| |colspan="2"|Lengte gemeten
| |
| |style="background-color: white;"|162 cm
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Vrouwelijke genitale verminking?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Type vrouwelijke genitale verminking
| |
| |style="background-color: white;"|Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96')
| |
| |}<section end=850810711 />
| |
| === Anamnese ===
| |
| <section begin=anamnese_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |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="3" width="25%"| Gegevenselement | | |colspan="3" width="25%"| Gegevenselement |
| || Waarde | | || Waarde |
|
| |
|
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Onder behandeling geweest?
| |
| |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;;"
| |
| |colspan="2"|Type operatie
| |
| |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
| |
| |}<section end=anamnese_850810711 />
| |
| === Zorgverlening ===
| |
| <section begin=zorgverlening_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Zorgverlening
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="5" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Datum start zorgverantwoordelijkheid
| |
| |style="background-color: white;"|3 feb 2014 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Datum einde zorgverantwoordelijkheid
| |
| |style="background-color: white;"|6 aug 2014 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;;"
| |
| |colspan="4"|Datum verwijzing
| |
| |style="background-color: white;"|6 aug 2014 00:00
| |
| |-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;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Zorginstelling | | |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;"|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;;"
| |
| |rowspan="1"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Perinatale periode
| |
| |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 />
| |
| === Zorgverlenerzorginstelling ===
| |
| <section begin=zorgverlenerzorginstelling_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorginstelling lvrid
| |
| |style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
| |
| |}<section end=zorgverlenerzorginstelling_850810711 />
| |
| === Zwangerschap ===
| |
| <section begin=zwangerschap_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Dossiernummer
| |
| |style="background-color: white;"|e1691540-209f-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Graviditeit
| |
| |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;"|18 aug 2014
| |
| |-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;"|7 may 2014 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;;"
| |
| |colspan="2"|Gewicht gemeten
| |
| |style="background-color: white;"|82 kg
| |
| |-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"|Datum
| |
| |style="background-color: white;"|7 may 2014 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"|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="3"|Maternale sterfte?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Wijze einde zwangerschap
| |
| |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
| |
| |}<section end=zwangerschap_850810711 />
| |
| === Bevalling ===
| |
| <section begin=bevalling_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || 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;;"
| |
| |colspan="2"|Niet vorderende uitdrijving?
| |
| |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;;"
| |
| |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;;"
| |
| |colspan="3"|Tijdstip begin actieve ontsluiting
| |
| |style="background-color: white;"|3 aug 2014 21:09
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Medicatie nageboortetijdperk groep
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Medicatie nageboortetijdperk?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Soort medicatie nageboortetijdperk
| |
| |style="background-color: white;"|Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|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="3"|Hoeveelheid bloedverlies
| |
| |style="background-color: white;"|1120 ml
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Conditie perineum postpartum
| |
| |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 />
| |
| === Uitkomst per kind ===
| |
| <section begin=uitkomst_per_kind_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="7" width="25%"| Gegevenselement
| |
| || 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;;"
| |
| |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;"|4 aug 2014 23:35
| |
| |-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;"|3 aug 2014 07:04
| |
| |-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;"|4 aug 2014 22:15
| |
| |-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;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="3"| | | |rowspan="3"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Vaginale kunstverlossing | | |colspan="2"|Zorginstelling agbid |
| |style="background-color: white;"|Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96')
| | |style="background-color: white;"|12345678 (in identificerend systeem: 1) |
| |-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;"|4 aug 2014 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 />
| |
| === Medisch onderzoek ===
| |
| <section begin=medisch_onderzoek_850810711 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || 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;;"
| |
| |colspan="2"|Irregulaire antistoffen?
| |
| |style="background-color: white;"|Nee | |
| |}<section end=medisch_onderzoek_850810711 />
| |
| ==Scenario 5. zorg volledig 2e lijn, vrouw overleden (voor vrouw met BSN: 912345676)==
| |
| <section begin=912345676 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Burgerservicenummer
| |
| |style="background-color: white;"|912345676
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Lokale persoonsidentificatie
| |
| |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;;"
| |
| |colspan="2"|Geboortedatum
| |
| |style="background-color: white;"|4 mar 1993
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Adres - postcode
| |
| |style="background-color: white;"|9562 GF
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Etniciteit
| |
| |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;;"
| |
| |colspan="2"|Lengte gemeten
| |
| |style="background-color: white;"|186 cm
| |
| |}<section end=912345676 />
| |
| === Anamnese ===
| |
| <section begin=anamnese_912345676 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Onder behandeling geweest?
| |
| |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;;"
| |
| |colspan="2"|Psychiatrie?
