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
__NUMBEREDHEADINGS__
Addenda voor inhoudelijke gegevens Kernset Neonatologie 3.0
Scenario Testscenario 1: uitgebreide problematiek
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 | ||
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) | |
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 | |||
Vrouw
| Vrouw | ||||
| Gegevenselement | Waarde | |||
| Demografische gegevens | ||||
| Patient | ||||
| Identificatienummer | 000000000 (in identificerend systeem: BSN) | |||
| Geboortedatum | T - 27 jaar | |||
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 | |||
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 | |||||
Scenario Testscenario 2: geb.trauma + neurologisch + anat afw + overlijden
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 | |||
Zorgaanbieder
| Zorgaanbieder | ||
| Gegevenselement | Waarde | |
| Zorgaanbieder identificatienummer | 0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) | |
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 | |||
Vrouw
| Vrouw | ||||
| Gegevenselement | Waarde | |||
| Demografische gegevens | ||||
| Patient | ||||
| Identificatienummer | (in identificerend systeem: BSN) | |||
| Geboortedatum | T - 26 jaar | |||
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 | |||
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 | |||||
Scenario Testscenario 3: stofwisselingsziekte
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 | |||
Zorgaanbieder
| Zorgaanbieder | ||
| Gegevenselement | Waarde | |
| Zorgaanbieder identificatienummer | 0000 (in identificerend systeem: AGB-Z) | |
| Zorgaanbieder identificatienummer | (in identificerend systeem: URA) | |
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 | |||
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') | ||
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 | |||||
Scenario Testscenario 4: gastro + chirurgie
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 | |||
Zorgaanbieder
| Zorgaanbieder | ||
| Gegevenselement | Waarde | |
| Zorgaanbieder identificatienummer | 0000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.93.2) | |
Vrouw
| Vrouw | ||||
| Gegevenselement | Waarde | |||
| Demografische gegevens | ||||
| Patient | ||||
| Identificatienummer | (in identificerend systeem: BSN) | |||
| Geboortedatum | ||||
Zwangerschapsgegevens
| Zwangerschapsgegevens | ||
| Gegevenselement | Waarde | |
| Graviditeit | 1 | |
| Pariteit voor deze zwangerschap | 0 | |
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 | |||||
Scenario Testscenario 5: zintuigen + FU
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 | ||
Zorgaanbieder
| Zorgaanbieder | ||
| Gegevenselement | Waarde | |
| Zorgaanbieder identificatienummer | ||
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') | |||
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') | |||||
Scenario Testscenario 6: overleden op verloskamer
Documentgegevens
| Documentgegevens | |||
| Gegevenselement | Waarde | ||
| Verificatie zorgverlener | |||
| Geverifieerd door zorgverlener? | Ja | ||
| Verificatie datum | |||
Zorgaanbieder
| Zorgaanbieder | ||
| Gegevenselement | Waarde | |
| Zorgaanbieder identificatienummer | ||
Vrouw
| Vrouw | ||||
| Gegevenselement | Waarde | |||
| Demografische gegevens | ||||
| Patient | ||||
| Identificatienummer | 000000000 (in identificerend systeem: BSN) | |||
| Geboortedatum | T - 29 jaar | |||
Zwangerschapsgegevens
| Zwangerschapsgegevens | |||
| Gegevenselement | Waarde | ||
| Graviditeit | 2 | ||
| Pariteit voor deze zwangerschap | 1 | ||
| Complicaties tijdens zwangerschap | |||
| Complicaties zwangerschap? | Nee | ||
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 | ||||