mp:Vdraft Sandbox: verschil tussen versies
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− | + | <noinclude> | |
+ | {{DISPLAYTITLE:Kernset Neonatologie 3.0 - inhoud kwalificatie}} | ||
__NUMBEREDHEADINGS__ | __NUMBEREDHEADINGS__ | ||
− | |||
− | =Addenda voor inhoudelijke gegevens= | + | =Addenda voor inhoudelijke gegevens Kernset Neonatologie 3.0=</noinclude> |
− | < | + | ==Scenario Testscenario 1: uitgebreide problematiek == |
− | ==Scenario | + | |
+ | === Documentgegevens === | ||
− | === | + | {| class="wikitable" width="85%" |
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Documentgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Identificatie | ||
+ | |style="background-color: white;"|0000 (in identificerend systeem: abc123) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Document datum | ||
+ | |style="background-color: white;"|T - 1 dag | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Set identificatie | ||
+ | |style="background-color: white;"|0000 (in identificerend systeem: abc123) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Versienummer | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Software naam | ||
+ | |style="background-color: white;"|InformatieSysteemX | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Verificatie zorgverlener | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Geverifieerd door zorgverlener? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Verificatie datum | ||
+ | |style="background-color: white;"|T - 0 dagen | ||
+ | |} | ||
+ | === Zorgaanbieder === | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgaanbieder |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="2" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Zorgaanbieder identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) |
− | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
− | |colspan=" | + | |colspan="2"|Zorgaanbieder identificatienummer |
+ | |style="background-color: white;"|0000 (in identificerend systeem: AGB-Z) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Zorgaanbieder identificatienummer |
− | |-style=" | + | |style="background-color: white;"|0000 (in identificerend systeem: URA) |
− | |colspan=" | + | |} |
+ | === Zorgverlener === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zorgverlener | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Zorgverlener identificatienummer |
+ | |style="background-color: white;"|0000 (in identificerend systeem: 2.16.528.1.1007.5.1) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Naamgegevens | |colspan="5"|Naamgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="12"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Voornamen | |colspan="3"|Voornamen | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Hans Peter |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Initialen | |colspan="3"|Initialen | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|HP |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Roepnaam | ||
+ | |style="background-color: white;"|Hans | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Naamgebruik | ||
+ | |style="background-color: white;"|Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geslachtsnaam | |colspan="4"|Geslachtsnaam | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Voorvoegsels | ||
+ | |style="background-color: white;"|van den | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Achternaam | ||
+ | |style="background-color: white;"|Akker | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslachtsnaam partner | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"|Achternaam | + | |colspan="2"|Achternaam partner |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Pieterse |
+ | |} | ||
+ | === Vrouw === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Vrouw | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Patient | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Identificatienummer | ||
+ | |style="background-color: white;"|000000000 (in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Geboortedatum | ||
+ | |style="background-color: white;"|T - 27 jaar | ||
+ | |} | ||
+ | === Zwangerschapsgegevens === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zwangerschapsgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Graviditeit | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Pariteit voor deze zwangerschap | ||
+ | |style="background-color: white;"|0 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Complicaties tijdens zwangerschap | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Complicaties zwangerschap? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem naam | ||
+ | |style="background-color: white;"|koorts (code = '386661006' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Verificatie status | ||
+ | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Magnesiumsulfaat | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Antenatale steroiden gegeven? |
+ | |style="background-color: white;"|Nee | ||
+ | |} | ||
+ | === Kind === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Kind | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="6" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Demografische gegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="14"| |
− | |style="background-color: | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="6"|Patient | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="12"| |
− | |style="background-color: | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="5"|Adresgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="4"| |
− | |style="background-color: | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="4"|Adresgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Postcode |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1234 AB |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Identificatienummer | |colspan="4"|Identificatienummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geboortedatum | |colspan="4"|Geboortedatum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 90 dagen om 12:13 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geslacht | |colspan="4"|Geslacht | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Meerling indicator | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Rangnummer kind | ||
+ | |style="background-color: white;"|2 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Overlijdens indicator | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Bevallingsgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|179 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Aantal geboren kinderen | ||
+ | |style="background-color: white;"|2 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Type partus | ||
+ | |style="background-color: white;"|Primair (code = '177141003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Locatie partus | ||
+ | |style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Zorgaanbieder | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorgaanbieder identificatienummer | ||
+ | |style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Organisatie naam | ||
+ | |style="background-color: white;"|UMC Papendorp | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Ondersteuning opvang |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="7"| | |rowspan="7"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="6"|Verrichting |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Verrichting type | ||
+ | |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Verrichting | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Verrichting type | ||
+ | |style="background-color: white;"|endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Opname gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="37"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Opname | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Opname datum | ||
+ | |style="background-color: white;"|T - 90 dagen om 13:30 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ic opname? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Heropname? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Herkomst kind | ||
+ | |style="background-color: white;"|In-hospital admission from obstetrical ward (procedure) (code = '59151000146103' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Opname indicatie | ||
+ | |style="background-color: white;"|Finding of length of gestation (finding) (code = '366323009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ontslag datum | ||
+ | |style="background-color: white;"|T - 31 dagen om 12 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Onderzoek | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="27"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Lichaamslengte | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Lengte waarde | ||
+ | |style="background-color: white;"|31 cm | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Lengte datum tijd | ||
+ | |style="background-color: white;"|T - 90 dagen om 13:20 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Lichaamsgewicht | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Gewicht waarde | ||
+ | |style="background-color: white;"|710 g | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Gewicht datum tijd | ||
+ | |style="background-color: white;"|T - 90 dagen om 13:21 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Lichaamstemperatuur | ||
|-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;;" | ||
+ | |colspan="3"|Temperatuur waarde | ||
+ | |style="background-color: white;"|37.4 graden celsius | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Temperatuur datum tijd | ||
+ | |style="background-color: white;"|T - 90 dagen om 13:22 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Toelichting | ||
+ | |style="background-color: white;"|abc | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Temperatuur type | ||
+ | |style="background-color: white;"|Rectale temperatuur (code = '307047009' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Schedelomvang |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="3"|Schedelomvang waarde |
− | |style="background-color: white;"|T + | + | |style="background-color: white;"|22.5 cm |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Schedelomvang datum tijd | ||
+ | |style="background-color: white;"|T - 90 dagen om 13:23 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Apgar score na 1 min | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Apgar score totaal | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Apgar score na 5 min | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Apgar score totaal | ||
+ | |style="background-color: white;"|5 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Nsp h arterieel | ||
+ | |style="background-color: white;"|7.05 ph | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Be | ||
+ | |style="background-color: white;"|-12.0 mmol/l | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Problematiek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="100"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Geboortetrauma | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Ademhalingsondersteuning | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="13"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ademhalingsondersteuning? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting start datum | ||
+ | |style="background-color: white;"|T - 90 dagen om 13:35 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting eind datum | ||
+ | |style="background-color: white;"|T - 33 dagen om 12 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|Oxygen therapy using high flow oxygen nasal cannula (procedure) (code = '57485005:424226004=426854004' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting start datum | ||
+ | |style="background-color: white;"|T - 33 dagen om 12 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting eind datum | ||
+ | |style="background-color: white;"|T - 31 dagen om 10 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|O2 op dag 28? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Respiratoir | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="14"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem naam | ||
+ | |style="background-color: white;"|Respiratory distress syndrome in the newborn (disorder) (code = '46775006' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verificatie status | ||
+ | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Aanvang | ||
+ | |style="background-color: white;"|Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Medicatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Stimulatie ademhaling | ||
+ | |style="background-color: white;"|COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Surfactant | ||
+ | |style="background-color: white;"|NATUURLIJKE FOSFOLIPIDEN - LONGSURFACTANTS (code = 'R07AA02' in codeSystem 'ATC-NL') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Medicatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Stimulatie ademhaling | ||
+ | |style="background-color: white;"|DOXAPRAM (code = 'R07AB01' in codeSystem 'ATC-NL') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Circulatoir | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem naam | ||
+ | |style="background-color: white;"|Patent ductus arteriosus (disorder) (code = '83330001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verificatie status | ||
+ | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|Drug therapy for patent ductus arteriosus (procedure) (code = '58801000146104' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Infectieus | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="13"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem naam | ||
+ | |style="background-color: white;"|Suspected sepsis (situation) (code = '9331000146100' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem begin datum | ||
+ | |style="background-color: white;"|T - 89 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem eind datum | ||
+ | |style="background-color: white;"|T - 86 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verificatie status | ||
+ | |style="background-color: white;"|Werk (code = '415684004' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Aanvang | ||
+ | |style="background-color: white;"|Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Microorganisme sepsis meningitis | ||
+ | |style="background-color: white;"|Other, specify (code = 'OTH' in codeSystem 'HL7 NullFlavor'): abc | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Lijnsepsis? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Onset | ||
