MedMij:Vdraft InhoudelijkeGegevens Integrale Zwangerschapskaart: verschil tussen versies
(ontwikkelversie GZ MM-Zwangerschapskaart (kwalificatiemateriaal)) |
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(12 tussenliggende versies door 3 gebruikers niet weergegeven) | |||
Regel 4: | Regel 4: | ||
=Addenda voor inhoudelijke gegevens Integrale zwangerschapskaart 3.2=</noinclude> | =Addenda voor inhoudelijke gegevens Integrale zwangerschapskaart 3.2=</noinclude> | ||
− | ==Scenario Vrouw 1, Kaart 1 - data 1e lijn ( | + | ==Scenario Vrouw 1, Kaart 1 - data 1e lijn (actieve zwangerschap)== |
<section begin= /> | <section begin= /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
Regel 31: | Regel 31: | ||
|colspan="6"|<span id="Vrouw1" title="Intern ID = Vrouw1">Patient Vrouw1</span> | |colspan="6"|<span id="Vrouw1" title="Intern ID = Vrouw1">Patient Vrouw1</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="20"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Naamgegevens | |colspan="5"|Naamgegevens | ||
Regel 74: | Regel 74: | ||
|colspan="3"|Adres soort | |colspan="3"|Adres soort | ||
|style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Identificatienummer | ||
+ | |style="background-color: white;"|999900717 (in identificerend systeem: BSN) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geboortedatum | |colspan="4"|Geboortedatum | ||
|style="background-color: white;"|18 okt 1985 | |style="background-color: white;"|18 okt 1985 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Geslacht | + | |colspan="4"|Geslacht administratief |
|style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|<span id=" | + | |colspan="6"|<span id="ZA1" title="Intern ID = ZA1">Zorgaanbieder ZA1</span> |
|-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="4"|Zorgaanbieder identificatienummer |
+ | |style="background-color: white;"|08001234 (in identificerend systeem: AGB-Z) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Organisatie naam |
− | + | |style="background-color: white;"|Verloskundigenpraktijk 't Groen | |
− | |||
− | |||
− | |style="background-color: white;"| | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Adresgegevens | |colspan="5"|Adresgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="7"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Straat | |colspan="3"|Straat | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Groeneweg |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Huisnummer | |colspan="3"|Huisnummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1000 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Postcode | |colspan="3"|Postcode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1234ZZ |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Woonplaats | |colspan="3"|Woonplaats | ||
|style="background-color: white;"|STITSWERD | |style="background-color: white;"|STITSWERD | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Land |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Adres soort |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Organisatie type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Verloskundigenpraktijk (code = 'G3' in codeSystem 'RoleCodeNL - zorgaanbiedertype (organisaties)') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|<span id=" | + | |colspan="6"|<span id="ZV1" title="Intern ID = ZV1">Zorgverlener ZV1</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="13"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Zorgverlener identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|12340001 (in identificerend systeem: UZI Personen) |
− | |||
− | |||
− | |||
|-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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="9"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Voornamen |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Gemma |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="3"|Naamgebruik | |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |colspan="3"|Naamgebruik | ||
|style="background-color: white;"|Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | |style="background-color: white;"|Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' 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;;" | ||
Regel 197: | Regel 151: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Specialisme | |colspan="4"|Specialisme | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|eerstelijnsverloskundige (beroep) (code = '158999002' in codeSystem 'SNOMED CT') |
− | |||
− | |||
− | |||
|}<section end=administratief_ /> | |}<section end=administratief_ /> | ||
=== Zorgverlening === | === Zorgverlening === | ||
Regel 213: | Regel 164: | ||
|colspan="4"|Zorg episode | |colspan="4"|Zorg episode | ||
|-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="2"|Begin datum | |colspan="2"|Begin datum | ||
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|T - 139 dagen |
− | |||
− | |||
− | |||
|}<section end=zorgverlening_ /> | |}<section end=zorgverlening_ /> | ||
=== Zwangerschapsgegevens === | === Zwangerschapsgegevens === | ||
Regel 230: | Regel 178: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Coordinerend zorgverlener |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
Regel 239: | Regel 187: | ||
|colspan="5"|Zwangerschap | |colspan="5"|Zwangerschap | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="10"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|56 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Pariteit | |colspan="3"|Pariteit | ||
Regel 245: | Regel 196: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Graviditeit | |colspan="3"|Graviditeit | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|3 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Aterme datum items | |colspan="4"|Aterme datum items | ||
|-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="2"|Aterme datum | |colspan="2"|Aterme datum | ||
− | |style="background-color: white;"|T | + | |style="background-color: white;"|T + 99 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Bepalings methode | |colspan="2"|Bepalings methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): zwangerschapstest clearlypink met zwangerschapsduur-indicator |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Datum bepaling | |colspan="2"|Datum bepaling | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|NullFlavor: UNK |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Datum laatste menstruatie | ||
+ | |style="background-color: white;"|T - 209 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Definitieve a terme datum observatie | |colspan="5"|Definitieve a terme datum observatie | ||
Regel 265: | Regel 219: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Definitieve a terme datum tijd | |colspan="3"|Definitieve a terme datum tijd | ||
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|T - 125 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Definitieve a terme waarde | |colspan="3"|Definitieve a terme waarde | ||
− | |style="background-color: white;"|T | + | |style="background-color: white;"|T + 94 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Definitieve a terme methode | |colspan="3"|Definitieve a terme methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografie van foetus (verrichting) (code = '241491007' in codeSystem 'SNOMED CT') |
− | | | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
− | + | |colspan="5"|Aantal foetussen observatie | |
− | + | |-style="vertical-align:top; background-color: #E3E3E3;;" | |
− | + | |rowspan="2"| | |
− | |||
− | |-style="background-color: # | ||
− | | | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Aantal foetussen waarde |
|style="background-color: white;"|1 | |style="background-color: white;"|1 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Aantal levende kinderen observatie |
|-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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Aantal levende kinderen datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 125 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Aantal levende kinderen waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Observatie methode |
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografie van foetus (verrichting) (code = '241491007' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Fetal loss observatie |
+ | |-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"|Fetal loss datum tijd |
+ | |style="background-color: white;"|NullFlavor: ASKU | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Fetal loss waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Toelichting |
− | |style="background-color: white;"| | + | |style="background-color: white;"|mw. zegt vroege miskraam te hebben gehad enkele maanden na eerste kind, destijds geen verloskundige gezien |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Foliumzuurgebruik observatie |
|-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="3"| | + | |colspan="3"|Foliumzuurgebruik datum tijd |
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|T - 139 dagen |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Foliumzuurgebruik waarde | ||
+ | |style="background-color: white;"|preconceptionele intake van foliumzuur via voeding (bevinding) (code = '29761000146100' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Prenatale controle |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="13"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Lichaamsgewicht |
− | |style="background-color: white;"|Zie [[# | + | |style="background-color: white;"|Zie [[#Gewicht-139D|Lichaamsgewicht: Gewicht-139D]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Bloeddruk |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Zie [[#BP-139D|Bloeddruk: BP-139D]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Alcohol gebruik |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Toelichting | ||
+ | |style="background-color: white;"|tbv conceptie al gestopt met alcohol consumptie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Alcohol gebruik status |
+ | |style="background-color: white;"|drinkt geen alcohol (code = '105542008' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Drugs gebruik |
|-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="2"| | + | |colspan="2"|Drugs gebruik status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|heeft nooit drugs gebruikt (code = '228368007' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Tabak gebruik | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Tabak gebruik status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|heeft nooit gerookt (code = '266919005' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Prenatale controle | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="8"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Leven voelen observatie |
|-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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Leven voelen datum tijd |
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|T - 10 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Leven voelen waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|zwakke foetale bewegingen (bevinding) (code = '276372004' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Toelichting |
− | |style="background-color: white;"| | + | |style="background-color: white;"|voelt sinds enkele dagen minder frequent bewegingen |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Lichaamsgewicht |
+ | |style="background-color: white;"|Zie [[#Gewicht-6D|Lichaamsgewicht: Gewicht-6D]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Bloeddruk |
− | |style="background-color: white;"|Zie [[# | + | |style="background-color: white;"|Zie [[#BP-6D|Bloeddruk: BP-6D]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|<span id="Probleem1" title="Intern ID = Probleem1">Probleem zwangerschap Probleem1</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="7"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Symptoom gerapporteerd door patiënt of andere bron van voorgeschiedenis (code = '418799008' in codeSystem 'SNOMED CT') |
|-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;"|zwakke foetale bewegingen (bevinding) (code = '276372004' in codeSystem 'SNOMED CT') |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Probleem begin datum |
+ | |style="background-color: white;"|T - 10 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem eind datum |
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|T - 6 dagen |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|189 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem status |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Niet actueel (code = '73425007' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verrichting zwangerschap |
+ | |-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"|Verrichting start datum |
+ | |style="background-color: white;"|T - 139 dagen | ||
|-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;"|echografie van foetus (verrichting) (code = '241491007' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verrichting zwangerschap |
