Gebz:Vdraft AddendaKwalificatieKernsetGeboortezorg23: verschil tussen versies

Uit informatiestandaarden
Ga naar: navigatie, zoeken
Regel 1: Regel 1:
  
−
{{#customtitle:Kernset Geboortezorg 2.3 - dekkingsgraad scenario's}}
+
{{#customtitle:Kernset Geboortezorg 2.3 - inhoud kwalificatie}}
 
__NUMBEREDHEADINGS__
 
__NUMBEREDHEADINGS__
 
{{IssueBox|Deze pagina is nog in bewerking}}
 
{{IssueBox|Deze pagina is nog in bewerking}}
 
[[Bestand:Nictiz_logo_PO_rechts_rgb.png |link=https://www.nictiz.nl/|rechts|Naar nictiz.nl]]
 
[[Bestand:Nictiz_logo_PO_rechts_rgb.png |link=https://www.nictiz.nl/|rechts|Naar nictiz.nl]]
  
−
=Dekkingsgraad scenario's voor Kernset Geboortezorg 2.3=
+
=Addenda voor inhoudelijke gegevens Kernset Geboortezorg 2.3=
−
De volgende scenario's zijn meegenomen:
+
==Scenario 1. Zorg volledig 1e lijn, herpes, strippen, gezonde eenling  (voor vrouw met BSN: 999910413)==
−
* 1. Zorg volledig 1e lijn, herpes, strippen, gezonde eenling (id: scenario1-23)
+
<section begin=999910413 />
−
* 2. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling(id: scenario2_1elijn-23)
 
−
* 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling(id: scenario2_2elijn-23)
 
−
* 3. zorg volledig in 2e lijn, meerling, 1 kind overleden(id: scenario3-23)
 
−
* 4. 1e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden(id: scenario4_1elijn-23)
 
−
* 4. 2e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden(id: scenario4_2elijn-23)
 
−
* 5. zorg volledig 2e lijn, vrouw overleden(id: scenario5-23)
 
−
* 6. 2e lijn(id: scenario6-23)
 
−
Zie voor de inhoud van deze scenario's: [[Gebz:Vdraft_AddendaKwalificatieKernsetGeboortezorg23]]. Onderstaande tabel toont de unieke waarden voor ieder veld. Lege velden worden niet geraakt door de meegenomen bovenstaande scenario's.
 
−
==Scenario (voor vrouw met BSN: 999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020)==
 
−
<section begin=999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />
 
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
 
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Vrouw
 
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Vrouw
Regel 26: Regel 16:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Burgerservicenummer
 
|colspan="2"|Burgerservicenummer
−
|style="background-color: white;"|999910413 - 961921821 - 895623146 - 850810711 - 912345676 - 100202020
+
|style="background-color: white;"|999910413
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Lokale persoonsidentificatie
 
|colspan="2"|Lokale persoonsidentificatie
−
|style="background-color: white;"|000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) - * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6) - 987654321 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
+
|style="background-color: white;"|000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Geboortedatum
 
|colspan="2"|Geboortedatum
−
|style="background-color: white;"|2 mei 1976   - 11 sep 1974  - 5 aug 1985  - 6 aug 1987  - 4 mrt 1993  - 1 jan 1989  
+
|style="background-color: white;"|2 may 1976   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Adres - postcode
 
|colspan="2"|Adres - postcode
−
|style="background-color: white;"|4563 AB - 5689 CZ - 5421 JG - 4589 BA - 9562 GF - 1234 AB
+
|style="background-color: white;"|4563 AB
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Etniciteit
 
|colspan="2"|Etniciteit
−
|style="background-color: white;"|Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28') - Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28') - Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28') - Latijns Amerikaans (code = '14' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
+
|style="background-color: white;"|Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Lengte gemeten
 