+ | |style="background-color: white;"|vroege neonatale periode (kwalificatiewaarde) (code = '303114002' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Antibiotica eerste 3 dagen? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Gastrointestinaal | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Hematologisch | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|Transfusion for anemia (procedure) (code = '59071000146107' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Metabool en endocrien | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|<span id="hyperbilirubemie" title="Intern ID = hyperbilirubemie">Probleem hyperbilirubemie</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem naam | ||
+ | |style="background-color: white;"|hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verificatie status | ||
+ | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Indicatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem | ||
+ | |style="background-color: white;"|Zie [[#hyperbilirubemie|Probleem: hyperbilirubemie]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Neurologisch | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Zintuigen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="11"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem naam | ||
+ | |style="background-color: white;"|Retinopathy of prematurity stage 2 - intraretinal ridge (disorder) (code = '408848001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verificatie status | ||
+ | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Rop screening verricht? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Rop screening afgesloten? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Aabr verricht? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Aabr afwijkend? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Bera verricht? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Congenitale aandoeningen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Ontslagoverplaatsing | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="15"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Nog opgenomen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Bestemming kind | ||
+ | |style="background-color: white;"|Discharge to other hospital (procedure) (code = '115851000146108' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Lichamelijk onderzoek | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Lichaamsgewicht | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Gewicht waarde | ||
+ | |style="background-color: white;"|1740 gram | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Gewicht datum tijd | ||
+ | |style="background-color: white;"|T - 31 dagen om 09 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Schedelomvang | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Schedelomvang meetmethode | ||
+ | |style="background-color: white;"|Meten van schedelomvang m.b.v. meetlint (code = '31551000146109' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Schedelomvang waarde | ||
+ | |style="background-color: white;"|30 cm | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Schedelomvang datum tijd | ||
+ | |style="background-color: white;"|T - 31 dagen om 09:01 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Voeding kind | ||
+ | |style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Mortaliteit | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Overlijden lt12 uur na opname nicu? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Overleden op verloskamer? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Staken icbehandeling? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Follow up | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Na ontslag | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|O2 op dag 28? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Gradatie bpd | ||
+ | |style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zintuigen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|NullFlavor: UNK | ||
+ | |} | ||
+ | ==Scenario Testscenario 2: geb.trauma + neurologisch + anat afw + overlijden == | ||
+ | |||
+ | === Documentgegevens === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Documentgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Identificatie | ||
+ | |style="background-color: white;"|0000 (in identificerend systeem: abc123) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Document datum | ||
+ | |style="background-color: white;"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Set identificatie | ||
+ | |style="background-color: white;"|0000 (in identificerend systeem: abc123) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Versienummer | ||
+ | |style="background-color: white;"|2 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Software naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|XIS |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Verificatie zorgverlener |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Geverifieerd door zorgverlener? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Verificatie datum |
+ | |style="background-color: white;"| | ||
+ | |} | ||
+ | === Zorgaanbieder === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgaanbieder | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgaanbieder identificatienummer | ||
+ | |style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) | ||
+ | |} | ||
+ | === Zorgverlener === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zorgverlener | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorgverlener identificatienummer | ||
+ | |style="background-color: white;"|0000 (in identificerend systeem: UZI Personen) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Naamgegevens | |colspan="5"|Naamgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="8"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Voornamen | |colspan="3"|Voornamen | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Hans Paul |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Initialen | |colspan="3"|Initialen | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|H.P. |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Roepnaam | |colspan="3"|Roepnaam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Hans |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Naamgebruik | ||
+ | |style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geslachtsnaam | |colspan="4"|Geslachtsnaam | ||
Regel 112: | Regel 756: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Achternaam | |colspan="2"|Achternaam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Pieterse |
+ | |} | ||
+ | === Vrouw === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Vrouw | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Patient | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Identificatienummer | ||
+ | |style="background-color: white;"|(in identificerend systeem: BSN) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Geboortedatum | ||
+ | |style="background-color: white;"|T - 26 jaar | ||
+ | |} | ||
+ | === Zwangerschapsgegevens === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zwangerschapsgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Graviditeit | ||
+ | |style="background-color: white;"|3 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Pariteit voor deze zwangerschap | ||
+ | |style="background-color: white;"|2 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Complicaties tijdens zwangerschap | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Complicaties zwangerschap? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem naam | ||
+ | |style="background-color: white;"|hypertensieve aandoening (aandoening) (code = '38341003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Verificatie status | ||
+ | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Magnesiumsulfaat | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Antenatale steroiden gegeven? | ||
+ | |style="background-color: white;"|NullFlavor: NA | ||
+ | |} | ||
+ | === Kind === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Kind | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="6" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Patient |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="7"| | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Identificatienummer | ||
+ | |style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortedatum | ||
+ | |style="background-color: white;"|T - 10 dagen om 10:44 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslacht | ||
+ | |style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Meerling indicator | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Overlijdens indicator | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Datum overlijden | ||
+ | |style="background-color: white;"|T - 10 dagen om 21 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Bevallingsgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|254 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Aantal geboren kinderen | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Type partus | ||
+ | |style="background-color: white;"|Primair (code = '177141003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Locatie partus | ||
+ | |style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="6"|Zorgaanbieder |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorgaanbieder identificatienummer | ||
+ | |style="background-color: white;"|234 (in identificerend systeem: AGB-Z) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Organisatie naam | ||
+ | |style="background-color: white;"|UMC Papendorp | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Ondersteuning opvang | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Verrichting | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Opname gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="28"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="6"|Opname |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Opname datum | ||
+ | |style="background-color: white;"|T - 10 dagen om 11:15 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ic opname? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Heropname? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Herkomst kind | ||
+ | |style="background-color: white;"|In-hospital admission from obstetrical ward (procedure) (code = '59151000146103' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Opname indicatie | ||
+ | |style="background-color: white;"|Perinatal asphyxia (disorder) (code = '281578009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Opname indicatie | ||
+ | |style="background-color: white;"|Infant in poor condition at birth (finding) (code = '276707008' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Opname indicatie | ||
+ | |style="background-color: white;"|Congenital disease (disorder) (code = '66091009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ontslag datum | ||
+ | |style="background-color: white;"|T - 10 dagen om 21 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Onderzoek | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="16"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Lichaamsgewicht | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Gewicht waarde | ||
+ | |style="background-color: white;"|3870 g | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Gewicht datum tijd | ||
+ | |style="background-color: white;"|T - 10 dagen om 11:01 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Lichaamstemperatuur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Temperatuur waarde | ||
+ | |style="background-color: white;"|36.1 graden celsius | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Temperatuur datum tijd | ||
+ | |style="background-color: white;"|T - 10 dagen om 11:02 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Temperatuur type | ||
+ | |style="background-color: white;"|Rectale temperatuur (code = '307047009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Apgar score na 1 min | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Apgar score totaal |
− | |style="background-color: white;"| | + | |style="background-color: white;"|0 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Apgar score na 5 min | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |rowspan="2"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="3"|Apgar score totaal | ||
+ | |style="background-color: white;"|2 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="7"| | + | |colspan="7"|Problematiek kind |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="71"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Geboortetrauma |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="6"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Probleem | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="3"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Spinal cord injury due to birth trauma (disorder) (code = '698500002' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verificatie status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Ademhalingsondersteuning |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="7"| | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ademhalingsondersteuning? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="5"|Verrichting |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting start datum | ||
+ | |style="background-color: white;"|T - 10 dagen om 11:16 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|O2 op dag 28? | ||
+ | |style="background-color: white;"|NullFlavor: NA | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Respiratoir | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Circulatoir | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem naam | ||
+ | |style="background-color: white;"|Neonatal hypotension (disorder) (code = '276519002' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verificatie status | ||
+ | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Infectieus | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Gastrointestinaal | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Hematologisch |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Metabool en endocrien | ||
+ | |-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"| | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Neurologisch |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="20"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|<span id="neonatal_encephalopathy" title="Intern ID = neonatal_encephalopathy">Probleem neonatal_encephalopathy</span> | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem naam | ||
+ | |style="background-color: white;"|Neonatal encephalopathy (disorder) (code = '95628005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Ernst encefalopathie | ||