| |
| |style="background-color: white;"|Ja
| |
| |}<section end=anamnese_912345676 />
| |
| === Zorgverlening ===
| |
| <section begin=zorgverlening_912345676 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlening
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Datum start zorgverantwoordelijkheid
| |
| |style="background-color: white;"|9 dec 2013 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Datum einde zorgverantwoordelijkheid
| |
| |style="background-color: white;"|4 aug 2014 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|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="2"|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="2"|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="2"|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="2"|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="2"|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="2"|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="2"|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="2"|Conclusie risicostatus na intake
| |
| |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 />
| |
| === Zorgverlenerzorginstelling ===
| |
| <section begin=zorgverlenerzorginstelling_912345676 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Zorginstelling lvrid | | |colspan="2"|Zorginstelling lvrid |
| |style="background-color: white;"|0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | | |style="background-color: white;"|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) - 0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
| |}<section end=zorgverlenerzorginstelling_912345676 /> | | |}<section end=zorgverlenerzorginstelling_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 /> |
| === 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_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 /> |
| {| class="wikitable" width="85%" | | {| class="wikitable" width="85%" |
| |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; font-weight: bold; text-align:center;" colspan="8" | 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="5" width="25%"| Gegevenselement | | |colspan="7" width="25%"| Gegevenselement |
| || Waarde | | || Waarde |
|
| |
|
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Wijze einde zwangerschap | | |colspan="7"|Wijze einde zwangerschap |
| |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Definitieve a terme datum | | |colspan="7"|Definitieve a terme datum |
| |style="background-color: white;"|5 jun 2012 | | |style="background-color: white;"|1 dec 2011 - 5 jun 2013 - 5 jun 2012 - 1 feb 2017 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="6"|Diagnose | | |colspan="8"|Diagnose |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="4"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Infectie | | |rowspan="13"| |
| |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="4"|Zwangerschapscholestase? | | |colspan="6"|Gynaecologische aandoening |
| |style="background-color: white;"|Ja | | |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;;"
| |
| |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;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Irregulaire antistoffen? | | |colspan="6"|Bloedverlies? |
| |style="background-color: white;"|Ja | | |style="background-color: white;"|Ja |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Eerdere bevalling
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="11"|
| | |colspan="6"|Cervixinsufficientie? |
| |-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;"|9 jun 2012 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;"|Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Percentiel van het geboortegewicht
| |
| |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;;"
| |
| |colspan="2"|Apgarscore na 5 min
| |
| |style="background-color: white;"|10
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Congenitale afwijkingen? | |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Nee |
| |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 />
| |
| === Zwangerschap ===
| |
| <section begin=zwangerschap_912345676 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschap
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Dossiernummer | | |colspan="6"|Infectie |
| |style="background-color: white;"|68a34ee0-20a0-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4) | | |style="background-color: white;"|Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') - Intra-uterien (code = '301775005' in codeSystem 'Snomed CT') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Graviditeit | | |colspan="6"|Hyperemesis gravidarum? |
| |style="background-color: white;"|2 | | |style="background-color: white;"|Ja - Nee |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Pariteit voor deze zwangerschap | | |colspan="6"|Hypertensieve aandoening |
| |style="background-color: white;"|1
| | |style="background-color: white;"|Zwangerschapshypertensie (code = '48194001' in codeSystem '2.16.840.1.113883.6.96') |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Definitieve a terme datum
| |
| |style="background-color: white;"|22 jul 2014
| |
| |-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;"|9 jan 2014 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;;"
| |
| |rowspan="5"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Datum
| |
| |style="background-color: white;"|9 jan 2014 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"|Afwijkende groei foetus
| |
| |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;;"
| |
| |colspan="2"|Abruptio placentae? | |
| |style="background-color: white;"|Ja | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Intrauteriene behandeling
| |
| |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;;"
| |
| |colspan="3"|Maternale sterfte?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Wijze einde zwangerschap
| |
| |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
| |
| |}<section end=zwangerschap_912345676 />
| |
| === Bevalling ===
| |
| <section begin=bevalling_912345676 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Bevalling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Partusnummer
| |
| |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;;"
| |
| |colspan="2"|Interventie begin baring
| |
| |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;;"
| |
| |colspan="2"|Indicatie interventie begin baring
| |
| |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;;"
| |
| |colspan="3"|Wijze waarop de baring begon
| |
| |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;;"
| |
| |rowspan="2"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Medicatie nageboortetijdperk?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Placenta - geboorte placenta
| |
| |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;;"
| |
| |colspan="3"|Hoeveelheid bloedverlies
| |
| |style="background-color: white;"|1500 ml
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Conditie perineum postpartum
| |
| |style="background-color: white;"|Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96')
| |
| |}<section end=bevalling_912345676 />
| |
| === Uitkomst per kind ===
| |
| <section begin=uitkomst_per_kind_912345676 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="6" width="25%"| Gegevenselement
| |
| || 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;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Ziekenhuisnummer lvrid | | |colspan="6"|Zwangerschapscholestase? |
| |style="background-color: white;"|0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | | |style="background-color: white;"|Ja - Nee |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Demografische gegevens
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="10"|
| | |colspan="6"|Diabetes gravidarum met insuline? |
| |-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;"|24 jul 2014 02:30
| |
| |-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="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;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Kleur en consistentie vruchtwater | | |colspan="6"|Afwijkende groei foetus |
| |style="background-color: white;"|meconium (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | | |style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') - Macrosomie (code = '199616008' in codeSystem 'Snomed CT') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Episiotomie? | | |colspan="6"|Dreigende partus immaturus? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Nee |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Ruggeprik gewenst niet gekregen? | | |colspan="6"|Dreigende partus prematurus? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Nee |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Pijnbestrijding? | | |colspan="6"|Abruptio placentae? |
| |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="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;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Supervisor - rol supervisor | | |colspan="7"|Irregulaire antistoffen? |
| |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | | |style="background-color: white;"|Nee - Ja |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Vaginale kunstverlossing groep | | |colspan="8"|Eerdere bevalling |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="3"| | | |rowspan="19"| |
| |-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;;"
| |
| |colspan="4"|Congenitale afwijkingen?
| |
| |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;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Specificatie congenitale afwijking groep | | |colspan="7"|Placenta |
| |-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;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="2"| | | |rowspan="2"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Specificatie chromosomale afwijking | | |colspan="5"|Geboorte placenta |
| |style="background-color: white;"|Complete trisomy 21 syndrome (disorder) (code = '41040004' in codeSystem '2.16.840.1.113883.6.96') | | |style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - Placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Problematiek kind? | | |colspan="6"|Hoeveelheid bloedverlies |
| |style="background-color: white;"|Ja
| | |style="background-color: white;"|550 ml - 895 ml |
| |-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 />
| |
| === Medisch onderzoek ===
| |
| <section begin=medisch_onderzoek_912345676 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | | |colspan="7"|Vorige uitkomst per kind |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="3"| | | |rowspan="13"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Irregulaire antistoffen?