|colspan="2"|Lengte gemeten
−
|style="background-color: white;"|170 cm - 184 cm - 167 cm - 162 cm - 186 cm - 172 cm
+
|style="background-color: white;"|170 cm
 +
|}<section end=999910413 />
 +
=== Anamnese ===
 +
<section begin=anamnese_999910413 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Anamnese
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Onder behandeling geweest?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Algemene anamnese
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Cardiovasculaire aandoening
 +
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Oncologische aandoening
 +
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Infectieziekte
 +
|style="background-color: white;"|Herpes (code = '23513009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Type operatie
 +
|style="background-color: white;"|Orthopedisch (code = '112697007' in codeSystem 'Snomed CT')
 +
|}<section end=anamnese_999910413 />
 +
=== Zorgverlening ===
 +
<section begin=zorgverlening_999910413 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgverlening
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum start zorgverantwoordelijkheid
 +
|style="background-color: white;"|1 mar 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum einde zorgverantwoordelijkheid
 +
|style="background-color: white;"|12 nov 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Conclusie risicostatus na intake
 +
|style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
 +
|}<section end=zorgverlening_999910413 />
 +
=== Zorgverlenerzorginstelling ===
 +
<section begin=zorgverlenerzorginstelling_999910413 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgverlenerzorginstelling
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorginstelling lvrid
 +
|style="background-color: white;"|1808
 +
|}<section end=zorgverlenerzorginstelling_999910413 />
 +
=== Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
 +
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Wijze einde zwangerschap
 +
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Definitieve a terme datum
 +
|style="background-color: white;"|1 dec 2011 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Irregulaire antistoffen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Eerdere bevalling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="12"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Placenta - geboorte placenta
 +
|style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Hoeveelheid bloedverlies
 +
|style="background-color: white;"|550 ml
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Vorige uitkomst per kind - vorige baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Demografische gegevens - geboortedatum
 +
|style="background-color: white;"|8 dec 2011  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Kindspecifieke gegevens vorige uitkomsten
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Type partus
 +
|style="background-color: white;"|Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Percentiel van het geboortegewicht
 +
|style="background-color: white;"|p50 tot p90 (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.50')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Apgarscore na 5 min
 +
|style="background-color: white;"|8
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Congenitale afwijkingen?
 +
|style="background-color: white;"|Nee
 +
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 />
 +
=== Zwangerschap ===
 +
<section begin=zwangerschap_999910413 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Zwangerschap
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Dossiernummer
 +
|style="background-color: white;"|0cbda760-1fdd-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Graviditeit
 +
|style="background-color: white;"|2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pariteit voor deze zwangerschap
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Definitieve a terme datum
 +
|style="background-color: white;"|9 oct 2014 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voornemens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie
 +
|style="background-color: white;"|Thuis (code = '169813005' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Prenatale controle
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum controle
 +
|style="background-color: white;"|2 mar 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zwangerschapsduur
 +
|style="background-color: white;"|59 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Leven voelen
 +
|style="background-color: white;"|goed (code = '289431008' in codeSystem 'Snomed CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Rookgedrag
 +
|style="background-color: white;"|niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Alcoholgebruik
 +
|style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Drugsgebruik?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Gewicht gemeten
 +
|style="background-color: white;"|70 kg
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Diagnose
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum
 +
|style="background-color: white;"|2 mar 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zwangerschapsduur
 +
|style="background-color: white;"|59 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Infectie
 +
|style="background-color: white;"|Urineweg infectie (code = '307534009' in codeSystem 'Snomed CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Maternale sterfte?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Wijze einde zwangerschap
 +
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 +
|}<section end=zwangerschap_999910413 />
 +
=== Bevalling ===
 +
<section begin=bevalling_999910413 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Bevalling
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Partusnummer
 +
|style="background-color: white;"|000000
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Aantal geboren kinderen
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Risicostatus voor baring
 +
|style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Interventies begin baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Interventie begin baring
 +
|style="background-color: white;"|Strippen (code = '236960006' in codeSystem 'Snomed CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Indicatie interventie begin baring
 +
|style="background-color: white;"|wens patiënt (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Wijze waarop de baring begon
 +
|style="background-color: white;"|Interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Tijdstip begin actieve ontsluiting
 +
|style="background-color: white;"|8 oct 2014  14:30
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Medicatie nageboortetijdperk groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Medicatie nageboortetijdperk?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Soort medicatie nageboortetijdperk
 +
|style="background-color: white;"|Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Placenta - geboorte placenta
 +
|style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Hoeveelheid bloedverlies
 +
|style="background-color: white;"|615 ml
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Conditie perineum postpartum
 +
|style="background-color: white;"|1e graads perineumruptuur (code = '199916005' in codeSystem 'Snomed CT')
 +
|}<section end=bevalling_999910413 />
 +
=== Uitkomst per kind ===
 +
<section begin=uitkomst_per_kind_999910413 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Uitkomst per kind
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="34"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Werkelijke plaats baring type locatie
 +
|style="background-color: white;"|Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Demografische gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="10"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Identificaties kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Bsn kind
 +
|style="background-color: white;"|999910383
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Geslacht medische observatie
 +
|style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Geboortedatum
 +
|style="background-color: white;"|8 oct 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Rangnummer kind
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Perinatale sterfte groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Perinatale sterfte?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Kindspecifieke maternale gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Tijdstip breken vliezen
 +
|style="background-color: white;"|8 oct 2014  09:15
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Kleur en consistentie vruchtwater
 +
|style="background-color: white;"|Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Tijdstip actief meepersen
 +
|style="background-color: white;"|8 oct 2014  12:13
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Episiotomie?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Ruggeprik gewenst niet gekregen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pijnbestrijding?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Sedatie?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Kindspecifieke uitkomstgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="11"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Type partus
 +
|style="background-color: white;"|Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Ligging bij geboorte
 +
|style="background-color: white;"|Achterhoofd-achter (code = '37235006' in codeSystem 'Snomed CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Aanpakker kind - rol aanpakker kind
 +
|style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Supervisor - rol supervisor
 +
|style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Lichamelijk onderzoek kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Geboortegewicht
 +
|style="background-color: white;"|3450 gram
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Congenitale afwijkingen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Problematiek kind?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Kinderarts betrokken?
 +
|style="background-color: white;"|Nee
 +
|}<section end=uitkomst_per_kind_999910413 />
 +
=== Medisch onderzoek ===
 +
<section begin=medisch_onderzoek_999910413 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Medisch onderzoek
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Irregulaire antistoffen?
 +
|style="background-color: white;"|Nee
 +
|}<section end=medisch_onderzoek_999910413 />
 +
=== Postnatale fase ===
 +
<section begin=postnatale_fase_999910413 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Postnatale fase
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="4" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Kindspecifieke gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voeding kind groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voeding kind datum
 +
|style="background-color: white;"|12 oct 2014 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Substantie voeding kind
 +
|style="background-color: white;"|borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Substantie voeding kind
 +
|style="background-color: white;"|kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')
 +
|}<section end=postnatale_fase_999910413 />
 +
==Scenario 2. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)==
 +
<section begin=961921821 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Vrouw
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Burgerservicenummer
 +
|style="background-color: white;"|961921821
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Lokale persoonsidentificatie
 +
|style="background-color: white;"|* (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Geboortedatum
 +
|style="background-color: white;"|11 sep 1974 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Adres - postcode
 +
|style="background-color: white;"|5689 CZ
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Etniciteit
 +
|style="background-color: white;"|Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Lengte gemeten
 +
|style="background-color: white;"|184 cm
 +
|}<section end=961921821 />
 +
=== Anamnese ===
 +
<section begin=anamnese_961921821 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Anamnese
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Onder behandeling geweest?
 +
|style="background-color: white;"|Nee
 +
|}<section end=anamnese_961921821 />
 +
=== Zorgverlening ===
 +
<section begin=zorgverlening_961921821 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Zorgverlening
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="6" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Datum start zorgverantwoordelijkheid
 +
|style="background-color: white;"|28 aug 2018 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Datum einde zorgverantwoordelijkheid
 +
|style="background-color: white;"|28 nov 2018 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Conclusie risicostatus na intake
 +
|style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Verwijsdetails
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="20"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Datum verwijzing
 +
|style="background-color: white;"|6 may 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Verwijzing van
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Zorginstelling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Zorgaanbieder identificatie nummer
 +
|style="background-color: white;"|1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Verwijzing naar
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Zorginstelling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Specialisme
 +
|style="background-color: white;"|Gynaecoloog 2e lijn (code = '02' in codeSystem 'Specialisme, specifiek voor perinatologie.')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Redenen van verwijzing
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Van 1e naar 2e lijn
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Zwangerschap
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Hypertensieve aandoening
 +
|style="background-color: white;"|Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Perinatale periode
 +
|style="background-color: white;"|voor 28e week (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52')
 +
|}<section end=zorgverlening_961921821 />
 +
=== Zorgverlenerzorginstelling ===
 +
<section begin=zorgverlenerzorginstelling_961921821 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgverlenerzorginstelling
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorginstelling lvrid
 +
|style="background-color: white;"|1504
 +
|}<section end=zorgverlenerzorginstelling_961921821 />
 +
=== Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
 +
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Wijze einde zwangerschap
 +
|style="background-color: white;"|Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Definitieve a terme datum
 +
|style="background-color: white;"|5 jun 2013 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Diagnose
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Bloedverlies?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Hyperemesis gravidarum?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Irregulaire antistoffen?
 +
|style="background-color: white;"|Ja
 +
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
 +
=== Zwangerschap ===
 +
<section begin=zwangerschap_961921821 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Zwangerschap
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Dossiernummer
 +
|style="background-color: white;"|5460cff0-2089-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Graviditeit
 +
|style="background-color: white;"|2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pariteit voor deze zwangerschap
 +
|style="background-color: white;"|0
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Definitieve a terme datum
 +