+ | |style="background-color: white;"|Ernstig (code = '24484000' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verificatie status | ||
+ | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem naam | ||
+ | |style="background-color: white;"|asfyxie bij geboorte (code = '413654009' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verificatie status | ||
+ | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem naam | ||
+ | |style="background-color: white;"|Intraventricular (nontraumatic) hemorrhage, grade 2, of fetus and newborn (disorder) (code = '206396002' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="4"|Indicatie |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem | ||
+ | |style="background-color: white;"|Zie [[#neonatal_encephalopathy|Probleem: neonatal_encephalopathy]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|echografische beeldvorming van hoofd (verrichting) (code = '241449005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Zintuigen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|NullFlavor: UNK | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Congenitale aandoeningen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Aangeboren anatomische afwijkingen majorsyndromen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem naam | ||
+ | |style="background-color: white;"|Overige congenitale afwijkingen zenuwstelsel (code = '09' in codeSystem '2.16.840.1.113883.2.4.4.13.8') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Verificatie status | ||
+ | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Ontslagoverplaatsing | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Nog opgenomen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Voeding kind | ||
+ | |style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Mortaliteit | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Overlijden lt12 uur na opname nicu? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Overleden op verloskamer? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Oorzaak overlijden | ||
+ | |style="background-color: white;"|multiorgaanfalen (aandoening) (code = '57653000' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Staken icbehandeling? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |} | ||
+ | ==Scenario Testscenario 3: stofwisselingsziekte == | ||
+ | |||
+ | === Documentgegevens === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Documentgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Identificatie | ||
+ | |style="background-color: white;"|0000 (in identificerend systeem: abc123) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Document datum | ||
+ | |style="background-color: white;"|T - 0 dagen om 17 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Set identificatie | ||
+ | |style="background-color: white;"|0000 (in identificerend systeem: abc123) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Versienummer | ||
+ | |style="background-color: white;"|3 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Software naam | ||
+ | |style="background-color: white;"|XIS | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Verificatie zorgverlener | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Geverifieerd door zorgverlener? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Verificatie datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
|} | |} | ||
− | === | + | === Zorgaanbieder === |
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgaanbieder |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="2" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgaanbieder identificatienummer | ||
+ | |style="background-color: white;"|0000 (in identificerend systeem: AGB-Z) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgaanbieder identificatienummer | ||
+ | |style="background-color: white;"|(in identificerend systeem: URA) | ||
+ | |} | ||
+ | === Zorgverlener === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zorgverlener | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zorgverlener identificatienummer | ||
+ | |style="background-color: white;"|0000 (in identificerend systeem: AGB-Z) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Naamgegevens |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Voornamen | ||
+ | |style="background-color: white;"|Hans Peter | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Initialen | ||
+ | |style="background-color: white;"|HP | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Roepnaam |
+ | |style="background-color: white;"|Hans | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Naamgebruik | ||
+ | |style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Geslachtsnaam |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Voorvoegsels |
− | |style="background-color: white;"| | + | |style="background-color: white;"|van de |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Achternaam | ||
+ | |style="background-color: white;"|Velde | ||
+ | |} | ||
+ | === Zwangerschapsgegevens === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschapsgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Graviditeit | ||
+ | |style="background-color: white;"|4 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="3"|Pariteit voor deze zwangerschap |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Complicaties tijdens zwangerschap | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Complicaties zwangerschap? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Antenatale steroiden gegeven? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Antenatale steroiden | ||
+ | |style="background-color: white;"|Complete steroid therapy for fetal lung maturation (procedure) (code = '255594003434601000124108' in codeSystem 'SNOMED CT') | ||
|} | |} | ||
− | === | + | === Kind === |
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Kind |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="6" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="7"|Demografische gegevens |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Patient | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |colspan="4"|Identificatienummer |
+ | |style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortedatum | ||
+ | |style="background-color: white;"|T - 76 dagen om 06:55 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslacht | ||
+ | |style="background-color: white;"|Ongedifferentieerd (code = 'UN' in codeSystem 'HL7 AdministrativeGender') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Overlijdens indicator | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Bevallingsgegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|215 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Aantal geboren kinderen | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Type partus | ||
+ | |style="background-color: white;"|Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Locatie partus | ||
+ | |style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Opname gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="29"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Opname | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Opname datum | ||
+ | |style="background-color: white;"|T - 0 dagen om 09:15 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ic opname? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Heropname? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Herkomst kind | ||
+ | |style="background-color: white;"|Hospital admission from home or birth center (procedure) (code = '59141000146101' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Opname indicatie | ||
+ | |style="background-color: white;"|Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): vaccinatie onder observatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ontslag datum | ||
+ | |style="background-color: white;"|T - 0 dagen om 16 uur | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Onderzoek |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="19"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Lichaamslengte | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="3"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Lengte waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|43 cm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Lengte datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 0 dagen om 09:30 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Lichaamsgewicht |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Gewicht waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1800 g |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Gewicht datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 0 dagen om 09:30 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Lichaamstemperatuur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Temperatuur waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|37.1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Temperatuur datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 0 dagen om 09:30 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Schedelomvang |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Schedelomvang waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|31 centimeter |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Schedelomvang datum tijd | ||
+ | |style="background-color: white;"|T - 0 dagen om 09:32 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Nsp h arterieel | ||
+ | |style="background-color: white;"|7.35 ph | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Be | ||
+ | |style="background-color: white;"|0.0 mmol/l | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Problematiek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Congenitale aandoeningen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Stofwisselingsziekten |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
Regel 278: | Regel 1.420: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Probleem naam | |colspan="2"|Probleem naam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|stoornis van mineraalstofwisseling (aandoening) (code = '45744005' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Verificatie status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Differentiaal (code = '410590009' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="7"|Ontslagoverplaatsing |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="5"|Nog opgenomen? |
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Bestemming kind | ||
+ | |style="background-color: white;"|Discharge to home (procedure) (code = '306689006' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Voeding kind | ||
+ | |style="background-color: white;"|moedermelk (substantie) (code = '226789007' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ondersteuning bij ontslag naar huis | ||
+ | |style="background-color: white;"|monitoren met cardiotachometer (regime/therapie) (code = '63818009' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Mortaliteit |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="4"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Overlijden lt12 uur na opname nicu? | ||
+ | |style="background-color: white;"|NullFlavor: NA | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Overleden op verloskamer? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Staken icbehandeling? | ||
+ | |style="background-color: white;"|NullFlavor: NA | ||
+ | |} | ||
+ | ==Scenario Testscenario 4: gastro + chirurgie == | ||
+ | |||
+ | === Documentgegevens === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Documentgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Identificatie | ||
+ | |style="background-color: white;"|0000 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Document datum | ||
+ | |style="background-color: white;"|T - 10 dagen om 10 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Set identificatie | ||
+ | |style="background-color: white;"|0000 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Versienummer | ||
+ | |style="background-color: white;"|1 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Software naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|InformatieSysteemX |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Verificatie zorgverlener |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Geverifieerd door zorgverlener? |
+ | |style="background-color: white;"|NullFlavor: NI | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Verificatie datum | ||
+ | |style="background-color: white;"| | ||
+ | |} | ||
+ | === Zorgaanbieder === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgaanbieder | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Zorgaanbieder identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) |
+ | |} | ||
+ | === Vrouw === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Vrouw | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Demografische gegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="5"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Patient |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|(in identificerend systeem: BSN) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Geboortedatum |
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
− | | | + | |} |
− | + | === Zwangerschapsgegevens === | |
− | |style="background-color: white;"| | + | |
− | |-style=" | + | {| class="wikitable" width="85%" |
− | |colspan="2"| | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zwangerschapsgegevens |
− | | | + | |-style="background-color: #1F497D;; color: white; text-align:left;" |
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Graviditeit |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Pariteit voor deze zwangerschap |
− | |style="background-color: white;"| | + | |style="background-color: white;"|0 |
|} | |} | ||
− | === | + | === Kind === |
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Kind |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan="6" width=" | + | |colspan="6" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="7"| | + | |colspan="7"|Demografische gegevens |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Patient | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Identificatienummer | ||
+ | |style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortedatum | ||
+ | |style="background-color: white;"|T - 87 dagen om 13 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslacht | ||
+ | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Meerling indicator | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Rangnummer kind |
+ | |style="background-color: white;"|2 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Overlijdens indicator | ||