| |
| |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 />
| |
| === Postnatale fase ===
| |
| <section begin=postnatale_fase_912345676 />
| |
| {| class="wikitable" width="85%"
| |
| |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;"
| |
| |colspan="4" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Diagnoseinterventie postpartum
| | |colspan="6"|Vorige baring |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="3"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Datum
| |
| |style="background-color: white;"|24 jul 2014 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;;"
| |
| |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;"|24 jul 2014
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Substantie voeding kind
| |
| |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 />
| |
| ==Scenario 6. 2e lijn (voor vrouw met BSN: 100202020)==
| |
| <section begin=100202020 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Vrouw
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Burgerservicenummer
| |
| |style="background-color: white;"|100202020
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Lokale persoonsidentificatie
| |
| |style="background-color: white;"|987654321 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Geboortedatum
| |
| |style="background-color: white;"|1 jan 1989
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Adres - postcode
| |
| |style="background-color: white;"|1234 AB
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Etniciteit
| |
| |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;;"
| |
| |colspan="2"|Lengte gemeten
| |
| |style="background-color: white;"|172 cm
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Vrouwelijke genitale verminking?
| |
| |style="background-color: white;"|Nee
| |
| |}<section end=100202020 />
| |
| === Anamnese ===
| |
| <section begin=anamnese_100202020 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Anamnese
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="3" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="3"|Onder behandeling geweest?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Algemene anamnese
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="18"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Autoimmuun aandoening
| |
| |style="background-color: white;"|Reuma (code = '396332003' in codeSystem 'Snomed CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Cardiovasculaire aandoening
| |
| |style="background-color: white;"|Overig, niet nader omschreven Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Urogenitale aandoening
| |
| |style="background-color: white;"|Pyelonefritis (code = '45816000' in codeSystem 'Snomed CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Oncologische aandoening
| |
| |style="background-color: white;"|Overig, niet nader omschreven Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Schildklier aandoening
| |
| |style="background-color: white;"|Hypothyreoidie (code = '40930008' in codeSystem 'Snomed CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Diabetes mellitus?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Neurologische aandoening
| |
| |style="background-color: white;"|Hernia nuclei pulposi (code = '84857004' in codeSystem 'Snomed CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Neurologische aandoening
| |
| |style="background-color: white;"|Overig, niet nader omschreven Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Mdl aandoening
| |
| |style="background-color: white;"|M. Crohn (code = '34000006' in codeSystem 'Snomed CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Anemie
| |
| |style="background-color: white;"|IJzergebrek (code = '87522002' in codeSystem 'Snomed CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Longaandoening
| |
| |style="background-color: white;"|Astma (code = '195967001' in codeSystem 'Snomed CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Orthopedische afwijking
| |
| |style="background-color: white;"|Trauma bekken (code = '282771003' in codeSystem 'Snomed CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Bloedtransfusie?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Type operatie
| |
| |style="background-color: white;"|Sectio (code = '11466000' in codeSystem 'Snomed CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Type operatie
| |
| |style="background-color: white;"|Rug (code = '129152004:260686004=129284003' in codeSystem '2.16.840.1.113883.6.96')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Psychiatrie?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Overige aandoening?
| |
| |style="background-color: white;"|Nee
| |
| |}<section end=anamnese_100202020 />
| |
| === Zorgverlening ===
| |
| <section begin=zorgverlening_100202020 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlening
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Datum start zorgverantwoordelijkheid
| |
| |style="background-color: white;"|1 mar 2019 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Datum einde zorgverantwoordelijkheid
| |
| |style="background-color: white;"|15 oct 2019 00:00
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|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="2"|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="2"|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="2"|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="2"|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="2"|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="2"|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="2"|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="2"|Conclusie risicostatus na intake
| |
| |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_100202020 />
| |
| === Zorgverlenerzorginstelling ===
| |
| <section begin=zorgverlenerzorginstelling_100202020 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgverlenerzorginstelling
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="2" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="2"|Zorginstelling lvrid
| |
| |style="background-color: white;"|0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
| |
| |}<section end=zorgverlenerzorginstelling_100202020 />
| |
| === Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
| |
| <section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_100202020 />
| |
| {| class="wikitable" width="85%"
| |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
| |
| |-style="background-color: #1F497D;; color: white; text-align:left;"
| |
| |colspan="6" width="25%"| Gegevenselement
| |
| || Waarde
| |
| | |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Wijze einde zwangerschap
| |
| |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="6"|Definitieve a terme datum
| |
| |style="background-color: white;"|1 feb 2017
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Diagnose
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="12"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Bloedverlies?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Cervixinsufficientie?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Infectie
| |
| |style="background-color: white;"|Intra-uterien (code = '301775005' in codeSystem 'Snomed CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Hyperemesis gravidarum?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Hypertensieve aandoening
| |
| |style="background-color: white;"|Zwangerschapshypertensie (code = '48194001' in codeSystem '2.16.840.1.113883.6.96')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Zwangerschapscholestase?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Diabetes gravidarum met insuline?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Afwijkende groei foetus
| |
| |style="background-color: white;"|Macrosomie (code = '199616008' in codeSystem 'Snomed CT')
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Dreigende partus immaturus?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Dreigende partus prematurus?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Abruptio placentae?
| |
| |style="background-color: white;"|Ja
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Irregulaire antistoffen?
