gz:InhoudelijkeGegevens Integrale Zwangerschapskaart Basis Verloskunde: verschil tussen versies
| Regel 1: | Regel 1: | ||
| − | + | <noinclude> | |
| + | {{DISPLAYTITLE:MedMij Integrale zwangerschapskaart - inhoud }} | ||
| + | __NUMBEREDHEADINGS__ | ||
| + | |||
| + | =Addenda voor inhoudelijke gegevens Integrale zwangerschapskaart 3.2=</noinclude> | ||
| + | ==Scenario Vrouw 1, Kaart 1 - data 1e lijn (actieve 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;" | ||
| + | |colspan="3" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Demografische gegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Patient | ||
| + | |style="background-color: white;"|Zie [[#Vrouw1|Patient: Vrouw1]] | ||
| + | |}<section end= /> | ||
| + | === Administratief === | ||
| + | <section begin=administratief_ /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D; color: white; font-weight: bold; text-align:center;" colspan="6" | Administratief | ||
| + | |-style="background-color: #1F497D; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="Contact-139D" title="Intern ID = Contact-139D">Contact Contact-139D</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Contact type | ||
| + | |style="background-color: white;"|Poliklinisch (code = 'AMB' in codeSystem '<span title="2.16.840.1.113883.5.4">HL7 ActCode</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Contact soort | ||
| + | |style="background-color: white;"|consult (verrichting) (code = '11429006' in codeSystem 'SNOMED CT') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Contact met | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Zorgverlener | ||
| + | |style="background-color: white;"|Zie [[#Sc1ZV1|Zorgverlener: Sc1ZV1]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Begin datum tijd | ||
| + | |style="background-color: white;"|T - 139 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Eind datum tijd | ||
| + | |style="background-color: white;"|T - 139 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="Contact-6D" title="Intern ID = Contact-6D">Contact Contact-6D</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Contact type | ||
| + | |style="background-color: white;"|Poliklinisch (code = 'AMB' in codeSystem '<span title="2.16.840.1.113883.5.4">HL7 ActCode</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Contact soort | ||
| + | |style="background-color: white;"|consult (verrichting) (code = '11429006' in codeSystem 'SNOMED CT') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Begin datum tijd | ||
| + | |style="background-color: white;"|T - 6 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Eind datum tijd | ||
| + | |style="background-color: white;"|T - 6 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="Vrouw1" title="Intern ID = Vrouw1">Patient Vrouw1</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="21"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Naamgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Voornamen | ||
| + | |style="background-color: white;"|Hanna | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Initialen | ||
| + | |style="background-color: white;"|H | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Naamgebruik | ||
| + | |style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '<span title="2.16.840.1.113883.2.4.3.11.60.101.5.4">ZIB Naamgebruik</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslachtsnaam | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Achternaam | ||
| + | |style="background-color: white;"|XXX_Kooij | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Adresgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Straat | ||
| + | |style="background-color: white;"|Knolweg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Huisnummer | ||
| + | |style="background-color: white;"|1002 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Postcode | ||
| + | |style="background-color: white;"|9999ZZ | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Woonplaats | ||
| + | |style="background-color: white;"|STITSWERD | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Land | ||
| + | |style="background-color: white;"|Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Adres soort | ||
| + | |style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem '<span title="2.16.840.1.113883.5.1119">HL7 AddressUse</span>') | ||
| + | |-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;" | ||
| + | |colspan="4"|Geboren indicator | ||
| + | |style="background-color: white;"|Ja | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geboortedatum | ||
| + | |style="background-color: white;"|18 okt 1985 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslacht administratief | ||
| + | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem '<span title="2.16.840.1.113883.5.1">HL7 AdministrativeGender</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="Sc1ZA1" title="Intern ID = Sc1ZA1">Zorgaanbieder Sc1ZA1</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="12"| | ||
| + | |-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;" | ||
| + | |colspan="4"|Organisatie naam | ||
| + | |style="background-color: white;"|Verloskundigenpraktijk 't Groen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Adresgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Straat | ||
| + | |style="background-color: white;"|Groeneweg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Huisnummer | ||
| + | |style="background-color: white;"|1000 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Postcode | ||
| + | |style="background-color: white;"|1234ZZ | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Woonplaats | ||
| + | |style="background-color: white;"|STITSWERD | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Land | ||
| + | |style="background-color: white;"|Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Adres soort | ||
| + | |style="background-color: white;"|Werkadres (code = 'WP' in codeSystem '<span title="2.16.840.1.113883.5.1119">HL7 AddressUse</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Organisatie type | ||
| + | |style="background-color: white;"|Verloskundigenpraktijk (code = 'G3' in codeSystem 'RoleCodeNL - zorgaanbiedertype (organisaties)') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="Sc1ZV1" title="Intern ID = Sc1ZV1">Zorgverlener Sc1ZV1</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="14"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zorgverlener identificatienummer | ||
| + | |style="background-color: white;"|12340001 (in identificerend systeem: UZI Personen) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Naamgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="9"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Voornamen | ||
| + | |style="background-color: white;"|Gemma | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Naamgebruik | ||
| + | |style="background-color: white;"|Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem '<span title="2.16.840.1.113883.2.4.3.11.60.101.5.4">ZIB Naamgebruik</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslachtsnaam | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Achternaam | ||
| + | |style="background-color: white;"|XXX_Groeneboom | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslachtsnaam partner | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Achternaam partner | ||
| + | |style="background-color: white;"|XXX_Gras | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Specialisme | ||
| + | |style="background-color: white;"|Verloskundige (code = '03.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zorgaanbieder | ||
| + | |style="background-color: white;"|Zie [[#Sc1ZA1|Zorgaanbieder: Sc1ZA1]] | ||
| + | |}<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;" | ||
| + | |colspan="4"|Zorg episode | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Identificatienummer | ||
| + | |style="background-color: white;"|5465498897 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Begin datum | ||
| + | |style="background-color: white;"|T - 139 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;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Zorgverlener | ||
| + | |style="background-color: white;"|Zie [[#Sc1ZV1|Zorgverlener: Sc1ZV1]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Zwangerschap | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="10"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Zwangerschapsduur | ||
| + | |style="background-color: white;"|NullFlavor: NA | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Pariteit | ||
| + | |style="background-color: white;"|1 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Graviditeit | ||
| + | |style="background-color: white;"|3 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Aterme datum items | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Aterme datum | ||
| + | |style="background-color: white;"|T + 99 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Bepalings methode | ||
| + | |style="background-color: white;"|Anders (code = 'OTH' in codeSystem '<span title="2.16.840.1.113883.5.1008">HL7 NullFlavor</span>'): zwangerschapstest clearlypink met zwangerschapsduur-indicator | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Datum bepaling | ||
| + | |style="background-color: white;"|NullFlavor: UNK | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Datum laatste menstruatie | ||
| + | |style="background-color: white;"|T - 195 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Definitieve a terme datum observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Definitieve a terme datum tijd | ||
| + | |style="background-color: white;"|T - 125 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Definitieve a terme waarde | ||
| + | |style="background-color: white;"|T + 94 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Definitieve a terme methode | ||
| + | |style="background-color: white;"|echografie (kwalificatiewaarde) (code = '278292003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Aantal levende kinderen observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Aantal levende kinderen datum tijd | ||
| + | |style="background-color: white;"|T - 125 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Aantal levende kinderen waarde | ||
| + | |style="background-color: white;"|1 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Foliumzuurgebruik observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Foliumzuurgebruik datum tijd | ||
| + | |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 '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Prenatale controle | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="15"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Contact | ||
| + | |style="background-color: white;"|Zie [[#Contact-139D|Contact: Contact-139D]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Zwangerschapsduur | ||
| + | |style="background-color: white;"|47 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Lichaamsgewicht | ||
| + | |style="background-color: white;"|Zie [[#Gewicht-139D|Lichaamsgewicht: Gewicht-139D]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Bloeddruk | ||
| + | |style="background-color: white;"|Zie [[#BP-139D|Bloeddruk: BP-139D]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |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;" | ||
| + | |colspan="2"|Alcohol gebruik status | ||
| + | |style="background-color: white;"|drinkt geen alcohol (code = '105542008' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Drugs gebruik | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Drugs gebruik status | ||
| + | |style="background-color: white;"|heeft nooit drugs gebruikt (code = '228368007' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Tabak gebruik | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Tabak gebruik status | ||
| + | |style="background-color: white;"|heeft nooit gerookt (code = '266919005' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Prenatale controle | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="10"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Contact | ||
| + | |style="background-color: white;"|Zie [[#Contact-6D|Contact: Contact-6D]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Zwangerschapsduur | ||
| + | |style="background-color: white;"|180 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Leven voelen observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Leven voelen datum tijd | ||
| + | |style="background-color: white;"|T - 10 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Leven voelen waarde | ||
| + | |style="background-color: white;"|zwakke foetale bewegingen (bevinding) (code = '276372004' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Toelichting | ||
| + | |style="background-color: white;"|voelt sinds enkele dagen minder frequent bewegingen | ||
| + | |-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;" | ||
| + | |colspan="3"|Bloeddruk | ||
| + | |style="background-color: white;"|Zie [[#BP-6D|Bloeddruk: BP-6D]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|<span id="Sc1Probleem1" title="Intern ID = Sc1Probleem1">Probleem zwangerschap Sc1Probleem1</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Probleem type | ||
| + | |style="background-color: white;"|bevinding gerapporteerd door patiënt of andere bron van voorgeschiedenis (code = '418799008' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Probleem naam | ||
| + | |style="background-color: white;"|zwakke foetale bewegingen (bevinding) (code = '276372004' in codeSystem 'SNOMED CT') | ||
| + | |-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;" | ||
| + | |colspan="3"|Probleem eind datum | ||
| + | |style="background-color: white;"|T - 6 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Zwangerschapsduur | ||
| + | |style="background-color: white;"|176 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Probleem status | ||
| + | |style="background-color: white;"|Niet actueel (code = '73425007' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Verrichting zwangerschap | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting start datum | ||
| + | |style="background-color: white;"|T - 139 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting type | ||
| + | |style="background-color: white;"|echografie van foetus (verrichting) (code = '241491007' in codeSystem 'SNOMED CT') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Verrichting zwangerschap | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting start datum | ||
| + | |style="background-color: white;"|T - 139 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting type | ||