|style="background-color: white;"|8 sep 2014 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voornemens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie
 +
|style="background-color: white;"|Nog niet bepaald (code = '05' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Prenatale controle
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum controle
 +
|style="background-color: white;"|6 may 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zwangerschapsduur
 +
|style="background-color: white;"|155 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Leven voelen
 +
|style="background-color: white;"|Weak fetal movements (finding) (code = '276372004' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Rookgedrag
 +
|style="background-color: white;"|gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Alcoholgebruik
 +
|style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Drugsgebruik?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Gewicht gemeten
 +
|style="background-color: white;"|85 kg
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Diagnose
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum
 +
|style="background-color: white;"|6 may 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zwangerschapsduur
 +
|style="background-color: white;"|155 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Hypertensieve aandoening
 +
|style="background-color: white;"|Pregnancy-induced hypertension (disorder) (code = '48194001' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Maternale sterfte?
 +
|style="background-color: white;"|Nee
 +
|}<section end=zwangerschap_961921821 />
 +
==Scenario 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)==
 +
<section begin=961921821 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Vrouw
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Burgerservicenummer
 +
|style="background-color: white;"|961921821
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Lokale persoonsidentificatie
 +
|style="background-color: white;"|* (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Geboortedatum
 +
|style="background-color: white;"|11 sep 1974 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Adres - postcode
 +
|style="background-color: white;"|5689 CZ
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Etniciteit
 +
|style="background-color: white;"|Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Lengte gemeten
 +
|style="background-color: white;"|184 cm
 +
|}<section end=961921821 />
 +
=== Anamnese ===
 +
<section begin=anamnese_961921821 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Anamnese
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Onder behandeling geweest?
 +
|style="background-color: white;"|Nee
 +
|}<section end=anamnese_961921821 />
 +
=== Zorgverlening ===
 +
<section begin=zorgverlening_961921821 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Zorgverlening
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="6" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Datum start zorgverantwoordelijkheid
 +
|style="background-color: white;"|12 may 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Datum einde zorgverantwoordelijkheid
 +
|style="background-color: white;"|9 oct 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Verwijsdetails
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="18"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Verwijzing van
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Zorginstelling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Zorgaanbieder identificatie nummer
 +
|style="background-color: white;"|1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Verwijzing naar
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Zorginstelling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Zorgaanbieder identificatie nummer
 +
|style="background-color: white;"|0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Redenen van verwijzing
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Van 1e naar 2e lijn
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Zwangerschap
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Hypertensieve aandoening
 +
|style="background-color: white;"|Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT')
 +
|}<section end=zorgverlening_961921821 />
 +
=== Zorgverlenerzorginstelling ===
 +
<section begin=zorgverlenerzorginstelling_961921821 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgverlenerzorginstelling
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorginstelling lvrid
 +
|style="background-color: white;"|0003
 +
|}<section end=zorgverlenerzorginstelling_961921821 />
 +
=== Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
 +
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Wijze einde zwangerschap
 +
|style="background-color: white;"|Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Definitieve a terme datum
 +
|style="background-color: white;"|5 jun 2013 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Diagnose
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Gynaecologische aandoening
 +
|style="background-color: white;"|Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Bloedverlies?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Hyperemesis gravidarum?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Irregulaire antistoffen?
 +
|style="background-color: white;"|Ja
 +
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_961921821 />
 +
=== Zwangerschap ===
 +
<section begin=zwangerschap_961921821 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Zwangerschap
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Dossiernummer
 +
|style="background-color: white;"|c2204d20-209a-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Graviditeit
 +
|style="background-color: white;"|2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pariteit voor deze zwangerschap
 +
|style="background-color: white;"|0
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Definitieve a terme datum
 +
|style="background-color: white;"|8 sep 2014 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voornemens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="1"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Prenatale controle
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum controle
 +
|style="background-color: white;"|12 may 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zwangerschapsduur
 +
|style="background-color: white;"|161 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Leven voelen
 +
|style="background-color: white;"|Reduced fetal movement (finding) (code = '276369006' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Rookgedrag
 +
|style="background-color: white;"|gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Alcoholgebruik
 +
|style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Drugsgebruik?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Gewicht gemeten
 +
|style="background-color: white;"|85 kg
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Diagnose
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum
 +
|style="background-color: white;"|12 may 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zwangerschapsduur
 +
|style="background-color: white;"|161 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Gynaecologische aandoening
 +
|style="background-color: white;"|Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Partiele mola?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Hypertensieve aandoening
 +
|style="background-color: white;"|Pre-eclampsia (disorder) (code = '398254007' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Maternale sterfte?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Wijze einde zwangerschap
 +
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 +
|}<section end=zwangerschap_961921821 />
 +
=== Bevalling ===
 +
<section begin=bevalling_961921821 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Bevalling
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Partusnummer
 +
|style="background-color: white;"|000000
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Aantal geboren kinderen
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Risicostatus voor baring
 +
|style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Interventies begin baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Interventie begin baring
 +
|style="background-color: white;"|Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Indicatie interventie begin baring
 +
|style="background-color: white;"|acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Wijze waarop de baring begon
 +
|style="background-color: white;"|interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Tijdstip begin actieve ontsluiting
 +
|style="background-color: white;"|30 aug 2014  14:09
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Medicatie nageboortetijdperk groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Medicatie nageboortetijdperk?
 +
|style="background-color: white;"|UNK
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Placenta - geboorte placenta
 +
|style="background-color: white;"|placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Hoeveelheid bloedverlies
 +
|style="background-color: white;"|980 ml
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Conditie perineum postpartum
 +
|style="background-color: white;"|Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96')
 +
|}<section end=bevalling_961921821 />
 +
=== Uitkomst per kind ===
 +
<section begin=uitkomst_per_kind_961921821 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Uitkomst per kind
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="6" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="51"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Werkelijke plaats baring type locatie
 +
|style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Ziekenhuis baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ziekenhuisnummer lvrid
 +
|style="background-color: white;"|0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Demografische gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="10"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Identificaties kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Bsn kind
 +
|style="background-color: white;"|951847624
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geslacht medische observatie
 +
|style="background-color: white;"|mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geboortedatum
 +
|style="background-color: white;"|1 sep 2014  02:34
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Rangnummer kind
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Perinatale sterfte groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Perinatale sterfte?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Kindspecifieke maternale gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="12"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Tijdstip breken vliezen
 +
|style="background-color: white;"|30 aug 2014  23:04
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Kleur en consistentie vruchtwater
 +
|style="background-color: white;"|geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ruggeprik gewenst niet gekregen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Pijnbestrijding?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Pijnbestrijding
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Methode
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Methode
 +
|style="background-color: white;"|Epidural anesthesia (procedure) (code = '18946005' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Periode
 +
|style="background-color: white;"|tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Sedatie?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Kindspecifieke uitkomstgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="21"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Type partus
 +
|style="background-color: white;"|Cesarean section (procedure) (code = '11466000' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ligging bij geboorte
 +
|style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Aanpakker kind - rol aanpakker kind
 +
|style="background-color: white;"|gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Supervisor - rol supervisor
 +
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Sectio caesarea group
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Indicatie primaire sectio
 +
|style="background-color: white;"|Suspected fetal distress (situation) (code = '444433005:246090004=130955003' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Indicatie primaire sectio
 +
|style="background-color: white;"|Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Lichamelijk onderzoek kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Geboortegewicht
 +
|style="background-color: white;"|3620 gram
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Congenitale afwijkingen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problematiek kind?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Kinderarts betrokken?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Betrokkenheid kinderarts
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Datum betrokkenheid
 +
|style="background-color: white;"|1 sep 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Reden betrokkenheid
 +
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Type betrokkenheid
 +
|style="background-color: white;"|consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Zorginstelling lvrid
 +
|style="background-color: white;"|0003
 +
|}<section end=uitkomst_per_kind_961921821 />
 +
=== Medisch onderzoek ===
 +
<section begin=medisch_onderzoek_961921821 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Medisch onderzoek
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Irregulaire antistoffen?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Welke irregulaire antistoffen vrouw aanwezig
 +
|style="background-color: white;"|Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96')
 +
|}<section end=medisch_onderzoek_961921821 />
 +
=== Postnatale fase ===
 +
<section begin=postnatale_fase_961921821 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Postnatale fase
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="4" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Diagnoseinterventie postpartum
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Datum
 +
|style="background-color: white;"|3 sep 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pathologie vrouw
 +
|style="background-color: white;"|Urinary tract infectious disease (disorder) (code = '68566005' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Kindspecifieke gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voeding kind groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voeding kind datum
 +
|style="background-color: white;"|7 oct 2014 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Substantie voeding kind
 +
|style="background-color: white;"|kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')
 +
|}<section end=postnatale_fase_961921821 />
 +
==Scenario 3. zorg volledig in 2e lijn, meerling, 1 kind overleden (voor vrouw met BSN: 895623146)==
 +
<section begin=895623146 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Vrouw
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Burgerservicenummer
 +
|style="background-color: white;"|895623146
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Lokale persoonsidentificatie
 +
|style="background-color: white;"|000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Geboortedatum
 +
|style="background-color: white;"|5 aug 1985 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Adres - postcode
 +
|style="background-color: white;"|5421 JG
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Etniciteit
 +
|style="background-color: white;"|Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Lengte gemeten
 +
|style="background-color: white;"|167 cm
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Vrouwelijke genitale verminking?
 