| |
| |style="background-color: white;"|Nee
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="7"|Eerdere bevalling
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |rowspan="15"|
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="5"|Placenta - geboorte placenta
| |
| |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;;"
| |
| |colspan="5"|Hoeveelheid bloedverlies
| |
| |style="background-color: white;"|895 ml
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="6"|Vorige uitkomst per kind - vorige baring | |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="11"| | | |rowspan="11"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Demografische gegevens - geboortedatum | | |colspan="4"|Geboortedatum |
| |style="background-color: white;"|15 dec 2016 | | |style="background-color: white;"|8 dec 2011 00:00 - 9 jun 2012 00:00 - 15 dec 2016 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Kindspecifieke gegevens vorige uitkomsten | | |colspan="5"|Kindspecifieke gegevens vorige uitkomsten |
| Regel 3.381: |
Regel 525: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Type partus | | |colspan="3"|Type partus |
| |style="background-color: white;"|Secundair (code = '274130007' in codeSystem '2.16.840.1.113883.6.96') | | |style="background-color: white;"|Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT') - Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') - Secundair (code = '274130007' in codeSystem '2.16.840.1.113883.6.96') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Percentiel van het geboortegewicht | | |colspan="3"|Percentiel van het geboortegewicht |
| |style="background-color: white;"|p2,3 tot p10 (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.50') | | |style="background-color: white;"|p50 tot p90 (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') - p2,3 tot p10 (code = '2' 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="3"|Apgarscore na 5 min | | |colspan="3"|Apgarscore na 5 min |
| |style="background-color: white;"|8 | | |style="background-color: white;"|8 - 10 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Congenitale afwijkingen? | | |colspan="3"|Congenitale afwijkingen? |
| |style="background-color: white;"|Ja | | |style="background-color: white;"|Nee - Ja |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Congenitale afwijkingen groep | | |colspan="4"|Congenitale afwijkingen groep |
| Regel 3.398: |
Regel 542: |
| |colspan="2"|Chromosomale afwijkingen? | | |colspan="2"|Chromosomale afwijkingen? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Nee |
| |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_100202020 /> | | |}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 /> |
| === Zwangerschap === | | === Zwangerschap === |
| <section begin=zwangerschap_100202020 /> | | <section begin=zwangerschap_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 /> |
| {| class="wikitable" width="85%" | | {| class="wikitable" width="85%" |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zwangerschap | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zwangerschap |
| Regel 3.407: |
Regel 551: |
| || Waarde | | || Waarde |
|
| |
|
| |-style="vertical-align:top; background-color: #E3E3E3;;"
| |
| |colspan="4"|Dossiernummer
| |
| |style="background-color: white;"|0af1e5b1-bf99-40a2-ade9-728186c32f31 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Graviditeit | | |colspan="4"|Graviditeit |
| |style="background-color: white;"|2 | | |style="background-color: white;"|2 - 1 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Pariteit voor deze zwangerschap | | |colspan="4"|Pariteit voor deze zwangerschap |
| |style="background-color: white;"|1 | | |style="background-color: white;"|1 - 0 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Definitieve a terme datum | | |colspan="4"|Definitieve a terme datum |
| |style="background-color: white;"|2 oct 2019 | | |style="background-color: white;"|9 okt 2014 - 8 sep 2014 - 22 sep 2014 - 18 aug 2014 - 22 jul 2014 - 2 okt 2019 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Voornemens | | |colspan="5"|Voornemens |
| Regel 3.425: |
Regel 566: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Voorgenomen plaats baring tijdens zwangerschap type locatie | | |colspan="3"|Voorgenomen plaats baring tijdens zwangerschap type locatie |
| |style="background-color: white;"|Ziekenhuis (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') | | |style="background-color: white;"|Thuis (code = '169813005' in codeSystem '2.16.840.1.113883.6.96') - Nog niet bepaald (code = '05' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Prenatale controle | | |colspan="5"|Prenatale controle |
| Regel 3.432: |
Regel 573: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Datum controle | | |colspan="3"|Datum controle |
| |style="background-color: white;"|1 mar 2019 00:00 | | |style="background-color: white;"|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 - 1 mrt 2019 00:00 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Zwangerschapsduur | | |colspan="3"|Zwangerschapsduur |
| |style="background-color: white;"|56 dagen | | |style="background-color: white;"|59 dagen - 155 dagen - 161 dagen - 156 dagen - 149 dagen - 86 dagen - 56 dagen |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Leven voelen | | |colspan="3"|Leven voelen |
| |style="background-color: white;"|geen (code = '289432001' in codeSystem '2.16.840.1.113883.6.96') | | |style="background-color: white;"|goed (code = '289431008' in codeSystem 'Snomed CT') - Weak fetal movements (finding) (code = '276372004' in codeSystem '2.16.840.1.113883.6.96') - Reduced fetal movement (finding) (code = '276369006' in codeSystem '2.16.840.1.113883.6.96') - Fetal movements absent (context-dependent category) (code = '289432001' in codeSystem '2.16.840.1.113883.6.96') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Rookgedrag | | |colspan="3"|Rookgedrag |
| |style="background-color: white;"|gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') | | |style="background-color: white;"|niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - gestopt tijdens huidige zwangerschap (code = '6' in codeSystem '2.16.840.1.113883.2.4.4.13.58') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Alcoholgebruik | | |colspan="3"|Alcoholgebruik |
| Regel 3.447: |
Regel 588: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Drugsgebruik? | | |colspan="3"|Drugsgebruik? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Nee - Ja |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Gewicht gemeten | | |colspan="3"|Gewicht gemeten |
| |style="background-color: white;"|68 kg | | |style="background-color: white;"|70 kg - 85 kg - 67 kg - 82 kg - 89 kg - 68 kg |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Diagnose | | |colspan="5"|Diagnose |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="18"| | | |rowspan="22"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Datum | | |colspan="3"|Datum |
| |style="background-color: white;"|1 mar 2019 00:00 | | |style="background-color: white;"|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 - 1 mrt 2019 00:00 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Zwangerschapsduur | | |colspan="3"|Zwangerschapsduur |