| + | |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;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting start datum | ||
| + | |style="background-color: white;"|T - 6 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting type | ||
| + | |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%" | ||
| + | |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;" | ||
| + | |colspan="6" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="7"|Maternale onderzoeksgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="33"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Urine bloed en aanvullende onderzoeken | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="31"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Psie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="29"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|<span id="Sc1ABO" title="Intern ID = Sc1ABO">Laboratorium test bloedgroep Sc1ABO</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test code | ||
| + | |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 A (bevinding) (code = '112144000' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|<span id="Sc1RhD" title="Intern ID = Sc1RhD">Laboratorium test rhesus d Sc1RhD</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-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;" | ||
| + | |colspan="2"|Test uitslag | ||
| + | |style="background-color: white;"|Rh D Positief (code = '165747007' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|<span id="Sc1Rhc" title="Intern ID = Sc1Rhc">Laboratorium test rhesus c Sc1Rhc</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test code | ||
| + | |style="background-color: white;"|Kleine c Ag [aanwezigheid] in erytrocyten (code = '1159-3' in codeSystem 'LOINC') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test uitslag | ||
| + | |style="background-color: white;"|Rh c Positief (code = '733120009' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Laboratorium test hbs ag | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test code | ||
| + | |style="background-color: white;"|Hepatitis B-virusoppervlakte Ag [eenheden/volume] in serum (code = '58452-4' in codeSystem 'LOINC') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test uitslag | ||
| + | |style="background-color: white;"|0 k[arb'U]/L | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Laboratorium test hiv | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test code | ||
| + | |style="background-color: white;"|HIV 1 As [aanwezigheid] in serum of plasma d.m.v. immunoassay (code = '29893-5' in codeSystem 'LOINC') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test uitslag | ||
| + | |style="background-color: white;"|humaan immunodeficiëntievirus negatief (bevinding) (code = '165815009' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Laboratorium test lues | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test code | ||
| + | |style="background-color: white;"|Treponema pallidum As [eenheden/volume] in serum (code = '11597-2' in codeSystem 'LOINC') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test uitslag | ||
| + | |style="background-color: white;"|0 k[arb'U]/L | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Irregulaire antistoffen observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Irregulaire antistoffen waarde | ||
| + | |style="background-color: white;"|Nee | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Welke antistoffen waarde | ||
| + | |style="background-color: white;"|irregulaire antilichamen afwezig (bevinding) (code = '568111000005107' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |}<section end=medisch_onderzoek_ /> | ||
| + | === Bouwstenen === | ||
| + | <section begin=bouwstenen_ /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D; color: white; font-weight: bold; text-align:center;" colspan="5" | Bouwstenen | ||
| + | |-style="background-color: #1F497D; color: white; text-align:left;" | ||
| + | |colspan="4" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Metingen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="19"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |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;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Systolische bloeddruk | ||
| + | |style="background-color: white;"|155 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Diastolische bloeddruk | ||
| + | |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;" | ||
| + | |colspan="4"|<span id="Gewicht-139D" title="Intern ID = Gewicht-139D">Lichaamsgewicht Gewicht-139D</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Gewicht waarde | ||
| + | |style="background-color: white;"|71 kg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Gewicht datum tijd | ||
| + | |style="background-color: white;"|T - 139 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|<span id="Gewicht-6D" title="Intern ID = Gewicht-6D">Lichaamsgewicht Gewicht-6D</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Gewicht waarde | ||
| + | |style="background-color: white;"|78 kg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Gewicht datum tijd | ||
| + | |style="background-color: white;"|T - 6 dagen | ||
| + | |}<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;" | ||
| + | |colspan="3" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Demografische gegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Patient | ||
| + | |style="background-color: white;"|Zie [[#XXX_Kooij_Vrouw|Patient: XXX_Kooij_Vrouw]] | ||
| + | |}<section end= /> | ||
| + | === Administratief === | ||
| + | <section begin=administratief_ /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D; color: white; font-weight: bold; text-align:center;" colspan="6" | Administratief | ||
| + | |-style="background-color: #1F497D; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="Contact-587D" title="Intern ID = Contact-587D">Contact Contact-587D</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Contact type | ||
| + | |style="background-color: white;"|Poliklinisch (code = 'AMB' in codeSystem '<span title="2.16.840.1.113883.5.4">HL7 ActCode</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Contact soort | ||
| + | |style="background-color: white;"|consult (verrichting) (code = '11429006' in codeSystem 'SNOMED CT') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Contact met | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Zorgverlener | ||
| + | |style="background-color: white;"|Zie [[#ZV1|Zorgverlener: ZV1]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Begin datum tijd | ||
| + | |style="background-color: white;"|T - 587 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Eind datum tijd | ||
| + | |style="background-color: white;"|T - 587 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="XXX_Kooij_Vrouw" title="Intern ID = XXX_Kooij_Vrouw">Patient XXX_Kooij_Vrouw</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="21"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Naamgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Voornamen | ||
| + | |style="background-color: white;"|Hanna | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Initialen | ||
| + | |style="background-color: white;"|H | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Naamgebruik | ||
| + | |style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '<span title="2.16.840.1.113883.2.4.3.11.60.101.5.4">ZIB Naamgebruik</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslachtsnaam | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Achternaam | ||
| + | |style="background-color: white;"|XXX_Kooij | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Adresgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Straat | ||
| + | |style="background-color: white;"|Knolweg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Huisnummer | ||
| + | |style="background-color: white;"|1002 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Postcode | ||
| + | |style="background-color: white;"|9999ZZ | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Woonplaats | ||
| + | |style="background-color: white;"|STITSWERD | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Land | ||
| + | |style="background-color: white;"|Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Adres soort | ||
| + | |style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem '<span title="2.16.840.1.113883.5.1119">HL7 AddressUse</span>') | ||
| + | |-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;" | ||
| + | |colspan="4"|Geboren indicator | ||
| + | |style="background-color: white;"|Ja | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geboortedatum | ||
| + | |style="background-color: white;"|18 okt 1985 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslacht administratief | ||
| + | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem '<span title="2.16.840.1.113883.5.1">HL7 AdministrativeGender</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="XXX_Kooij_Kind" title="Intern ID = XXX_Kooij_Kind">Patient XXX_Kooij_Kind</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="11"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Naamgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Voornamen | ||
| + | |style="background-color: white;"|Eduard | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Roepnaam | ||
| + | |style="background-color: white;"|Ed | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslachtsnaam | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Achternaam | ||
| + | |style="background-color: white;"|XXX_Kooij | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geboren indicator | ||
| + | |style="background-color: white;"|Ja | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geboortedatum | ||
| + | |style="background-color: white;"|10 feb 2010 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslacht administratief | ||
| + | |style="background-color: white;"|Man (code = 'M' in codeSystem '<span title="2.16.840.1.113883.5.1">HL7 AdministrativeGender</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |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;" | ||
| + | |colspan="4"|Zorgaanbieder identificatienummer | ||
| + | |style="background-color: white;"|08001234 (in identificerend systeem: AGB-Z) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Organisatie naam | ||
| + | |style="background-color: white;"|Verloskundigenpraktijk 't Groen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Adresgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Straat | ||
| + | |style="background-color: white;"|Groeneweg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Huisnummer | ||
| + | |style="background-color: white;"|1000 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Postcode | ||
| + | |style="background-color: white;"|1234ZZ | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Woonplaats | ||
| + | |style="background-color: white;"|STITSWERD | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Land | ||
| + | |style="background-color: white;"|Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Adres soort | ||
| + | |style="background-color: white;"|Werkadres (code = 'WP' in codeSystem '<span title="2.16.840.1.113883.5.1119">HL7 AddressUse</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Organisatie type | ||
| + | |style="background-color: white;"|Verloskundigenpraktijk (code = 'G3' in codeSystem 'RoleCodeNL - zorgaanbiedertype (organisaties)') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="ZV1" title="Intern ID = ZV1">Zorgverlener ZV1</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="14"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zorgverlener identificatienummer | ||
| + | |style="background-color: white;"|12340001 (in identificerend systeem: UZI Personen) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Naamgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="9"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Roepnaam | ||
| + | |style="background-color: white;"|Gemma | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Naamgebruik | ||
| + | |style="background-color: white;"|Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem '<span title="2.16.840.1.113883.2.4.3.11.60.101.5.4">ZIB Naamgebruik</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslachtsnaam | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Achternaam | ||
| + | |style="background-color: white;"|XXX_Groeneboom | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslachtsnaam partner | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Achternaam partner | ||
| + | |style="background-color: white;"|XXX_Gras | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Specialisme | ||
| + | |style="background-color: white;"|Verloskundige (code = '03.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zorgaanbieder | ||
| + | |style="background-color: white;"|Zie [[#ZA1|Zorgaanbieder: ZA1]] | ||
| + | |}<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;" | ||
| + | |colspan="4"|Zorg episode | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Identificatienummer | ||
| + | |style="background-color: white;"|9955687 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Begin datum | ||
| + | |style="background-color: white;"|T - 841 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Eind datum | ||
| + | |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;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Zorgverlener | ||
| + | |style="background-color: white;"|Zie [[#ZV1|Zorgverlener: ZV1]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Zwangerschap | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="10"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Zwangerschapsduur | ||
| + | |style="background-color: white;"|NullFlavor: NA | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Pariteit | ||
| + | |style="background-color: white;"|0 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Graviditeit | ||
| + | |style="background-color: white;"|1 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Aterme datum items | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Aterme datum | ||
| + | |style="background-color: white;"|T - 587 dagen | ||
| + | |-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 '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Datum bepaling | ||
| + | |style="background-color: white;"|NullFlavor: UNK | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Datum laatste menstruatie | ||
| + | |style="background-color: white;"|T - 895 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Definitieve a terme datum observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Definitieve a terme datum tijd | ||