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Bevallingsgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="5"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|236 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Aantal geboren kinderen | ||
+ | |style="background-color: white;"|2 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Type partus | ||
+ | |style="background-color: white;"|Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Locatie partus | ||
+ | |style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Ondersteuning opvang |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Verrichting | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Verrichting type | ||
+ | |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Opname gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="23"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Opname | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="11"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Opname datum | ||
+ | |style="background-color: white;"|T - 80 dagen om 09 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ic opname? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Heropname? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="4"|Herkomst kind |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Hospital admission, transfer from other hospital or health care facility (procedure) (code = '4563007' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zorgaanbieder | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Zorgaanbieder identificatienummer | ||
+ | |style="background-color: white;"|0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Organisatie naam | ||
+ | |style="background-color: white;"|AZ Papendorp | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Opname indicatie | ||
+ | |style="background-color: white;"|Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): abc | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ontslag datum | ||
+ | |style="background-color: white;"|T - 11 dagen om 16 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Onderzoek | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Lichaamslengte | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Lengte waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|43 cm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Lengte datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 80 dagen om 09:30 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Lichaamsgewicht |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Gewicht waarde | ||
+ | |style="background-color: white;"|1530 g | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Gewicht datum tijd | ||
+ | |style="background-color: white;"|T - 80 dagen om 09:30 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Problematiek kind | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="104"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Geboortetrauma |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Ademhalingsondersteuning | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="6"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ademhalingsondersteuning? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|O2 op dag 28? | ||
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Respiratoir |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="9"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-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"|Probleem naam | |colspan="3"|Probleem naam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Bronchopulmonary dysplasia of newborn (disorder) (code = '67569000' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Verificatie status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Medicatie |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Stimulatie ademhaling | ||
+ | |style="background-color: white;"|COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Circulatoir | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Neonatal hypotension (disorder) (code = '276519002' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Infectieus | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem naam | ||
+ | |style="background-color: white;"|neonatale sepsis (aandoening) (code = '206376005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Microorganisme sepsis meningitis | ||
+ | |style="background-color: white;"|Listeria monocytogenes (organism) (code = '36094007' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Lijnsepsis? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Onset | ||
+ | |style="background-color: white;"|late neonatale periode (kwalificatiewaarde) (code = '303115001' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Antibiotica eerste 3 dagen? | ||
+ | |style="background-color: white;"|NullFlavor: NA | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Infuus | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Infuuskatheter | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Medisch hulpmiddel | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Begin datum | ||
+ | |style="background-color: white;"|T - 80 dagen om 10 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Einddatum | ||
+ | |style="background-color: white;"|T - 17 dagen om 09 uur | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Gastrointestinaal |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="18"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|<span id=" | + | |colspan="5"|<span id="enterocolitis" title="Intern ID = enterocolitis">Probleem enterocolitis</span> |
|-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"|Probleem naam | |colspan="3"|Probleem naam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Necrotizing enterocolitis in fetus OR newborn - Bell stage IIIA (disorder) (code = '21941000146103' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Verificatie status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Verrichting |
|-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"|Indicatie | |colspan="4"|Indicatie | ||
Regel 432: | Regel 1.798: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Probleem | |colspan="2"|Probleem | ||
− | |style="background-color: white;"|Zie [[# | + | |style="background-color: white;"|Zie [[#enterocolitis|Probleem: enterocolitis]] |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|Laparotomy (procedure) (code = '86481000' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="5"| |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Indicatie | |colspan="4"|Indicatie | ||
Regel 446: | Regel 1.812: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Probleem | |colspan="2"|Probleem | ||
− | |style="background-color: white;"|Zie [[# | + | |style="background-color: white;"|Zie [[#enterocolitis|Probleem: enterocolitis]] |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Hematologisch | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="5"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting type |
+ | |style="background-color: white;"|Transfusion for anemia (procedure) (code = '59071000146107' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Metabool en endocrien | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="22"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
|style="background-color: white;"|Ja | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|<span id="hyperbilirubinemie" title="Intern ID = hyperbilirubinemie">Probleem hyperbilirubinemie</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem naam | ||
+ | |style="background-color: white;"|hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verificatie status | ||
+ | |style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"|<span id=" | + | |colspan="5"|<span id="hypoglycemia" title="Intern ID = hypoglycemia">Probleem hypoglycemia</span> |
|-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"|Probleem naam | |colspan="3"|Probleem naam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Hypoglycemia (disorder) (code = '302866003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Verificatie status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Differentiaal (code = '410590009' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Verrichting |
|-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;;" | ||
+ | |colspan="4"|Indicatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem | ||
+ | |style="background-color: white;"|Zie [[#hyperbilirubinemie|Probleem: hyperbilirubinemie]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Indicatie | |colspan="4"|Indicatie | ||
Regel 487: | Regel 1.881: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Probleem | |colspan="2"|Probleem | ||
− | |style="background-color: white;"|Zie [[# | + | |style="background-color: white;"|Zie [[#hypoglycemia|Probleem: hypoglycemia]] |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|Intravenous infusion of glucose in hypoglycemia (procedure) (code = '109091000146105' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Zintuigen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|NullFlavor: NI | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Congenitale aandoeningen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Chirurgische ingrepen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Verrichting | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Verrichting type | ||
+ | |style="background-color: white;"|Endoscopie van oesofagus (verrichting) (code = '49230008' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Ontslagoverplaatsing | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Nog opgenomen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Bestemming kind | ||
+ | |style="background-color: white;"|Discharge to other location within hospital premises (procedure) (code = '115841000146105' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Lichamelijk onderzoek | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Lichaamsgewicht | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Gewicht waarde | ||
+ | |style="background-color: white;"|2800 gram | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Gewicht datum tijd | ||
+ | |style="background-color: white;"|T - 11 dagen om 15 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Voeding kind | ||
+ | |style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Mortaliteit | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Overlijden lt12 uur na opname nicu? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Overleden op verloskamer? | ||
+ | |style="background-color: white;"|Nee | ||
|} | |} | ||
− | === | + | ==Scenario Testscenario 5: zintuigen + FU == |
+ | |||
+ | === Documentgegevens === | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Documentgegevens |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Identificatie | ||
+ | |style="background-color: white;"|0000 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Document datum | ||
+ | |style="background-color: white;"|T - 14 dagen om 10 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Set identificatie | ||
+ | |style="background-color: white;"|0000 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Versienummer | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Software naam | ||
+ | |style="background-color: white;"|InformatieSysteemX | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Verificatie zorgverlener |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Geverifieerd door zorgverlener? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Verificatie datum | ||
+ | |style="background-color: white;"|T - 14 dagen om 11 uur | ||
+ | |} | ||
+ | === Zorgaanbieder === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgaanbieder | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Zorgaanbieder identificatienummer | ||
+ | |style="background-color: white;"| | ||
+ | |} | ||
+ | === Zwangerschapsgegevens === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zwangerschapsgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Graviditeit | ||
+ | |style="background-color: white;"|5 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Pariteit voor deze zwangerschap | ||
+ | |style="background-color: white;"|4 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Complicaties tijdens zwangerschap |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="9"| | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Complicaties zwangerschap? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem naam | ||
+ | |style="background-color: white;"|preterm en prematuur gebroken vliezen (aandoening) (code = '312974005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Verificatie status | ||
+ | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Magnesiumsulfaat | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Antenatale steroiden gegeven? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Antenatale steroiden | ||
+ | |style="background-color: white;"|Complete steroid therapy for fetal lung maturation (procedure) (code = '255594003434601000124108' in codeSystem 'SNOMED CT') | ||
+ | |} | ||
+ | === Kind === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Kind | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="6" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="13"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Patient |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="11"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Adresgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="4"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Adresgegevens |
|-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"| | + | |colspan="2"|Postcode |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1234 AB |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="4"|Identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999) |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geboortedatum | ||
+ | |style="background-color: white;"|T - 179 dagen om 14 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslacht | ||
+ | |style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Meerling indicator | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Overlijdens indicator | ||
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="7"| | + | |colspan="7"|Bevallingsgegevens |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|177 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Type partus | ||
+ | |style="background-color: white;"|Sectio Caesarea (code = '11466000' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="5"|Locatie partus |
+ | |style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Ondersteuning opvang |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="7"| | |rowspan="7"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="2"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Verrichting type | ||