| |style="background-color: white;"|56 dagen | | |style="background-color: white;"|59 dagen - 155 dagen - 161 dagen - 156 dagen - 149 dagen - 86 dagen - 56 dagen |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Gynaecologische aandoening | | |colspan="3"|Gynaecologische aandoening |
| |style="background-color: white;"|Overig, niet nader gespecificeerd Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | | |style="background-color: white;"|Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') - Overig, niet nader gespecificeerd 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="3"|Bloedverlies? | | |colspan="3"|Bloedverlies? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Ja - Nee |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Partiele mola? | | |colspan="3"|Partiele mola? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Ja - Nee |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Cervixinsufficientie? | | |colspan="3"|Cervixinsufficientie? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Nee |
| | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| | |colspan="3"|Infectie |
| | |style="background-color: white;"|Urineweg infectie (code = '307534009' in codeSystem 'Snomed CT') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Hyperemesis gravidarum? | | |colspan="3"|Hyperemesis gravidarum? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Nee |
| | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| | |colspan="3"|Hypertensieve aandoening |
| | |style="background-color: white;"|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') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Zwangerschapscholestase? | | |colspan="3"|Zwangerschapscholestase? |
| Regel 3.484: |
Regel 631: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Afwijkende groei foetus | | |colspan="3"|Afwijkende groei foetus |
| |style="background-color: white;"|Dysmaturiteit (code = '267258002' in codeSystem 'Snomed CT') | | |style="background-color: white;"|Small for gestational age fetus (disorder) (code = '267258002' in codeSystem '2.16.840.1.113883.6.96') - Large-for-dates fetus (disorder) (code = '199616008' in codeSystem '2.16.840.1.113883.6.96') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Dreigende partus immaturus? | | |colspan="3"|Dreigende partus immaturus? |
| Regel 3.493: |
Regel 640: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Abruptio placentae? | | |colspan="3"|Abruptio placentae? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Ja - Nee |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Navelstrengprolaps? | | |colspan="3"|Navelstrengprolaps? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Nee |
| | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| | |colspan="3"|Liggingsafwijking |
| | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Intrauteriene vruchtdood | | |colspan="4"|Intrauteriene vruchtdood |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="2"| | | |rowspan="3"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Vermoeden intrauteriene vruchtdood? | | |colspan="2"|Vermoeden intrauteriene vruchtdood? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Nee |
| | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| | |colspan="2"|Vermoeden iuvd op basis van |
| | |style="background-color: white;"| |
| | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| | |colspan="4"|Intrauteriene behandeling |
| | |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="4"|Maternale sterfte? | | |colspan="4"|Maternale sterfte? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Nee - Ja |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Wijze einde zwangerschap | | |colspan="4"|Wijze einde zwangerschap |
| |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') | | |style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') |
| |}<section end=zwangerschap_100202020 /> | | |}<section end=zwangerschap_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 /> |
| === Bevalling === | | === Bevalling === |
| <section begin=bevalling_100202020 /> | | <section begin=bevalling_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 /> |
| {| class="wikitable" width="85%" | | {| class="wikitable" width="85%" |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Bevalling | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Bevalling |
| Regel 3.521: |
Regel 677: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Partusnummer | | |colspan="4"|Partusnummer |
| |style="background-color: white;"|4567890123 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.7) | | |style="background-color: white;"|000000 - 4567890123 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.7) |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Diagnose bevalling | | |colspan="5"|Diagnose bevalling |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="12"| | | |rowspan="13"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Pprom? | | |colspan="3"|Pprom? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Ja - Nee |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Prom? | | |colspan="3"|Prom? |
| Regel 3.537: |
Regel 693: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Niet vorderende ontsluiting? | | |colspan="3"|Niet vorderende ontsluiting? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Ja - Nee |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Niet vorderende uitdrijving? | | |colspan="3"|Niet vorderende uitdrijving? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Ja - Nee |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Verdenking foetale nood? | | |colspan="3"|Verdenking foetale nood? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Ja - Nee |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Intrauteriene vruchtdood | | |colspan="4"|Intrauteriene vruchtdood |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="2"| | | |rowspan="3"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Vermoeden intrauteriene vruchtdood? | | |colspan="2"|Vermoeden intrauteriene vruchtdood? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Nee |
| | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| | |colspan="2"|Vermoeden iuvd op basis van |
| | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Vastzittende placenta? | | |colspan="3"|Vastzittende placenta? |
| Regel 3.559: |
Regel 718: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Aantal geboren kinderen | | |colspan="4"|Aantal geboren kinderen |
| |style="background-color: white;"|1 | | |style="background-color: white;"|1 - 2 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Risicostatus voor baring | | |colspan="4"|Risicostatus voor baring |
| |style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') | | |style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') - 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Interventies begin baring | | |colspan="5"|Interventies begin baring |
| Regel 3.569: |
Regel 728: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Interventie begin baring | | |colspan="3"|Interventie begin baring |
| |style="background-color: white;"|Primen prostaglandine (code = '236966000' in codeSystem 'Snomed CT') | | |style="background-color: white;"|Strippen (code = '236960006' in codeSystem 'Snomed CT') - Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96') - Primen prostaglandine (code = '236966000' in codeSystem 'Snomed CT') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Indicatie interventie begin baring | | |colspan="3"|Indicatie interventie begin baring |