+ | |-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"|Verrichting start datum |
+ | |style="background-color: white;"|T - 139 dagen | ||
|-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;"|aanbieden van voorlichtingsmateriaal (verrichting) (code = '445283009' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting zwangerschap | ||
|-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"|Verrichting start datum |
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|T - 6 dagen |
− | |}<section end= | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
− | === | + | |colspan="3"|Verrichting type |
− | <section begin= | + | |style="background-color: white;"|monitoren van foetale hart (regime/therapie) (code = '281568006' in codeSystem 'SNOMED CT') |
+ | |}<section end=zwangerschapsgegevens_ /> | ||
+ | === Medisch onderzoek === | ||
+ | <section begin=medisch_onderzoek_ /> | ||
{| 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" | Medisch onderzoek |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="6" width="25%"| Gegevenselement | |colspan="6" width="25%"| Gegevenselement | ||
Regel 414: | Regel 388: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="7"| | + | |colspan="7"|Maternale onderzoeksgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="17"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Urine bloed en aanvullende onderzoeken | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="15"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Psie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="13"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|<span id="ABO" title="Intern ID = ABO">Laboratorium test bloedgroep ABO</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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Test code |
− | |style="background-color: white;"| | + | |style="background-color: white;"|ABO group [Type] in Blood (code = '883-9' in codeSystem 'LOINC') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Test uitslag |
− | |style="background-color: white;"| | + | |style="background-color: white;"|bloedgroep A (bevinding) (code = '112144000' in codeSystem 'SNOMED CT') |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|<span id="RhD" title="Intern ID = RhD">Laboratorium test rhesus d RhD</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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Test code |
+ | |style="background-color: white;"|D Ag [Presence] in Blood (code = '1305-2' in codeSystem 'LOINC') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Test uitslag |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Rh D Positief (code = '165747007' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|<span id="Rhc" title="Intern ID = Rhc">Laboratorium test rhesus c Rhc</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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Test code |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Kleine c Ag [aanwezigheid] in erytrocyten (code = '1159-3' in codeSystem 'LOINC') |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="2"|Test uitslag | |
− | + | |style="background-color: white;"|Rh c Positief (code = '733120009' in codeSystem 'SNOMED CT') | |
− | + | |}<section end=medisch_onderzoek_ /> | |
− | + | === Bouwstenen === | |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |colspan="2"| | ||
− | |style="background-color: white;"| | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |}<section end= | ||
− | === Bouwstenen === | ||
<section begin=bouwstenen_ /> | <section begin=bouwstenen_ /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
Regel 506: | Regel 441: | ||
|colspan="5"|Metingen | |colspan="5"|Metingen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="17"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|<span id=" | + | |colspan="4"|<span id="BP-139D" title="Intern ID = BP-139D">Bloeddruk BP-139D</span> |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Systolische bloeddruk | ||
+ | |style="background-color: white;"|133 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Diastolische bloeddruk | ||
+ | |style="background-color: white;"|89 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Bloeddruk datum tijd | ||
+ | |style="background-color: white;"|T - 139 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|<span id="BP-6D" title="Intern ID = BP-6D">Bloeddruk BP-6D</span> | ||
|-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="2"|Systolische bloeddruk | |colspan="2"|Systolische bloeddruk | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|155 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Diastolische bloeddruk | |colspan="2"|Diastolische bloeddruk | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|97 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Bloeddruk datum tijd | ||
+ | |style="background-color: white;"|T - 6 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|<span id=" | + | |colspan="4"|<span id="Gewicht-139D" title="Intern ID = Gewicht-139D">Lichaamsgewicht Gewicht-139D</span> |
|-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"|Gewicht waarde | |colspan="2"|Gewicht waarde | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|71 kg |
− | |}<section end=bouwstenen_ /> | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
− | ==Scenario Vrouw 1, Kaart 2 - data 1e lijn ( | + | |colspan="4"|<span id="Gewicht-6D" title="Intern ID = Gewicht-6D">Lichaamsgewicht Gewicht-6D</span> |
− | <section begin= /> | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
− | {| class="wikitable" width="85%" | + | |rowspan="2"| |
− | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Vrouw | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="2"|Gewicht waarde | ||
+ | |style="background-color: white;"|78 kg | ||
+ | |}<section end=bouwstenen_ /> | ||
+ | ==Scenario Vrouw 1, Kaart 2 - data 1e lijn (vorige zwangerschap)== | ||
+ | <section begin= /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Vrouw | ||
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="3" width="25%"| Gegevenselement | |colspan="3" width="25%"| Gegevenselement | ||
Regel 552: | Regel 510: | ||
|colspan="6"|<span id="Vrouw1" title="Intern ID = Vrouw1">Patient Vrouw1</span> | |colspan="6"|<span id="Vrouw1" title="Intern ID = Vrouw1">Patient Vrouw1</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="20"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Naamgegevens | |colspan="5"|Naamgegevens | ||
Regel 595: | Regel 553: | ||
|colspan="3"|Adres soort | |colspan="3"|Adres soort | ||
|style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | |style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Identificatienummer | ||
+ | |style="background-color: white;"|999900717 (in identificerend systeem: BSN) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geboortedatum | |colspan="4"|Geboortedatum | ||
|style="background-color: white;"|18 okt 1985 | |style="background-color: white;"|18 okt 1985 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Geslacht | + | |colspan="4"|Geslacht administratief |
|style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|<span id=" | + | |colspan="6"|<span id="Kind1" title="Intern ID = Kind1">Patient Kind1</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="18"| |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-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;;" | |-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="3"| | + | |colspan="3"|Voornamen |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Helen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Initialen |
− | |style="background-color: white;"| | + | |style="background-color: white;"|H.I. |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Naamgebruik |
− | |style="background-color: white;"| | + | |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;;" | ||
+ | |colspan="4"|Geslachtsnaam | ||
|-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"|Achternaam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|XXX_Kooij |
+ | |-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="5"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Straat |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Knolweg |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Huisnummer |
+ | |style="background-color: white;"|1002 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Postcode |
− | |style="background-color: white;"| | + | |style="background-color: white;"|9999ZZ |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Woonplaats |
+ | |style="background-color: white;"|STITSWERD | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Geboortedatum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 587 dagen |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Geslacht administratief | ||
+ | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|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="6"|<span id="ZA1" title="Intern ID = ZA1">Zorgaanbieder ZA1</span> |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="12"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Zorgaanbieder identificatienummer |
+ | |style="background-color: white;"|08001234 (in identificerend systeem: AGB-Z) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Organisatie naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Verloskundigenpraktijk 't Groen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Adresgegevens |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="7"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Straat |
+ | |style="background-color: white;"|Groeneweg | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Huisnummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1000 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Postcode |
− | + | |style="background-color: white;"|1234ZZ | |
− | |||
− | |||
− | |||
− | |||
− | |||
− | | | ||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Woonplaats |
+ | |style="background-color: white;"|STITSWERD | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Land |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Adres soort |
+ | |style="background-color: white;"|Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Organisatie type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Verloskundigenpraktijk (code = 'G3' in codeSystem 'RoleCodeNL - zorgaanbiedertype (organisaties)') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|<span id="ZV1" title="Intern ID = ZV1">Zorgverlener ZV1</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="14"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Zorgverlener identificatienummer |
− | |style="background-color: white;"| | + | |style="background-color: white;"|12340001 (in identificerend systeem: UZI Personen) |
− | |||
− | |||
− | |||
|-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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="9"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Roepnaam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Gemma |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Naamgebruik |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' 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=" | + | |colspan="4"|Geslachtsnaam |
|-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="2"|Achternaam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|XXX_Groeneboom |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Geslachtsnaam partner |
|-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="2"|Achternaam partner |
− | |style="background-color: white;"| | + | |style="background-color: white;"|XXX_Gras |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Specialisme |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Verloskundige (code = '03.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Zorgverleners rol |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Case manager (code = '768832004' in codeSystem 'SNOMED CT') |
+ | |}<section end=administratief_ /> | ||
+ | === Zorgverlening === | ||
+ | <section begin=zorgverlening_ /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="4" | Zorgverlening | ||
+ | |-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=" | + | |colspan="4"|Zorg episode |
|-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=" | + | |colspan="2"|Begin datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 841 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="2"|Eind datum |
− | |style="background-color: | + | |style="background-color: white;"|T - 587 dagen |
+ | |}<section end=zorgverlening_ /> | ||
+ | === Zwangerschapsgegevens === | ||
+ | <section begin=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="5"|Coordinerend zorgverlener | ||
|-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"|Zorgverlener |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Zie [[#ZV1|Zorgverlener: ZV1]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Zwangerschap |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="10"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Zwangerschapsduur |