| + | |style="background-color: white;"|T - 587 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Definitieve a terme waarde | ||
| + | |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;" | ||
| + | |colspan="5"|Prenatale controle | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Contact | ||
| + | |style="background-color: white;"|Zie [[#Contact-587D|Contact: Contact-587D]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Zwangerschapsduur | ||
| + | |style="background-color: white;"|280 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Lichaamsgewicht | ||
| + | |style="background-color: white;"|Zie [[#gew1|Lichaamsgewicht: gew1]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Bloeddruk | ||
| + | |style="background-color: white;"|Zie [[#BP1|Bloeddruk: BP1]] | ||
| + | |}<section end=zwangerschapsgegevens_ /> | ||
| + | === 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;" | ||
| + | |colspan="4"|Partusnummer | ||
| + | |style="background-color: white;"|1 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zwangerschapsduur | ||
| + | |style="background-color: white;"|280 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|<span id="Probleem1" title="Intern ID = Probleem1">Probleem maternaal Probleem1</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="6"| | ||
| + | |-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;" | ||
| + | |colspan="3"|Probleem begin datum | ||
| + | |style="background-color: white;"|T - 587 dagen om 12:02 uur | ||
| + | |-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;" | ||
| + | |colspan="3"|Zwangerschapsduur | ||
| + | |style="background-color: white;"|280 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Probleem status | ||
| + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|<span id="Verrichting1" title="Intern ID = Verrichting1">Verrichting maternaal Verrichting1</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting start datum | ||
| + | |style="background-color: white;"|T - 587 dagen om 02:19 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting type | ||
| + | |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;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting start datum | ||
| + | |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;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Probleem maternaal | ||
| + | |style="background-color: white;"|Zie [[#Probleem1|Probleem maternaal: Probleem1]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting type | ||
| + | |style="background-color: white;"|episiotomie mediolateraal links (verrichting) (code = '114961000146100' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Ontsluitingsfase | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="12"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Actieve ontsluiting observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Observatie datum tijd | ||
| + | |style="background-color: white;"|T - 587 dagen om 02:19 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Begin actieve ontsluiting waarde | ||
| + | |style="background-color: white;"|T - 587 dagen om 02:19 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Observatie methode | ||
| + | |style="background-color: white;"|palpatie (verrichting) (code = '113011001' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Toelichting | ||
| + | |style="background-color: white;"|5 cm ontsluiting | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Wijze begin baring observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Observatie datum tijd | ||
| + | |style="background-color: white;"|T - 588 dagen om 23:50 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Begin baring waarde | ||
| + | |style="background-color: white;"|spontaan breken van vliezen (bevinding) (code = '169734005' in codeSystem 'SNOMED CT') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Observatie methode | ||
| + | |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;" | ||
| + | |rowspan="15"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Patient | ||
| + | |style="background-color: white;"|Zie [[#XXX_Kooij_Kind|Patient: XXX_Kooij_Kind]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Type partus observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Observatie datum tijd | ||
| + | |style="background-color: white;"|T - 587 dagen om 12:04 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Type partus waarde | ||
| + | |style="background-color: white;"|begeleiding van normale bevalling (verrichting) (code = '177184002' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Werkelijke plaats baring type locatie observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Werkelijke plaats baring waarde | ||
| + | |style="background-color: white;"|thuisbevalling (bevinding) (code = '169813005' in codeSystem 'SNOMED CT') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|<span id="Probleem2" title="Intern ID = Probleem2">Probleem kindspecifieke maternale problemen Probleem2</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Probleem naam | ||
| + | |style="background-color: white;"|foetale nood durante partu (bevinding) (code = '288274003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-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;" | ||
| + | |colspan="2"|Probleem eind datum | ||
| + | |style="background-color: white;"|T - 587 dagen om 12:04 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Probleem status | ||
| + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |}<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;" | ||
| + | |colspan="7"|Demografische gegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Patient | ||
| + | |style="background-color: white;"|Zie [[#XXX_Kooij_Kind|Patient: XXX_Kooij_Kind]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="7"|Lichamelijk onderzoek kind | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="23"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Geboortegewicht lichaamsgewicht | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Gewicht waarde | ||
| + | |style="background-color: white;"|3415 gram | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Lichaamslengte | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Lengte waarde | ||
| + | |style="background-color: white;"|49.7 cm | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Schedelomvang | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Schedelomvang waarde | ||
| + | |style="background-color: white;"|33.6 cm | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Bevindingen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="12"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Algemene indruk | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="10"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Apgar score1min | ||
| + | |-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;"|7 | ||
| + | |-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 === | ||
| + | <section begin=bouwstenen_ /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D; color: white; font-weight: bold; text-align:center;" colspan="5" | Bouwstenen | ||
| + | |-style="background-color: #1F497D; color: white; text-align:left;" | ||
| + | |colspan="4" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Metingen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="10"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|<span id="BP1" title="Intern ID = BP1">Bloeddruk BP1</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;"|95 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Diastolische bloeddruk | ||
| + | |style="background-color: white;"|50 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Bloeddruk datum tijd | ||
| + | |style="background-color: white;"|T - 587 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|<span id="gew1" title="Intern ID = gew1">Lichaamsgewicht gew1</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Gewicht waarde | ||
| + | |style="background-color: white;"|63 kg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Gewicht datum tijd | ||
| + | |style="background-color: white;"|T - 587 dagen | ||
| + | |}<section end=bouwstenen_ /> | ||
| + | ==Scenario Vrouw 2, Kaart 3 - data 1e lijn (meerling)== | ||
| + | <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;" | ||
| + | |colspan="3" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Demografische gegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Patient | ||
| + | |style="background-color: white;"|Zie [[#Vrouw2|Patient: Vrouw2]] | ||
| + | |}<section end= /> | ||
| + | === Administratief === | ||
| + | <section begin=administratief_ /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D; color: white; font-weight: bold; text-align:center;" colspan="6" | Administratief | ||
| + | |-style="background-color: #1F497D; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="Contact-205D" title="Intern ID = Contact-205D">Contact Contact-205D</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Contact type | ||
| + | |style="background-color: white;"|Poliklinisch (code = 'AMB' in codeSystem '<span title="2.16.840.1.113883.5.4">HL7 ActCode</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Contact soort | ||
| + | |style="background-color: white;"|consult (verrichting) (code = '11429006' in codeSystem 'SNOMED CT') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Contact met | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Zorgverlener | ||
| + | |style="background-color: white;"|Zie [[#ZV1|Zorgverlener: ZV1]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Begin datum tijd | ||
| + | |style="background-color: white;"|T - 205 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Eind datum tijd | ||
| + | |style="background-color: white;"|T - 205 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="Vrouw2" title="Intern ID = Vrouw2">Patient Vrouw2</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="21"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Naamgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Voornamen | ||
| + | |style="background-color: white;"|Jamila | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Initialen | ||
| + | |style="background-color: white;"|J | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Naamgebruik | ||
| + | |style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '<span title="2.16.840.1.113883.2.4.3.11.60.101.5.4">ZIB Naamgebruik</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslachtsnaam | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Achternaam | ||
| + | |style="background-color: white;"|XXX_Kwee | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Adresgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Straat | ||
| + | |style="background-color: white;"|Knolweg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Huisnummer | ||
| + | |style="background-color: white;"|1000 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Postcode | ||
| + | |style="background-color: white;"|9999XA | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Woonplaats | ||
| + | |style="background-color: white;"|STITSWERD | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Land | ||
| + | |style="background-color: white;"|Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||
| + | |-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;" | ||
| + | |colspan="4"|Geboren indicator | ||
| + | |style="background-color: white;"|Ja | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geboortedatum | ||
| + | |style="background-color: white;"|20 okt 1985 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslacht administratief | ||
| + | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem '<span title="2.16.840.1.113883.5.1">HL7 AdministrativeGender</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Meerling indicator | ||
| + | |style="background-color: white;"|Nee | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |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;" | ||
| + | |colspan="4"|Zorgaanbieder identificatienummer | ||
| + | |style="background-color: white;"|08001234 (in identificerend systeem: AGB-Z) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Organisatie naam | ||
| + | |style="background-color: white;"|Verloskundigenpraktijk 't Groen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Adresgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Straat | ||
| + | |style="background-color: white;"|Groeneweg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Huisnummer | ||
| + | |style="background-color: white;"|1000 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Postcode | ||
| + | |style="background-color: white;"|1234ZZ | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Woonplaats | ||
| + | |style="background-color: white;"|STITSWERD | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Land | ||
| + | |style="background-color: white;"|Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Adres soort | ||
| + | |style="background-color: white;"|Werkadres (code = 'WP' in codeSystem '<span title="2.16.840.1.113883.5.1119">HL7 AddressUse</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Organisatie type | ||
| + | |style="background-color: white;"|Verloskundigenpraktijk (code = 'G3' in codeSystem 'RoleCodeNL - zorgaanbiedertype (organisaties)') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="ZV1" title="Intern ID = ZV1">Zorgverlener ZV1</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="14"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zorgverlener identificatienummer | ||
| + | |style="background-color: white;"|12340001 (in identificerend systeem: UZI Personen) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Naamgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="9"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Roepnaam | ||
| + | |style="background-color: white;"|Gemma | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Naamgebruik | ||
| + | |style="background-color: white;"|Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem '<span title="2.16.840.1.113883.2.4.3.11.60.101.5.4">ZIB Naamgebruik</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslachtsnaam | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Achternaam | ||
| + | |style="background-color: white;"|XXX_Groeneboom | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslachtsnaam partner | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Achternaam partner | ||
| + | |style="background-color: white;"|XXX_Gras | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Specialisme | ||
| + | |style="background-color: white;"|Verloskundige (code = '03.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zorgaanbieder | ||
| + | |style="background-color: white;"|Zie [[#ZA1|Zorgaanbieder: ZA1]] | ||