+ | |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Opname gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="33"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Opname | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Opname datum | ||
+ | |style="background-color: white;"|T - 179 dagen om 14:30 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ic opname? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Heropname? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Herkomst kind | ||
+ | |style="background-color: white;"|Hospital admission, transfer from other hospital or health care facility (procedure) (code = '4563007' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Opname indicatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Finding of length of gestation (finding) (code = '366323009' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Ontslag datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 44 dagen om 12 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Onderzoek |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="23"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Lichaamsgewicht |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Gewicht waarde | ||
+ | |style="background-color: white;"|710 g | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Gewicht datum tijd | ||
+ | |style="background-color: white;"|T - 179 dagen om 14:30 uur | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Lichaamstemperatuur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Temperatuur waarde | ||
+ | |style="background-color: white;"|36.7 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Temperatuur datum tijd | ||
+ | |style="background-color: white;"|T - 179 dagen om 14:35 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Toelichting | ||
+ | |style="background-color: white;"|geen bijzonderheden | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Temperatuur type | ||
+ | |style="background-color: white;"|Orale temperatuur (onder de tong) (code = '415945006' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Schedelomvang |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Schedelomvang waarde | ||
+ | |style="background-color: white;"|25.5 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Schedelomvang datum tijd | ||
+ | |style="background-color: white;"|T - 179 dagen om 14:35 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Apgar score na 1 min | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Apgar score totaal |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Apgar score na 5 min | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |rowspan="2"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="3"|Apgar score totaal | ||
+ | |style="background-color: white;"|4 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Nsp h arterieel | ||
+ | |style="background-color: white;"|7.21 ph | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Be | ||
+ | |style="background-color: white;"|-11 mmol/l | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Problematiek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="127"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Geboortetrauma | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Ademhalingsondersteuning | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="15"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ademhalingsondersteuning? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verrichting |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Verrichting type |
+ | |style="background-color: white;"|toedienen van zuurstof via neusbril (verrichting) (code = '371907003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verrichting |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Verrichting type |
+ | |style="background-color: white;"|Oxygen therapy using high flow oxygen nasal cannula (procedure) (code = '57485005:424226004=426854004' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Continuous positive airway pressure ventilation treatment (procedure) (code = '47545007' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Noninvasive ventilation (procedure) (code = '428311008' in codeSystem 'SNOMED CT') |
− | | | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
− | + | |colspan="4"|O2 op dag 28? | |
− | == | + | |style="background-color: white;"|Ja |
− | + | |-style="vertical-align:top; background-color: #E3E3E3;;" | |
− | === | + | |colspan="6"|Respiratoir |
− | + | |-style="vertical-align:top; background-color: #E3E3E3;;" | |
− | + | |rowspan="21"| | |
− | |style="background-color: # | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
− | |-style="background-color: # | + | |colspan="4"|Problemen aanwezig? |
− | |colspan=" | + | |style="background-color: white;"|Ja |
− | || | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
− | + | |colspan="5"|Probleem | |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem naam | ||
+ | |style="background-color: white;"|Respiratory distress syndrome in the newborn (disorder) (code = '46775006' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem begin datum | ||
+ | |style="background-color: white;"|T - 152 dagen om 08 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Aanvang | ||
+ | |style="background-color: white;"|Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Bronchopulmonary dysplasia of newborn - grade 3 (disorder) (code = '22041000146108' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="2"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|Extracorporeal membrane oxygenation (procedure) (code = '233573008' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Medicatie |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Stimulatie ademhaling | ||
+ | |style="background-color: white;"|COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Surfactant | ||
+ | |style="background-color: white;"|NATUURLIJKE FOSFOLIPIDEN - LONGSURFACTANTS (code = 'R07AA02' in codeSystem 'ATC-NL') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Systemische steroiden |
+ | |style="background-color: white;"|CORTICOSTEROIDEN VOOR SYSTEMISCH GEBRUIK - SYSTEMISCHE HORMOONPREPARATEN, EXCL GESLACHTSHORMONEN (code = 'H02' in codeSystem 'ATC-NL') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Medicatie |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Stimulatie ademhaling |
+ | |style="background-color: white;"|DOXAPRAM (code = 'R07AB01' in codeSystem 'ATC-NL') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Circulatoir | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="5"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Low blood pressure (disorder) (code = '45007003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Infectieus |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="15"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Problemen aanwezig? |
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Probleem | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="4"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|neonatale sepsis (aandoening) (code = '206376005' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Lijnsepsis? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Onset |
− | |style="background-color: white;"| | + | |style="background-color: white;"|vroege neonatale periode (kwalificatiewaarde) (code = '303114002' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Probleem | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="3"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|urineweginfectie (aandoening) (code = '68566005' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verificatie status | ||
+ | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Neonatal pneumonia (disorder) (code = '233619008' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Antibiotica eerste 3 dagen? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Infuus |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="7"| | |rowspan="7"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Infuuskatheter |
|-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"| | + | |colspan="4"|Medisch hulpmiddel |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Begin datum |
− | |style="background-color: white;"|T | + | |style="background-color: white;"|T - 179 dagen om 17 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Einddatum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 148 dagen om 08 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Gastrointestinaal |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="8"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Indicatie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem | ||
+ | |style="background-color: white;"|Zie [[#|: ]] | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Hematologisch | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|Treatment for trombocytopenia (procedure) (code = '59091000146106' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Metabool en endocrien | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="14"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Probleem naam |
+ | |style="background-color: white;"|hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Probleem |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="2"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Hypoglycemia (disorder) (code = '302866003' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Intravenous infusion of glucose in hypoglycemia (procedure) (code = '109091000146105' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Neurologisch |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="8"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming van hoofd (verrichting) (code = '241449005' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|'magnetic resonance imaging' van hoofd (verrichting) (code = '241601008' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Zintuigen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="15"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Probleem | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Probleem naam | ||
+ | |style="background-color: white;"|Plus disease (disorder) (code = '56341000146109' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verificatie status | ||
+ | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Rop screening verricht? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Rop screening afgesloten? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Aabr verricht? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Aabr afwijkend? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Bera verricht? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Bera | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Bera afwijkend? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Bera lateraliteit | ||
+ | |style="background-color: white;"|Links (code = '7771000' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Ontslagoverplaatsing | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="15"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Nog opgenomen? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Bestemming kind | ||
+ | |style="background-color: white;"|Discharge to other hospital (procedure) (code = '115851000146108' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Lichamelijk onderzoek | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="10"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Lichaamsgewicht | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Gewicht waarde | ||
+ | |style="background-color: white;"|4 kg | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Gewicht datum tijd | ||
+ | |style="background-color: white;"|T - 44 dagen om 09 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Schedelomvang | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Schedelomvang meetmethode | ||
+ | |style="background-color: white;"|Meten van schedelomvang m.b.v. echografisch onderzoek (code = '31561000146107' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Schedelomvang waarde | ||
+ | |style="background-color: white;"|34.6 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Schedelomvang datum tijd | ||
+ | |style="background-color: white;"|T - 45 dagen om 10:20 uur | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Voeding kind |
− | |style="background-color: white;"| | + | |style="background-color: white;"|niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="7"| | + | |colspan="7"|Mortaliteit |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Overlijden lt12 uur na opname nicu? | ||
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="5"|Overleden op verloskamer? |
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Follow up |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="21"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Na ontslag | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="19"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|O2 op dag 28? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Gradatie bpd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Bronchopulmonary dysplasia of newborn - grade 1 (disorder) (code = '22021000146102' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zintuigen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |rowspan="15"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="3"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem naam | ||
+ | |style="background-color: white;"|Plus disease (disorder) (code = '56341000146109' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Verificatie status |
+ | |style="background-color: white;"|Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Rop screening verricht? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Rop screening afgesloten? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Aabr verricht? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Aabr afwijkend? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Bera verricht? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Bera |
|-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;;" | ||
+ | |colspan="2"|Bera afwijkend? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Bera lateraliteit |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Links (code = '7771000' in codeSystem 'SNOMED CT') |
+ | |} | ||
+ | ==Scenario Testscenario 6: overleden op verloskamer == | ||
+ | |||
+ | === Documentgegevens === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Documentgegevens | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="3" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Verificatie zorgverlener |
|-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;;" | ||