− | |style="background-color: white;"| | + | |style="background-color: white;"|294 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Pariteit |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Graviditeit |
+ | |style="background-color: white;"|1 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Aterme datum items |
|-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=" | + | |colspan="2"|Aterme datum |
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|T - 587 dagen |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Bepalings methode |
+ | |style="background-color: white;"|aterme datum berekend door middel van diagnostische ultrasonografie (code = '31541000146106' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Datum bepaling |
− | |style="background-color: white;"| | + | |style="background-color: white;"|NullFlavor: UNK |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Datum laatste menstruatie |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 895 dagen |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Definitieve a terme datum observatie |
|-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="3"| | + | |colspan="3"|Definitieve a terme datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 587 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Definitieve a terme waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 587 dagen |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Definitieve a terme methode | ||
+ | |style="background-color: white;"|observatie (regime/therapie) (code = '225308005' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Aantal foetussen observatie |
|-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="3"| | + | |colspan="3"|Aantal foetussen waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
− | | | + | |}<section end=zwangerschapsgegevens_ /> |
− | |colspan=" | + | === Bevalling === |
+ | <section begin=bevalling_ /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Bevalling | ||
+ | |-style="background-color: #1F497D;; color: white; 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"|Partusnummer |
+ | |style="background-color: white;"|1 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Zwangerschapsduur |
− | |style="background-color: white;"| | + | |style="background-color: white;"|294 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|<span id="Probleem1" title="Intern ID = Probleem1">Probleem maternaal Probleem1</span> |
|-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="3"|Probleem naam |
+ | |style="background-color: white;"|niet vorderende uitdrijving (code = '249166003' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Probleem begin datum |
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|T - 587 dagen om 12:02 uur |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Probleem eind datum |
+ | |style="background-color: white;"|T - 587 dagen om 12:04 uur | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Zwangerschapsduur |
− | |style="background-color: white;"| | + | |style="background-color: white;"|294 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|<span id="Verrichting1" title="Intern ID = Verrichting1">Verrichting maternaal Verrichting1</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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Verrichting start datum |
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|T - 587 dagen om 02:19 uur |
|-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;"|vaginaal toucher (verrichting) (code = '51597003' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|<span id="Verrichting2" title="Intern ID = Verrichting2">Verrichting maternaal Verrichting2</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="6"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Verrichting start datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 587 dagen om 12:04 uur |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Indicatie | ||
|-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"|Probleem maternaal |
− | |style="background-color: white;"|Zie [[# | + | |style="background-color: white;"|Zie [[#Probleem1|Probleem zwangerschap: Probleem1]] |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="3"|Verrichting type |
+ | |style="background-color: white;"|episiotomie mediolateraal rechts (verrichting) (code = '236992007' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Ontsluitingsfase |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="12"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Actieve ontsluiting observatie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="5"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Observatie datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 587 dagen om 02:19 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Begin actieve ontsluiting waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 587 dagen om 02:19 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Observatie methode |
− | |style="background-color: white;"| | + | |style="background-color: white;"|palpatie (verrichting) (code = '113011001' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Toelichting |
− | |style="background-color: white;"| | + | |style="background-color: white;"|5 cm ontsluiting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Wijze begin baring observatie |
|-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=" | + | |colspan="2"|Observatie datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 588 dagen om 23:50 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Begin baring waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|spontaan breken van vliezen (bevinding) (code = '169734005' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Observatie methode |
− | |style="background-color: white;"| | + | |style="background-color: white;"|evaluatie (kwalificatiewaarde) (code = '129265001' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Uitdrijvingsfase | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |rowspan="14"| |
− | |style="background-color: white;"| | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="3"|Patient | ||
+ | |style="background-color: white;"|Zie [[#Kind1|Patient: Kind1]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Type partus observatie |
|-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"|Observatie datum tijd |
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|T - 587 dagen om 12:04 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Type partus waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|begeleiding van normale bevalling (verrichting) (code = '177184002' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Werkelijke plaats baring type locatie observatie |
|-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="2"|Werkelijke plaats baring waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|thuisbevalling (bevinding) (code = '169813005' in codeSystem 'SNOMED CT') |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|<span id="Probleem2" title="Intern ID = Probleem2">Probleem kindspecifieke maternale problemen Probleem2</span> |
|-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=" | + | |colspan="2"|Probleem naam |
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|foetale nood durante partu (bevinding) (code = '288274003' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Probleem begin datum | ||
+ | |style="background-color: white;"|T - 587 dagen om 12:02 uur | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Probleem eind datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 587 dagen om 12:04 uur |
− | |}<section end= | + | |}<section end=bevalling_ /> |
− | === | + | === Kind === |
− | <section begin= | + | <section begin=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="25%"| Gegevenselement | |colspan="6" width="25%"| Gegevenselement | ||
Regel 944: | Regel 905: | ||
|-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;;" | |-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="5"| | + | |colspan="5"|Patient |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Zie [[#Kind1|Patient: Kind1]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="7"| | + | |colspan="7"|Lichamelijk onderzoek kind |
|-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="6"| | + | |colspan="6"|Geboortegewicht lichaamsgewicht |
|-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="4"|Gewicht waarde |
+ | |style="background-color: white;"|3415 gram | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Lichaamslengte |
|-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="4"|Lengte waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|49.7 cm |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Schedelomvang |
|-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="4"|Schedelomvang waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|33.6 cm |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Bevindingen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="12"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Algemene indruk |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="10"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Apgar score1min | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Apgar score totaal |
− | |style="background-color: white;"| | + | |style="background-color: white;"|7 |
− | |}<section end= | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="4"|Apgar score5min | ||
+ | |-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;"|8 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Apgar score10min | ||
+ | |-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;"|10 | ||
+ | |}<section end=kind_ /> | ||
=== Bouwstenen === | === Bouwstenen === | ||
<section begin=bouwstenen_ /> | <section begin=bouwstenen_ /> | ||
Regel 1.004: | Regel 977: | ||
|colspan="5"|Metingen | |colspan="5"|Metingen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="9"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|<span id=" | + | |colspan="4"|<span id="BP1" title="Intern ID = BP1">Bloeddruk BP1</span> |
|-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="2"|Systolische bloeddruk | |colspan="2"|Systolische bloeddruk | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|95 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Diastolische bloeddruk | |colspan="2"|Diastolische bloeddruk | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|50 |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="2"|Bloeddruk datum tijd | |
− | + | |style="background-color: white;"|T - 587 dagen | |
− | |colspan="2"| | ||
− | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="4"|<span id="gew1" title="Intern ID = gew1">Lichaamsgewicht gew1</span> | |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |colspan="4"|<span id=" | ||
|-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"|Gewicht waarde | |colspan="2"|Gewicht waarde | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|63 kg |
|}<section end=bouwstenen_ /> | |}<section end=bouwstenen_ /> | ||
− | ==Scenario Vrouw 2, Kaart 3 - data 1e lijn (meerling | + | ==Scenario Vrouw 2, Kaart 3 - data 1e lijn (meerling)== |
<section begin= /> | <section begin= /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
Regel 1.084: | Regel 1.039: | ||
|colspan="6"|<span id="Vrouw2" title="Intern ID = Vrouw2">Patient Vrouw2</span> | |colspan="6"|<span id="Vrouw2" title="Intern ID = Vrouw2">Patient Vrouw2</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="19"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Naamgegevens | |colspan="5"|Naamgegevens | ||
Regel 1.121: | Regel 1.076: | ||
|colspan="3"|Woonplaats | |colspan="3"|Woonplaats | ||
|style="background-color: white;"|STITSWERD | |style="background-color: white;"|STITSWERD | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Identificatienummer | ||
+ | |style="background-color: white;"|999900730 (in identificerend systeem: BSN) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geboortedatum | |colspan="4"|Geboortedatum | ||
|style="background-color: white;"|20 okt 1985 | |style="background-color: white;"|20 okt 1985 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Geslacht | + | |colspan="4"|Geslacht administratief |
|style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 1.234: | Regel 1.192: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Coordinerend zorgverlener |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
Regel 1.243: | Regel 1.201: | ||
|colspan="6"|Zwangerschap | |colspan="6"|Zwangerschap | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="10"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|59 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Pariteit | |colspan="4"|Pariteit | ||
Regel 1.253: | Regel 1.214: | ||
|colspan="5"|Aterme datum items | |colspan="5"|Aterme datum items | ||
|-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="3"|Aterme datum | |colspan="3"|Aterme datum | ||
Regel 1.263: | Regel 1.224: | ||
|colspan="3"|Datum bepaling | |colspan="3"|Datum bepaling | ||