| + | |}<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;" | ||
| + | |colspan="4"|Zorg episode | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Identificatienummer | ||
| + | |style="background-color: white;"|543136978 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Begin datum | ||
| + | |style="background-color: white;"|T - 205 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Eind datum | ||
| + | |style="background-color: white;"|T - 194 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="6" | Zwangerschapsgegevens | ||
| + | |-style="background-color: #1F497D; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Coordinerend zorgverlener | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zorgverlener | ||
| + | |style="background-color: white;"|Zie [[#ZV1|Zorgverlener: ZV1]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Zwangerschap | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="10"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zwangerschapsduur | ||
| + | |style="background-color: white;"|NullFlavor: NA | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Pariteit | ||
| + | |style="background-color: white;"|0 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Graviditeit | ||
| + | |style="background-color: white;"|1 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Aterme datum items | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Aterme datum | ||
| + | |style="background-color: white;"|T + 10 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Bepalings methode | ||
| + | |style="background-color: white;"|aterme datum berekend door middel van diagnostische ultrasonografie (code = '31541000146106' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Datum bepaling | ||
| + | |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;" | ||
| + | |colspan="6"|Meerling zwangerschap observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Meerling zwangerschap datum tijd | ||
| + | |style="background-color: white;"|T - 205 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Tweelingzwangerschap waarde | ||
| + | |style="background-color: white;"|dichoriale diamniotische tweelingzwangerschap (aandoening) (code = '459166009' in codeSystem 'SNOMED CT') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Observatie methode | ||
| + | |style="background-color: white;"|echografie (kwalificatiewaarde) (code = '278292003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Foliumzuurgebruik observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Foliumzuurgebruik datum tijd | ||
| + | |style="background-color: white;"|T - 205 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Foliumzuurgebruik waarde | ||
| + | |style="background-color: white;"|geen preconceptionele intake van foliumzuur via voeding (bevinding) (code = '30391000146101' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Prenatale controle | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="19"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Contact | ||
| + | |style="background-color: white;"|Zie [[#Contact-205D|Contact: Contact-205D]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zwangerschapsduur | ||
| + | |style="background-color: white;"|73 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Lichaamsgewicht | ||
| + | |style="background-color: white;"|Zie [[#Gew-205D|Lichaamsgewicht: Gew-205D]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Bloeddruk | ||
| + | |style="background-color: white;"|Zie [[#BP-205D|Bloeddruk: BP-205D]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Alcohol gebruik | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Alcohol gebruik status | ||
| + | |style="background-color: white;"|drinkt geen alcohol (code = '105542008' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Drugs gebruik | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Drugs gebruik status | ||
| + | |style="background-color: white;"|heeft nooit drugs gebruikt (code = '228368007' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Tabak gebruik | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |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 '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Soort tabak gebruik | ||
| + | |style="background-color: white;"|gebruiker van elektronische sigaret (code = '722499006' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Waarneming gebruik | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Start datum | ||
| + | |style="background-color: white;"|1 jun 2019 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Hoeveelheid | ||
| + | |style="background-color: white;"|6 keer per dag inhaleren | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="Probleem1" title="Intern ID = Probleem1">Probleem zwangerschap Probleem1</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="6"| | ||
| + | |-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;" | ||
| + | |colspan="4"|Probleem begin datum | ||
| + | |style="background-color: white;"|T - 205 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zwangerschapsduur | ||
| + | |style="background-color: white;"|73 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Probleem status | ||
| + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Toelichting | ||
| + | |style="background-color: white;"|mw.door verwijzen naar Sophia | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Verrichting zwangerschap | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Verrichting start datum | ||
| + | |style="background-color: white;"|T - 205 dagen om 11 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Verrichting eind datum | ||
| + | |style="background-color: white;"|T - 205 dagen om 11:05 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Verrichting type | ||
| + | |style="background-color: white;"|bloedonderzoek (verrichting) (code = '396550006' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Verrichting zwangerschap | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Verrichting start datum | ||
| + | |style="background-color: white;"|T - 205 dagen om 11 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Verrichting eind datum | ||
| + | |style="background-color: white;"|T - 205 dagen om 11:30 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Verrichting type | ||
| + | |style="background-color: white;"|dieetmanagement (verrichting) (code = '410175003' in codeSystem 'SNOMED CT') | ||
| + | |}<section end=zwangerschapsgegevens_ /> | ||
| + | === 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;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Verrichting start datum | ||
| + | |style="background-color: white;"|T - 195 dagen om 11 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Verrichting eind datum | ||
| + | |style="background-color: white;"|T - 195 dagen om 11 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Verrichting type | ||
| + | |style="background-color: white;"|echografie ter bepaling van geschatte datum van partus (verrichting) (code = '133601000146101' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Maternale onderzoeksgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Urine bloed en aanvullende onderzoeken | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Laboratorium test hb | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-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') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test uitslag | ||
| + | |style="background-color: white;"|6.3 mmol/L | ||
| + | |}<section end=medisch_onderzoek_ /> | ||
| + | === Bouwstenen === | ||
| + | <section begin=bouwstenen_ /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D; color: white; font-weight: bold; text-align:center;" colspan="5" | Bouwstenen | ||
| + | |-style="background-color: #1F497D; color: white; text-align:left;" | ||
| + | |colspan="4" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Metingen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="11"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|<span id="BP-205D" title="Intern ID = BP-205D">Bloeddruk BP-205D</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;"|114 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Diastolische bloeddruk | ||
| + | |style="background-color: white;"|87 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Bloeddruk datum tijd | ||
| + | |style="background-color: white;"|T - 205 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|<span id="Gew-205D" title="Intern ID = Gew-205D">Lichaamsgewicht Gew-205D</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Gewicht waarde | ||
| + | |style="background-color: white;"|63 kg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Gewicht datum tijd | ||
| + | |style="background-color: white;"|T - 205 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Kleding | ||
| + | |style="background-color: white;"|Lichte kleding/ondergoed (code = 'MINIMAL' in codeSystem '<span title="2.16.840.1.113883.2.4.3.11.60.40.4.8.1">ZIB ContextKleding</span>') | ||
| + | |}<section end=bouwstenen_ /> | ||
| + | ==Scenario Vrouw 2, Kaart 3 - data 2e lijn (meerling)== | ||
| + | <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;" | ||
| + | |colspan="3" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Demografische gegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Patient | ||
| + | |style="background-color: white;"|Zie [[#XXX_Kwee_Vrouw|Patient: XXX_Kwee_Vrouw]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Bloedonderzoek | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Laboratorium test bloedgroep | ||
| + | |style="background-color: white;"|Zie [[#Sc4_ABO|Laboratorium test bloedgroep: Sc4_ABO]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Laboratorium test rhesus d | ||
| + | |style="background-color: white;"|Zie [[#Sc4_RhD|Laboratorium test rhesus d: Sc4_RhD]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Laboratorium test rhesus c | ||
| + | |style="background-color: white;"|Zie [[#Sc4_Rhc|Laboratorium test rhesus c: Sc4_Rhc]] | ||
| + | |}<section end= /> | ||
| + | === Administratief === | ||
| + | <section begin=administratief_ /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D; color: white; font-weight: bold; text-align:center;" colspan="6" | Administratief | ||
| + | |-style="background-color: #1F497D; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="Contact-193D" title="Intern ID = Contact-193D">Contact Contact-193D</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Contact type | ||
| + | |style="background-color: white;"|Poliklinisch (code = 'AMB' in codeSystem '<span title="2.16.840.1.113883.5.4">HL7 ActCode</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Contact soort | ||
| + | |style="background-color: white;"|consult (verrichting) (code = '11429006' in codeSystem 'SNOMED CT') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Contact met | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Zorgverlener | ||
| + | |style="background-color: white;"|Zie [[#ZV2|Zorgverlener: ZV2]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Begin datum tijd | ||
| + | |style="background-color: white;"|T - 193 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Eind datum tijd | ||
| + | |style="background-color: white;"|T - 193 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="Contact-76D" title="Intern ID = Contact-76D">Contact Contact-76D</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Contact type | ||
| + | |style="background-color: white;"|Poliklinisch (code = 'AMB' in codeSystem '<span title="2.16.840.1.113883.5.4">HL7 ActCode</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Contact soort | ||
| + | |style="background-color: white;"|consult (verrichting) (code = '11429006' in codeSystem 'SNOMED CT') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Contact met | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Zorgverlener | ||
| + | |style="background-color: white;"|Zie [[#ZV2|Zorgverlener: ZV2]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Begin datum tijd | ||
| + | |style="background-color: white;"|T - 76 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Eind datum tijd | ||
| + | |style="background-color: white;"|T - 76 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="Contact-5D" title="Intern ID = Contact-5D">Contact Contact-5D</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Contact type | ||
| + | |style="background-color: white;"|Poliklinisch (code = 'AMB' in codeSystem '<span title="2.16.840.1.113883.5.4">HL7 ActCode</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Contact soort | ||
| + | |style="background-color: white;"|begeleiden van bevalling (verrichting) (code = '236973005' in codeSystem 'SNOMED CT') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Contact met | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Zorgverlener | ||
| + | |style="background-color: white;"|Zie [[#ZV2|Zorgverlener: ZV2]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Begin datum tijd | ||
| + | |style="background-color: white;"|T - 5 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Eind datum tijd | ||
| + | |style="background-color: white;"|T - 5 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="XXX_Kwee_Vrouw" title="Intern ID = XXX_Kwee_Vrouw">Patient XXX_Kwee_Vrouw</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="21"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Naamgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Voornamen | ||
| + | |style="background-color: white;"|Jamila | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Initialen | ||
| + | |style="background-color: white;"|J | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Naamgebruik | ||
| + | |style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '<span title="2.16.840.1.113883.2.4.3.11.60.101.5.4">ZIB Naamgebruik</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslachtsnaam | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Achternaam | ||
| + | |style="background-color: white;"|XXX_Kwee | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Adresgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Straat | ||
| + | |style="background-color: white;"|Knolweg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Huisnummer | ||
| + | |style="background-color: white;"|1000 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Postcode | ||
| + | |style="background-color: white;"|9999XA | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Woonplaats | ||
| + | |style="background-color: white;"|STITSWERD | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Land | ||
| + | |style="background-color: white;"|Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||
| + | |-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;" | ||