|colspan="2"|Vrouwelijke genitale verminking?
−
|style="background-color: white;"|Ja - Nee
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Type vrouwelijke genitale verminking
 
|colspan="2"|Type vrouwelijke genitale verminking
−
|style="background-color: white;"|Female genital mutilation type 2 (disorder) (code = '130621000119105' in codeSystem '2.16.840.1.113883.6.96') - Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96')
+
|style="background-color: white;"|Female genital mutilation type 2 (disorder) (code = '130621000119105' in codeSystem '2.16.840.1.113883.6.96')
−
|}<section end=999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />
+
|}<section end=895623146 />
 
=== Anamnese ===
 
=== Anamnese ===
−
<section begin=anamnese_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />
+
<section begin=anamnese_895623146 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
 
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Anamnese
 
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Anamnese
Regel 59: Regel 1.169:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Onder behandeling geweest?
 
|colspan="3"|Onder behandeling geweest?
−
|style="background-color: white;"|Ja - Nee
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="4"|Algemene anamnese
 
|colspan="4"|Algemene anamnese
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="21"|
+
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Cardiovasculaire aandoening
 +
|style="background-color: white;"|Cardiac arrhythmia (disorder) (code = '698247007' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Schildklier aandoening
 +
|style="background-color: white;"|Hyperthyroidism (disorder) (code = '34486009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Anemie
 +
|style="background-color: white;"|Iron deficiency anemia (disorder) (code = '87522002' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Bloedtransfusie?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Type operatie
 +
|style="background-color: white;"|Operation on heart (procedure) (code = '64915003' in codeSystem '2.16.840.1.113883.6.96')
 +
|}<section end=anamnese_895623146 />
 +
=== Zorgverlening ===
 +
<section begin=zorgverlening_895623146 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgverlening
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum start zorgverantwoordelijkheid
 +
|style="background-color: white;"|10 mar 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum einde zorgverantwoordelijkheid
 +
|style="background-color: white;"|3 nov 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Conclusie risicostatus na intake
 +
|style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
 +
|}<section end=zorgverlening_895623146 />
 +
=== Zorgverlenerzorginstelling ===
 +
<section begin=zorgverlenerzorginstelling_895623146 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgverlenerzorginstelling
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorginstelling lvrid
 +
|style="background-color: white;"|9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|}<section end=zorgverlenerzorginstelling_895623146 />
 +
=== Zwangerschap ===
 +
<section begin=zwangerschap_895623146 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Zwangerschap
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Dossiernummer
 +
|style="background-color: white;"|ad9c3280-209d-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Graviditeit
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pariteit voor deze zwangerschap
 +
|style="background-color: white;"|0
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Definitieve a terme datum
 +
|style="background-color: white;"|22 sep 2014 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voornemens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie
 +
|style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Prenatale controle
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum controle
 +
|style="background-color: white;"|21 may 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zwangerschapsduur
 +
|style="background-color: white;"|156 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Leven voelen
 +
|style="background-color: white;"|Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Rookgedrag
 +
|style="background-color: white;"|niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Alcoholgebruik
 +
|style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Drugsgebruik?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Gewicht gemeten
 +
|style="background-color: white;"|67 kg
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Diagnose
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="7"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum
 +
|style="background-color: white;"|21 may 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zwangerschapsduur
 +
|style="background-color: white;"|156 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Bloedverlies?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Infectie
 +
|style="background-color: white;"|Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Afwijkende groei foetus
 +
|style="background-color: white;"|Small for gestational age fetus (disorder) (code = '267258002' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Abruptio placentae?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Maternale sterfte?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Wijze einde zwangerschap
 +
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 +
|}<section end=zwangerschap_895623146 />
 +
=== Bevalling ===
 +
<section begin=bevalling_895623146 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Bevalling
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Partusnummer
 +
|style="background-color: white;"|000000
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Diagnose bevalling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Pprom?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Verdenking foetale nood?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Aantal geboren kinderen
 +
|style="background-color: white;"|2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Risicostatus voor baring
 +
|style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Wijze waarop de baring begon
 +
|style="background-color: white;"|spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Tijdstip begin actieve ontsluiting
 +
|style="background-color: white;"|27 aug 2014  22:09
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Medicatie nageboortetijdperk groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Medicatie nageboortetijdperk?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Placenta - geboorte placenta
 +
|style="background-color: white;"|controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Hoeveelheid bloedverlies
 +
|style="background-color: white;"|1740 ml
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Conditie perineum postpartum
 +
|style="background-color: white;"|Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96')
 +
|}<section end=bevalling_895623146 />
 +
=== Uitkomst per kind ===
 +
<section begin=uitkomst_per_kind_895623146 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="8" | Uitkomst per kind
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="7" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="8"|Baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="59"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Werkelijke plaats baring type locatie
 +
|style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Ziekenhuis baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ziekenhuisnummer lvrid
 +
|style="background-color: white;"|9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Demografische gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="10"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Identificaties kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Bsn kind
 +
|style="background-color: white;"|847035116
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Geslacht medische observatie
 +
|style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Geboortedatum
 +
|style="background-color: white;"|28 aug 2014  06:30
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Rangnummer kind
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Perinatale sterfte groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Perinatale sterfte?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Kindspecifieke maternale gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="19"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Tijdstip breken vliezen
 +
|style="background-color: white;"|27 aug 2014  22:09
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Kleur en consistentie vruchtwater
 +
|style="background-color: white;"|kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Tijdstip actief meepersen
 +
|style="background-color: white;"|27 aug 2014  23:49
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Episiotomie?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Locatie episiotomie
 +
|style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ruggeprik gewenst niet gekregen?
 +
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Autoimmuun aandoening
+
|colspan="5"|Pijnbestrijding?
−
|style="background-color: white;"|Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96')
+
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Pijnbestrijding
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Cardiovasculaire aandoening
+
|rowspan="9"|
−
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - Cardiac arrhythmia (disorder) (code = '698247007' in codeSystem '2.16.840.1.113883.6.96') - Hypertensive disorder, systemic arterial (disorder) (code = '38341003' in codeSystem '2.16.840.1.113883.6.96')
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Methode
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Urogenitale aandoening
+
|rowspan="6"|
−
|style="background-color: white;"|Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96') - Pyelonefritis (code = '45816000' in codeSystem 'Snomed CT')
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Oncologische aandoening
+
|colspan="3"|Methode
 