|style="background-color: white;"|T + 10 dagen | |style="background-color: white;"|T + 10 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Datum laatste menstruatie | ||
+ | |style="background-color: white;"|T - 278 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|<span id="AantalFoetussen" title="Intern ID = AantalFoetussen">Aantal foetussen observatie AantalFoetussen</span> | |colspan="6"|<span id="AantalFoetussen" title="Intern ID = AantalFoetussen">Aantal foetussen observatie AantalFoetussen</span> | ||
Regel 1.288: | Regel 1.252: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Observatie methode | |colspan="4"|Observatie methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Foliumzuurgebruik observatie | |colspan="6"|Foliumzuurgebruik observatie | ||
Regel 1.302: | Regel 1.266: | ||
|colspan="6"|Prenatale controle | |colspan="6"|Prenatale controle | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="17"| |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Lichaamsgewicht | |colspan="4"|Lichaamsgewicht | ||
Regel 1.329: | Regel 1.279: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Alcohol gebruik status | |colspan="3"|Alcohol gebruik status | ||
− | |style="background-color: white;"|drinkt geen alcohol | + | |style="background-color: white;"|drinkt geen alcohol (code = '105542008' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Drugs gebruik | |colspan="5"|Drugs gebruik | ||
Regel 1.341: | Regel 1.291: | ||
|-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="3"|Tabak gebruik status | ||
+ | |style="background-color: white;"|rookt soms sigaretten (code = '230059006' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Soort tabak gebruik | |colspan="3"|Soort tabak gebruik | ||
|style="background-color: white;"|gebruiker van elektronische sigaret (code = '722499006' in codeSystem 'SNOMED CT') | |style="background-color: white;"|gebruiker van elektronische sigaret (code = '722499006' in codeSystem 'SNOMED CT') | ||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Waarneming gebruik | |colspan="4"|Waarneming gebruik | ||
Regel 1.360: | Regel 1.310: | ||
|colspan="6"|<span id="Probleem1" title="Intern ID = Probleem1">Probleem zwangerschap Probleem1</span> | |colspan="6"|<span id="Probleem1" title="Intern ID = Probleem1">Probleem zwangerschap Probleem1</span> | ||
|-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"|Probleem naam | |colspan="4"|Probleem naam | ||
Regel 1.367: | Regel 1.317: | ||
|colspan="4"|Probleem begin datum | |colspan="4"|Probleem begin datum | ||
|style="background-color: white;"|T - 205 dagen | |style="background-color: white;"|T - 205 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|59 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Toelichting | |colspan="4"|Toelichting | ||
Regel 1.402: | Regel 1.355: | ||
|colspan="7"|Verrichting onderzoek | |colspan="7"|Verrichting onderzoek | ||
|-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="5"|Verrichting start datum | |colspan="5"|Verrichting start datum | ||
+ | |style="background-color: white;"|T-195D | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verrichting eind datum | ||
|style="background-color: white;"|T - 195 dagen | |style="background-color: white;"|T - 195 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 1.498: | Regel 1.454: | ||
|style="background-color: white;"|Lichte kleding/ondergoed (code = 'MINIMAL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1') | |style="background-color: white;"|Lichte kleding/ondergoed (code = 'MINIMAL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1') | ||
|}<section end=bouwstenen_ /> | |}<section end=bouwstenen_ /> | ||
− | ==Scenario Vrouw 2, Kaart 3 - data 2e lijn (meerling | + | ==Scenario Vrouw 2, Kaart 3 - data 2e lijn (meerling)== |
<section begin= /> | <section begin= /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
Regel 1.538: | Regel 1.494: | ||
|colspan="6"|<span id="Vrouw2" title="Intern ID = Vrouw2">Patient Vrouw2</span> | |colspan="6"|<span id="Vrouw2" title="Intern ID = Vrouw2">Patient Vrouw2</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="19"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Naamgegevens | |colspan="5"|Naamgegevens | ||
Regel 1.575: | Regel 1.531: | ||
|colspan="3"|Woonplaats | |colspan="3"|Woonplaats | ||
|style="background-color: white;"|STITSWERD | |style="background-color: white;"|STITSWERD | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Identificatienummer | ||
+ | |style="background-color: white;"|999900730 (in identificerend systeem: BSN) | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geboortedatum | |colspan="4"|Geboortedatum | ||
|style="background-color: white;"|20 okt 1985 | |style="background-color: white;"|20 okt 1985 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Geslacht | + | |colspan="4"|Geslacht administratief |
|style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 1.625: | Regel 1.584: | ||
|style="background-color: white;"|T - 5 dagen | |style="background-color: white;"|T - 5 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Geslacht | + | |colspan="4"|Geslacht administratief |
|style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |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;;" | ||
Regel 1.674: | Regel 1.633: | ||
|style="background-color: white;"|T - 5 dagen | |style="background-color: white;"|T - 5 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Geslacht | + | |colspan="4"|Geslacht administratief |
|style="background-color: white;"|Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | |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;;" | ||
Regel 1.780: | Regel 1.739: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Coordinerend zorgverlener |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="2"| | |rowspan="2"| | ||
Regel 1.789: | Regel 1.748: | ||
|colspan="6"|Zwangerschap | |colspan="6"|Zwangerschap | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="10"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|259 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Pariteit | |colspan="4"|Pariteit | ||
Regel 1.799: | Regel 1.761: | ||
|colspan="5"|Aterme datum items | |colspan="5"|Aterme datum items | ||
|-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="3"|Aterme datum | |colspan="3"|Aterme datum | ||
Regel 1.809: | Regel 1.771: | ||
|colspan="3"|Datum bepaling | |colspan="3"|Datum bepaling | ||
|style="background-color: white;"|T - 205 dagen | |style="background-color: white;"|T - 205 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Datum laatste menstruatie | ||
+ | |style="background-color: white;"|T - 278 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Definitieve a terme datum observatie | |colspan="6"|Definitieve a terme datum observatie | ||
Regel 1.821: | Regel 1.786: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Definitieve a terme methode | |colspan="4"|Definitieve a terme methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|<span id="AantalFoetussen" title="Intern ID = AantalFoetussen">Aantal foetussen observatie AantalFoetussen</span> | |colspan="6"|<span id="AantalFoetussen" title="Intern ID = AantalFoetussen">Aantal foetussen observatie AantalFoetussen</span> | ||
Regel 1.834: | Regel 1.799: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Observatie methode | |colspan="4"|Observatie methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Meerling zwangerschap observatie | |colspan="6"|Meerling zwangerschap observatie | ||
Regel 1.850: | Regel 1.815: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Observatie methode | |colspan="4"|Observatie methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Aantal levende kinderen observatie | |colspan="6"|Aantal levende kinderen observatie | ||
Regel 1.863: | Regel 1.828: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Observatie methode | |colspan="4"|Observatie methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Foliumzuurgebruik observatie | |colspan="6"|Foliumzuurgebruik observatie | ||
Regel 1.880: | Regel 1.845: | ||
|colspan="6"|Prenatale controle | |colspan="6"|Prenatale controle | ||
|-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="5"|Leven voelen observatie | |colspan="5"|Leven voelen observatie | ||
Regel 1.920: | Regel 1.871: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Alcohol gebruik status | |colspan="3"|Alcohol gebruik status | ||
− | |style="background-color: white;"|drinkt geen alcohol | + | |style="background-color: white;"|drinkt geen alcohol (code = '105542008' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Drugs gebruik | |colspan="5"|Drugs gebruik | ||
Regel 1.935: | Regel 1.886: | ||
|colspan="3"|Toelichting | |colspan="3"|Toelichting | ||
|style="background-color: white;"|gestopt op advies verloskundige | |style="background-color: white;"|gestopt op advies verloskundige | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Tabak gebruik status | ||
+ | |style="background-color: white;"|rookte vroeger (code = '8517006' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Soort tabak gebruik | |colspan="3"|Soort tabak gebruik | ||
|style="background-color: white;"|gebruiker van elektronische sigaret (code = '722499006' in codeSystem 'SNOMED CT') | |style="background-color: white;"|gebruiker van elektronische sigaret (code = '722499006' in codeSystem 'SNOMED CT') | ||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Waarneming gebruik | |colspan="4"|Waarneming gebruik | ||
Regel 1.952: | Regel 1.903: | ||
|style="background-color: white;"|T - 198 dagen | |style="background-color: white;"|T - 198 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Prenatale controle |
|-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"|Bloeddruk | ||
+ | |style="background-color: white;"|Zie [[#BP-76D|Bloeddruk: BP-76D]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="6"|<span id="Probleem1" title="Intern ID = Probleem1">Probleem zwangerschap Probleem1</span> |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="4"|Probleem naam |
+ | |style="background-color: white;"|meerlingzwangerschap (aandoening) (code = '16356006' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem begin datum |
|style="background-color: white;"|T - 193 dagen | |style="background-color: white;"|T - 193 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Zwangerschapsduur |
− | |style="background-color: white;"| | + | |style="background-color: white;"|71 dagen |
− | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
− | |colspan=" | + | |colspan="6"|<span id="Probleem2" title="Intern ID = Probleem2">Probleem zwangerschap Probleem2</span> |
− | |||
− | |||
− | | | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="6"| | |rowspan="6"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem type |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Klinische bevinding (code = '404684003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|intra-uteriene groeiretardatie (aandoening) (code = '22033007' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Probleem begin datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 76 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Zwangerschapsduur |
− | |style="background-color: white;"| | + | |style="background-color: white;"|188 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Toelichting |
− | |style="background-color: white;"| | + | |style="background-color: white;"|tweede kind blijft erg achter in ontwikkeling |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Verrichting zwangerschap |
|-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="4"|Verrichting start datum |
+ | |style="background-color: white;"|T - 193 dagen | ||
|-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;"|bloedonderzoek (verrichting) (code = '396550006' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Verrichting zwangerschap |
|-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=" | + | |colspan="4"|Verrichting start datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 5 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Verrichting type |
− | |style="background-color: white;"|Zie [[# | + | |style="background-color: white;"|opname in ziekenhuis (verrichting) (code = '32485007' in codeSystem 'SNOMED CT') |
+ | |}<section end=zwangerschapsgegevens_ /> | ||
+ | === Bevalling === | ||
+ | <section begin=bevalling_ /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Bevalling | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="5" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Partusnummer | ||
+ | |style="background-color: white;"|1 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Zwangerschapsduur | ||
+ | |style="background-color: white;"|259 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Uitdrijvingsfase | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="30"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Patient | ||
+ | |style="background-color: white;"|Zie [[#Kind2|Patient: Kind2]] | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Type partus observatie |