| + | |colspan="4"|Geboren indicator | ||
| + | |style="background-color: white;"|Ja | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geboortedatum | ||
| + | |style="background-color: white;"|20 okt 1985 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslacht administratief | ||
| + | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem '<span title="2.16.840.1.113883.5.1">HL7 AdministrativeGender</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Meerling indicator | ||
| + | |style="background-color: white;"|Nee | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="XXX_Kwee_Kind1" title="Intern ID = XXX_Kwee_Kind1">Patient XXX_Kwee_Kind1</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="12"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Naamgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Initialen | ||
| + | |style="background-color: white;"|F | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Roepnaam | ||
| + | |style="background-color: white;"|Frida | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslachtsnaam | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Achternaam | ||
| + | |style="background-color: white;"|XXX_Kwee | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geboren indicator | ||
| + | |style="background-color: white;"|Ja | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geboortedatum | ||
| + | |style="background-color: white;"|T - 5 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslacht administratief | ||
| + | |style="background-color: white;"|Man (code = 'M' in codeSystem '<span title="2.16.840.1.113883.5.1">HL7 AdministrativeGender</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Meerling indicator | ||
| + | |style="background-color: white;"|Ja | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="XXX_Kwee_Kind2" title="Intern ID = XXX_Kwee_Kind2">Patient XXX_Kwee_Kind2</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="11"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Naamgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Voornamen | ||
| + | |style="background-color: white;"|Louis | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslachtsnaam | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Achternaam | ||
| + | |style="background-color: white;"|XXX_Kwee | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geboren indicator | ||
| + | |style="background-color: white;"|Ja | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geboortedatum | ||
| + | |style="background-color: white;"|T - 5 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslacht administratief | ||
| + | |style="background-color: white;"|Man (code = 'M' in codeSystem '<span title="2.16.840.1.113883.5.1">HL7 AdministrativeGender</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Meerling indicator | ||
| + | |style="background-color: white;"|Ja | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="ZA2" title="Intern ID = ZA2">Zorgaanbieder ZA2</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="12"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zorgaanbieder identificatienummer | ||
| + | |style="background-color: white;"|06020806 (in identificerend systeem: AGB-Z) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Organisatie naam | ||
| + | |style="background-color: white;"|Erasmus MC, Sophia kinderziekenhuis | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Adresgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Straat | ||
| + | |style="background-color: white;"|Dr. Molewaterplein | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Huisnummer | ||
| + | |style="background-color: white;"|60 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Postcode | ||
| + | |style="background-color: white;"|3015 GJ | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Woonplaats | ||
| + | |style="background-color: white;"|ROTTERDAM | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Land | ||
| + | |style="background-color: white;"|Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Adres soort | ||
| + | |style="background-color: white;"|Werkadres (code = 'WP' in codeSystem '<span title="2.16.840.1.113883.5.1119">HL7 AddressUse</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Organisatie type | ||
| + | |style="background-color: white;"|Universitair Medisch Centrum (code = 'V5' in codeSystem 'RoleCodeNL - zorgaanbiedertype (organisaties)') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="ZV2" title="Intern ID = ZV2">Zorgverlener ZV2</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="14"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zorgverlener identificatienummer | ||
| + | |style="background-color: white;"|98765432 (in identificerend systeem: UZI Personen) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Naamgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="9"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Roepnaam | ||
| + | |style="background-color: white;"|Eduard | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Naamgebruik | ||
| + | |style="background-color: white;"|Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem '<span title="2.16.840.1.113883.2.4.3.11.60.101.5.4">ZIB Naamgebruik</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslachtsnaam | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Achternaam | ||
| + | |style="background-color: white;"|XXX_Egelinks | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslachtsnaam partner | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Achternaam partner | ||
| + | |style="background-color: white;"|XXX_Gras | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Specialisme | ||
| + | |style="background-color: white;"|Gynaecoloog (code = '01.046' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zorgaanbieder | ||
| + | |style="background-color: white;"|Zie [[#ZA2|Zorgaanbieder: ZA2]] | ||
| + | |}<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;" | ||
| + | |colspan="4"|Zorg episode | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Identificatienummer | ||
| + | |style="background-color: white;"|123123249 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Begin datum | ||
| + | |style="background-color: white;"|T - 193 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="6" | Zwangerschapsgegevens | ||
| + | |-style="background-color: #1F497D; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Coordinerend zorgverlener | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zorgverlener | ||
| + | |style="background-color: white;"|Zie [[#ZV2|Zorgverlener: ZV2]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Zwangerschap | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="10"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zwangerschapsduur | ||
| + | |style="background-color: white;"|NullFlavor: NA | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Pariteit | ||
| + | |style="background-color: white;"|0 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Graviditeit | ||
| + | |style="background-color: white;"|1 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Aterme datum items | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Aterme datum | ||
| + | |style="background-color: white;"|T + 10 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Bepalings methode | ||
| + | |style="background-color: white;"|Anders (code = 'OTH' in codeSystem '<span title="2.16.840.1.113883.5.1008">HL7 NullFlavor</span>'): uit verwijzing verloskundigenpraktijk | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Datum bepaling | ||
| + | |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;" | ||
| + | |colspan="6"|Definitieve a terme datum observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Definitieve a terme datum tijd | ||
| + | |style="background-color: white;"|T - 126 dagen om 13:45 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Definitieve a terme waarde | ||
| + | |style="background-color: white;"|T + 2 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Definitieve a terme methode | ||
| + | |style="background-color: white;"|echografie (kwalificatiewaarde) (code = '278292003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Meerling zwangerschap observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Meerling zwangerschap datum tijd | ||
| + | |style="background-color: white;"|T - 193 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Tweelingzwangerschap waarde | ||
| + | |style="background-color: white;"|monochoriale diamniotische tweelingzwangerschap (aandoening) (code = '459168005' in codeSystem 'SNOMED CT') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Observatie methode | ||
| + | |style="background-color: white;"|echografie (kwalificatiewaarde) (code = '278292003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Aantal levende kinderen observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Aantal levende kinderen datum tijd | ||
| + | |style="background-color: white;"|T - 76 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Aantal levende kinderen waarde | ||
| + | |style="background-color: white;"|2 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Foliumzuurgebruik observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Foliumzuurgebruik datum tijd | ||
| + | |style="background-color: white;"|T - 193 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Foliumzuurgebruik waarde | ||
| + | |style="background-color: white;"|intake van foliumzuur via voeding vanaf vastgestelde zwangerschap (bevinding) (code = '29771000146106' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Toelichting | ||
| + | |style="background-color: white;"|op advies verloskundigenpraktijk gestart | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Prenatale controle | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="25"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Contact | ||
| + | |style="background-color: white;"|Zie [[#Contact-193D|Contact: Contact-193D]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zwangerschapsduur | ||
| + | |style="background-color: white;"|85 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Leven voelen observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Leven voelen datum tijd | ||
| + | |style="background-color: white;"|T - 193 dagen om 13:40 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Leven voelen waarde | ||
| + | |style="background-color: white;"|foetale bewegingen aanwezig (bevinding) (code = '289431008' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Observatie methode | ||
| + | |style="background-color: white;"|palpatie (verrichting) (code = '113011001' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Lichaamsgewicht | ||
| + | |style="background-color: white;"|Zie [[#Gewicht-193D|Lichaamsgewicht: Gewicht-193D]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Bloeddruk | ||
| + | |style="background-color: white;"|Zie [[#BP-193D|Bloeddruk: BP-193D]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Alcohol gebruik | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Alcohol gebruik status | ||
| + | |style="background-color: white;"|drinkt geen alcohol (code = '105542008' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Drugs gebruik | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Drugs gebruik status | ||
| + | |style="background-color: white;"|heeft nooit drugs gebruikt (code = '228368007' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Tabak gebruik | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="8"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Toelichting | ||
| + | |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 '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Soort tabak gebruik | ||
| + | |style="background-color: white;"|gebruiker van elektronische sigaret (code = '722499006' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Waarneming gebruik | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Start datum | ||
| + | |style="background-color: white;"|1 jun 2019 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Stop datum | ||
| + | |style="background-color: white;"|T - 198 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Prenatale controle | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Contact | ||
| + | |style="background-color: white;"|Zie [[#Contact-76D|Contact: Contact-76D]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zwangerschapsduur | ||
| + | |style="background-color: white;"|202 dagen | ||
| + | |-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;" | ||
| + | |colspan="6"|<span id="Probleem1" title="Intern ID = Probleem1">Probleem zwangerschap Probleem1</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="5"| | ||
| + | |-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;" | ||
| + | |colspan="4"|Probleem begin datum | ||
| + | |style="background-color: white;"|T - 193 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zwangerschapsduur | ||
| + | |style="background-color: white;"|85 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Probleem status | ||
| + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|<span id="Probleem2" title="Intern ID = Probleem2">Probleem zwangerschap Probleem2</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Probleem type | ||
| + | |style="background-color: white;"|klinische bevinding (code = '404684003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Probleem naam | ||
| + | |style="background-color: white;"|intra-uteriene groeiretardatie (aandoening) (code = '22033007' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Probleem begin datum | ||
| + | |style="background-color: white;"|T - 76 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zwangerschapsduur | ||
| + | |style="background-color: white;"|202 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Probleem status | ||
| + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Toelichting | ||
| + | |style="background-color: white;"|tweede kind blijft erg achter in ontwikkeling | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Verrichting zwangerschap | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-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;" | ||
| + | |colspan="4"|Verrichting type | ||
| + | |style="background-color: white;"|bloedonderzoek (verrichting) (code = '396550006' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Verrichting zwangerschap | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Verrichting start datum | ||
| + | |style="background-color: white;"|T - 5 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Verrichting type | ||