| |style="background-color: white;"|niet levensbedreigend (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') | | |style="background-color: white;"|wens patiënt (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') - acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') - niet levensbedreigend (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Wijze waarop de baring begon | | |colspan="4"|Wijze waarop de baring begon |
| |style="background-color: white;"|Spontane weeën (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') | | |style="background-color: white;"|Interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') - spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') - Spontane weeën (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Tijdstip begin actieve ontsluiting | | |colspan="4"|Tijdstip begin actieve ontsluiting |
| |style="background-color: white;"|15 oct 2019 03:45 | | |style="background-color: white;"|8 okt 2014 14:30 - 30 aug 2014 14:09 - 27 aug 2014 22:09 - 3 aug 2014 21:09 - 15 okt 2019 03:45 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Medicatie nageboortetijdperk groep | | |colspan="5"|Medicatie nageboortetijdperk groep |
| Regel 3.585: |
Regel 744: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Medicatie nageboortetijdperk? | | |colspan="3"|Medicatie nageboortetijdperk? |
| |style="background-color: white;"|Ja | | |style="background-color: white;"|Ja - UNK - Nee |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Soort medicatie nageboortetijdperk | | |colspan="3"|Soort medicatie nageboortetijdperk |
| |style="background-color: white;"|Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') | | |style="background-color: white;"|Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') - Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73') |
| | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| | |colspan="5"|Placenta |
| | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| | |rowspan="2"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Placenta - geboorte placenta | | |colspan="3"|Geboorte placenta |
| |style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') | | |style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Hoeveelheid bloedverlies | | |colspan="4"|Hoeveelheid bloedverlies |
| |style="background-color: white;"|650 ml | | |style="background-color: white;"|615 ml - 980 ml - 1740 ml - 1120 ml - 1500 ml - 650 ml |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Conditie perineum postpartum | | |colspan="4"|Conditie perineum postpartum |
| |style="background-color: white;"|1e graads perineumruptuur (code = '199916005' in codeSystem 'Snomed CT') | | |style="background-color: white;"|1e graads perineumruptuur (code = '199916005' in codeSystem 'Snomed CT') - Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') - Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96') - Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96') |
| |}<section end=bevalling_100202020 /> | | |}<section end=bevalling_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 /> |
| === Uitkomst per kind === | | === Uitkomst per kind === |
| <section begin=uitkomst_per_kind_100202020 /> | | <section begin=uitkomst_per_kind_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 /> |
| {| class="wikitable" width="85%" | | {| class="wikitable" width="85%" |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="8" | Uitkomst per kind |
| Regel 3.610: |
Regel 773: |
| |colspan="8"|Baring | | |colspan="8"|Baring |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="67"| | | |rowspan="79"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="6"|Werkelijke plaats baring type locatie | | |colspan="6"|Werkelijke plaats baring type locatie |
| |style="background-color: white;"|Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') | | |style="background-color: white;"|Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="7"|Ziekenhuis baring | | |colspan="7"|Ziekenhuis baring |
| Regel 3.620: |
Regel 783: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Ziekenhuisnummer lvrid | | |colspan="5"|Ziekenhuisnummer lvrid |
| |style="background-color: white;"|0803 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | | |style="background-color: white;"|0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0803 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="7"|Demografische gegevens | | |colspan="7"|Demografische gegevens |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="10"| | | |rowspan="12"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="6"|Identificaties kind | | |colspan="6"|Identificaties kind |
| Regel 3.631: |
Regel 794: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Bsn kind | | |colspan="4"|Bsn kind |
| |style="background-color: white;"|847035116 | | |style="background-color: white;"|999910383 - 951847624 - 847035116 - 847035128 - 840736526 - 528741913 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Geslacht medische observatie | | |colspan="5"|Geslacht medische observatie |
| |style="background-color: white;"|mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21') | | |style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') - mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21') - twijfelachtig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.21') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Geboortedatum | | |colspan="5"|Geboortedatum |
| |style="background-color: white;"|15 oct 2019 | | |style="background-color: white;"|8 okt 2014 00:00 - 1 sep 2014 02:34 - 28 aug 2014 06:30 - 28 aug 2014 07:02 - 4 aug 2014 23:35 - 24 jul 2014 02:30 - 15 okt 2019 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Rangnummer kind | | |colspan="5"|Rangnummer kind |
| |style="background-color: white;"|1 | | |style="background-color: white;"|1 - 2 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="6"|Perinatale sterfte groep | | |colspan="6"|Perinatale sterfte groep |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="2"| | | |rowspan="4"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Perinatale sterfte? | | |colspan="4"|Perinatale sterfte? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Nee - 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;"|28 aug 2014 08:10 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="7"|Kindspecifieke maternale gegevens | | |colspan="7"|Kindspecifieke maternale gegevens |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="20"| | | |rowspan="21"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Bijstimulatie toegediend? | | |colspan="5"|Bijstimulatie toegediend? |
| Regel 3.657: |
Regel 826: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Tijdstip breken vliezen | | |colspan="5"|Tijdstip breken vliezen |
| |style="background-color: white;"|19 oct 2019 04:30 | | |style="background-color: white;"|8 okt 2014 09:15 - 30 aug 2014 23:04 - 27 aug 2014 22:09 - 27 aug 2014 23:13 - 3 aug 2014 07:04 - 19 okt 2019 04:30 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Kleur en consistentie vruchtwater | | |colspan="5"|Kleur en consistentie vruchtwater |