|-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"|Observatie datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 5 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Type partus waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|sectio caesarea (verrichting) (code = '11466000' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Werkelijke plaats baring type locatie observatie |
|-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=" | + | |colspan="3"|Observatie datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 5 dagen om 14:38 uur |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Werkelijke plaats baring waarde | ||
+ | |style="background-color: white;"|geboorte in ziekenhuis (bevinding) (code = '56321000146103' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Toelichting |
− | |style="background-color: white;"| | + | |style="background-color: white;"|geplande sectio |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Ziekenhuis baring | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Zorgaanbieder |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Zie [[#ZA2|Zorgaanbieder: ZA2]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|<span id="Probleem3" title="Intern ID = Probleem3">Probleem kindspecifieke maternale problemen Probleem3</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=" | + | |colspan="3"|Probleem naam |
− | |style="background-color: white;"| | + | |style="background-color: white;"|liggingsafwijking van foetus (bevinding) (code = '15028002' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Probleem begin datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 5 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verrichting kindspecifieke maternale verrichtingen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="7"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting start datum |
− | |style="background-color: white;"|T - 5 dagen | + | |style="background-color: white;"|T - 5 dagen om 14:03 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Verrichting eind datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 5 dagen om 14:52 uur |
− | + | |-style="vertical-align:top; background-color: #E3E3E3;;" | |
− | + | |colspan="4"|Indicatie | |
− | |||
− | |||
− | |style=" | ||
− | |||
− | |colspan=" | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="2"| |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Probleem kindspecifieke maternale problemen |
+ | |style="background-color: white;"|Zie [[#Probleem2|Probleem kindspecifieke maternale problemen: Probleem2]] | ||
|-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;"|primaire sectio caesarea (verrichting) (code = '80771000146107' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Verrichting kindspecifieke maternale verrichtingen |
|-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"| | + | |colspan="3"|Verrichting start datum |
− | |style="background-color: white;"|T - 5 dagen | + | |style="background-color: white;"|T - 5 dagen om 14:50 uur |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|vitamine K toediening aan neonaat (code = '698350008:370131001=133933007' in codeSystem 'SNOMED CT') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Uitdrijvingsfase | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="30"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Patient |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Zie [[#Kind3|Patient: Kind3]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Type partus observatie |
|-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"|Observatie datum tijd | |colspan="3"|Observatie datum tijd | ||
− | |style="background-color: white;"|T - 5 dagen | + | |style="background-color: white;"|T - 5 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="3"| | + | |colspan="3"|Type partus waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|sectio caesarea (verrichting) (code = '11466000' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Werkelijke plaats baring type locatie observatie | |colspan="5"|Werkelijke plaats baring type locatie observatie | ||
Regel 2.119: | Regel 2.090: | ||
|colspan="3"|Zorgaanbieder | |colspan="3"|Zorgaanbieder | ||
|style="background-color: white;"|Zie [[#ZA2|Zorgaanbieder: ZA2]] | |style="background-color: white;"|Zie [[#ZA2|Zorgaanbieder: ZA2]] | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verrichting kindspecifieke maternale verrichtingen | |colspan="5"|Verrichting kindspecifieke maternale verrichtingen | ||
Regel 2.155: | Regel 2.116: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verrichting start datum | |colspan="3"|Verrichting start datum | ||
− | |style="background-color: white;"|T - 5 dagen om 14: | + | |style="background-color: white;"|T - 5 dagen om 14:52 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verrichting type | |colspan="3"|Verrichting type | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|inflatie van long door intermitterende compressie van reservoirballon (code = '243140006' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Verrichting kindspecifieke maternale verrichtingen |
|-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=" | + | |colspan="3"|Verrichting start datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 5 dagen om 14:55 uur |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verrichting type | ||
+ | |style="background-color: white;"|vitamine K toediening aan neonaat (code = '698350008:370131001=133933007' in codeSystem 'SNOMED CT') | ||
+ | |}<section end=bevalling_ /> | ||
+ | === Kind === | ||
+ | <section begin=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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Demografische gegevens |
|-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="5"|Patient |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Zie [[#Kind2|Patient: Kind2]] |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="7"|Lichamelijk onderzoek kind | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="25"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Geboortegewicht lichaamsgewicht |
|-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=" | + | |colspan="4"|Gewicht waarde |
− | |style="background-color: white;"|T - 5 dagen om | + | |style="background-color: white;"|2605 gram |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Gewicht datum tijd | ||
+ | |style="background-color: white;"|T - 5 dagen om 15:10 uur | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Kleding |
− | |style="background-color: white;"|2 | + | |style="background-color: white;"|Luier (code = 'DIAPER' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Lichaamslengte |
|-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="4"|Lengte waarde |
− | + | |style="background-color: white;"|48 | |
− | |||
− | |||
− | |style="background-color: white;"| | ||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Schedelomvang |
|-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"|Schedelomvang waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|32.6 cm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Bevindingen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="12"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Algemene indruk | ||
|-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="4"| | + | |colspan="4"|Apgar score1min |
|-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"|Apgar score totaal |
− | |style="background-color: white;"| | + | |style="background-color: white;"|7 |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Apgar score5min |
|-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="2"|Apgar score totaal |
− | |style="background-color: white;"| | + | |style="background-color: white;"|10 |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Apgar score10min |
|-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="2"|Apgar score totaal |
− | |style="background-color: white;"| | + | |style="background-color: white;"|10 |
− | + | |}<section end=kind_ /> | |
− | |||
− | |||
− | |}<section end= | ||
=== Kind === | === Kind === | ||
<section begin=kind_ /> | <section begin=kind_ /> | ||
Regel 2.258: | Regel 2.218: | ||
|colspan="7"|Demografische gegevens | |colspan="7"|Demografische gegevens | ||
|-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="5"|Patient | |colspan="5"|Patient | ||
− | |style="background-color: white;"|Zie [[# | + | |style="background-color: white;"|Zie [[#Kind3|Patient: Kind3]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Lichamelijk onderzoek kind |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="25"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Geboortegewicht lichaamsgewicht |
|-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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Gewicht waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2089 gram |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Gewicht datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 5 dagen om 15:05 uur |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Kleding |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Zonder kleding. (code = 'UNDRESSED' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|Lichaamslengte |
|-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="4"| | + | |colspan="4"|Lengte waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|46 |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Schedelomvang | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |rowspan="2"| | |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |rowspan="2"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Schedelomvang waarde | |colspan="4"|Schedelomvang waarde | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|31.8 cm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Bevindingen | |colspan="6"|Bevindingen | ||
Regel 2.340: | Regel 2.267: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Apgar score totaal | |colspan="2"|Apgar score totaal | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|5 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Apgar score5min | |colspan="4"|Apgar score5min | ||
Regel 2.347: | Regel 2.274: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Apgar score totaal | |colspan="2"|Apgar score totaal | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|9 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Apgar score10min | |colspan="4"|Apgar score10min | ||
Regel 2.356: | Regel 2.283: | ||
|style="background-color: white;"|10 | |style="background-color: white;"|10 | ||
|}<section end=kind_ /> | |}<section end=kind_ /> | ||
− | === | + | === Medisch onderzoek === |
− | <section begin= | + | <section begin=medisch_onderzoek_ /> |
{| 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" | Medisch onderzoek |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
|colspan="6" width="25%"| Gegevenselement | |colspan="6" width="25%"| Gegevenselement | ||
Regel 2.365: | Regel 2.292: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="7"| | + | |colspan="7"|Verrichting onderzoek |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="5"|Verrichting start datum |
+ | |style="background-color: white;"|T-193D | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="5"| | + | |colspan="5"|Verrichting eind datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 193 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="7"|Maternale onderzoeksgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="27"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Urine bloed en aanvullende onderzoeken |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="25"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Psie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="13"| |
− | |style="background-color: | + | |-style="vertical-align:top; background-color: #E3E3E3;;" |
+ | |colspan="4"|<span id="ABO" title="Intern ID = ABO">Laboratorium test bloedgroep ABO</span> | ||
|-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="2"|Test code |
− | |style="background-color: white;"| | + | |style="background-color: white;"|ABO group [Type] in Blood (code = '883-9' in codeSystem 'LOINC') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Test uitslag | ||
+ | |style="background-color: white;"|bloedgroep O (bevinding) (code = '58460004' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|<span id="RhD" title="Intern ID = RhD">Laboratorium test rhesus d RhD</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;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Test code |
− | |style="background-color: white;"| | + | |style="background-color: white;"|D Ag [Presence] in Blood (code = '1305-2' in codeSystem 'LOINC') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="2"|Test uitslag |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Rh D Positief (code = '165747007' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|<span id="Rhc" title="Intern ID = Rhc">Laboratorium test rhesus c Rhc</span> | ||
|-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="2"|Test code |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Kleine c Ag [aanwezigheid] in erytrocyten (code = '1159-3' in codeSystem 'LOINC') |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Test uitslag |