| + | |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;"|273 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Uitdrijvingsfase | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="31"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Patient | ||
| + | |style="background-color: white;"|Zie [[#XXX_Kwee_Kind1|Patient: XXX_Kwee_Kind1]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Type partus observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Observatie datum tijd | ||
| + | |style="background-color: white;"|T - 5 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Type partus waarde | ||
| + | |style="background-color: white;"|primaire sectio caesarea (verrichting) (code = '80771000146107' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Werkelijke plaats baring type locatie observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Observatie datum tijd | ||
| + | |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;" | ||
| + | |colspan="3"|Toelichting | ||
| + | |style="background-color: white;"|geplande sectio | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Ziekenhuis baring | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Zorgaanbieder | ||
| + | |style="background-color: white;"|Zie [[#ZA2|Zorgaanbieder: ZA2]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|<span id="Probleem3" title="Intern ID = Probleem3">Probleem kindspecifieke maternale problemen Probleem3</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Probleem naam | ||
| + | |style="background-color: white;"|liggingsafwijking van foetus (bevinding) (code = '15028002' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Probleem begin datum | ||
| + | |style="background-color: white;"|T - 5 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Probleem status | ||
| + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Verrichting kindspecifieke maternale verrichtingen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting start datum | ||
| + | |style="background-color: white;"|T - 5 dagen om 14:03 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting eind datum | ||
| + | |style="background-color: white;"|T - 5 dagen om 14:52 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Indicatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Probleem kindspecifieke maternale problemen | ||
| + | |style="background-color: white;"|Zie [[#Probleem3|Probleem kindspecifieke maternale problemen: Probleem3]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting type | ||
| + | |style="background-color: white;"|primaire sectio caesarea (verrichting) (code = '80771000146107' in codeSystem 'SNOMED CT') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Verrichting kindspecifieke maternale verrichtingen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting start datum | ||
| + | |style="background-color: white;"|T - 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 '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Uitdrijvingsfase | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="38"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Patient | ||
| + | |style="background-color: white;"|Zie [[#XXX_Kwee_Kind2|Patient: XXX_Kwee_Kind2]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Type partus observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Observatie datum tijd | ||
| + | |style="background-color: white;"|T - 5 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Type partus waarde | ||
| + | |style="background-color: white;"|primaire sectio caesarea (verrichting) (code = '80771000146107' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Werkelijke plaats baring type locatie observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Observatie datum tijd | ||
| + | |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;" | ||
| + | |colspan="3"|Toelichting | ||
| + | |style="background-color: white;"|geplande sectio | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Ziekenhuis baring | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Zorgaanbieder | ||
| + | |style="background-color: white;"|Zie [[#ZA2|Zorgaanbieder: ZA2]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|<span id="Probleem4" title="Intern ID = Probleem4">Probleem kindspecifieke maternale problemen Probleem4</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Probleem naam | ||
| + | |style="background-color: white;"|immaturiteit (aandoening) (code = '276658003' in codeSystem 'SNOMED CT') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Probleem begin datum | ||
| + | |style="background-color: white;"|T - 5 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Probleem status | ||
| + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Verrichting kindspecifieke maternale verrichtingen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting start datum | ||
| + | |style="background-color: white;"|T - 5 dagen om 14:03 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting eind datum | ||
| + | |style="background-color: white;"|T - 5 dagen om 14:52 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Indicatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Probleem kindspecifieke maternale problemen | ||
| + | |style="background-color: white;"|Zie [[#Probleem3|Probleem kindspecifieke maternale problemen: Probleem3]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting type | ||
| + | |style="background-color: white;"|primaire sectio caesarea (verrichting) (code = '80771000146107' in codeSystem 'SNOMED CT') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Verrichting kindspecifieke maternale verrichtingen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting start datum | ||
| + | |style="background-color: white;"|T - 5 dagen om 14:52 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Indicatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Probleem kindspecifieke maternale problemen | ||
| + | |style="background-color: white;"|Zie [[#Probleem4|Probleem kindspecifieke maternale problemen: Probleem4]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting type | ||
| + | |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;" | ||
| + | |colspan="5"|Verrichting kindspecifieke maternale verrichtingen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Verrichting start datum | ||
| + | |style="background-color: white;"|T - 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 '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |}<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;" | ||
| + | |colspan="7"|Demografische gegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Patient | ||
| + | |style="background-color: white;"|Zie [[#XXX_Kwee_Kind1|Patient: XXX_Kwee_Kind1]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="7"|Lichamelijk onderzoek kind | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="25"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Geboortegewicht lichaamsgewicht | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Gewicht waarde | ||
| + | |style="background-color: white;"|2605 g | ||
| + | |-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;" | ||
| + | |colspan="4"|Kleding | ||
| + | |style="background-color: white;"|Luier (code = 'DIAPER' in codeSystem '<span title="2.16.840.1.113883.2.4.3.11.60.40.4.8.1">ZIB ContextKleding</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Lichaamslengte | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Lengte waarde | ||
| + | |style="background-color: white;"|48 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Schedelomvang | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Schedelomvang waarde | ||
| + | |style="background-color: white;"|32.6 cm | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Bevindingen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="12"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Algemene indruk | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="10"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Apgar score1min | ||
| + | |-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;"|7 | ||
| + | |-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;"|10 | ||
| + | |-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_ /> | ||
| + | === 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;" | ||
| + | |colspan="7"|Demografische gegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Patient | ||
| + | |style="background-color: white;"|Zie [[#XXX_Kwee_Kind2|Patient: XXX_Kwee_Kind2]] | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="7"|Lichamelijk onderzoek kind | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="25"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Geboortegewicht lichaamsgewicht | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Gewicht waarde | ||
| + | |style="background-color: white;"|2089 g | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Gewicht datum tijd | ||
| + | |style="background-color: white;"|T - 5 dagen om 15:05 uur | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Kleding | ||
| + | |style="background-color: white;"|Zonder kleding. (code = 'UNDRESSED' in codeSystem '<span title="2.16.840.1.113883.2.4.3.11.60.40.4.8.1">ZIB ContextKleding</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Lichaamslengte | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Lengte waarde | ||
| + | |style="background-color: white;"|46 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Schedelomvang | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Schedelomvang waarde | ||
| + | |style="background-color: white;"|31.8 cm | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Bevindingen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="12"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Algemene indruk | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="10"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Apgar score1min | ||
| + | |-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;"|5 | ||
| + | |-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;"|9 | ||
| + | |-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_ /> | ||
| + | === Medisch onderzoek === | ||
| + | <section begin=medisch_onderzoek_ /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |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;" | ||
| + | |colspan="6" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="7"|Verrichting onderzoek | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Verrichting start datum | ||
| + | |style="background-color: white;"|T - 195 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Verrichting eind datum | ||
| + | |style="background-color: white;"|T - 195 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Verrichting type | ||
| + | |style="background-color: white;"|laboratoriumonderzoek (verrichting) (code = '15220000' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="7"|Maternale onderzoeksgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="43"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Urine bloed en aanvullende onderzoeken | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="41"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Psie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="29"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|<span id="Sc4_ABO" title="Intern ID = Sc4_ABO">Laboratorium test bloedgroep Sc4_ABO</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test code | ||
| + | |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 '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|<span id="Sc4_RhD" title="Intern ID = Sc4_RhD">Laboratorium test rhesus d Sc4_RhD</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-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;" | ||
| + | |colspan="2"|Test uitslag | ||
| + | |style="background-color: white;"|Rh D Positief (code = '165747007' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|<span id="Sc4_Rhc" title="Intern ID = Sc4_Rhc">Laboratorium test rhesus c Sc4_Rhc</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test code | ||
| + | |style="background-color: white;"|Kleine c Ag [aanwezigheid] in erytrocyten (code = '1159-3' in codeSystem 'LOINC') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test uitslag | ||
| + | |style="background-color: white;"|Rh c Positief (code = '733120009' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Laboratorium test hbs ag | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test code | ||
| + | |style="background-color: white;"|Hepatitis B-virusoppervlakte Ag [eenheden/volume] in serum (code = '58452-4' in codeSystem 'LOINC') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test uitslag | ||
| + | |style="background-color: white;"|0 k[arb'U]/L | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Laboratorium test hiv | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test code | ||
| + | |style="background-color: white;"|HIV 1 As [aanwezigheid] in serum of plasma d.m.v. immunoassay (code = '29893-5' in codeSystem 'LOINC') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test uitslag | ||
| + | |style="background-color: white;"|humaan immunodeficiëntievirus negatief (bevinding) (code = '165815009' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Laboratorium test lues | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test code | ||
| + | |style="background-color: white;"|Treponema pallidum As [eenheden/volume] in serum (code = '11597-2' in codeSystem 'LOINC') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test uitslag | ||
| + | |style="background-color: white;"|11868 k[arb'U]/L | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Irregulaire antistoffen observatie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Irregulaire antistoffen waarde | ||
| + | |style="background-color: white;"|Nee | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Welke antistoffen waarde | ||
| + | |style="background-color: white;"|irregulaire antilichamen afwezig (bevinding) (code = '568111000005107' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|<span id="Sc4_Hb" title="Intern ID = Sc4_Hb">Laboratorium test hb Sc4_Hb</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|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;" | ||
| + | |colspan="3"|Test uitslag | ||
| + | |style="background-color: white;"|7.0 mmol/L | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Torch | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Laboratorium test torch | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test code | ||
| + | |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;" | ||
| + | |colspan="2"|Test uitslag | ||
| + | |style="background-color: white;"|9 k[arb'U]/L | ||
| + | |}<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;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Verrichting start datum | ||