| |style="background-color: white;"|Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') | | |style="background-color: white;"|Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') - geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') - bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18') - meconium (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.18') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Tijdstip actief meepersen | | |colspan="5"|Tijdstip actief meepersen |
| |style="background-color: white;"|19 oct 2019 05:00 | | |style="background-color: white;"|8 okt 2014 12:13 - 27 aug 2014 23:49 - 28 aug 2014 06:45 - 4 aug 2014 22:15 - 19 okt 2019 05:00 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Episiotomie? | | |colspan="5"|Episiotomie? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Nee - Ja |
| | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| | |colspan="5"|Indicatie episiotomie |
| | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Locatie episiotomie | | |colspan="5"|Locatie episiotomie |
| Regel 3.672: |
Regel 844: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Ruggeprik gewenst niet gekregen? | | |colspan="5"|Ruggeprik gewenst niet gekregen? |
| |style="background-color: white;"|Ja | | |style="background-color: white;"|Nee - Ja |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Pijnbestrijding? | | |colspan="5"|Pijnbestrijding? |
| |style="background-color: white;"|Ja | | |style="background-color: white;"|Nee - Ja |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="6"|Pijnbestrijding | | |colspan="6"|Pijnbestrijding |
| Regel 3.686: |
Regel 858: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Methode | | |colspan="3"|Methode |
| |style="background-color: white;"|Overig middel (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') | | |style="background-color: white;"|Epidural anesthesia (procedure) (code = '18946005' in codeSystem '2.16.840.1.113883.6.96') - Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - General anesthesia (procedure) (code = '50697003' in codeSystem '2.16.840.1.113883.6.96') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Overig middel | | |colspan="4"|Overig middel |
| Regel 3.693: |
Regel 865: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Middel | | |colspan="2"|Middel |
| |style="background-color: white;"|Entonox (code = '426060003' in codeSystem 'Snomed CT') | | |style="background-color: white;"|Administration of morphinomimetic analgesic (procedure) (code = '52685006:363701004=404642006' in codeSystem '2.16.840.1.113883.6.96') - Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Toediening | | |colspan="2"|Toediening |
| |style="background-color: white;"|Inhalatie (code = '241717009' in codeSystem 'Snomed CT') | | |style="background-color: white;"|Administration of substance via intravenous route (procedure) (code = '431215000' in codeSystem '2.16.840.1.113883.6.96') - Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Periode | | |colspan="4"|Periode |
| |style="background-color: white;"|tijdens ontsluitingsperiode > 3 cm (code = 'OntMt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') | | |style="background-color: white;"|tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - tijdens ontsluitingsperiode > 3 cm (code = 'OntMt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Sedatie? | | |colspan="5"|Sedatie? |
| |style="background-color: white;"|Ja | | |style="background-color: white;"|Nee - Ja |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="7"|Kindspecifieke uitkomstgegevens | | |colspan="7"|Kindspecifieke uitkomstgegevens |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="29"| | | |rowspan="38"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Type partus | | |colspan="5"|Type partus |
| |style="background-color: white;"|Spontaan (code = '177184002' in codeSystem '2.16.840.1.113883.6.96') | | |style="background-color: white;"|Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT') - Cesarean section (procedure) (code = '11466000' in codeSystem 'SNOMED CT') - Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') - Emergency cesarian section (procedure) (code = '274130007' in codeSystem 'SNOMED CT') - Spontaan (code = '177184002' in codeSystem '2.16.840.1.113883.6.96') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Ligging bij geboorte | | |colspan="5"|Ligging bij geboorte |
| |style="background-color: white;"|Achterhoofd-voor (code = '70028003' in codeSystem 'Snomed CT') | | |style="background-color: white;"|Achterhoofd-achter (code = '37235006' in codeSystem 'Snomed CT') - Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') - Face presentation (finding) (code = '21882006' in codeSystem '2.16.840.1.113883.6.96') - Complete breech presentation (finding) (code = '49168004' in codeSystem '2.16.840.1.113883.6.96') - Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') - Onbekend (code = 'UNK' in codeSystem '2.16.840.1.113883.5.1008') - Achterhoofd-voor (code = '70028003' in codeSystem 'Snomed CT') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Aanpakker kind - rol aanpakker kind | | |colspan="5"|Aanpakker kind - rol aanpakker kind |
| |style="background-color: white;"|klinisch verloskundige (code = '25' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') | | |style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - klinisch verloskundige (code = '25' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Supervisor - rol supervisor | | |colspan="5"|Supervisor - rol supervisor |
| |style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') | | |style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="6"|Vaginale kunstverlossing groep | | |colspan="6"|Vaginale kunstverlossing groep |
| Regel 3.725: |
Regel 897: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Vaginale kunstverlossing | | |colspan="4"|Vaginale kunstverlossing |
| |style="background-color: white;"|Vacuüm (code = '61586001' in codeSystem 'Snomed CT') | | |style="background-color: white;"|Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') - Total breech extraction (procedure) (code = '416055001' in codeSystem '2.16.840.1.113883.6.96') - Delivery by vacuum extraction (procedure) (code = '61586001' in codeSystem '2.16.840.1.113883.6.96') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Succes vaginale kunstverlossing? | | |colspan="4"|Succes vaginale kunstverlossing? |
| |style="background-color: white;"|Ja | | |style="background-color: white;"|Ja - Nee |
| | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| | |colspan="6"|Sectio caesarea group |
| | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| | |rowspan="4"| |
| | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| | |colspan="4"|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="4"|Indicatie primaire sectio |
| | |style="background-color: white;"|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') |
| | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| | |colspan="4"|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"|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;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="6"|Lichamelijk onderzoek kind | | |colspan="6"|Lichamelijk onderzoek kind |
| Regel 3.738: |