+ | |style="background-color: white;"|Rh c Positief (code = '733120009' in codeSystem 'SNOMED CT') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Laboratorium test hb |
|-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=" | + | |colspan="3"|Test code |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Hemoglobin [Moles/volume] in Venous blood (code = '93846-4' in codeSystem 'LOINC') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="3"|Test uitslag |
− | |style="background-color: white;"| | + | |style="background-color: white;"|7.0 g/dl |
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Torch |
|-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=" | + | |colspan="4"|Laboratorium test torch |
|-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=" | + | |colspan="2"|Test code |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Toxoplasma gondii IgG Ab [Units/volume] in Serum (code = '8039-0' in codeSystem 'LOINC') |
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Test uitslag |
− | |-style="vertical-align:top; background-color: #E3E3E3;;" | + | |style="background-color: white;"|9 k[arb'u]/l |
− | |colspan=" | + | |}<section end=medisch_onderzoek_ /> |
+ | === Medisch onderzoek === | ||
+ | <section begin=medisch_onderzoek_ /> | ||
+ | {| class="wikitable" width="85%" | ||
+ | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="6" | Medisch onderzoek | ||
+ | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
+ | |colspan="5" width="25%"| Gegevenselement | ||
+ | || Waarde | ||
+ | |||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|Verrichting onderzoek | ||
|-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="4"|Verrichting start datum |
+ | |style="background-color: white;"|T-76D | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Verrichting eind datum |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 76 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="6"|Maternale onderzoeksgegevens |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="7"| |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Urine bloed en aanvullende onderzoeken | ||
|-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="4"| | + | |colspan="4"|Laboratorium test hb |
|-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"|Test code | |
− | + | |style="background-color: white;"|Hemoglobin [Moles/volume] in Venous blood (code = '93846-4' in codeSystem 'LOINC') | |
− | |||
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− | |colspan="2"|Test code | ||
− | |style="background-color: white;"|Hemoglobin [Moles/volume] in Venous blood (code = '93846-4' in codeSystem 'LOINC') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Test uitslag | |colspan="2"|Test uitslag | ||
Regel 2.592: | Regel 2.416: | ||
|colspan="6"|Verrichting onderzoek | |colspan="6"|Verrichting onderzoek | ||
|-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="4"|Verrichting start datum | |colspan="4"|Verrichting start datum | ||
+ | |style="background-color: white;"|T-5D | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Verrichting eind datum | ||
|style="background-color: white;"|T - 5 dagen | |style="background-color: white;"|T - 5 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
Regel 2.685: | Regel 2.512: | ||
|style="background-color: white;"|T - 5 dagen | |style="background-color: white;"|T - 5 dagen | ||
|}<section end=bouwstenen_ /> | |}<section end=bouwstenen_ /> | ||
− | ==Scenario Vrouw 3, geen zwangerschapskaart beschikbaar | + | ==Scenario Vrouw 3, geen zwangerschapskaart beschikbaar== |
<section begin= /><section end= /> | <section begin= /><section end= /> | ||
=== Administratief === | === Administratief === | ||
Regel 2.742: | Regel 2.569: | ||
|style="background-color: white;"|22 okt 1985 | |style="background-color: white;"|22 okt 1985 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"|Geslacht | + | |colspan="4"|Geslacht administratief |
|style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" |
Huidige versie van 12 mei 2022 om 12:40
Inhoud
- 1 Addenda voor inhoudelijke gegevens Integrale zwangerschapskaart 3.2
- 1.1 Scenario Vrouw 1, Kaart 1 - data 1e lijn (actieve zwangerschap)
- 1.2 Scenario Vrouw 1, Kaart 2 - data 1e lijn (vorige zwangerschap)
- 1.3 Scenario Vrouw 2, Kaart 3 - data 1e lijn (meerling)
- 1.4 Scenario Vrouw 2, Kaart 3 - data 2e lijn (meerling)
- 1.5 Scenario Vrouw 3, geen zwangerschapskaart beschikbaar
1 Addenda voor inhoudelijke gegevens Integrale zwangerschapskaart 3.2
1.1 Scenario Vrouw 1, Kaart 1 - data 1e lijn (actieve zwangerschap)
Vrouw | |||
Gegevenselement | Waarde | ||
Demografische gegevens | |||
Patient | Zie Patient: Vrouw1 |
1.1.1 Administratief
Administratief | |||||
Gegevenselement | Waarde | ||||
Patient Vrouw1 | |||||
Naamgegevens | |||||
Voornamen | Hanna | ||||
Initialen | H | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Kooij | ||||
Adresgegevens | |||||
Straat | Knolweg | ||||
Huisnummer | 1002 | ||||
Postcode | 9999ZZ | ||||
Woonplaats | STITSWERD | ||||
Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||||
Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | ||||
Identificatienummer | 999900717 (in identificerend systeem: BSN) | ||||
Geboortedatum | 18 okt 1985 | ||||
Geslacht administratief | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
Zorgaanbieder ZA1 | |||||
Zorgaanbieder identificatienummer | 08001234 (in identificerend systeem: AGB-Z) | ||||
Organisatie naam | Verloskundigenpraktijk 't Groen | ||||
Adresgegevens | |||||
Straat | Groeneweg | ||||
Huisnummer | 1000 | ||||
Postcode | 1234ZZ | ||||
Woonplaats | STITSWERD | ||||
Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||||
Adres soort | Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
Organisatie type | Verloskundigenpraktijk (code = 'G3' in codeSystem 'RoleCodeNL - zorgaanbiedertype (organisaties)') | ||||
Zorgverlener ZV1 | |||||
Zorgverlener identificatienummer | 12340001 (in identificerend systeem: UZI Personen) | ||||
Naamgegevens | |||||
Voornamen | Gemma | ||||
Naamgebruik | Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Groeneboom | ||||
Geslachtsnaam partner | |||||
Achternaam partner | XXX_Gras | ||||
Specialisme | eerstelijnsverloskundige (beroep) (code = '158999002' in codeSystem 'SNOMED CT') |
1.1.2 Zorgverlening
Zorgverlening | |||
Gegevenselement | Waarde | ||
Zorg episode | |||
Begin datum | T - 139 dagen |
1.1.3 Zwangerschapsgegevens
Zwangerschapsgegevens | ||||
Gegevenselement | Waarde | |||
Coordinerend zorgverlener | ||||
Zorgverlener | Zie Zorgverlener: ZV1 | |||
Zwangerschap | ||||
Zwangerschapsduur | 56 dagen | |||
Pariteit | 1 | |||
Graviditeit | 3 | |||
Aterme datum items | ||||
Aterme datum | T + 99 dagen | |||
Bepalings methode | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): zwangerschapstest clearlypink met zwangerschapsduur-indicator | |||
Datum bepaling | NullFlavor: UNK | |||
Datum laatste menstruatie | T - 209 dagen | |||
Definitieve a terme datum observatie | ||||
Definitieve a terme datum tijd | T - 125 dagen | |||
Definitieve a terme waarde | T + 94 dagen | |||
Definitieve a terme methode | echografie van foetus (verrichting) (code = '241491007' in codeSystem 'SNOMED CT') | |||
Aantal foetussen observatie | ||||
Aantal foetussen waarde | 1 | |||
Aantal levende kinderen observatie | ||||
Aantal levende kinderen datum tijd | T - 125 dagen | |||
Aantal levende kinderen waarde | 1 | |||
Observatie methode | echografie van foetus (verrichting) (code = '241491007' in codeSystem 'SNOMED CT') | |||
Fetal loss observatie | ||||
Fetal loss datum tijd | NullFlavor: ASKU | |||
Fetal loss waarde | ||||
Toelichting | mw. zegt vroege miskraam te hebben gehad enkele maanden na eerste kind, destijds geen verloskundige gezien | |||
Foliumzuurgebruik observatie | ||||
Foliumzuurgebruik datum tijd | T - 139 dagen | |||
Foliumzuurgebruik waarde | preconceptionele intake van foliumzuur via voeding (bevinding) (code = '29761000146100' in codeSystem 'SNOMED CT') | |||
Prenatale controle | ||||
Lichaamsgewicht | Zie Lichaamsgewicht: Gewicht-139D | |||
Bloeddruk | Zie Bloeddruk: BP-139D | |||
Alcohol gebruik | ||||
Toelichting | tbv conceptie al gestopt met alcohol consumptie | |||
Alcohol gebruik status | drinkt geen alcohol (code = '105542008' in codeSystem 'SNOMED CT') | |||
Drugs gebruik | ||||
Drugs gebruik status | heeft nooit drugs gebruikt (code = '228368007' in codeSystem 'SNOMED CT') | |||
Tabak gebruik | ||||
Tabak gebruik status | heeft nooit gerookt (code = '266919005' in codeSystem 'SNOMED CT') | |||
Prenatale controle | ||||
Leven voelen observatie | ||||
Leven voelen datum tijd | T - 10 dagen | |||
Leven voelen waarde | zwakke foetale bewegingen (bevinding) (code = '276372004' in codeSystem 'SNOMED CT') | |||
Toelichting | voelt sinds enkele dagen minder frequent bewegingen | |||
Lichaamsgewicht | Zie Lichaamsgewicht: Gewicht-6D | |||
Bloeddruk | Zie Bloeddruk: BP-6D | |||
Probleem zwangerschap Probleem1 | ||||
Probleem type | Symptoom gerapporteerd door patiënt of andere bron van voorgeschiedenis (code = '418799008' in codeSystem 'SNOMED CT') | |||
Probleem naam | zwakke foetale bewegingen (bevinding) (code = '276372004' in codeSystem 'SNOMED CT') | |||
Probleem begin datum | T - 10 dagen | |||
Probleem eind datum | T - 6 dagen | |||
Zwangerschapsduur | 189 dagen | |||
Probleem status | Niet actueel (code = '73425007' in codeSystem 'SNOMED CT') | |||
Verrichting zwangerschap | ||||
Verrichting start datum | T - 139 dagen | |||
Verrichting type | echografie van foetus (verrichting) (code = '241491007' in codeSystem 'SNOMED CT') | |||
Verrichting zwangerschap | ||||
Verrichting start datum | T - 139 dagen | |||
Verrichting type | aanbieden van voorlichtingsmateriaal (verrichting) (code = '445283009' in codeSystem 'SNOMED CT') | |||
Verrichting zwangerschap | ||||
Verrichting start datum | T - 6 dagen | |||
Verrichting type | monitoren van foetale hart (regime/therapie) (code = '281568006' in codeSystem 'SNOMED CT') |
1.1.4 Medisch onderzoek
Medisch onderzoek | ||||||
Gegevenselement | Waarde | |||||
Maternale onderzoeksgegevens | ||||||
Urine bloed en aanvullende onderzoeken | ||||||
Psie | ||||||
Laboratorium test bloedgroep ABO | ||||||
Test code | ABO group [Type] in Blood (code = '883-9' in codeSystem 'LOINC') | |||||
Test uitslag | bloedgroep A (bevinding) (code = '112144000' in codeSystem 'SNOMED CT') | |||||
Laboratorium test rhesus d RhD | ||||||
Test code | D Ag [Presence] in Blood (code = '1305-2' in codeSystem 'LOINC') | |||||
Test uitslag | Rh D Positief (code = '165747007' in codeSystem 'SNOMED CT') | |||||
Laboratorium test rhesus c Rhc | ||||||
Test code | Kleine c Ag [aanwezigheid] in erytrocyten (code = '1159-3' in codeSystem 'LOINC') | |||||
Test uitslag | Rh c Positief (code = '733120009' in codeSystem 'SNOMED CT') |
1.1.5 Bouwstenen
Bouwstenen | ||||
Gegevenselement | Waarde | |||
Metingen | ||||
Bloeddruk BP-139D | ||||
Systolische bloeddruk | 133 | |||
Diastolische bloeddruk | 89 | |||
Bloeddruk datum tijd | T - 139 dagen | |||
Bloeddruk BP-6D | ||||
Systolische bloeddruk | 155 | |||
Diastolische bloeddruk | 97 | |||
Bloeddruk datum tijd | T - 6 dagen | |||
Lichaamsgewicht Gewicht-139D | ||||
Gewicht waarde | 71 kg | |||
Lichaamsgewicht Gewicht-6D | ||||
Gewicht waarde | 78 kg |
1.2 Scenario Vrouw 1, Kaart 2 - data 1e lijn (vorige zwangerschap)
Vrouw | |||
Gegevenselement | Waarde | ||
Demografische gegevens | |||
Patient | Zie Patient: Vrouw1 |
1.2.1 Administratief
Administratief | |||||
Gegevenselement | Waarde | ||||
Patient Vrouw1 | |||||
Naamgegevens | |||||
Voornamen | Hanna | ||||
Initialen | H | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Kooij | ||||
Adresgegevens | |||||
Straat | Knolweg | ||||
Huisnummer | 1002 | ||||
Postcode | 9999ZZ | ||||
Woonplaats | STITSWERD | ||||
Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||||
Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | ||||
Identificatienummer | 999900717 (in identificerend systeem: BSN) | ||||
Geboortedatum | 18 okt 1985 | ||||
Geslacht administratief | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
Patient Kind1 | |||||
Naamgegevens | |||||
Voornamen | Helen | ||||
Initialen | H.I. | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Kooij | ||||
Adresgegevens | |||||
Straat | Knolweg | ||||
Huisnummer | 1002 | ||||
Postcode | 9999ZZ | ||||
Woonplaats | STITSWERD | ||||
Geboortedatum | T - 587 dagen | ||||
Geslacht administratief | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
Meerling indicator | Nee | ||||
Zorgaanbieder ZA1 | |||||
Zorgaanbieder identificatienummer | 08001234 (in identificerend systeem: AGB-Z) | ||||
Organisatie naam | Verloskundigenpraktijk 't Groen | ||||
Adresgegevens | |||||
Straat | Groeneweg | ||||
Huisnummer | 1000 | ||||
Postcode | 1234ZZ | ||||
Woonplaats | STITSWERD | ||||
Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||||
Adres soort | Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
Organisatie type | Verloskundigenpraktijk (code = 'G3' in codeSystem 'RoleCodeNL - zorgaanbiedertype (organisaties)') | ||||