+ | |colspan="2"|Geverifieerd door zorgverlener? | ||
+ | |style="background-color: white;"|Ja | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Verificatie datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
+ | |} | ||
+ | === Zorgaanbieder === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="3" | Zorgaanbieder | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="2" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Zorgaanbieder identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
+ | |} | ||
+ | === Vrouw === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Vrouw | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="4" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Demografische gegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Patient |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|000000000 (in identificerend systeem: BSN) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Geboortedatum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 29 jaar |
|} | |} | ||
− | === | + | === Zwangerschapsgegevens === |
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zwangerschapsgegevens |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
− | |colspan=" | + | |colspan="3" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Complicaties tijdens zwangerschap |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="2"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Complicaties zwangerschap? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |} | ||
+ | === Kind === | ||
+ | |||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Kind | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="5" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Demografische gegevens | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Patient |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Identificatienummer | ||
+ | |style="background-color: white;"|123 (in identificerend systeem: 1.2.3.999) | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Geboortedatum | ||
+ | |style="background-color: white;"|T - 18 dagen om 13:20 uur | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Geslacht |
+ | |style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Meerling indicator |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Overlijdens indicator |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Ja |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Datum overlijden |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 18 dagen om 19 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="6"|Bevallingsgegevens |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|266 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Aantal geboren kinderen | ||
+ | |style="background-color: white;"|1 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Type partus |
+ | |style="background-color: white;"|Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Locatie partus |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Ondersteuning opvang | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="10"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verrichting |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Verrichting type |
+ | |style="background-color: white;"|Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|mechanische thoraxcompressies (verrichting) (code = '33631000146101' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verrichting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="2"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|injectie van adrenaline (verrichting) (code = '313191000' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Opname gegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="21"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Opname |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Opname datum | ||
+ | |style="background-color: white;"|T - 18 dagen om 13:30 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Ic opname? | ||
+ | |style="background-color: white;"|NullFlavor: NA | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Heropname? | ||
+ | |style="background-color: white;"|NullFlavor: NA | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Ontslag datum | ||
+ | |style="background-color: white;"|T - 18 dagen om 19 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Onderzoek | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="13"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Lichaamsgewicht |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="3"| | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Gewicht waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|3100 g |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Gewicht datum tijd | ||
+ | |style="background-color: white;"|T - 18 dagen om 13:30 uur | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Apgar score na 1 min | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Apgar score totaal | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Apgar score na 5 min | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Apgar score totaal | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Nsp h arterieel | ||
+ | |style="background-color: white;"|7.13 ph | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Be | ||
+ | |style="background-color: white;"|-6.9 mmol/l | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Problematiek kind | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="19"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ademhalingsondersteuning | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Ademhalingsondersteuning? | ||
+ | |style="background-color: white;"|NullFlavor: NI | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Circulatoir | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Problemen aanwezig? | ||
+ | |style="background-color: white;"|Nee | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Infectieus | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Hematologisch |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Problemen aanwezig? |
+ | |style="background-color: white;"|Nee | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Zintuigen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Congenitale aandoeningen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Problemen aanwezig? |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nee |
− | | | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="6"|Mortaliteit | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Overlijden lt12 uur na opname nicu? | ||
+ | |style="background-color: white;"|NullFlavor: NA | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Overleden op verloskamer? | ||
+ | |style="background-color: white;"|Ja | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Oorzaak overlijden | ||
+ | |style="background-color: white;"|ernstige asfyxie bij geboorte (aandoening) (code = '57284007' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Staken icbehandeling? | ||
+ | |style="background-color: white;"|NullFlavor: NA | ||
+ | |} | ||
+ | [[Categorie:Kwalificatie]] |
Versie van 12 jan 2022 10:24
1 Addenda voor inhoudelijke gegevens Kernset Neonatologie 3.0
1.1 Scenario Testscenario 1: uitgebreide problematiek
1.1.1 Documentgegevens
Documentgegevens | |||
Gegevenselement | Waarde | ||
Identificatie | 0000 (in identificerend systeem: abc123) | ||
Document datum | T - 1 dag | ||
Set identificatie | 0000 (in identificerend systeem: abc123) | ||
Versienummer | 1 | ||
Software naam | InformatieSysteemX | ||
Verificatie zorgverlener | |||
Geverifieerd door zorgverlener? | Ja | ||
Verificatie datum | T - 0 dagen |
1.1.2 Zorgaanbieder
Zorgaanbieder | ||
Gegevenselement | Waarde | |
Zorgaanbieder identificatienummer | 0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) | |
Zorgaanbieder identificatienummer | 0000 (in identificerend systeem: AGB-Z) | |
Zorgaanbieder identificatienummer | 0000 (in identificerend systeem: URA) |
1.1.3 Zorgverlener
Zorgverlener | ||||
Gegevenselement | Waarde | |||
Zorgverlener identificatienummer | 0000 (in identificerend systeem: 2.16.528.1.1007.5.1) | |||
Naamgegevens | ||||
Voornamen | Hans Peter | |||
Initialen | HP | |||
Roepnaam | Hans | |||
Naamgebruik | Geslachtsnaam partner gevolgd door eigen geslachtsnaam (code = 'NL3' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
Geslachtsnaam | ||||
Voorvoegsels | van den | |||
Achternaam | Akker | |||
Geslachtsnaam partner | ||||
Achternaam partner | Pieterse |
1.1.4 Vrouw
Vrouw | ||||
Gegevenselement | Waarde | |||
Demografische gegevens | ||||
Patient | ||||
Identificatienummer | 000000000 (in identificerend systeem: BSN) | |||
Geboortedatum | T - 27 jaar |
1.1.5 Zwangerschapsgegevens
Zwangerschapsgegevens | ||||
Gegevenselement | Waarde | |||
Graviditeit | 1 | |||
Pariteit voor deze zwangerschap | 0 | |||
Complicaties tijdens zwangerschap | ||||
Complicaties zwangerschap? | Ja | |||
Probleem | ||||
Probleem naam | koorts (code = '386661006' in codeSystem 'SNOMED CT') | |||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||
Magnesiumsulfaat | Ja | |||
Antenatale steroiden gegeven? | Nee |
1.1.6 Kind
Kind | ||||||
Gegevenselement | Waarde | |||||
Demografische gegevens | ||||||
Patient | ||||||
Adresgegevens | ||||||
Adresgegevens | ||||||
Postcode | 1234 AB | |||||
Identificatienummer | 123 (in identificerend systeem: 1.2.3.999) | |||||
Geboortedatum | T - 90 dagen om 12:13 uur | |||||
Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |||||
Meerling indicator | Ja | |||||
Rangnummer kind | 2 | |||||
Overlijdens indicator | Nee | |||||
Bevallingsgegevens | ||||||
Zwangerschapsduur | 179 dagen | |||||
Aantal geboren kinderen | 2 | |||||
Type partus | Primair (code = '177141003' in codeSystem 'SNOMED CT') | |||||
Locatie partus | Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') | |||||
Zorgaanbieder | ||||||
Zorgaanbieder identificatienummer | 0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) | |||||
Organisatie naam | UMC Papendorp | |||||
Ondersteuning opvang | ||||||
Verrichting | ||||||
Verrichting type | Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT') | |||||
Opname gegevens | ||||||
Opname | ||||||
Opname datum | T - 90 dagen om 13:30 uur | |||||
Ic opname? | Ja | |||||
Heropname? | Nee | |||||
Herkomst kind | In-hospital admission from obstetrical ward (procedure) (code = '59151000146103' in codeSystem 'SNOMED CT') | |||||
Opname indicatie | Finding of length of gestation (finding) (code = '366323009' in codeSystem 'SNOMED CT') | |||||
Ontslag datum | T - 31 dagen om 12 uur | |||||
Onderzoek | ||||||
Lichaamslengte | ||||||
Lengte waarde | 31 cm | |||||
Lengte datum tijd | T - 90 dagen om 13:20 uur | |||||
Lichaamsgewicht | ||||||
Gewicht waarde | 710 g | |||||
Gewicht datum tijd | T - 90 dagen om 13:21 uur | |||||
Lichaamstemperatuur | ||||||
Temperatuur waarde | 37.4 graden celsius | |||||
Temperatuur datum tijd | T - 90 dagen om 13:22 uur | |||||
Toelichting | abc | |||||
Temperatuur type | Rectale temperatuur (code = '307047009' in codeSystem 'SNOMED CT') | |||||
Schedelomvang | ||||||
Schedelomvang waarde | 22.5 cm | |||||
Schedelomvang datum tijd | T - 90 dagen om 13:23 uur | |||||
Apgar score na 1 min | ||||||
Apgar score totaal | 1 | |||||
Apgar score na 5 min | ||||||
Apgar score totaal | 5 | |||||
Nsp h arterieel | 7.05 ph | |||||
Be | -12.0 mmol/l | |||||
Problematiek kind | ||||||
Geboortetrauma | ||||||
Problemen aanwezig? | Nee | |||||
Ademhalingsondersteuning | ||||||
Ademhalingsondersteuning? | Ja | |||||
Verrichting | ||||||
Verrichting start datum | T - 90 dagen om 13:35 uur | |||||
Verrichting eind datum | T - 33 dagen om 12 uur | |||||
Verrichting type | Oxygen therapy using high flow oxygen nasal cannula (procedure) (code = '57485005:424226004=426854004' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting start datum | T - 33 dagen om 12 uur | |||||
Verrichting eind datum | T - 31 dagen om 10 uur | |||||
Verrichting type | Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | |||||
O2 op dag 28? | Ja | |||||
Respiratoir | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Respiratory distress syndrome in the newborn (disorder) (code = '46775006' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Aanvang | Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT') | |||||
Medicatie | ||||||
Stimulatie ademhaling | COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL') | |||||
Surfactant | NATUURLIJKE FOSFOLIPIDEN - LONGSURFACTANTS (code = 'R07AA02' in codeSystem 'ATC-NL') | |||||
Medicatie | ||||||
Stimulatie ademhaling | DOXAPRAM (code = 'R07AB01' in codeSystem 'ATC-NL') | |||||
Circulatoir | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Patent ductus arteriosus (disorder) (code = '83330001' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | Drug therapy for patent ductus arteriosus (procedure) (code = '58801000146104' in codeSystem 'SNOMED CT') | |||||
Infectieus | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Suspected sepsis (situation) (code = '9331000146100' in codeSystem 'SNOMED CT') | |||||
Probleem begin datum | T - 89 dagen | |||||
Probleem eind datum | T - 86 dagen | |||||
Verificatie status | Werk (code = '415684004' in codeSystem 'SNOMED CT') | |||||
Aanvang | Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT') | |||||
Microorganisme sepsis meningitis | Other, specify (code = 'OTH' in codeSystem 'HL7 NullFlavor'): abc | |||||
Lijnsepsis? | Nee | |||||
Onset | vroege neonatale periode (kwalificatiewaarde) (code = '303114002' in codeSystem 'SNOMED CT') | |||||
Antibiotica eerste 3 dagen? | Ja | |||||
Gastrointestinaal | ||||||
Problemen aanwezig? | Ja | |||||
Verrichting | ||||||
Verrichting type | Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT') | |||||
Hematologisch | ||||||
Problemen aanwezig? | Ja | |||||
Verrichting | ||||||
Verrichting type | Transfusion for anemia (procedure) (code = '59071000146107' in codeSystem 'SNOMED CT') | |||||
Metabool en endocrien | ||||||
Problemen aanwezig? | Ja | |||||
Probleem hyperbilirubemie | ||||||
Probleem naam | hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Indicatie | ||||||
Probleem | Zie Probleem: hyperbilirubemie | |||||
Verrichting type | Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT') | |||||
Neurologisch | ||||||
Problemen aanwezig? | Nee | |||||
Zintuigen | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Retinopathy of prematurity stage 2 - intraretinal ridge (disorder) (code = '408848001' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Rop screening verricht? | Ja | |||||
Rop screening afgesloten? | Ja | |||||
Aabr verricht? | Ja | |||||
Aabr afwijkend? | Ja | |||||
Bera verricht? | Nee | |||||
Congenitale aandoeningen | ||||||
Problemen aanwezig? | Nee | |||||