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Overig middel
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Schildklier aandoening
+
|rowspan="3"|
−
|style="background-color: white;"|Hyperthyroidism (disorder) (code = '34486009' in codeSystem '2.16.840.1.113883.6.96') - Hypothyreoidie (code = '40930008' in codeSystem 'Snomed CT')
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Middel
 +
|style="background-color: white;"|Administration of morphinomimetic analgesic (procedure) (code = '52685006:363701004=404642006' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Toediening
 +
|style="background-color: white;"|Administration of substance via intravenous route (procedure) (code = '431215000' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Periode
 +
|style="background-color: white;"|tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Sedatie?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Kindspecifieke uitkomstgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="22"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Type partus
 +
|style="background-color: white;"|Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ligging bij geboorte
 +
|style="background-color: white;"|Face presentation (finding) (code = '21882006' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Aanpakker kind - rol aanpakker kind
 +
|style="background-color: white;"|arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Supervisor - rol supervisor
 +
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Vaginale kunstverlossing groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Vaginale kunstverlossing
 +
|style="background-color: white;"|Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Succes vaginale kunstverlossing?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Lichamelijk onderzoek kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geboortegewicht
 +
|style="background-color: white;"|2040 gram
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Congenitale afwijkingen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Problematiek kind?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Problematiek kind
 +
|style="background-color: white;"|Birth trauma of fetus (disorder) (code = '56110009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Kinderarts betrokken?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Betrokkenheid kinderarts
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Datum betrokkenheid
 +
|style="background-color: white;"|28 aug 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Reden betrokkenheid
 +
|style="background-color: white;"|Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Type betrokkenheid
 +
|style="background-color: white;"|consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Zorginstelling lvrid
 +
|style="background-color: white;"|9999
 +
|}<section end=uitkomst_per_kind_895623146 />
 +
=== Uitkomst per kind ===
 +
<section begin=uitkomst_per_kind_895623146 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="8" | Uitkomst per kind
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="7" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="8"|Baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="71"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Werkelijke plaats baring type locatie
 +
|style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Ziekenhuis baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ziekenhuisnummer lvrid
 +
|style="background-color: white;"|9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Demografische gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="12"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Identificaties kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Bsn kind
 +
|style="background-color: white;"|847035128
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Geslacht medische observatie
 +
|style="background-color: white;"|mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Geboortedatum
 +
|style="background-color: white;"|28 aug 2014  07:02
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Rangnummer kind
 +
|style="background-color: white;"|2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Perinatale sterfte groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Perinatale sterfte?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Fase perinatale sterfte
 +
|style="background-color: white;"|Newborn death (event) (code = '276506001' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Diabetes mellitus?
+
|colspan="4"|Datumtijd vaststelling perinatale sterfte
−
|style="background-color: white;"|Ja - Nee
+
|style="background-color: white;"|28 aug 2014  08:10
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Kindspecifieke maternale gegevens
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Neurologische aandoening
+
|rowspan="19"|
−
|style="background-color: white;"|Epilepsy (disorder) (code = '84757009' in codeSystem '2.16.840.1.113883.6.96') - Hernia nuclei pulposi (code = '84857004' in codeSystem 'Snomed CT') - Overig, niet nader omschreven Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Infectieziekte
+
|colspan="5"|Tijdstip breken vliezen
−
|style="background-color: white;"|Herpes (code = '23513009' in codeSystem '2.16.840.1.113883.6.96')
+
|style="background-color: white;"|27 aug 2014  23:13
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Mdl aandoening
+
|colspan="5"|Kleur en consistentie vruchtwater
−
|style="background-color: white;"|Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96') - M. Crohn (code = '34000006' in codeSystem 'Snomed CT')
+
|style="background-color: white;"|kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Anemie
+
|colspan="5"|Tijdstip actief meepersen
−
|style="background-color: white;"|Iron deficiency anemia (disorder) (code = '87522002' in codeSystem '2.16.840.1.113883.6.96') - IJzergebrek (code = '87522002' in codeSystem 'Snomed CT')
+
|style="background-color: white;"|28 aug 2014  06:45
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Longaandoening
+
|colspan="5"|Episiotomie?
−
|style="background-color: white;"|Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96') - Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Gynaecologische aandoening
+
|colspan="5"|Locatie episiotomie
−
|style="background-color: white;"|
+
|style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Orthopedische afwijking
+
|colspan="5"|Ruggeprik gewenst niet gekregen?
−
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - Trauma bekken (code = '282771003' in codeSystem 'Snomed CT')
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Bloedtransfusie?
+
|colspan="5"|Pijnbestrijding?
−
|style="background-color: white;"|Ja - Nee
+
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Pijnbestrijding
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Transfusiereactie?
+
|rowspan="9"|
−
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Methode
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Type operatie
+
|rowspan="6"|
−
|style="background-color: white;"|Orthopedisch (code = '112697007' in codeSystem 'Snomed CT') - Operation on heart (procedure) (code = '64915003' in codeSystem '2.16.840.1.113883.6.96') - Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96') - Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - Sectio (code = '11466000' in codeSystem 'Snomed CT') - Rug (code = '129152004:260686004=129284003' in codeSystem '2.16.840.1.113883.6.96')
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Type stollingsprobleem
+
|colspan="3"|Methode
 