Zorgverlener ZV1 | |||||
Zorgverlener identificatienummer | 12340001 (in identificerend systeem: UZI Personen) | ||||
Naamgegevens | |||||
Roepnaam | Gemma | ||||
Naamgebruik | Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Groeneboom | ||||
Geslachtsnaam partner | |||||
Achternaam partner | XXX_Gras | ||||
Specialisme | Verloskundige (code = '03.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||
Zorgverleners rol | Case manager (code = '768832004' in codeSystem 'SNOMED CT') |
1.2.2 Zorgverlening
Zorgverlening | |||
Gegevenselement | Waarde | ||
Zorg episode | |||
Begin datum | T - 841 dagen | ||
Eind datum | T - 587 dagen |
1.2.3 Zwangerschapsgegevens
Zwangerschapsgegevens | ||||
Gegevenselement | Waarde | |||
Coordinerend zorgverlener | ||||
Zorgverlener | Zie Zorgverlener: ZV1 | |||
Zwangerschap | ||||
Zwangerschapsduur | 294 dagen | |||
Pariteit | 1 | |||
Graviditeit | 1 | |||
Aterme datum items | ||||
Aterme datum | T - 587 dagen | |||
Bepalings methode | aterme datum berekend door middel van diagnostische ultrasonografie (code = '31541000146106' in codeSystem 'SNOMED CT') | |||
Datum bepaling | NullFlavor: UNK | |||
Datum laatste menstruatie | T - 895 dagen | |||
Definitieve a terme datum observatie | ||||
Definitieve a terme datum tijd | T - 587 dagen | |||
Definitieve a terme waarde | T - 587 dagen | |||
Definitieve a terme methode | observatie (regime/therapie) (code = '225308005' in codeSystem 'SNOMED CT') | |||
Aantal foetussen observatie | ||||
Aantal foetussen waarde | 1 |
1.2.4 Bevalling
Bevalling | ||||
Gegevenselement | Waarde | |||
Partusnummer | 1 | |||
Zwangerschapsduur | 294 dagen | |||
Probleem maternaal Probleem1 | ||||
Probleem naam | niet vorderende uitdrijving (code = '249166003' in codeSystem 'SNOMED CT') | |||
Probleem begin datum | T - 587 dagen om 12:02 uur | |||
Probleem eind datum | T - 587 dagen om 12:04 uur | |||
Zwangerschapsduur | 294 dagen | |||
Verrichting maternaal Verrichting1 | ||||
Verrichting start datum | T - 587 dagen om 02:19 uur | |||
Verrichting type | vaginaal toucher (verrichting) (code = '51597003' in codeSystem 'SNOMED CT') | |||
Verrichting maternaal Verrichting2 | ||||
Verrichting start datum | T - 587 dagen om 12:04 uur | |||
Indicatie | ||||
Probleem maternaal | Zie Probleem zwangerschap: Probleem1 | |||
Verrichting type | episiotomie mediolateraal rechts (verrichting) (code = '236992007' in codeSystem 'SNOMED CT') | |||
Ontsluitingsfase | ||||
Actieve ontsluiting observatie | ||||
Observatie datum tijd | T - 587 dagen om 02:19 uur | |||
Begin actieve ontsluiting waarde | T - 587 dagen om 02:19 uur | |||
Observatie methode | palpatie (verrichting) (code = '113011001' in codeSystem 'SNOMED CT') | |||
Toelichting | 5 cm ontsluiting | |||
Wijze begin baring observatie | ||||
Observatie datum tijd | T - 588 dagen om 23:50 uur | |||
Begin baring waarde | spontaan breken van vliezen (bevinding) (code = '169734005' in codeSystem 'SNOMED CT') | |||
Observatie methode | evaluatie (kwalificatiewaarde) (code = '129265001' in codeSystem 'SNOMED CT') | |||
Uitdrijvingsfase | ||||
Patient | Zie Patient: Kind1 | |||
Type partus observatie | ||||
Observatie datum tijd | T - 587 dagen om 12:04 uur | |||
Type partus waarde | begeleiding van normale bevalling (verrichting) (code = '177184002' in codeSystem 'SNOMED CT') | |||
Werkelijke plaats baring type locatie observatie | ||||
Werkelijke plaats baring waarde | thuisbevalling (bevinding) (code = '169813005' in codeSystem 'SNOMED CT') | |||
Probleem kindspecifieke maternale problemen Probleem2 | ||||
Probleem naam | foetale nood durante partu (bevinding) (code = '288274003' in codeSystem 'SNOMED CT') | |||
Probleem begin datum | T - 587 dagen om 12:02 uur | |||
Probleem eind datum | T - 587 dagen om 12:04 uur |
1.2.5 Kind
Kind | ||||||
Gegevenselement | Waarde | |||||
Demografische gegevens | ||||||
Patient | Zie Patient: Kind1 | |||||
Lichamelijk onderzoek kind | ||||||
Geboortegewicht lichaamsgewicht | ||||||
Gewicht waarde | 3415 gram | |||||
Lichaamslengte | ||||||
Lengte waarde | 49.7 cm | |||||
Schedelomvang | ||||||
Schedelomvang waarde | 33.6 cm | |||||
Bevindingen | ||||||
Algemene indruk | ||||||
Apgar score1min | ||||||
Apgar score totaal | 7 | |||||
Apgar score5min | ||||||
Apgar score totaal | 8 | |||||
Apgar score10min | ||||||
Apgar score totaal | 10 |
1.2.6 Bouwstenen
Bouwstenen | ||||
Gegevenselement | Waarde | |||
Metingen | ||||
Bloeddruk BP1 | ||||
Systolische bloeddruk | 95 | |||
Diastolische bloeddruk | 50 | |||
Bloeddruk datum tijd | T - 587 dagen | |||
Lichaamsgewicht gew1 | ||||
Gewicht waarde | 63 kg |
1.3 Scenario Vrouw 2, Kaart 3 - data 1e lijn (meerling)
Vrouw | |||
Gegevenselement | Waarde | ||
Demografische gegevens | |||
Patient | Zie Patient: Vrouw2 | ||
Bloedonderzoek | |||
Laboratorium test bloedgroep | Zie Laboratorium test bloedgroep: ABO | ||
Laboratorium test rhesus d | Zie Laboratorium test rhesus d: RhD | ||
Laboratorium test rhesus c | Zie Laboratorium test rhesus c: Rhc |
1.3.1 Administratief
Administratief | |||||
Gegevenselement | Waarde | ||||
Patient Vrouw2 | |||||
Naamgegevens | |||||
Voornamen | Jamila | ||||
Initialen | J | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Kwee | ||||
Adresgegevens | |||||
Straat | Knolweg | ||||
Huisnummer | 1000 | ||||
Postcode | 9999XA | ||||
Woonplaats | STITSWERD | ||||
Identificatienummer | 999900730 (in identificerend systeem: BSN) | ||||
Geboortedatum | 20 okt 1985 | ||||
Geslacht administratief | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
Meerling indicator | Nee | ||||
Zorgaanbieder ZA1 | |||||
Zorgaanbieder identificatienummer | 08001234 (in identificerend systeem: AGB-Z) | ||||
Organisatie naam | Verloskundigenpraktijk 't Groen | ||||
Adresgegevens | |||||
Straat | Groeneweg | ||||
Huisnummer | 1000 | ||||
Postcode | 9999XY | ||||
Woonplaats | STITSWERD | ||||
Land | Nederland (code = '6030' in codeSystem 'GBA Tabel 34 Landentabel') | ||||
Adres soort | Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
Organisatie type | Verloskundigenpraktijk (code = 'G3' in codeSystem 'RoleCodeNL - zorgaanbiedertype (organisaties)') | ||||
Zorgverlener ZV1 | |||||
Zorgverlener identificatienummer | 12340001 (in identificerend systeem: UZI Personen) | ||||
Naamgegevens | |||||
Roepnaam | Gemma | ||||
Naamgebruik | Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Groeneboom | ||||
Geslachtsnaam partner | |||||
Achternaam partner | XXX_Gras | ||||
Specialisme | eerstelijnsverloskundige (beroep) (code = '158999002' in codeSystem 'SNOMED CT') | ||||
Zorgaanbieder | Zie Zorgaanbieder: ZA1 | ||||
Zorgverleners rol | Case manager (code = '768832004' in codeSystem 'SNOMED CT') |
1.3.2 Zorgverlening
Zorgverlening | |||
Gegevenselement | Waarde | ||
Zorg episode | |||
Begin datum | T - 205 dagen | ||
Eind datum | T - 194 dagen |
1.3.3 Zwangerschapsgegevens
Zwangerschapsgegevens | |||||
Gegevenselement | Waarde | ||||
Coordinerend zorgverlener | |||||
Zorgverlener | Zie Zorgverlener: ZV1 | ||||
Zwangerschap | |||||
Zwangerschapsduur | 59 dagen | ||||
Pariteit | 0 | ||||
Graviditeit | 1 | ||||
Aterme datum items | |||||
Aterme datum | T - 205 dagen | ||||
Bepalings methode | aterme datum berekend door middel van diagnostische ultrasonografie (code = '31541000146106' in codeSystem 'SNOMED CT') | ||||
Datum bepaling | T + 10 dagen | ||||
Datum laatste menstruatie | T - 278 dagen | ||||
Aantal foetussen observatie AantalFoetussen | |||||
Aantal foetussen datum tijd | T - 205 dagen | ||||
Aantal foetussen waarde | 2 | ||||
Observatie methode | echografie van foetus (verrichting) (code = '241491007' in codeSystem 'SNOMED CT') | ||||
Meerling zwangerschap observatie | |||||
Meerling zwangerschap datum tijd | T - 205 dagen | ||||
Aantal foetussen observatie | Zie Aantal foetussen observatie: AantalFoetussen | ||||
Observatie methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | ||||
Foliumzuurgebruik observatie | |||||
Foliumzuurgebruik datum tijd | T - 205 dagen | ||||
Foliumzuurgebruik waarde | geen preconceptionele intake van foliumzuur via voeding (bevinding) (code = '30391000146101' in codeSystem 'SNOMED CT') | ||||
Prenatale controle | |||||
Lichaamsgewicht | Zie Lichaamsgewicht: Gew-205D | ||||
Bloeddruk | Zie Bloeddruk: BP-205D | ||||
Alcohol gebruik | |||||
Alcohol gebruik status | drinkt geen alcohol (code = '105542008' in codeSystem 'SNOMED CT') | ||||
Drugs gebruik | |||||
Drugs gebruik status | heeft nooit drugs gebruikt (code = '228368007' in codeSystem 'SNOMED CT') | ||||
Tabak gebruik | |||||
Tabak gebruik status | rookt soms sigaretten (code = '230059006' in codeSystem 'SNOMED CT') | ||||
Soort tabak gebruik | gebruiker van elektronische sigaret (code = '722499006' in codeSystem 'SNOMED CT') | ||||
Waarneming gebruik | |||||
Start datum | 1 jun 2019 | ||||
Hoeveelheid | 6 keer per dag inhaleren | ||||
Probleem zwangerschap Probleem1 | |||||
Probleem naam | meerlingzwangerschap (aandoening) (code = '16356006' in codeSystem 'SNOMED CT') | ||||
Probleem begin datum | T - 205 dagen | ||||
Zwangerschapsduur | 59 dagen | ||||
Toelichting | mw.door verwijzen naar Sophia | ||||
Verrichting zwangerschap | |||||
Verrichting start datum | T - 205 dagen | ||||
Verrichting type | bloedonderzoek (verrichting) (code = '396550006' in codeSystem 'SNOMED CT') | ||||
Verrichting zwangerschap | |||||
Verrichting start datum | T - 205 dagen | ||||
Verrichting type | dieetmanagement (verrichting) (code = '410175003' in codeSystem 'SNOMED CT') |
1.3.4 Medisch onderzoek
Medisch onderzoek | ||||||
Gegevenselement | Waarde | |||||
Verrichting onderzoek | ||||||
Verrichting start datum | T-195D | |||||
Verrichting eind datum | T - 195 dagen | |||||
Maternale onderzoeksgegevens | ||||||
Urine bloed en aanvullende onderzoeken | ||||||
Psie | ||||||
Laboratorium test bloedgroep ABO | ||||||
Test code | ABO group [Type] in Blood (code = '883-9' in codeSystem 'LOINC') | |||||
Test uitslag | bloedgroep O (bevinding) (code = '58460004' in codeSystem 'SNOMED CT') | |||||
Laboratorium test rhesus d RhD | ||||||
Test code | D Ag [Presence] in Blood (code = '1305-2' in codeSystem 'LOINC') | |||||
Test uitslag | Rh D Positief (code = '165747007' in codeSystem 'SNOMED CT') | |||||
Laboratorium test rhesus c Rhc | ||||||
Test code | Kleine c Ag [aanwezigheid] in erytrocyten (code = '1159-3' in codeSystem 'LOINC') | |||||
Test uitslag | Rh c Positief (code = '733120009' in codeSystem 'SNOMED CT') | |||||
Laboratorium test hb | ||||||
Test code | Hemoglobin [Moles/volume] in Venous blood (code = '93846-4' in codeSystem 'LOINC') | |||||
Test uitslag | 7.3 g/dl |
1.3.5 Bouwstenen
Bouwstenen | ||||
Gegevenselement | Waarde | |||
Metingen | ||||
Bloeddruk BP-205D | ||||
Systolische bloeddruk | 114 | |||
Diastolische bloeddruk | 87 | |||
Bloeddruk datum tijd | T - 205 dagen | |||
Lichaamsgewicht Gew-205D | ||||
Gewicht waarde | 63 kg | |||
Gewicht datum tijd | T - 205 dagen | |||
Kleding | Lichte kleding/ondergoed (code = 'MINIMAL' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1') |
1.4 Scenario Vrouw 2, Kaart 3 - data 2e lijn (meerling)
Vrouw | |||
Gegevenselement | Waarde | ||
Demografische gegevens | |||
Patient | Zie Patient: Vrouw2 | ||
Bloedonderzoek | |||
Laboratorium test bloedgroep | Zie Laboratorium test bloedgroep: ABO | ||
Laboratorium test rhesus d | Zie Laboratorium test rhesus d: RhD | ||
Laboratorium test rhesus c | Zie Laboratorium test rhesus c: Rhc |
1.4.1 Administratief
Administratief | |||||
Gegevenselement | Waarde | ||||
Patient Vrouw2 | |||||
Naamgegevens | |||||
Voornamen | Jamila | ||||
Initialen | J | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Kwee | ||||
Adresgegevens | |||||
Straat | Knolweg | ||||
Huisnummer | 1000 | ||||
Postcode | 9999XA | ||||
Woonplaats | STITSWERD | ||||
Identificatienummer | 999900730 (in identificerend systeem: BSN) | ||||
Geboortedatum | 20 okt 1985 | ||||
Geslacht administratief | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
Meerling indicator | Nee | ||||
Patient Kind2 | |||||
Naamgegevens | |||||
Voornamen | Jusef | ||||
Initialen | J | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Kwee | ||||
Adresgegevens | |||||
Straat | Knolweg | ||||
Huisnummer | 1000 | ||||
Postcode | 9999XA | ||||
Woonplaats | STITSWERD | ||||
Geboortedatum | T - 5 dagen | ||||
Geslacht administratief | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | ||||
Meerling indicator | Ja | ||||
Rangnummer | 1 | ||||
Patient Kind3 | |||||
Naamgegevens | |||||
Voornamen | Jamal | ||||
Initialen | J | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Kwee | ||||
Adresgegevens | |||||
Straat | Knolweg | ||||
Huisnummer | 1000 | ||||
Postcode | 9999XA | ||||
Woonplaats | STITSWERD | ||||
Geboortedatum | T - 5 dagen | ||||
Geslacht administratief | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | ||||
Meerling indicator | Ja | ||||
Rangnummer | 2 | ||||
Zorgaanbieder ZA2 | |||||
Zorgaanbieder identificatienummer | 06020806 (in identificerend systeem: AGB-Z) | ||||
Organisatie naam | Erasmus MC, Sophia kinderziekenhuis | ||||
Adresgegevens | |||||
Straat | Dr. Molewaterplein | ||||
Huisnummer | 60 | ||||
Postcode | 3015 GJ | ||||