| + | |style="background-color: white;"|T - 76 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Verrichting eind datum | ||
| + | |style="background-color: white;"|T - 76 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Verrichting type | ||
| + | |style="background-color: white;"|laboratoriumonderzoek (verrichting) (code = '15220000' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Maternale onderzoeksgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Urine bloed en aanvullende onderzoeken | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Laboratorium test hb | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-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') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test uitslag | ||
| + | |style="background-color: white;"|6.7 mmol/L | ||
| + | |}<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;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Verrichting start datum | ||
| + | |style="background-color: white;"|T - 5 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Verrichting eind datum | ||
| + | |style="background-color: white;"|T - 5 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Verrichting type | ||
| + | |style="background-color: white;"|laboratoriumonderzoek (verrichting) (code = '15220000' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Maternale onderzoeksgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Urine bloed en aanvullende onderzoeken | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Laboratorium test hb | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-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') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test uitslag | ||
| + | |style="background-color: white;"|6.5 mmol/L | ||
| + | |}<section end=medisch_onderzoek_ /> | ||
| + | === Bouwstenen === | ||
| + | <section begin=bouwstenen_ /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D; color: white; font-weight: bold; text-align:center;" colspan="6" | Bouwstenen | ||
| + | |-style="background-color: #1F497D; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Metingen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="21"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|<span id="BP-193D" title="Intern ID = BP-193D">Bloeddruk BP-193D</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Systolische bloeddruk | ||
| + | |style="background-color: white;"|121 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Diastolische bloeddruk | ||
| + | |style="background-color: white;"|83 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Bloeddruk datum tijd | ||
| + | |style="background-color: white;"|T - 193 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|<span id="BP-76D" title="Intern ID = BP-76D">Bloeddruk BP-76D</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="4"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Systolische bloeddruk | ||
| + | |style="background-color: white;"|115 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Diastolische bloeddruk | ||
| + | |style="background-color: white;"|75 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Bloeddruk datum tijd | ||
| + | |style="background-color: white;"|T - 76 dagen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Laboratorium uitslag | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="5"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Laboratorium test | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Test code | ||
| + | |style="background-color: white;"|(code = '' in codeSystem 'LOINC') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Interpretatie methode | ||
| + | |style="background-color: white;"|EUCAST (code = 'tbd' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|<span id="Gewicht-193D" title="Intern ID = Gewicht-193D">Lichaamsgewicht Gewicht-193D</span> | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="3"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Gewicht waarde | ||
| + | |style="background-color: white;"|65 kg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Gewicht datum tijd | ||
| + | |style="background-color: white;"|T - 193 dagen | ||
| + | |}<section end=bouwstenen_ /> | ||
| + | ==Scenario Vrouw 3, geen zwangerschapskaart beschikbaar== | ||
| + | <section begin= /><section end= /> | ||
| + | === Administratief === | ||
| + | <section begin=administratief_ /> | ||
| + | {| class="wikitable" width="85%" | ||
| + | |style="background-color: #1F497D; color: white; font-weight: bold; text-align:center;" colspan="6" | Administratief | ||
| + | |-style="background-color: #1F497D; color: white; text-align:left;" | ||
| + | |colspan="5" width="25%"| Gegevenselement | ||
| + | || Waarde | ||
| + | |||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Patient | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="20"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Naamgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="7"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Voornamen | ||
| + | |style="background-color: white;"|Julia | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Initialen | ||
| + | |style="background-color: white;"|J | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Naamgebruik | ||
| + | |style="background-color: white;"|Eigen geslachtsnaam (code = 'NL1' in codeSystem '<span title="2.16.840.1.113883.2.4.3.11.60.101.5.4">ZIB Naamgebruik</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslachtsnaam | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="2"|Achternaam | ||
| + | |style="background-color: white;"|Laarhoven | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="5"|Adresgegevens | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="6"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Straat | ||
| + | |style="background-color: white;"|Knolweg | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Huisnummer | ||
| + | |style="background-color: white;"|1002 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Postcode | ||
| + | |style="background-color: white;"|9999ZZ | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Woonplaats | ||
| + | |style="background-color: white;"|Stitswerd | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="3"|Land | ||
| + | |style="background-color: white;"|Nederland (code = '6030' in codeSystem 'GBA Tabel 34 Landen') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Identificatienummer | ||
| + | |style="background-color: white;"|999900754 (in identificerend systeem: BSN) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geboren indicator | ||
| + | |style="background-color: white;"|Ja | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geboortedatum | ||
| + | |style="background-color: white;"|22 okt 1985 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Geslacht administratief | ||
| + | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem '<span title="2.16.840.1.113883.5.1">HL7 AdministrativeGender</span>') | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Zorgaanbieder | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zorgaanbieder identificatienummer | ||
| + | |style="background-color: white;"|(in identificerend systeem: URA) | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="6"|Zorgverlener | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |rowspan="2"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;" | ||
| + | |colspan="4"|Zorgverlener identificatienummer | ||
| + | |style="background-color: white;"|(in identificerend systeem: UZI Personen) | ||
| + | |}<section end=administratief_ /> | ||
Versie van 6 aug 2025 om 13:45
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 | ||||
| Contact Contact-139D | |||||
| Contact type | Poliklinisch (code = 'AMB' in codeSystem 'HL7 ActCode') | ||||
| Contact soort | consult (verrichting) (code = '11429006' in codeSystem 'SNOMED CT') | ||||
| Contact met | |||||
| Zorgverlener | Zie Zorgverlener: Sc1ZV1 | ||||
| Begin datum tijd | T - 139 dagen | ||||
| Eind datum tijd | T - 139 dagen | ||||
| Contact Contact-6D | |||||
| Contact type | Poliklinisch (code = 'AMB' in codeSystem 'HL7 ActCode') | ||||
| Contact soort | consult (verrichting) (code = '11429006' in codeSystem 'SNOMED CT') | ||||
| Begin datum tijd | T - 6 dagen | ||||
| Eind datum tijd | T - 6 dagen | ||||
| Patient Vrouw1 | |||||
| Naamgegevens | |||||
| Voornamen | Hanna | ||||
| Initialen | H | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem 'ZIB Naamgebruik') | ||||
| 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) | ||||
| Geboren indicator | Ja | ||||
| Geboortedatum | 18 okt 1985 | ||||
| Geslacht administratief | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
| Zorgaanbieder Sc1ZA1 | |||||
| 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 Sc1ZV1 | |||||
| Zorgverlener identificatienummer | 12340001 (in identificerend systeem: UZI Personen) | ||||
| Naamgegevens | |||||
| Voornamen | Gemma | ||||
| Naamgebruik | Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem 'ZIB Naamgebruik') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Groeneboom | ||||
| Geslachtsnaam partner | |||||
| Achternaam partner | XXX_Gras | ||||
| Specialisme | Verloskundige (code = '03.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||
| Zorgaanbieder | Zie Zorgaanbieder: Sc1ZA1 | ||||
1.1.2 Zorgverlening
| Zorgverlening | |||
| Gegevenselement | Waarde | ||
| Zorg episode | |||
| Identificatienummer | 5465498897 | ||
| Begin datum | T - 139 dagen | ||
1.1.3 Zwangerschapsgegevens
| Zwangerschapsgegevens | ||||
| Gegevenselement | Waarde | |||
| Coordinerend zorgverlener | ||||
| Zorgverlener | Zie Zorgverlener: Sc1ZV1 | |||
| Zwangerschap | ||||
| Zwangerschapsduur | NullFlavor: NA | |||
| 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 - 195 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 (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||
| Aantal levende kinderen observatie | ||||
| Aantal levende kinderen datum tijd | T - 125 dagen | |||
| Aantal levende kinderen waarde | 1 | |||
| 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 | ||||
| Contact | Zie Contact: Contact-139D | |||
| Zwangerschapsduur | 47 dagen | |||
| 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 | ||||
| Contact | Zie Contact: Contact-6D | |||
| Zwangerschapsduur | 180 dagen | |||
| 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 Sc1Probleem1 | ||||
| Probleem type | bevinding 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 | 176 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 Sc1ABO | ||||||
| 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 Sc1RhD | ||||||
| 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 Sc1Rhc | ||||||
| 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 hbs ag | ||||||
| Test code | Hepatitis B-virusoppervlakte Ag [eenheden/volume] in serum (code = '58452-4' in codeSystem 'LOINC') | |||||
| Test uitslag | 0 k[arb'U]/L | |||||
| Laboratorium test hiv | ||||||
| Test code | HIV 1 As [aanwezigheid] in serum of plasma d.m.v. immunoassay (code = '29893-5' in codeSystem 'LOINC') | |||||
| Test uitslag | humaan immunodeficiëntievirus negatief (bevinding) (code = '165815009' in codeSystem 'SNOMED CT') | |||||
| Laboratorium test lues | ||||||
| Test code | Treponema pallidum As [eenheden/volume] in serum (code = '11597-2' in codeSystem 'LOINC') | |||||
| Test uitslag | 0 k[arb'U]/L | |||||
| Irregulaire antistoffen observatie | ||||||
| Irregulaire antistoffen waarde | Nee | |||||
| Welke antistoffen waarde | irregulaire antilichamen afwezig (bevinding) (code = '568111000005107' 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 | |||
| Gewicht datum tijd | T - 139 dagen | |||
| Lichaamsgewicht Gewicht-6D | ||||
| Gewicht waarde | 78 kg | |||
| Gewicht datum tijd | T - 6 dagen | |||
1.2 Scenario Vrouw 1, Kaart 2 - data 1e lijn (vorige zwangerschap)
| Vrouw | |||
| Gegevenselement | Waarde | ||
| Demografische gegevens | |||
| Patient | Zie Patient: XXX_Kooij_Vrouw | ||
1.2.1 Administratief
| Administratief | |||||
| Gegevenselement | Waarde | ||||
| Contact Contact-587D | |||||
| Contact type | Poliklinisch (code = 'AMB' in codeSystem 'HL7 ActCode') | ||||
| Contact soort | consult (verrichting) (code = '11429006' in codeSystem 'SNOMED CT') | ||||
| Contact met | |||||
| Zorgverlener | Zie Zorgverlener: ZV1 | ||||
| Begin datum tijd | T - 587 dagen | ||||
| Eind datum tijd | T - 587 dagen | ||||
| Patient XXX_Kooij_Vrouw | |||||
| Naamgegevens | |||||
| Voornamen | Hanna | ||||
| Initialen | H | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem 'ZIB Naamgebruik') | ||||
| 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) | ||||
| Geboren indicator | Ja | ||||
| Geboortedatum | 18 okt 1985 | ||||
| Geslacht administratief | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
| Patient XXX_Kooij_Kind | |||||
| Naamgegevens | |||||
| Voornamen | Eduard | ||||
| Roepnaam | Ed | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Kooij | ||||
| Geboren indicator | Ja | ||||
| Geboortedatum | 10 feb 2010 | ||||
| Geslacht administratief | Man (code = 'M' 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 | |||||
| Roepnaam | Gemma | ||||
| Naamgebruik | Eigen geslachtsnaam gevolgd door geslachtsnaam partner (code = 'NL4' in codeSystem 'ZIB Naamgebruik') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Groeneboom | ||||
| Geslachtsnaam partner | |||||
| Achternaam partner | XXX_Gras | ||||
| Specialisme | Verloskundige (code = '03.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||
| Zorgaanbieder | Zie Zorgaanbieder: ZA1 | ||||
1.2.2 Zorgverlening
| Zorgverlening | |||
| Gegevenselement | Waarde | ||
| Zorg episode | |||
| Identificatienummer | 9955687 | ||
| 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 | NullFlavor: NA | |||
| Pariteit | 0 | |||
| 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') | |||
| Prenatale controle | ||||
| Contact | Zie Contact: Contact-587D | |||
| Zwangerschapsduur | 280 dagen | |||
| Lichaamsgewicht | Zie Lichaamsgewicht: gew1 | |||
| Bloeddruk | Zie Bloeddruk: BP1 | |||
1.2.4 Bevalling
| Bevalling | ||||
| Gegevenselement | Waarde | |||
| Partusnummer | 1 | |||
| Zwangerschapsduur | 280 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 | 280 dagen | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
| 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 maternaal: Probleem1 | |||
| Verrichting type | episiotomie mediolateraal links (verrichting) (code = '114961000146100' 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: XXX_Kooij_Kind | |||
| 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 | |||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||
1.2.5 Kind
| Kind | ||||||
| Gegevenselement | Waarde | |||||