Ontslagoverplaatsing | ||||||
Nog opgenomen? | Nee | |||||
Bestemming kind | Discharge to other hospital (procedure) (code = '115851000146108' in codeSystem 'SNOMED CT') | |||||
Lichamelijk onderzoek | ||||||
Lichaamsgewicht | ||||||
Gewicht waarde | 1740 gram | |||||
Gewicht datum tijd | T - 31 dagen om 09 uur | |||||
Schedelomvang | ||||||
Schedelomvang meetmethode | Meten van schedelomvang m.b.v. meetlint (code = '31551000146109' in codeSystem 'SNOMED CT') | |||||
Schedelomvang waarde | 30 cm | |||||
Schedelomvang datum tijd | T - 31 dagen om 09:01 uur | |||||
Voeding kind | niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') | |||||
Mortaliteit | ||||||
Overlijden lt12 uur na opname nicu? | Nee | |||||
Overleden op verloskamer? | Nee | |||||
Staken icbehandeling? | Nee | |||||
Follow up | ||||||
Na ontslag | ||||||
O2 op dag 28? | Nee | |||||
Gradatie bpd | niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') | |||||
Zintuigen | ||||||
Problemen aanwezig? | NullFlavor: UNK |
1.2 Scenario Testscenario 2: geb.trauma + neurologisch + anat afw + overlijden
1.2.1 Documentgegevens
Documentgegevens | |||
Gegevenselement | Waarde | ||
Identificatie | 0000 (in identificerend systeem: abc123) | ||
Document datum | |||
Set identificatie | 0000 (in identificerend systeem: abc123) | ||
Versienummer | 2 | ||
Software naam | XIS | ||
Verificatie zorgverlener | |||
Geverifieerd door zorgverlener? | Ja | ||
Verificatie datum |
1.2.2 Zorgaanbieder
Zorgaanbieder | ||
Gegevenselement | Waarde | |
Zorgaanbieder identificatienummer | 0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) |
1.2.3 Zorgverlener
Zorgverlener | ||||
Gegevenselement | Waarde | |||
Zorgverlener identificatienummer | 0000 (in identificerend systeem: UZI Personen) | |||
Naamgegevens | ||||
Voornamen | Hans Paul | |||
Initialen | H.P. | |||
Roepnaam | Hans | |||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |||
Geslachtsnaam | ||||
Achternaam | Pieterse |
1.2.4 Vrouw
Vrouw | ||||
Gegevenselement | Waarde | |||
Demografische gegevens | ||||
Patient | ||||
Identificatienummer | (in identificerend systeem: BSN) | |||
Geboortedatum | T - 26 jaar |
1.2.5 Zwangerschapsgegevens
Zwangerschapsgegevens | ||||
Gegevenselement | Waarde | |||
Graviditeit | 3 | |||
Pariteit voor deze zwangerschap | 2 | |||
Complicaties tijdens zwangerschap | ||||
Complicaties zwangerschap? | Ja | |||
Probleem | ||||
Probleem naam | hypertensieve aandoening (aandoening) (code = '38341003' in codeSystem 'SNOMED CT') | |||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||
Magnesiumsulfaat | Nee | |||
Antenatale steroiden gegeven? | NullFlavor: NA |
1.2.6 Kind
Kind | ||||||
Gegevenselement | Waarde | |||||
Demografische gegevens | ||||||
Patient | ||||||
Identificatienummer | 123 (in identificerend systeem: 1.2.3.999) | |||||
Geboortedatum | T - 10 dagen om 10:44 uur | |||||
Geslacht | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |||||
Meerling indicator | Nee | |||||
Overlijdens indicator | Ja | |||||
Datum overlijden | T - 10 dagen om 21 uur | |||||
Bevallingsgegevens | ||||||
Zwangerschapsduur | 254 dagen | |||||
Aantal geboren kinderen | 1 | |||||
Type partus | Primair (code = '177141003' in codeSystem 'SNOMED CT') | |||||
Locatie partus | Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') | |||||
Zorgaanbieder | ||||||
Zorgaanbieder identificatienummer | 234 (in identificerend systeem: AGB-Z) | |||||
Organisatie naam | UMC Papendorp | |||||
Ondersteuning opvang | ||||||
Verrichting | ||||||
Verrichting type | endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT') | |||||
Opname gegevens | ||||||
Opname | ||||||
Opname datum | T - 10 dagen om 11:15 uur | |||||
Ic opname? | Ja | |||||
Heropname? | Nee | |||||
Herkomst kind | In-hospital admission from obstetrical ward (procedure) (code = '59151000146103' in codeSystem 'SNOMED CT') | |||||
Opname indicatie | Perinatal asphyxia (disorder) (code = '281578009' in codeSystem 'SNOMED CT') | |||||
Opname indicatie | Infant in poor condition at birth (finding) (code = '276707008' in codeSystem 'SNOMED CT') | |||||
Opname indicatie | Congenital disease (disorder) (code = '66091009' in codeSystem 'SNOMED CT') | |||||
Ontslag datum | T - 10 dagen om 21 uur | |||||
Onderzoek | ||||||
Lichaamsgewicht | ||||||
Gewicht waarde | 3870 g | |||||
Gewicht datum tijd | T - 10 dagen om 11:01 uur | |||||
Lichaamstemperatuur | ||||||
Temperatuur waarde | 36.1 graden celsius | |||||
Temperatuur datum tijd | T - 10 dagen om 11:02 uur | |||||
Temperatuur type | Rectale temperatuur (code = '307047009' in codeSystem 'SNOMED CT') | |||||
Apgar score na 1 min | ||||||
Apgar score totaal | 0 | |||||
Apgar score na 5 min | ||||||
Apgar score totaal | 2 | |||||
Problematiek kind | ||||||
Geboortetrauma | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Spinal cord injury due to birth trauma (disorder) (code = '698500002' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Ademhalingsondersteuning | ||||||
Ademhalingsondersteuning? | Ja | |||||
Verrichting | ||||||
Verrichting start datum | T - 10 dagen om 11:16 uur | |||||
Verrichting type | Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | |||||
O2 op dag 28? | NullFlavor: NA | |||||
Respiratoir | ||||||
Problemen aanwezig? | Nee | |||||
Circulatoir | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Neonatal hypotension (disorder) (code = '276519002' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Infectieus | ||||||
Problemen aanwezig? | Ja | |||||
Gastrointestinaal | ||||||
Problemen aanwezig? | Nee | |||||
Hematologisch | ||||||
Problemen aanwezig? | Ja | |||||
Metabool en endocrien | ||||||
Problemen aanwezig? | Nee | |||||
Neurologisch | ||||||
Problemen aanwezig? | Ja | |||||
Probleem neonatal_encephalopathy | ||||||
Probleem naam | Neonatal encephalopathy (disorder) (code = '95628005' in codeSystem 'SNOMED CT') | |||||
Ernst encefalopathie | Ernstig (code = '24484000' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Probleem | ||||||
Probleem naam | asfyxie bij geboorte (code = '413654009' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Probleem | ||||||
Probleem naam | Intraventricular (nontraumatic) hemorrhage, grade 2, of fetus and newborn (disorder) (code = '206396002' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Indicatie | ||||||
Probleem | Zie Probleem: neonatal_encephalopathy | |||||
Verrichting type | echografische beeldvorming van hoofd (verrichting) (code = '241449005' in codeSystem 'SNOMED CT') | |||||
Zintuigen | ||||||
Problemen aanwezig? | NullFlavor: UNK | |||||
Congenitale aandoeningen | ||||||
Problemen aanwezig? | Ja | |||||
Aangeboren anatomische afwijkingen majorsyndromen | ||||||
Probleem | ||||||
Probleem naam | Overige congenitale afwijkingen zenuwstelsel (code = '09' in codeSystem '2.16.840.1.113883.2.4.4.13.8') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Ontslagoverplaatsing | ||||||
Nog opgenomen? | Nee | |||||
Voeding kind | niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') | |||||
Mortaliteit | ||||||
Overlijden lt12 uur na opname nicu? | Ja | |||||
Overleden op verloskamer? | Nee | |||||
Oorzaak overlijden | multiorgaanfalen (aandoening) (code = '57653000' in codeSystem 'SNOMED CT') | |||||
Staken icbehandeling? | Ja |
1.3 Scenario Testscenario 3: stofwisselingsziekte
1.3.1 Documentgegevens
Documentgegevens | |||
Gegevenselement | Waarde | ||
Identificatie | 0000 (in identificerend systeem: abc123) | ||
Document datum | T - 0 dagen om 17 uur | ||
Set identificatie | 0000 (in identificerend systeem: abc123) | ||
Versienummer | 3 | ||
Software naam | XIS | ||
Verificatie zorgverlener | |||
Geverifieerd door zorgverlener? | Nee | ||
Verificatie datum |
1.3.2 Zorgaanbieder
Zorgaanbieder | ||
Gegevenselement | Waarde | |
Zorgaanbieder identificatienummer | 0000 (in identificerend systeem: AGB-Z) | |
Zorgaanbieder identificatienummer | (in identificerend systeem: URA) |
1.3.3 Zorgverlener
Zorgverlener | ||||
Gegevenselement | Waarde | |||
Zorgverlener identificatienummer | 0000 (in identificerend systeem: AGB-Z) | |||
Naamgegevens | ||||
Voornamen | Hans Peter | |||
Initialen | HP | |||
Roepnaam | Hans | |||
Naamgebruik | Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor') | |||
Geslachtsnaam | ||||
Voorvoegsels | van de | |||
Achternaam | Velde |
1.3.4 Zwangerschapsgegevens
Zwangerschapsgegevens | |||
Gegevenselement | Waarde | ||
Graviditeit | 4 | ||
Pariteit voor deze zwangerschap | 2 | ||
Complicaties tijdens zwangerschap | |||
Complicaties zwangerschap? | Ja | ||
Antenatale steroiden gegeven? | Ja | ||
Antenatale steroiden | Complete steroid therapy for fetal lung maturation (procedure) (code = '255594003434601000124108' in codeSystem 'SNOMED CT') |
1.3.5 Kind
Kind | ||||||
Gegevenselement | Waarde | |||||
Demografische gegevens | ||||||
Patient | ||||||
Identificatienummer | 123 (in identificerend systeem: 1.2.3.999) | |||||
Geboortedatum | T - 76 dagen om 06:55 uur | |||||
Geslacht | Ongedifferentieerd (code = 'UN' in codeSystem 'HL7 AdministrativeGender') | |||||
Overlijdens indicator | Nee | |||||
Bevallingsgegevens | ||||||
Zwangerschapsduur | 215 dagen | |||||
Aantal geboren kinderen | 1 | |||||
Type partus | Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | |||||
Locatie partus | Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') | |||||
Opname gegevens | ||||||
Opname | ||||||
Opname datum | T - 0 dagen om 09:15 uur | |||||
Ic opname? | Nee | |||||
Heropname? | Ja | |||||
Herkomst kind | Hospital admission from home or birth center (procedure) (code = '59141000146101' in codeSystem 'SNOMED CT') | |||||
Opname indicatie | Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): vaccinatie onder observatie | |||||
Ontslag datum | T - 0 dagen om 16 uur | |||||
Onderzoek | ||||||
Lichaamslengte | ||||||
Lengte waarde | 43 cm | |||||
Lengte datum tijd | T - 0 dagen om 09:30 uur | |||||
Lichaamsgewicht | ||||||
Gewicht waarde | 1800 g | |||||
Gewicht datum tijd | T - 0 dagen om 09:30 uur | |||||
Lichaamstemperatuur | ||||||
Temperatuur waarde | 37.1 | |||||
Temperatuur datum tijd | T - 0 dagen om 09:30 uur | |||||
Schedelomvang | ||||||
Schedelomvang waarde | 31 centimeter | |||||
Schedelomvang datum tijd | T - 0 dagen om 09:32 uur | |||||
Nsp h arterieel | 7.35 ph | |||||
Be | 0.0 mmol/l | |||||
Problematiek kind | ||||||
Congenitale aandoeningen | ||||||
Problemen aanwezig? | Ja | |||||
Stofwisselingsziekten | ||||||
Probleem | ||||||
Probleem naam | stoornis van mineraalstofwisseling (aandoening) (code = '45744005' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Differentiaal (code = '410590009' in codeSystem 'SNOMED CT') | |||||
Ontslagoverplaatsing | ||||||
Nog opgenomen? | Nee | |||||
Bestemming kind | Discharge to home (procedure) (code = '306689006' in codeSystem 'SNOMED CT') | |||||
Voeding kind | moedermelk (substantie) (code = '226789007' in codeSystem 'SNOMED CT') | |||||
Ondersteuning bij ontslag naar huis | monitoren met cardiotachometer (regime/therapie) (code = '63818009' in codeSystem 'SNOMED CT') | |||||
Mortaliteit | ||||||
Overlijden lt12 uur na opname nicu? | NullFlavor: NA | |||||
Overleden op verloskamer? | Nee | |||||
Staken icbehandeling? | NullFlavor: NA |
1.4 Scenario Testscenario 4: gastro + chirurgie
1.4.1 Documentgegevens
Documentgegevens | |||
Gegevenselement | Waarde | ||
Identificatie | 0000 | ||
Document datum | T - 10 dagen om 10 uur | ||
Set identificatie | 0000 | ||
Versienummer | 1 | ||
Software naam | InformatieSysteemX | ||
Verificatie zorgverlener | |||
Geverifieerd door zorgverlener? | NullFlavor: NI | ||
Verificatie datum |
1.4.2 Zorgaanbieder
Zorgaanbieder | ||
Gegevenselement | Waarde | |
Zorgaanbieder identificatienummer | 0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) |
1.4.3 Vrouw
Vrouw | ||||
Gegevenselement | Waarde | |||
Demografische gegevens | ||||
Patient | ||||
Identificatienummer | (in identificerend systeem: BSN) | |||
Geboortedatum |
1.4.4 Zwangerschapsgegevens
Zwangerschapsgegevens | ||
Gegevenselement | Waarde | |
Graviditeit | 1 | |
Pariteit voor deze zwangerschap | 0 |
1.4.5 Kind
Kind | ||||||
Gegevenselement | Waarde | |||||
Demografische gegevens | ||||||
Patient | ||||||
Identificatienummer | 123 (in identificerend systeem: 1.2.3.999) | |||||
Geboortedatum | T - 87 dagen om 13 uur | |||||
Geslacht | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |||||
Meerling indicator | Ja | |||||
Rangnummer kind | 2 | |||||
Overlijdens indicator | Nee | |||||
Bevallingsgegevens | ||||||
Zwangerschapsduur | 236 dagen | |||||
Aantal geboren kinderen | 2 | |||||
Type partus | Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | |||||
Locatie partus | Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') | |||||
Ondersteuning opvang | ||||||
Verrichting | ||||||
Verrichting type | Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | |||||
Opname gegevens | ||||||
Opname | ||||||
Opname datum | T - 80 dagen om 09 uur | |||||
Ic opname? | Ja | |||||
Heropname? | Ja | |||||
Herkomst kind | Hospital admission, transfer from other hospital or health care facility (procedure) (code = '4563007' in codeSystem 'SNOMED CT') | |||||
Zorgaanbieder | ||||||
Zorgaanbieder identificatienummer | 0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) | |||||
Organisatie naam | AZ Papendorp | |||||
Opname indicatie | Other (code = 'OTH' in codeSystem 'HL7 NullFlavor'): abc | |||||
Ontslag datum | T - 11 dagen om 16 uur | |||||
Onderzoek | ||||||
Lichaamslengte | ||||||
Lengte waarde | 43 cm | |||||
Lengte datum tijd | T - 80 dagen om 09:30 uur | |||||
Lichaamsgewicht | ||||||
Gewicht waarde | 1530 g | |||||
Gewicht datum tijd | T - 80 dagen om 09:30 uur | |||||
Problematiek kind | ||||||
Geboortetrauma | ||||||
Problemen aanwezig? | Nee | |||||
Ademhalingsondersteuning | ||||||
Ademhalingsondersteuning? | Ja | |||||
Verrichting | ||||||
Verrichting type | Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | |||||
O2 op dag 28? | Nee | |||||
Respiratoir | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Bronchopulmonary dysplasia of newborn (disorder) (code = '67569000' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Medicatie | ||||||
Stimulatie ademhaling | COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL') | |||||
Circulatoir | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Neonatal hypotension (disorder) (code = '276519002' in codeSystem 'SNOMED CT') | |||||
Infectieus | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | neonatale sepsis (aandoening) (code = '206376005' in codeSystem 'SNOMED CT') | |||||
Microorganisme sepsis meningitis | Listeria monocytogenes (organism) (code = '36094007' in codeSystem 'SNOMED CT') | |||||
Lijnsepsis? | Ja | |||||
Onset | late neonatale periode (kwalificatiewaarde) (code = '303115001' in codeSystem 'SNOMED CT') | |||||