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Overig middel
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Middel
 +
|style="background-color: white;"|Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Toediening
 +
|style="background-color: white;"|Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Periode
 +
|style="background-color: white;"|tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Sedatie?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Kindspecifieke uitkomstgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="32"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Type partus
 +
|style="background-color: white;"|Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ligging bij geboorte
 +
|style="background-color: white;"|Complete breech presentation (finding) (code = '49168004' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Aanpakker kind - rol aanpakker kind
 +
|style="background-color: white;"|arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Supervisor - rol supervisor
 +
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Vaginale kunstverlossing groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Vaginale kunstverlossing
 +
|style="background-color: white;"|Total breech extraction (procedure) (code = '416055001' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Succes vaginale kunstverlossing?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Overige interventies
 +
|style="background-color: white;"|Maneuvers for delivery in shoulder dystocia (procedure) (code = '237008007' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Lichamelijk onderzoek kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geboortegewicht
 +
|style="background-color: white;"|1580 gram
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Congenitale afwijkingen?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Congenitale afwijkingen groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Specificatie congenitale afwijking groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Specificatie congenitale afwijking
 +
|style="background-color: white;"|Spina bifida occulta (disorder) (code = '76916001' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Specificatie congenitale afwijking groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Specificatie congenitale afwijking
 +
|style="background-color: white;"|Multiple congenital cardiac defects (disorder) (code = '94702005' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Chromosomale afwijkingen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Problematiek kind?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Problematiek kind
 +
|style="background-color: white;"|Subdural intracranial hemorrhage due to birth trauma (disorder) (code = '126941005' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Kinderarts betrokken?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Betrokkenheid kinderarts
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Datum betrokkenheid
 +
|style="background-color: white;"|28 aug 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Reden betrokkenheid
 +
|style="background-color: white;"|Finding of neonatal condition (finding) (code = '364737004' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Type betrokkenheid
 +
|style="background-color: white;"|overdracht (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Zorginstelling lvrid
 +
|style="background-color: white;"|0001
 +
|}<section end=uitkomst_per_kind_895623146 />
 +
=== Medisch onderzoek ===
 +
<section begin=medisch_onderzoek_895623146 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Medisch onderzoek
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Psychiatrie?
+
|rowspan="2"|
−
|style="background-color: white;"|Ja - Nee
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Overige aandoening?
+
|colspan="2"|Irregulaire antistoffen?
 
|style="background-color: white;"|Nee
 
|style="background-color: white;"|Nee
 +
|}<section end=medisch_onderzoek_895623146 />
 +
=== Postnatale fase ===
 +
<section begin=postnatale_fase_895623146 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Postnatale fase
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="4" width="25%"| Gegevenselement
 +
|| Waarde
 +
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Kindspecifieke gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Overige aandoening
+
|colspan="3"|Rangnummer kind
 
|style="background-color: white;"|
 
|style="background-color: white;"|
−
|}<section end=anamnese_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />
+
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voeding kind groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voeding kind datum
 +
|style="background-color: white;"|3 sep 2014 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Substantie voeding kind
 +
|style="background-color: white;"|borstmelk (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')
 +
|}<section end=postnatale_fase_895623146 />
 +
==Scenario 4. 1e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)==
 +
<section begin=850810711 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Vrouw
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Burgerservicenummer
 +
|style="background-color: white;"|850810711
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Lokale persoonsidentificatie
 +
|style="background-color: white;"|* (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Geboortedatum
 +
|style="background-color: white;"|6 aug 1987 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Adres - postcode
 +
|style="background-color: white;"|4589 BA
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Etniciteit
 +
|style="background-color: white;"|Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Lengte gemeten
 +
|style="background-color: white;"|162 cm
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Vrouwelijke genitale verminking?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Type vrouwelijke genitale verminking
 +
|style="background-color: white;"|Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96')
 +
|}<section end=850810711 />
 +
=== Anamnese ===
 +
<section begin=anamnese_850810711 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Anamnese
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Onder behandeling geweest?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Algemene anamnese
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Autoimmuun aandoening
 +
|style="background-color: white;"|Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Urogenitale aandoening
 +
|style="background-color: white;"|Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Diabetes mellitus?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Mdl aandoening
 +
|style="background-color: white;"|Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Longaandoening
 +
|style="background-color: white;"|Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Type operatie
 +
|style="background-color: white;"|Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Type operatie
 +
|style="background-color: white;"|Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Type operatie
 +
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|}<section end=anamnese_850810711 />
 
=== Zorgverlening ===
 
=== Zorgverlening ===
−
<section begin=zorgverlening_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />
+
<section begin=zorgverlening_850810711 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
−
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="8" | Zorgverlening
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Zorgverlening
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Datum start zorgverantwoordelijkheid
 +
|style="background-color: white;"|7 aug 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Datum einde zorgverantwoordelijkheid
 +
|style="background-color: white;"|15 sep 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Conclusie risicostatus na intake
 +
|style="background-color: white;"|3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Verwijsdetails
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="15"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verwijzing van
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Zorginstelling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorgaanbieder identificatie nummer
 +
|style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verwijzing naar
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Zorginstelling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorgaanbieder identificatie nummer
 +
|style="background-color: white;"|1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Redenen van verwijzing
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="1"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Redenen van verwijzing
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="1"|
 +
|}<section end=zorgverlening_850810711 />
 +
=== Zorgverlenerzorginstelling ===
 +
<section begin=zorgverlenerzorginstelling_850810711 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgverlenerzorginstelling
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorginstelling lvrid
 +
|style="background-color: white;"|1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|}<section end=zorgverlenerzorginstelling_850810711 />
 +
=== Zwangerschap ===
 +
<section begin=zwangerschap_850810711 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zwangerschap
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Dossiernummer
 +
|style="background-color: white;"|05e54070-209f-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Graviditeit
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Pariteit voor deze zwangerschap
 +
|style="background-color: white;"|0
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Definitieve a terme datum
 +
|style="background-color: white;"|18 aug 2014 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Maternale sterfte?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Wijze einde zwangerschap
 +
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 +
|}<section end=zwangerschap_850810711 />
 +
=== Bevalling ===
 +
<section begin=bevalling_850810711 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Bevalling
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Aantal geboren kinderen
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Risicostatus voor baring
 +
|style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Wijze waarop de baring begon
 +
|style="background-color: white;"|spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Tijdstip begin actieve ontsluiting
 +
|style="background-color: white;"|3 aug 2014  21:09
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Medicatie nageboortetijdperk groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Medicatie nageboortetijdperk?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Soort medicatie nageboortetijdperk
 +
|style="background-color: white;"|Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Placenta - geboorte placenta
 +
|style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Hoeveelheid bloedverlies
 +
|style="background-color: white;"|1120 ml
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Conditie perineum postpartum
 +
|style="background-color: white;"|Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96')
 +
|}<section end=bevalling_850810711 />
 +
=== Uitkomst per kind ===
 +
<section begin=uitkomst_per_kind_850810711 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="8" | Uitkomst per kind
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|colspan="7" width="25%"| Gegevenselement
 