| Demografische gegevens | ||||||
| Patient | Zie Patient: XXX_Kooij_Kind | |||||
| 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 | |||
| Gewicht datum tijd | T - 587 dagen | |||
1.3 Scenario Vrouw 2, Kaart 3 - data 1e lijn (meerling)
| Vrouw | |||
| Gegevenselement | Waarde | ||
| Demografische gegevens | |||
| Patient | Zie Patient: Vrouw2 | ||
1.3.1 Administratief
| Administratief | |||||
| Gegevenselement | Waarde | ||||
| Contact Contact-205D | |||||
| Contact type | Poliklinisch (code = 'AMB' in codeSystem 'HL7 ActCode') | ||||
| Contact soort | consult (verrichting) (code = '11429006' in codeSystem 'SNOMED CT') | ||||
| Contact met | |||||
| Zorgverlener | Zie Zorgverlener: ZV1 | ||||
| Begin datum tijd | T - 205 dagen | ||||
| Eind datum tijd | T - 205 dagen | ||||
| Patient Vrouw2 | |||||
| Naamgegevens | |||||
| Voornamen | Jamila | ||||
| Initialen | J | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem 'ZIB Naamgebruik') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Kwee | ||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1000 | ||||
| Postcode | 9999XA | ||||
| Woonplaats | STITSWERD | ||||
| Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||||
| Identificatienummer | 999900730 (in identificerend systeem: BSN) | ||||
| Geboren indicator | Ja | ||||
| 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 | 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 'ZIB Naamgebruik') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Groeneboom | ||||
| Geslachtsnaam partner | |||||
| Achternaam partner | XXX_Gras | ||||
| Specialisme | Verloskundige (code = '03.000' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||
| Zorgaanbieder | Zie Zorgaanbieder: ZA1 | ||||
1.3.2 Zorgverlening
| Zorgverlening | |||
| Gegevenselement | Waarde | ||
| Zorg episode | |||
| Identificatienummer | 543136978 | ||
| 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 | NullFlavor: NA | ||||
| Pariteit | 0 | ||||
| Graviditeit | 1 | ||||
| Aterme datum items | |||||
| Aterme datum | T + 10 dagen | ||||
| Bepalings methode | aterme datum berekend door middel van diagnostische ultrasonografie (code = '31541000146106' in codeSystem 'SNOMED CT') | ||||
| Datum bepaling | T - 205 dagen | ||||
| Datum laatste menstruatie | T - 278 dagen | ||||
| Meerling zwangerschap observatie | |||||
| Meerling zwangerschap datum tijd | T - 205 dagen | ||||
| Tweelingzwangerschap waarde | dichoriale diamniotische tweelingzwangerschap (aandoening) (code = '459166009' in codeSystem 'SNOMED CT') | ||||
| Observatie methode | echografie (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 | |||||
| Contact | Zie Contact: Contact-205D | ||||
| Zwangerschapsduur | 73 dagen | ||||
| 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 | 73 dagen | ||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||||
| Toelichting | mw.door verwijzen naar Sophia | ||||
| Verrichting zwangerschap | |||||
| Verrichting start datum | T - 205 dagen om 11 uur | ||||
| Verrichting eind datum | T - 205 dagen om 11:05 uur | ||||
| Verrichting type | bloedonderzoek (verrichting) (code = '396550006' in codeSystem 'SNOMED CT') | ||||
| Verrichting zwangerschap | |||||
| Verrichting start datum | T - 205 dagen om 11 uur | ||||
| Verrichting eind datum | T - 205 dagen om 11:30 uur | ||||
| 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 - 195 dagen om 11 uur | ||||
| Verrichting eind datum | T - 195 dagen om 11 uur | ||||
| Verrichting type | echografie ter bepaling van geschatte datum van partus (verrichting) (code = '133601000146101' in codeSystem 'SNOMED CT') | ||||
| 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 | 6.3 mmol/L | ||||
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 'ZIB ContextKleding') | |||
1.4 Scenario Vrouw 2, Kaart 3 - data 2e lijn (meerling)
| Vrouw | |||
| Gegevenselement | Waarde | ||
| Demografische gegevens | |||
| Patient | Zie Patient: XXX_Kwee_Vrouw | ||
| Bloedonderzoek | |||
| Laboratorium test bloedgroep | Zie Laboratorium test bloedgroep: Sc4_ABO | ||
| Laboratorium test rhesus d | Zie Laboratorium test rhesus d: Sc4_RhD | ||
| Laboratorium test rhesus c | Zie Laboratorium test rhesus c: Sc4_Rhc | ||
1.4.1 Administratief
| Administratief | |||||
| Gegevenselement | Waarde | ||||
| Contact Contact-193D | |||||
| Contact type | Poliklinisch (code = 'AMB' in codeSystem 'HL7 ActCode') | ||||
| Contact soort | consult (verrichting) (code = '11429006' in codeSystem 'SNOMED CT') | ||||
| Contact met | |||||
| Zorgverlener | Zie Zorgverlener: ZV2 | ||||
| Begin datum tijd | T - 193 dagen | ||||
| Eind datum tijd | T - 193 dagen | ||||
| Contact Contact-76D | |||||
| Contact type | Poliklinisch (code = 'AMB' in codeSystem 'HL7 ActCode') | ||||
| Contact soort | consult (verrichting) (code = '11429006' in codeSystem 'SNOMED CT') | ||||
| Contact met | |||||
| Zorgverlener | Zie Zorgverlener: ZV2 | ||||
| Begin datum tijd | T - 76 dagen | ||||
| Eind datum tijd | T - 76 dagen | ||||
| Contact Contact-5D | |||||
| Contact type | Poliklinisch (code = 'AMB' in codeSystem 'HL7 ActCode') | ||||
| Contact soort | begeleiden van bevalling (verrichting) (code = '236973005' in codeSystem 'SNOMED CT') | ||||
| Contact met | |||||
| Zorgverlener | Zie Zorgverlener: ZV2 | ||||
| Begin datum tijd | T - 5 dagen | ||||
| Eind datum tijd | T - 5 dagen | ||||
| Patient XXX_Kwee_Vrouw | |||||
| Naamgegevens | |||||
| Voornamen | Jamila | ||||
| Initialen | J | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem 'ZIB Naamgebruik') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Kwee | ||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1000 | ||||
| Postcode | 9999XA | ||||
| Woonplaats | STITSWERD | ||||
| Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||||
| Identificatienummer | 999900730 (in identificerend systeem: BSN) | ||||
| Geboren indicator | Ja | ||||
| Geboortedatum | 20 okt 1985 | ||||
| Geslacht administratief | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
| Meerling indicator | Nee | ||||
| Patient XXX_Kwee_Kind1 | |||||
| Naamgegevens | |||||
| Initialen | F | ||||
| Roepnaam | Frida | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Kwee | ||||
| Geboren indicator | Ja | ||||
| Geboortedatum | T - 5 dagen | ||||
| Geslacht administratief | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | ||||
| Meerling indicator | Ja | ||||
| Patient XXX_Kwee_Kind2 | |||||
| Naamgegevens | |||||
| Voornamen | Louis | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Kwee | ||||
| Geboren indicator | Ja | ||||
| Geboortedatum | T - 5 dagen | ||||
| Geslacht administratief | Man (code = 'M' in codeSystem 'HL7 AdministrativeGender') | ||||
| Meerling indicator | Ja | ||||
| 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 | ||||
| Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||||
| 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 'ZIB Naamgebruik') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Egelinks | ||||
| Geslachtsnaam partner | |||||
| Achternaam partner | XXX_Gras | ||||
| Specialisme | Gynaecoloog (code = '01.046' in codeSystem 'RoleCodeNL - zorgverlenertype (personen)') | ||||
| Zorgaanbieder | Zie Zorgaanbieder: ZA2 | ||||
1.4.2 Zorgverlening
| Zorgverlening | |||
| Gegevenselement | Waarde | ||
| Zorg episode | |||
| Identificatienummer | 123123249 | ||
| Begin datum | T - 193 dagen | ||
1.4.3 Zwangerschapsgegevens
| Zwangerschapsgegevens | |||||
| Gegevenselement | Waarde | ||||
| Coordinerend zorgverlener | |||||
| Zorgverlener | Zie Zorgverlener: ZV2 | ||||
| Zwangerschap | |||||
| Zwangerschapsduur | NullFlavor: NA | ||||
| Pariteit | 0 | ||||
| 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 | echografie (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | ||||
| Meerling zwangerschap observatie | |||||
| Meerling zwangerschap datum tijd | T - 193 dagen | ||||
| Tweelingzwangerschap waarde | monochoriale diamniotische tweelingzwangerschap (aandoening) (code = '459168005' in codeSystem 'SNOMED CT') | ||||
| Observatie methode | echografie (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | ||||
| Aantal levende kinderen observatie | |||||
| Aantal levende kinderen datum tijd | T - 76 dagen | ||||
| Aantal levende kinderen waarde | 2 | ||||
| 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 | |||||
| Contact | Zie Contact: Contact-193D | ||||
| Zwangerschapsduur | 85 dagen | ||||
| 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: Gewicht-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 | |||||
| Contact | Zie Contact: Contact-76D | ||||
| Zwangerschapsduur | 202 dagen | ||||
| 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 | 85 dagen | ||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||||
| 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 | 202 dagen | ||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||||
| 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 | 273 dagen | ||||
| Uitdrijvingsfase | |||||
| Patient | Zie Patient: XXX_Kwee_Kind1 | ||||
| Type partus observatie | |||||
| Observatie datum tijd | T - 5 dagen | ||||
| Type partus waarde | primaire sectio caesarea (verrichting) (code = '80771000146107' 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 | ||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||||
| 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: Probleem3 | ||||
| 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: XXX_Kwee_Kind2 | ||||
| Type partus observatie | |||||
| Observatie datum tijd | T - 5 dagen | ||||
| Type partus waarde | primaire sectio caesarea (verrichting) (code = '80771000146107' 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 Probleem4 | |||||
| Probleem naam | immaturiteit (aandoening) (code = '276658003' in codeSystem 'SNOMED CT') | ||||
| Probleem begin datum | T - 5 dagen | ||||
| Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | ||||
| 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: Probleem3 | ||||
| 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 | ||||
| Indicatie | |||||
| Probleem kindspecifieke maternale problemen | Zie Probleem kindspecifieke maternale problemen: Probleem4 | ||||
| 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: XXX_Kwee_Kind1 | |||||
| Lichamelijk onderzoek kind | ||||||
| Geboortegewicht lichaamsgewicht | ||||||
| Gewicht waarde | 2605 g | |||||
| Gewicht datum tijd | T - 5 dagen om 15:10 uur | |||||
| Kleding | Luier (code = 'DIAPER' in codeSystem 'ZIB ContextKleding') | |||||
| 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: XXX_Kwee_Kind2 | |||||
| Lichamelijk onderzoek kind | ||||||
| Geboortegewicht lichaamsgewicht | ||||||
| Gewicht waarde | 2089 g | |||||
| Gewicht datum tijd | T - 5 dagen om 15:05 uur | |||||
| Kleding | Zonder kleding. (code = 'UNDRESSED' in codeSystem 'ZIB ContextKleding') | |||||
| 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 - 195 dagen | |||||
| Verrichting eind datum | T - 195 dagen | |||||
| Verrichting type | laboratoriumonderzoek (verrichting) (code = '15220000' in codeSystem 'SNOMED CT') | |||||
| Maternale onderzoeksgegevens | ||||||
| Urine bloed en aanvullende onderzoeken | ||||||
| Psie | ||||||
| Laboratorium test bloedgroep Sc4_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 Sc4_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 Sc4_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 hbs ag | ||||||
| Test code | Hepatitis B-virusoppervlakte Ag [eenheden/volume] in serum (code = '58452-4' in codeSystem 'LOINC') | |||||
| Test uitslag | 0 k[arb'U]/L | |||||
| Laboratorium test hiv | ||||||
| Test code | HIV 1 As [aanwezigheid] in serum of plasma d.m.v. immunoassay (code = '29893-5' in codeSystem 'LOINC') | |||||
| Test uitslag | humaan immunodeficiëntievirus negatief (bevinding) (code = '165815009' in codeSystem 'SNOMED CT') | |||||
| Laboratorium test lues | ||||||
| Test code | Treponema pallidum As [eenheden/volume] in serum (code = '11597-2' in codeSystem 'LOINC') | |||||
| Test uitslag | 11868 k[arb'U]/L | |||||
| Irregulaire antistoffen observatie | ||||||
| Irregulaire antistoffen waarde | Nee | |||||
| Welke antistoffen waarde | irregulaire antilichamen afwezig (bevinding) (code = '568111000005107' in codeSystem 'SNOMED CT') | |||||
| Laboratorium test hb Sc4_Hb | ||||||
| Test code | Hemoglobin [Moles/volume] in Venous blood (code = '93846-4' in codeSystem 'LOINC') | |||||
| Test uitslag | 7.0 mmol/L | |||||
| 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 - 76 dagen | ||||
| Verrichting eind datum | T - 76 dagen | ||||
| Verrichting type | laboratoriumonderzoek (verrichting) (code = '15220000' in codeSystem 'SNOMED CT') | ||||
| 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 mmol/L | ||||
1.4.9 Medisch onderzoek
| Medisch onderzoek | |||||
| Gegevenselement | Waarde | ||||
| Verrichting onderzoek | |||||
| Verrichting start datum | T - 5 dagen | ||||
| Verrichting eind datum | T - 5 dagen | ||||
| Verrichting type | laboratoriumonderzoek (verrichting) (code = '15220000' in codeSystem 'SNOMED CT') | ||||
| 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 mmol/L | ||||
1.4.10 Bouwstenen
| Bouwstenen | |||||
| Gegevenselement | Waarde | ||||
| Metingen | |||||
| Bloeddruk BP-193D | |||||
| Systolische bloeddruk | 121 | ||||
| Diastolische bloeddruk | 83 | ||||
| Bloeddruk datum tijd | T - 193 dagen | ||||
| Bloeddruk BP-76D | |||||
| Systolische bloeddruk | 115 | ||||
| Diastolische bloeddruk | 75 | ||||
| Bloeddruk datum tijd | T - 76 dagen | ||||
| Laboratorium uitslag | |||||
| Laboratorium test | |||||
| Test code | (code = in codeSystem 'LOINC') | ||||
| Interpretatie methode | EUCAST (code = 'tbd' in codeSystem 'SNOMED CT') | ||||
| Lichaamsgewicht Gewicht-193D | |||||
| Gewicht waarde | 65 kg | ||||
| Gewicht datum tijd | T - 193 dagen | ||||
1.5 Scenario Vrouw 3, geen zwangerschapskaart beschikbaar
1.5.1 Administratief
| Administratief | |||||
| Gegevenselement | Waarde | ||||
| Patient | |||||
| Naamgegevens | |||||
| Voornamen | Julia | ||||
| Initialen | J | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem 'ZIB Naamgebruik') | ||||
| Geslachtsnaam | |||||
| Achternaam | Laarhoven | ||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1002 | ||||
| Postcode | 9999ZZ | ||||
| Woonplaats | Stitswerd | ||||
| Land | Nederland (code = '6030' in codeSystem 'GBA Tabel 34 Landen') | ||||
| Identificatienummer | 999900754 (in identificerend systeem: BSN) | ||||
| Geboren indicator | Ja | ||||
| Geboortedatum | 22 okt 1985 | ||||
| Geslacht administratief | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
| Zorgaanbieder | |||||
| Zorgaanbieder identificatienummer | (in identificerend systeem: URA) | ||||
| Zorgverlener | |||||
| Zorgverlener identificatienummer | (in identificerend systeem: UZI Personen) | ||||