Antibiotica eerste 3 dagen? | NullFlavor: NA | |||||
Infuus | ||||||
Infuuskatheter | ||||||
Medisch hulpmiddel | ||||||
Begin datum | T - 80 dagen om 10 uur | |||||
Einddatum | T - 17 dagen om 09 uur | |||||
Gastrointestinaal | ||||||
Problemen aanwezig? | Ja | |||||
Probleem enterocolitis | ||||||
Probleem naam | Necrotizing enterocolitis in fetus OR newborn - Bell stage IIIA (disorder) (code = '21941000146103' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Indicatie | ||||||
Probleem | Zie Probleem: enterocolitis | |||||
Verrichting type | Laparotomy (procedure) (code = '86481000' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Indicatie | ||||||
Probleem | Zie Probleem: enterocolitis | |||||
Verrichting type | Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT') | |||||
Hematologisch | ||||||
Problemen aanwezig? | Ja | |||||
Verrichting | ||||||
Verrichting type | Transfusion for anemia (procedure) (code = '59071000146107' in codeSystem 'SNOMED CT') | |||||
Metabool en endocrien | ||||||
Problemen aanwezig? | Ja | |||||
Probleem hyperbilirubinemie | ||||||
Probleem naam | hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor') | |||||
Probleem hypoglycemia | ||||||
Probleem naam | Hypoglycemia (disorder) (code = '302866003' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Differentiaal (code = '410590009' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Indicatie | ||||||
Probleem | Zie Probleem: hyperbilirubinemie | |||||
Verrichting type | Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Indicatie | ||||||
Probleem | Zie Probleem: hypoglycemia | |||||
Verrichting type | Intravenous infusion of glucose in hypoglycemia (procedure) (code = '109091000146105' in codeSystem 'SNOMED CT') | |||||
Zintuigen | ||||||
Problemen aanwezig? | NullFlavor: NI | |||||
Congenitale aandoeningen | ||||||
Problemen aanwezig? | Ja | |||||
Chirurgische ingrepen | ||||||
Verrichting | ||||||
Verrichting type | Endoscopie van oesofagus (verrichting) (code = '49230008' in codeSystem 'SNOMED CT') | |||||
Ontslagoverplaatsing | ||||||
Nog opgenomen? | Nee | |||||
Bestemming kind | Discharge to other location within hospital premises (procedure) (code = '115841000146105' in codeSystem 'SNOMED CT') | |||||
Lichamelijk onderzoek | ||||||
Lichaamsgewicht | ||||||
Gewicht waarde | 2800 gram | |||||
Gewicht datum tijd | T - 11 dagen om 15 uur | |||||
Voeding kind | niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') | |||||
Mortaliteit | ||||||
Overlijden lt12 uur na opname nicu? | Nee | |||||
Overleden op verloskamer? | Nee |
1.5 Scenario Testscenario 5: zintuigen + FU
1.5.1 Documentgegevens
Documentgegevens | |||
Gegevenselement | Waarde | ||
Identificatie | 0000 | ||
Document datum | T - 14 dagen om 10 uur | ||
Set identificatie | 0000 | ||
Versienummer | 1 | ||
Software naam | InformatieSysteemX | ||
Verificatie zorgverlener | |||
Geverifieerd door zorgverlener? | Ja | ||
Verificatie datum | T - 14 dagen om 11 uur |
1.5.2 Zorgaanbieder
Zorgaanbieder | ||
Gegevenselement | Waarde | |
Zorgaanbieder identificatienummer |
1.5.3 Zwangerschapsgegevens
Zwangerschapsgegevens | ||||
Gegevenselement | Waarde | |||
Graviditeit | 5 | |||
Pariteit voor deze zwangerschap | 4 | |||
Complicaties tijdens zwangerschap | ||||
Complicaties zwangerschap? | Ja | |||
Probleem | ||||
Probleem naam | preterm en prematuur gebroken vliezen (aandoening) (code = '312974005' in codeSystem 'SNOMED CT') | |||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||
Magnesiumsulfaat | Ja | |||
Antenatale steroiden gegeven? | Ja | |||
Antenatale steroiden | Complete steroid therapy for fetal lung maturation (procedure) (code = '255594003434601000124108' in codeSystem 'SNOMED CT') |
1.5.4 Kind
Kind | ||||||
Gegevenselement | Waarde | |||||
Demografische gegevens | ||||||
Patient | ||||||
Adresgegevens | ||||||
Adresgegevens | ||||||
Postcode | 1234 AB | |||||
Identificatienummer | 123 (in identificerend systeem: 1.2.3.999) | |||||
Geboortedatum | T - 179 dagen om 14 uur | |||||
Geslacht | Onbekend (code = 'UNK' in codeSystem 'HL7 NullFlavor') | |||||
Meerling indicator | Nee | |||||
Overlijdens indicator | Nee | |||||
Bevallingsgegevens | ||||||
Zwangerschapsduur | 177 dagen | |||||
Type partus | Sectio Caesarea (code = '11466000' in codeSystem 'SNOMED CT') | |||||
Locatie partus | Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') | |||||
Ondersteuning opvang | ||||||
Verrichting | ||||||
Verrichting type | Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | endotracheale ademhalingsondersteuning (verrichting) (code = '182686001' in codeSystem 'SNOMED CT') | |||||
Opname gegevens | ||||||
Opname | ||||||
Opname datum | T - 179 dagen om 14:30 uur | |||||
Ic opname? | Ja | |||||
Heropname? | Nee | |||||
Herkomst kind | Hospital admission, transfer from other hospital or health care facility (procedure) (code = '4563007' in codeSystem 'SNOMED CT') | |||||
Opname indicatie | Finding of length of gestation (finding) (code = '366323009' in codeSystem 'SNOMED CT') | |||||
Ontslag datum | T - 44 dagen om 12 uur | |||||
Onderzoek | ||||||
Lichaamsgewicht | ||||||
Gewicht waarde | 710 g | |||||
Gewicht datum tijd | T - 179 dagen om 14:30 uur | |||||
Lichaamstemperatuur | ||||||
Temperatuur waarde | 36.7 | |||||
Temperatuur datum tijd | T - 179 dagen om 14:35 uur | |||||
Toelichting | geen bijzonderheden | |||||
Temperatuur type | Orale temperatuur (onder de tong) (code = '415945006' in codeSystem 'SNOMED CT') | |||||
Schedelomvang | ||||||
Schedelomvang waarde | 25.5 | |||||
Schedelomvang datum tijd | T - 179 dagen om 14:35 uur | |||||
Apgar score na 1 min | ||||||
Apgar score totaal | 1 | |||||
Apgar score na 5 min | ||||||
Apgar score totaal | 4 | |||||
Nsp h arterieel | 7.21 ph | |||||
Be | -11 mmol/l | |||||
Problematiek kind | ||||||
Geboortetrauma | ||||||
Problemen aanwezig? | Nee | |||||
Ademhalingsondersteuning | ||||||
Ademhalingsondersteuning? | Ja | |||||
Verrichting | ||||||
Verrichting type | toedienen van zuurstof via neusbril (verrichting) (code = '371907003' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | Oxygen therapy using high flow oxygen nasal cannula (procedure) (code = '57485005:424226004=426854004' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | Continuous positive airway pressure ventilation treatment (procedure) (code = '47545007' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | Noninvasive ventilation (procedure) (code = '428311008' in codeSystem 'SNOMED CT') | |||||
O2 op dag 28? | Ja | |||||
Respiratoir | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Respiratory distress syndrome in the newborn (disorder) (code = '46775006' in codeSystem 'SNOMED CT') | |||||
Probleem begin datum | T - 152 dagen om 08 uur | |||||
Aanvang | Health care facility where patient is registered (environment) (code = '58841000146101' in codeSystem 'SNOMED CT') | |||||
Probleem | ||||||
Probleem naam | Bronchopulmonary dysplasia of newborn - grade 3 (disorder) (code = '22041000146108' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | Extracorporeal membrane oxygenation (procedure) (code = '233573008' in codeSystem 'SNOMED CT') | |||||
Medicatie | ||||||
Stimulatie ademhaling | COFFEINE (code = 'N06BC01' in codeSystem 'ATC-NL') | |||||
Surfactant | NATUURLIJKE FOSFOLIPIDEN - LONGSURFACTANTS (code = 'R07AA02' in codeSystem 'ATC-NL') | |||||
Systemische steroiden | CORTICOSTEROIDEN VOOR SYSTEMISCH GEBRUIK - SYSTEMISCHE HORMOONPREPARATEN, EXCL GESLACHTSHORMONEN (code = 'H02' in codeSystem 'ATC-NL') | |||||
Medicatie | ||||||
Stimulatie ademhaling | DOXAPRAM (code = 'R07AB01' in codeSystem 'ATC-NL') | |||||
Circulatoir | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Low blood pressure (disorder) (code = '45007003' in codeSystem 'SNOMED CT') | |||||
Infectieus | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | neonatale sepsis (aandoening) (code = '206376005' in codeSystem 'SNOMED CT') | |||||
Lijnsepsis? | Nee | |||||
Onset | vroege neonatale periode (kwalificatiewaarde) (code = '303114002' in codeSystem 'SNOMED CT') | |||||
Probleem | ||||||
Probleem naam | urineweginfectie (aandoening) (code = '68566005' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Probleem | ||||||
Probleem naam | Neonatal pneumonia (disorder) (code = '233619008' in codeSystem 'SNOMED CT') | |||||
Antibiotica eerste 3 dagen? | Ja | |||||
Infuus | ||||||
Infuuskatheter | ||||||
Medisch hulpmiddel | ||||||
Begin datum | T - 179 dagen om 17 uur | |||||
Einddatum | T - 148 dagen om 08 uur | |||||
Gastrointestinaal | ||||||
Problemen aanwezig? | Ja | |||||
Verrichting | ||||||
Indicatie | ||||||
Probleem | Zie : | |||||
Verrichting type | Total parenteral nutrition (procedure) (code = '225372007' in codeSystem 'SNOMED CT') | |||||
Hematologisch | ||||||
Problemen aanwezig? | Ja | |||||
Verrichting | ||||||
Verrichting type | Treatment for trombocytopenia (procedure) (code = '59091000146106' in codeSystem 'SNOMED CT') | |||||
Metabool en endocrien | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | hyperbilirubinemie (aandoening) (code = '14783006' in codeSystem 'SNOMED CT') | |||||
Probleem | ||||||
Probleem naam | Hypoglycemia (disorder) (code = '302866003' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | Phototherapy of newborn (procedure) (code = '35683002' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | Intravenous infusion of glucose in hypoglycemia (procedure) (code = '109091000146105' in codeSystem 'SNOMED CT') | |||||
Neurologisch | ||||||
Problemen aanwezig? | Ja | |||||
Verrichting | ||||||
Verrichting type | echografische beeldvorming van hoofd (verrichting) (code = '241449005' in codeSystem 'SNOMED CT') | |||||
Verrichting | ||||||
Verrichting type | 'magnetic resonance imaging' van hoofd (verrichting) (code = '241601008' in codeSystem 'SNOMED CT') | |||||
Zintuigen | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Plus disease (disorder) (code = '56341000146109' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Rop screening verricht? | Ja | |||||
Rop screening afgesloten? | Nee | |||||
Aabr verricht? | Ja | |||||
Aabr afwijkend? | Ja | |||||
Bera verricht? | Ja | |||||
Bera | ||||||
Bera afwijkend? | Ja | |||||
Bera lateraliteit | Links (code = '7771000' in codeSystem 'SNOMED CT') | |||||
Ontslagoverplaatsing | ||||||
Nog opgenomen? | Nee | |||||
Bestemming kind | Discharge to other hospital (procedure) (code = '115851000146108' in codeSystem 'SNOMED CT') | |||||
Lichamelijk onderzoek | ||||||
Lichaamsgewicht | ||||||
Gewicht waarde | 4 kg | |||||
Gewicht datum tijd | T - 44 dagen om 09 uur | |||||
Schedelomvang | ||||||
Schedelomvang meetmethode | Meten van schedelomvang m.b.v. echografisch onderzoek (code = '31561000146107' in codeSystem 'SNOMED CT') | |||||
Schedelomvang waarde | 34.6 | |||||
Schedelomvang datum tijd | T - 45 dagen om 10:20 uur | |||||
Voeding kind | niet van toepassing (code = 'NA' in codeSystem 'HL7 NullFlavor') | |||||
Mortaliteit | ||||||
Overlijden lt12 uur na opname nicu? | Nee | |||||
Overleden op verloskamer? | Nee | |||||
Follow up | ||||||
Na ontslag | ||||||
O2 op dag 28? | Nee | |||||
Gradatie bpd | Bronchopulmonary dysplasia of newborn - grade 1 (disorder) (code = '22021000146102' in codeSystem 'SNOMED CT') | |||||
Zintuigen | ||||||
Problemen aanwezig? | Ja | |||||
Probleem | ||||||
Probleem naam | Plus disease (disorder) (code = '56341000146109' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Bevestigd (code = '410605003' in codeSystem 'SNOMED CT') | |||||
Rop screening verricht? | Ja | |||||
Rop screening afgesloten? | Ja | |||||
Aabr verricht? | Ja | |||||
Aabr afwijkend? | Ja | |||||
Bera verricht? | Ja | |||||
Bera | ||||||
Bera afwijkend? | Ja | |||||
Bera lateraliteit | Links (code = '7771000' in codeSystem 'SNOMED CT') |
1.6 Scenario Testscenario 6: overleden op verloskamer
1.6.1 Documentgegevens
Documentgegevens | |||
Gegevenselement | Waarde | ||
Verificatie zorgverlener | |||
Geverifieerd door zorgverlener? | Ja | ||
Verificatie datum |
1.6.2 Zorgaanbieder
Zorgaanbieder | ||
Gegevenselement | Waarde | |
Zorgaanbieder identificatienummer |
1.6.3 Vrouw
Vrouw | ||||
Gegevenselement | Waarde | |||
Demografische gegevens | ||||
Patient | ||||
Identificatienummer | 000000000 (in identificerend systeem: BSN) | |||
Geboortedatum | T - 29 jaar |
1.6.4 Zwangerschapsgegevens
Zwangerschapsgegevens | |||
Gegevenselement | Waarde | ||
Graviditeit | 2 | ||
Pariteit voor deze zwangerschap | 1 | ||
Complicaties tijdens zwangerschap | |||
Complicaties zwangerschap? | Nee |
1.6.5 Kind
Kind | |||||
Gegevenselement | Waarde | ||||
Demografische gegevens | |||||
Patient | |||||
Identificatienummer | 123 (in identificerend systeem: 1.2.3.999) | ||||
Geboortedatum | T - 18 dagen om 13:20 uur | ||||
Geslacht | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | ||||
Meerling indicator | Nee | ||||
Overlijdens indicator | Ja | ||||
Datum overlijden | T - 18 dagen om 19 uur | ||||
Bevallingsgegevens | |||||
Zwangerschapsduur | 266 dagen | ||||
Aantal geboren kinderen | 1 | ||||
Type partus | Vaginale kunstverlossing (code = '3311000146109' in codeSystem 'SNOMED CT') | ||||
Locatie partus | Birth in hospital (finding) (code = '56321000146103' in codeSystem 'SNOMED CT') | ||||
Ondersteuning opvang | |||||
Verrichting | |||||
Verrichting type | Oxygen therapy (procedure) (code = '57485005' in codeSystem 'SNOMED CT') | ||||
Verrichting | |||||
Verrichting type | mechanische thoraxcompressies (verrichting) (code = '33631000146101' in codeSystem 'SNOMED CT') | ||||
Verrichting | |||||
Verrichting type | injectie van adrenaline (verrichting) (code = '313191000' in codeSystem 'SNOMED CT') | ||||
Opname gegevens | |||||
Opname | |||||
Opname datum | T - 18 dagen om 13:30 uur | ||||
Ic opname? | NullFlavor: NA | ||||
Heropname? | NullFlavor: NA | ||||
Ontslag datum | T - 18 dagen om 19 uur | ||||
Onderzoek | |||||
Lichaamsgewicht | |||||
Gewicht waarde | 3100 g | ||||
Gewicht datum tijd | T - 18 dagen om 13:30 uur | ||||
Apgar score na 1 min | |||||
Apgar score totaal | 1 | ||||
Apgar score na 5 min | |||||
Apgar score totaal | 1 | ||||
Nsp h arterieel | 7.13 ph | ||||
Be | -6.9 mmol/l | ||||
Problematiek kind | |||||
Ademhalingsondersteuning | |||||
Ademhalingsondersteuning? | NullFlavor: NI | ||||
Circulatoir | |||||
Problemen aanwezig? | Nee | ||||
Infectieus | |||||
Problemen aanwezig? | Nee | ||||
Hematologisch | |||||
Problemen aanwezig? | Nee | ||||
Zintuigen | |||||
Problemen aanwezig? | Nee | ||||
Congenitale aandoeningen | |||||
Problemen aanwezig? | Nee | ||||
Mortaliteit | |||||
Overlijden lt12 uur na opname nicu? | NullFlavor: NA | ||||
Overleden op verloskamer? | Ja | ||||
Oorzaak overlijden | ernstige asfyxie bij geboorte (aandoening) (code = '57284007' in codeSystem 'SNOMED CT') | ||||
Staken icbehandeling? | NullFlavor: NA |