|colspan="7" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="8"|Baring
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="7"|Datum start zorgverantwoordelijkheid
+
|rowspan="58"|
−
|style="background-color: white;"|1 mrt 2014  00:00 - 28 aug 2018  - 12 mei 2014  00:00 - 10 mrt 2014  00:00 - 7 aug 2014  00:00 - 3 feb 2014  00:00 - 9 dec 2013  00:00 - 1 mrt 2019  00:00
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="7"|Datum einde zorgverantwoordelijkheid
+
|colspan="6"|Werkelijke plaats baring type locatie
−
|style="background-color: white;"|12 nov 2014  00:00 - 28 nov 2018  - 9 okt 2014  00:00 - 3 nov 2014  00:00 - 15 sep 2014  00:00 - 6 aug 2014  00:00 - 4 aug 2014  00:00 - 15 okt 2019  00:00
+
|style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Ziekenhuis baring
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="7"|Eindverantwoordelijk in welke perinatale periode?
+
|rowspan="2"|
−
|style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20') - follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ziekenhuisnummer lvrid
 +
|style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Demografische gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="10"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Identificaties kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Bsn kind
 +
|style="background-color: white;"|840736526
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Geslacht medische observatie
 +
|style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Geboortedatum
 +
|style="background-color: white;"|4 aug 2014  23:35
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Rangnummer kind
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Perinatale sterfte groep
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="7"|Conclusie risicostatus na intake
+
|rowspan="2"|
−
|style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26') - 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26') - 3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Perinatale sterfte?
 +
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="8"|Verwijsdetails
+
|colspan="7"|Kindspecifieke maternale gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="19"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Tijdstip breken vliezen
 +
|style="background-color: white;"|3 aug 2014  07:04
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Kleur en consistentie vruchtwater
 +
|style="background-color: white;"|bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Tijdstip actief meepersen
 +
|style="background-color: white;"|4 aug 2014  22:15
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Episiotomie?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="99"|
+
|colspan="5"|Locatie episiotomie
 +
|style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Datum verwijzing
+
|colspan="5"|Ruggeprik gewenst niet gekregen?
−
|style="background-color: white;"|6 mei 2014  00:00 - 6 aug 2014  00:00
+
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Pijnbestrijding?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="7"|Verwijzing van
+
|colspan="6"|Pijnbestrijding
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Methode
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="5"|
+
|colspan="3"|Methode
 +
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="6"|Zorginstelling
+
|colspan="4"|Overig middel
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="3"|
 
|rowspan="3"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Zorgaanbieder identificatie nummer
+
|colspan="2"|Middel
−
|style="background-color: white;"|1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
+
|style="background-color: white;"|Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Specialisme
+
|colspan="2"|Toediening
−
|style="background-color: white;"|
+
|style="background-color: white;"|Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Periode
 +
|style="background-color: white;"|tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Sedatie?
 +
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="7"|Verwijzing naar
+
|colspan="7"|Kindspecifieke uitkomstgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="21"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Type partus
 +
|style="background-color: white;"|Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ligging bij geboorte
 +
|style="background-color: white;"|Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="6"|
+
|colspan="5"|Aanpakker kind - rol aanpakker kind
 +
|style="background-color: white;"|co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Supervisor - rol supervisor
 +
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="6"|Zorginstelling
+
|colspan="6"|Vaginale kunstverlossing groep
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="3"|
 
|rowspan="3"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Zorgaanbieder identificatie nummer
+
|colspan="4"|Vaginale kunstverlossing
−
|style="background-color: white;"|0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
+
|style="background-color: white;"|Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Succes vaginale kunstverlossing?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Lichamelijk onderzoek kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geboortegewicht
 +
|style="background-color: white;"|4205 gram
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Congenitale afwijkingen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Problematiek kind?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Kinderarts betrokken?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Betrokkenheid kinderarts
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Datum betrokkenheid
 +
|style="background-color: white;"|4 aug 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Reden betrokkenheid
 +
|style="background-color: white;"|Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Type betrokkenheid
 +
|style="background-color: white;"|consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Specialisme
+
|colspan="4"|Zorginstelling lvrid
−
|style="background-color: white;"|Gynaecoloog 2e lijn (code = '02' in codeSystem 'Specialisme, specifiek voor perinatologie.')
+
|style="background-color: white;"|0010
 +
|}<section end=uitkomst_per_kind_850810711 />
 +
=== Postnatale fase ===
 +
<section begin=postnatale_fase_850810711 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Postnatale fase
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="4" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Diagnoseinterventie postpartum
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Datum
 +
|style="background-color: white;"|8 aug 2014  00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="5"|Type verwijzing
+
|colspan="3"|Pathologie vrouw
−
|style="background-color: white;"|
+
|style="background-color: white;"|Embolism (disorder) (code = '414086009' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="7"|Redenen van verwijzing
+
|colspan="5"|Diagnoseinterventie postpartum
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="82"|
+
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Datum
 +
|style="background-color: white;"|8 aug 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pathologie vrouw
 +
|style="background-color: white;"|Episiotomy infection (disorder) (code = '300927001' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="6"|Van 1e naar 2e lijn
+
|colspan="5"|Kindspecifieke gegevens
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="77"|
+
|rowspan="5"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="5"|Algemene anamnese
+
|colspan="4"|Voeding kind groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voeding kind datum
 +
|style="background-color: white;"|15 sep 2014 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Substantie voeding kind
 +
|style="background-color: white;"|kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')
 +
|}<section end=postnatale_fase_850810711 />
 +
==Scenario 4. 2e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)==
 +
<section begin=850810711 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Vrouw
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Burgerservicenummer
 +
|style="background-color: white;"|850810711
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Lokale persoonsidentificatie
 +
|style="background-color: white;"|* (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Geboortedatum
 +
|style="background-color: white;"|6 aug 1987 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="20"|
+
|colspan="2"|Adres - postcode
 +
|style="background-color: white;"|4589 BA
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Etniciteit
 +
|style="background-color: white;"|Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Lengte gemeten
 +
|style="background-color: white;"|162 cm
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Vrouwelijke genitale verminking?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Type vrouwelijke genitale verminking
 +
|style="background-color: white;"|Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96')
 +
|}<section end=850810711 />
 +
=== Anamnese ===
 +
<section begin=anamnese_850810711 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Anamnese
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Autoimmuun aandoening
+
|colspan="3"|Onder behandeling geweest?
−
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Algemene anamnese
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Cardiovasculaire aandoening
+
|rowspan="9"|
−
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Urogenitale aandoening
+
|colspan="2"|Autoimmuun aandoening
−
|style="background-color: white;"|
+
|style="background-color: white;"|Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Oncologische aandoening
+
|colspan="2"|Urogenitale aandoening
−
|style="background-color: white;"|
+
|style="background-color: white;"|Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Schildklier aandoening
+
|colspan="2"|Diabetes mellitus?
−
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Diabetes mellitus?
+
|colspan="2"|Mdl aandoening
−
|style="background-color: white;"|
+
|style="background-color: white;"|Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Neurologische aandoening
+
|colspan="2"|Longaandoening
−
|style="background-color: white;"|
+
|style="background-color: white;"|Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Infectieziekte
+
|colspan="2"|Type operatie
−
|style="background-color: white;"|
+
|style="background-color: white;"|Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Mdl aandoening
+
|colspan="2"|Type operatie
−
|style="background-color: white;"|
+
|style="background-color: white;"|Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Anemie
+
|colspan="2"|Type operatie
−
|style="background-color: white;"|
+
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|}<section end=anamnese_850810711 />
 +
=== Zorgverlening ===
 +
<section begin=zorgverlening_850810711 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Zorgverlening
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Longaandoening
+
|colspan="5"|Datum start zorgverantwoordelijkheid
−
|style="background-color: white;"|
+
|style="background-color: white;"|3 feb 2014  00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Gynaecologische aandoening
+
|colspan="5"|Datum einde zorgverantwoordelijkheid
−
|style="background-color: white;"|
+
|style="background-color: white;"|6 aug 2014  00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Orthopedische afwijking
+
|colspan="5"|Eindverantwoordelijk in welke perinatale periode?
−
|style="background-color: white;"|
+
|style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Bloedtransfusie?
+
|colspan="5"|Eindverantwoordelijk in welke perinatale periode?
−
|style="background-color: white;"|
+
|style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Transfusiereactie?
+
|colspan="5"|Eindverantwoordelijk in welke perinatale periode?
−
|style="background-color: white;"|
+
|style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Type operatie
+
|colspan="5"|Eindverantwoordelijk in welke perinatale periode?
−
|style="background-color: white;"|
+
|style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Type stollingsprobleem
+
|colspan="5"|Eindverantwoordelijk in welke perinatale periode?
−
|style="background-color: white;"|
+
|style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Psychiatrie?
+
|colspan="5"|Eindverantwoordelijk in welke perinatale periode?
−
|style="background-color: white;"|
+
|style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Overige aandoening?
+
|colspan="5"|Conclusie risicostatus na intake
−
|style="background-color: white;"|
+
|style="background-color: white;"|3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="5"|Obstetrische anamnese
+
|colspan="6"|Verwijsdetails
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="15"|
 