Regel 926: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Geboortegewicht | | |colspan="4"|Geboortegewicht |
| |style="background-color: white;"|3550 gram | | |style="background-color: white;"|3450 gram - 3620 gram - 2040 gram - 1580 gram - 4205 gram - 3750 gram - 3550 gram |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Congenitale afwijkingen? | | |colspan="5"|Congenitale afwijkingen? |
| |style="background-color: white;"|Ja | | |style="background-color: white;"|Nee - Ja |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="6"|Congenitale afwijkingen groep | | |colspan="6"|Congenitale afwijkingen groep |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |rowspan="5"| | | |rowspan="8"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Specificatie congenitale afwijking groep | | |colspan="5"|Specificatie congenitale afwijking groep |
| Regel 3.752: |
Regel 940: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Specificatie congenitale afwijking | | |colspan="3"|Specificatie congenitale afwijking |
| |style="background-color: white;"|overige congenitale huidafwijking (code = '74' in codeSystem '2.16.840.1.113883.2.4.4.13.8') | | |style="background-color: white;"|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') - overige congenitale huidafwijking (code = '74' in codeSystem '2.16.840.1.113883.2.4.4.13.8') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Chromosomale afwijkingen? | | |colspan="4"|Chromosomale afwijkingen? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Nee - Ja |
| | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| | |colspan="5"|Specificatie chromosomale afwijking groep |
| | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| | |rowspan="2"| |
| | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| | |colspan="3"|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;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Problematiek kind? | | |colspan="5"|Problematiek kind? |
| |style="background-color: white;"|Ja | | |style="background-color: white;"|Nee - Ja |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Problematiek kind | | |colspan="5"|Problematiek kind |
| |style="background-color: white;"|Geboortetrauma (code = '56110009' in codeSystem 'Snomed CT') | | |style="background-color: white;"|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') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Kinderarts betrokken? | | |colspan="5"|Kinderarts betrokken? |
| |style="background-color: white;"|Ja | | |style="background-color: white;"|Nee - Ja |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="6"|Betrokkenheid kinderarts | | |colspan="6"|Betrokkenheid kinderarts |
| Regel 3.771: |
Regel 966: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Datum betrokkenheid | | |colspan="4"|Datum betrokkenheid |
| |style="background-color: white;"|15 oct 2019 00:00 | | |style="background-color: white;"|1 sep 2014 00:00 - 28 aug 2014 00:00 - 4 aug 2014 00:00 - 15 okt 2019 00:00 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Reden betrokkenheid | | |colspan="4"|Reden betrokkenheid |
| |style="background-color: white;"|kunstverlossing (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') | | |style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') - Finding of neonatal condition (finding) (code = '364737004' in codeSystem '2.16.840.1.113883.6.96') - kunstverlossing (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Type betrokkenheid | | |colspan="4"|Type betrokkenheid |
| |style="background-color: white;"|Consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') | | |style="background-color: white;"|consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') - overdracht (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.17') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Zorginstelling lvrid | | |colspan="4"|Zorginstelling lvrid |
| |style="background-color: white;"|0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) | | |style="background-color: white;"|0003 - 9999 - 0001 - 0010 - 0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) |
| |}<section end=uitkomst_per_kind_100202020 /> | | |}<section end=uitkomst_per_kind_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 /> |
| === Medisch onderzoek === | | === Medisch onderzoek === |
| <section begin=medisch_onderzoek_100202020 /> | | <section begin=medisch_onderzoek_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 /> |
| {| class="wikitable" width="85%" | | {| class="wikitable" width="85%" |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Medisch onderzoek |
| Regel 3.793: |
Regel 988: |
| |colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE | | |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"| | | |rowspan="3"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Irregulaire antistoffen? | | |colspan="2"|Irregulaire antistoffen? |
| |style="background-color: white;"|Nee | | |style="background-color: white;"|Nee - Ja |
| |}<section end=medisch_onderzoek_100202020 /> | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| | |colspan="2"|Welke irregulaire antistoffen vrouw aanwezig |
| | |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 - 100202020 /> |
| === Postnatale fase === | | === Postnatale fase === |
| <section begin=postnatale_fase_100202020 /> | | <section begin=postnatale_fase_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 /> |
| {| class="wikitable" width="85%" | | {| class="wikitable" width="85%" |
| |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase | | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Postnatale fase |
| Regel 3.806: |
Regel 1.004: |
| || 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;"|3 sep 2014 00:00 - 8 aug 2014 00:00 - 24 jul 2014 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') - 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') |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="5"|Kindspecifieke gegevens | | |colspan="5"|Kindspecifieke gegevens |
| Regel 3.812: |
Regel 1.020: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="3"|Rangnummer kind | | |colspan="3"|Rangnummer kind |
| |style="background-color: white;"|1 | | |style="background-color: white;"| |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="4"|Voeding kind groep | | |colspan="4"|Voeding kind groep |
| Regel 3.819: |
Regel 1.027: |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Voeding kind datum | | |colspan="2"|Voeding kind datum |
| |style="background-color: white;"|15 oct 2019 | | |style="background-color: white;"|12 okt 2014 - 7 okt 2014 - 3 sep 2014 - 15 sep 2014 - 24 jul 2014 - 15 okt 2019 |
| |-style="vertical-align:top; background-color: #E3E3E3;;" | | |-style="vertical-align:top; background-color: #E3E3E3;;" |
| |colspan="2"|Substantie voeding kind | | |colspan="2"|Substantie voeding kind |
| |style="background-color: white;"|borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') | | |style="background-color: white;"|borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') - kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') |
| |}<section end=postnatale_fase_100202020 /> | | |}<section end=postnatale_fase_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 /> |
| [[Categorie:Kwalificatie]] | | [[Categorie:Kwalificatie]] |