Woonplaats | ROTTERDAM | ||||
Adres soort | Werkadres (code = 'WP' in codeSystem 'HL7 AddressUse') | ||||
Organisatie type | Universitair Medisch Centrum (code = 'V5' in codeSystem 'RoleCodeNL - zorgaanbiedertype (organisaties)') | ||||
Zorgverlener ZV2 | |||||
Zorgverlener identificatienummer | 98765432 (in identificerend systeem: UZI Personen) | ||||
Naamgegevens | |||||
Roepnaam | Eduard | ||||
Naamgebruik | Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Egelinks | ||||
Geslachtsnaam partner | |||||
Achternaam partner | XXX_Gras | ||||
Specialisme | Gynaecoloog (code = '01.046' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||
Zorgaanbieder | Zie Zorgaanbieder: ZA2 | ||||
Zorgverleners rol | Hoofdbehandelaar (code = 'RESP' in codeSystem 'HL7 ParticipationType') |
1.4.2 Zorgverlening
Zorgverlening | |||
Gegevenselement | Waarde | ||
Zorg episode | |||
Begin datum | T - 193 dagen |
1.4.3 Zwangerschapsgegevens
Zwangerschapsgegevens | |||||
Gegevenselement | Waarde | ||||
Coordinerend zorgverlener | |||||
Zorgverlener | Zie Zorgverlener: ZV2 | ||||
Zwangerschap | |||||
Zwangerschapsduur | 259 dagen | ||||
Pariteit | 1 | ||||
Graviditeit | 1 | ||||
Aterme datum items | |||||
Aterme datum | T + 10 dagen | ||||
Bepalings methode | Anders (code = 'OTH' in codeSystem 'HL7 NullFlavor'): uit verwijzing verloskundigenpraktijk | ||||
Datum bepaling | T - 205 dagen | ||||
Datum laatste menstruatie | T - 278 dagen | ||||
Definitieve a terme datum observatie | |||||
Definitieve a terme datum tijd | T - 126 dagen om 13:45 uur | ||||
Definitieve a terme waarde | T + 2 dagen | ||||
Definitieve a terme methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | ||||
Aantal foetussen observatie AantalFoetussen | |||||
Aantal foetussen datum tijd | T - 193 dagen | ||||
Aantal foetussen waarde | 2 | ||||
Observatie methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | ||||
Meerling zwangerschap observatie | |||||
Meerling zwangerschap datum tijd | T - 193 dagen | ||||
Typering gemellizwangerschap waarde | monochoriale diamniotische tweelingzwangerschap (aandoening) (code = '459168005' in codeSystem 'SNOMED CT') | ||||
Aantal foetussen observatie | Zie Aantal foetussen observatie: AantalFoetussen | ||||
Observatie methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | ||||
Aantal levende kinderen observatie | |||||
Aantal levende kinderen datum tijd | T - 76 dagen | ||||
Aantal levende kinderen waarde | 2 | ||||
Observatie methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | ||||
Foliumzuurgebruik observatie | |||||
Foliumzuurgebruik datum tijd | T - 193 dagen | ||||
Foliumzuurgebruik waarde | intake van foliumzuur via voeding vanaf vastgestelde zwangerschap (bevinding) (code = '29771000146106' in codeSystem 'SNOMED CT') | ||||
Toelichting | op advies verloskundigenpraktijk gestart | ||||
Prenatale controle | |||||
Leven voelen observatie | |||||
Leven voelen datum tijd | T - 193 dagen om 13:40 uur | ||||
Leven voelen waarde | foetale bewegingen aanwezig (bevinding) (code = '289431008' in codeSystem 'SNOMED CT') | ||||
Observatie methode | palpatie (verrichting) (code = '113011001' in codeSystem 'SNOMED CT') | ||||
Lichaamsgewicht | Zie Lichaamsgewicht: Gew-193D | ||||
Bloeddruk | Zie Bloeddruk: BP-193D | ||||
Alcohol gebruik | |||||
Alcohol gebruik status | drinkt geen alcohol (code = '105542008' in codeSystem 'SNOMED CT') | ||||
Drugs gebruik | |||||
Drugs gebruik status | heeft nooit drugs gebruikt (code = '228368007' in codeSystem 'SNOMED CT') | ||||
Tabak gebruik | |||||
Toelichting | gestopt op advies verloskundige | ||||
Tabak gebruik status | rookte vroeger (code = '8517006' in codeSystem 'SNOMED CT') | ||||
Soort tabak gebruik | gebruiker van elektronische sigaret (code = '722499006' in codeSystem 'SNOMED CT') | ||||
Waarneming gebruik | |||||
Start datum | 1 jun 2019 | ||||
Stop datum | T - 198 dagen | ||||
Prenatale controle | |||||
Bloeddruk | Zie Bloeddruk: BP-76D | ||||
Probleem zwangerschap Probleem1 | |||||
Probleem naam | meerlingzwangerschap (aandoening) (code = '16356006' in codeSystem 'SNOMED CT') | ||||
Probleem begin datum | T - 193 dagen | ||||
Zwangerschapsduur | 71 dagen | ||||
Probleem zwangerschap Probleem2 | |||||
Probleem type | Klinische bevinding (code = '404684003' in codeSystem 'SNOMED CT') | ||||
Probleem naam | intra-uteriene groeiretardatie (aandoening) (code = '22033007' in codeSystem 'SNOMED CT') | ||||
Probleem begin datum | T - 76 dagen | ||||
Zwangerschapsduur | 188 dagen | ||||
Toelichting | tweede kind blijft erg achter in ontwikkeling | ||||
Verrichting zwangerschap | |||||
Verrichting start datum | T - 193 dagen | ||||
Verrichting type | bloedonderzoek (verrichting) (code = '396550006' in codeSystem 'SNOMED CT') | ||||
Verrichting zwangerschap | |||||
Verrichting start datum | T - 5 dagen | ||||
Verrichting type | opname in ziekenhuis (verrichting) (code = '32485007' in codeSystem 'SNOMED CT') |
1.4.4 Bevalling
Bevalling | |||||
Gegevenselement | Waarde | ||||
Partusnummer | 1 | ||||
Zwangerschapsduur | 259 dagen | ||||
Uitdrijvingsfase | |||||
Patient | Zie Patient: Kind2 | ||||
Type partus observatie | |||||
Observatie datum tijd | T - 5 dagen | ||||
Type partus waarde | sectio caesarea (verrichting) (code = '11466000' in codeSystem 'SNOMED CT') | ||||
Werkelijke plaats baring type locatie observatie | |||||
Observatie datum tijd | T - 5 dagen om 14:38 uur | ||||
Werkelijke plaats baring waarde | geboorte in ziekenhuis (bevinding) (code = '56321000146103' in codeSystem 'SNOMED CT') | ||||
Toelichting | geplande sectio | ||||
Ziekenhuis baring | |||||
Zorgaanbieder | Zie Zorgaanbieder: ZA2 | ||||
Probleem kindspecifieke maternale problemen Probleem3 | |||||
Probleem naam | liggingsafwijking van foetus (bevinding) (code = '15028002' in codeSystem 'SNOMED CT') | ||||
Probleem begin datum | T - 5 dagen | ||||
Verrichting kindspecifieke maternale verrichtingen | |||||
Verrichting start datum | T - 5 dagen om 14:03 uur | ||||
Verrichting eind datum | T - 5 dagen om 14:52 uur | ||||
Indicatie | |||||
Probleem kindspecifieke maternale problemen | Zie Probleem kindspecifieke maternale problemen: Probleem2 | ||||
Verrichting type | primaire sectio caesarea (verrichting) (code = '80771000146107' in codeSystem 'SNOMED CT') | ||||
Verrichting kindspecifieke maternale verrichtingen | |||||
Verrichting start datum | T - 5 dagen om 14:50 uur | ||||
Verrichting type | vitamine K toediening aan neonaat (code = '698350008:370131001=133933007' in codeSystem 'SNOMED CT') | ||||
Uitdrijvingsfase | |||||
Patient | Zie Patient: Kind3 | ||||
Type partus observatie | |||||
Observatie datum tijd | T - 5 dagen | ||||
Type partus waarde | sectio caesarea (verrichting) (code = '11466000' in codeSystem 'SNOMED CT') | ||||
Werkelijke plaats baring type locatie observatie | |||||
Observatie datum tijd | T - 5 dagen om 14:38 uur | ||||
Werkelijke plaats baring waarde | geboorte in ziekenhuis (bevinding) (code = '56321000146103' in codeSystem 'SNOMED CT') | ||||
Toelichting | geplande sectio | ||||
Ziekenhuis baring | |||||
Zorgaanbieder | Zie Zorgaanbieder: ZA2 | ||||
Verrichting kindspecifieke maternale verrichtingen | |||||
Verrichting start datum | T - 5 dagen om 14:03 uur | ||||
Verrichting eind datum | T - 5 dagen om 14:52 uur | ||||
Indicatie | |||||
Probleem kindspecifieke maternale problemen | Zie Probleem kindspecifieke maternale problemen: Probleem2 | ||||
Verrichting type | primaire sectio caesarea (verrichting) (code = '80771000146107' in codeSystem 'SNOMED CT') | ||||
Verrichting kindspecifieke maternale verrichtingen | |||||
Verrichting start datum | T - 5 dagen om 14:52 uur | ||||
Verrichting type | inflatie van long door intermitterende compressie van reservoirballon (code = '243140006' in codeSystem 'SNOMED CT') | ||||
Verrichting kindspecifieke maternale verrichtingen | |||||
Verrichting start datum | T - 5 dagen om 14:55 uur | ||||
Verrichting type | vitamine K toediening aan neonaat (code = '698350008:370131001=133933007' in codeSystem 'SNOMED CT') |
1.4.5 Kind
Kind | ||||||
Gegevenselement | Waarde | |||||
Demografische gegevens | ||||||
Patient | Zie Patient: Kind2 | |||||
Lichamelijk onderzoek kind | ||||||
Geboortegewicht lichaamsgewicht | ||||||
Gewicht waarde | 2605 gram | |||||
Gewicht datum tijd | T - 5 dagen om 15:10 uur | |||||
Kleding | Luier (code = 'DIAPER' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1') | |||||
Lichaamslengte | ||||||
Lengte waarde | 48 | |||||
Schedelomvang | ||||||
Schedelomvang waarde | 32.6 cm | |||||
Bevindingen | ||||||
Algemene indruk | ||||||
Apgar score1min | ||||||
Apgar score totaal | 7 | |||||
Apgar score5min | ||||||
Apgar score totaal | 10 | |||||
Apgar score10min | ||||||
Apgar score totaal | 10 |
1.4.6 Kind
Kind | ||||||
Gegevenselement | Waarde | |||||
Demografische gegevens | ||||||
Patient | Zie Patient: Kind3 | |||||
Lichamelijk onderzoek kind | ||||||
Geboortegewicht lichaamsgewicht | ||||||
Gewicht waarde | 2089 gram | |||||
Gewicht datum tijd | T - 5 dagen om 15:05 uur | |||||
Kleding | Zonder kleding. (code = 'UNDRESSED' in codeSystem '2.16.840.1.113883.2.4.3.11.60.40.4.8.1') | |||||
Lichaamslengte | ||||||
Lengte waarde | 46 | |||||
Schedelomvang | ||||||
Schedelomvang waarde | 31.8 cm | |||||
Bevindingen | ||||||
Algemene indruk | ||||||
Apgar score1min | ||||||
Apgar score totaal | 5 | |||||
Apgar score5min | ||||||
Apgar score totaal | 9 | |||||
Apgar score10min | ||||||
Apgar score totaal | 10 |
1.4.7 Medisch onderzoek
Medisch onderzoek | ||||||
Gegevenselement | Waarde | |||||
Verrichting onderzoek | ||||||
Verrichting start datum | T-193D | |||||
Verrichting eind datum | T - 193 dagen | |||||
Maternale onderzoeksgegevens | ||||||
Urine bloed en aanvullende onderzoeken | ||||||
Psie | ||||||
Laboratorium test bloedgroep ABO | ||||||
Test code | ABO group [Type] in Blood (code = '883-9' in codeSystem 'LOINC') | |||||
Test uitslag | bloedgroep O (bevinding) (code = '58460004' in codeSystem 'SNOMED CT') | |||||
Laboratorium test rhesus d RhD | ||||||
Test code | D Ag [Presence] in Blood (code = '1305-2' in codeSystem 'LOINC') | |||||
Test uitslag | Rh D Positief (code = '165747007' in codeSystem 'SNOMED CT') | |||||
Laboratorium test rhesus c Rhc | ||||||
Test code | Kleine c Ag [aanwezigheid] in erytrocyten (code = '1159-3' in codeSystem 'LOINC') | |||||
Test uitslag | Rh c Positief (code = '733120009' in codeSystem 'SNOMED CT') | |||||
Laboratorium test hb | ||||||
Test code | Hemoglobin [Moles/volume] in Venous blood (code = '93846-4' in codeSystem 'LOINC') | |||||
Test uitslag | 7.0 g/dl | |||||
Torch | ||||||
Laboratorium test torch | ||||||
Test code | Toxoplasma gondii IgG Ab [Units/volume] in Serum (code = '8039-0' in codeSystem 'LOINC') | |||||
Test uitslag | 9 k[arb'u]/l |
1.4.8 Medisch onderzoek
Medisch onderzoek | |||||
Gegevenselement | Waarde | ||||
Verrichting onderzoek | |||||
Verrichting start datum | T-76D | ||||
Verrichting eind datum | T - 76 dagen | ||||
Maternale onderzoeksgegevens | |||||
Urine bloed en aanvullende onderzoeken | |||||
Laboratorium test hb | |||||
Test code | Hemoglobin [Moles/volume] in Venous blood (code = '93846-4' in codeSystem 'LOINC') | ||||
Test uitslag | 6.7 g/dl |
1.4.9 Medisch onderzoek
Medisch onderzoek | |||||
Gegevenselement | Waarde | ||||
Verrichting onderzoek | |||||
Verrichting start datum | T-5D | ||||
Verrichting eind datum | T - 5 dagen | ||||
Maternale onderzoeksgegevens | |||||
Urine bloed en aanvullende onderzoeken | |||||
Laboratorium test hb | |||||
Test code | Hemoglobin [Moles/volume] in Venous blood (code = '93846-4' in codeSystem 'LOINC') | ||||
Test uitslag | 6.5 g/dl |
1.4.10 Bouwstenen
Bouwstenen | ||||
Gegevenselement | Waarde | |||
Metingen | ||||
Bloeddruk BP-193D | ||||
Systolische bloeddruk | 123 | |||
Diastolische bloeddruk | 81 | |||
Bloeddruk datum tijd | T - 193 dagen | |||
Lichaamsgewicht Gew-193D | ||||
Gewicht waarde | 65 kg | |||
Gewicht datum tijd | T - 193 dagen | |||
Metingen | ||||
Bloeddruk BP-76D | ||||
Systolische bloeddruk | 108 | |||
Diastolische bloeddruk | 79 | |||
Bloeddruk datum tijd | T - 76 dagen | |||
Metingen | ||||
Bloeddruk BP-5D | ||||
Systolische bloeddruk | 91 | |||
Diastolische bloeddruk | 57 | |||
Bloeddruk datum tijd | T - 5 dagen |
1.5 Scenario Vrouw 3, geen zwangerschapskaart beschikbaar
1.5.1 Administratief
Administratief | |||||
Gegevenselement | Waarde | ||||
Patient Vrouw3 | |||||
Naamgegevens | |||||
Voornamen | Julia | ||||
Initialen | J | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem '2.16.840.1.113883.2.4.3.11.60.101.5.4') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Laarhoven | ||||
Adresgegevens | |||||
Straat | Knolweg | ||||
Huisnummer | 1002 | ||||
Postcode | 9999ZZ | ||||
Woonplaats | STITSWERD | ||||
Identificatienummer | 999900754 (in identificerend systeem: BSN) | ||||
Geboortedatum | 22 okt 1985 | ||||
Geslacht administratief | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
Zorgaanbieder | |||||
Zorgaanbieder identificatienummer | (in identificerend systeem: AGB-Z) | ||||
Zorgverlener | |||||
Zorgverlener identificatienummer | (in identificerend systeem: AGB-Z) |