|rowspan="15"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Gynaecologische aandoening
+
|colspan="4"|Datum verwijzing
−
|style="background-color: white;"|
+
|style="background-color: white;"|6 aug 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verwijzing van
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Zorginstelling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorgaanbieder identificatie nummer
 +
|style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Verwijzing naar
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Zorginstelling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorgaanbieder identificatie nummer
 +
|style="background-color: white;"|1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Redenen van verwijzing
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="1"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Perinatale periode
 +
|style="background-color: white;"|2e t/m 7e dag (code = '92' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52')
 +
|}<section end=zorgverlening_850810711 />
 +
=== Zorgverlenerzorginstelling ===
 +
<section begin=zorgverlenerzorginstelling_850810711 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgverlenerzorginstelling
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorginstelling lvrid
 +
|style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|}<section end=zorgverlenerzorginstelling_850810711 />
 +
=== Zwangerschap ===
 +
<section begin=zwangerschap_850810711 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Zwangerschap
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Dossiernummer
 +
|style="background-color: white;"|e1691540-209f-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Graviditeit
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pariteit voor deze zwangerschap
 +
|style="background-color: white;"|0
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Definitieve a terme datum
 +
|style="background-color: white;"|18 aug 2014 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voornemens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie
 +
|style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Prenatale controle
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum controle
 +
|style="background-color: white;"|7 may 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zwangerschapsduur
 +
|style="background-color: white;"|149 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Leven voelen
 +
|style="background-color: white;"|Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Rookgedrag
 +
|style="background-color: white;"|niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Alcoholgebruik
 +
|style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Drugsgebruik?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Gewicht gemeten
 +
|style="background-color: white;"|82 kg
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Diagnose
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Bloedverlies?
+
|rowspan="4"|
−
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Partiele mola?
+
|colspan="2"|Datum
−
|style="background-color: white;"|
+
|style="background-color: white;"|7 may 2014  00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Cervixinsufficientie?
+
|colspan="2"|Zwangerschapsduur
−
|style="background-color: white;"|
+
|style="background-color: white;"|149 dagen
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Infectie
+
|colspan="2"|Infectie
−
|style="background-color: white;"|
+
|style="background-color: white;"|Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Hyperemesis gravidarum?
+
|colspan="3"|Maternale sterfte?
−
|style="background-color: white;"|
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Hypertensieve aandoening
+
|colspan="3"|Wijze einde zwangerschap
−
|style="background-color: white;"|
+
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 +
|}<section end=zwangerschap_850810711 />
 +
=== Bevalling ===
 +
<section begin=bevalling_850810711 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Bevalling
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Diagnose bevalling
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Zwangerschapscholestase?
+
|rowspan="3"|
−
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Diabetes gravidarum met insuline?
+
|colspan="2"|Niet vorderende ontsluiting?
−
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Afwijkende groei foetus
+
|colspan="2"|Niet vorderende uitdrijving?
−
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Dreigende partus immaturus?
+
|colspan="3"|Aantal geboren kinderen
−
|style="background-color: white;"|
+
|style="background-color: white;"|1
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Dreigende partus prematurus?
+
|colspan="3"|Risicostatus voor baring
−
|style="background-color: white;"|
+
|style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Abruptio placentae?
+
|colspan="3"|Wijze waarop de baring begon
−
|style="background-color: white;"|
+
|style="background-color: white;"|spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Fluxus postpartum?
+
|colspan="3"|Tijdstip begin actieve ontsluiting
−
|style="background-color: white;"|
+
|style="background-color: white;"|3 aug 2014  21:09
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="5"|Zwangerschap
+
|colspan="4"|Medicatie nageboortetijdperk groep
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="19"|
+
|rowspan="3"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Gynaecologische aandoening
+
|colspan="2"|Medicatie nageboortetijdperk?
−
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Bloedverlies?
+
|colspan="2"|Soort medicatie nageboortetijdperk
−
|style="background-color: white;"|
+
|style="background-color: white;"|Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Partiele mola?
+
|colspan="3"|Placenta - geboorte placenta
−
|style="background-color: white;"|
+
|style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Cervixinsufficientie?
+
|colspan="3"|Hoeveelheid bloedverlies
−
|style="background-color: white;"|
+
|style="background-color: white;"|1120 ml
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Infectie
+
|colspan="3"|Conditie perineum postpartum
−
|style="background-color: white;"|
+
|style="background-color: white;"|Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96')
 +
|}<section end=bevalling_850810711 />
 +
=== Uitkomst per kind ===
 +
<section begin=uitkomst_per_kind_850810711 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="8" | Uitkomst per kind
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="7" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="8"|Baring
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Hyperemesis gravidarum?
+
|rowspan="58"|
−
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Hypertensieve aandoening
+
|colspan="6"|Werkelijke plaats baring type locatie
−
|style="background-color: white;"|Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT') - Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT')
+
|style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Ziekenhuis baring
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Zwangerschapscholestase?
+
|rowspan="2"|
−
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Diabetes gravidarum met insuline?
+
|colspan="5"|Ziekenhuisnummer lvrid
−
|style="background-color: white;"|
+
|style="background-color: white;"|0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Demografische gegevens
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Afwijkende groei foetus
+
|rowspan="10"|
−
|style="background-color: white;"|
+
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Identificaties kind
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Dreigende partus immaturus?
+
|rowspan="2"|
−
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Dreigende partus prematurus?
+
|colspan="4"|Bsn kind
−
|style="background-color: white;"|
+
|style="background-color: white;"|840736526
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Abruptio placentae?
+
|colspan="5"|Geslacht medische observatie
−
|style="background-color: white;"|
+
|style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Navelstrengprolaps?
+
|colspan="5"|Geboortedatum
−
|style="background-color: white;"|
+
|style="background-color: white;"|4 aug 2014  23:35
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Liggingsafwijking
+
|colspan="5"|Rangnummer kind
−
|style="background-color: white;"|
+
|style="background-color: white;"|1
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="4"|Intrauteriene vruchtdood
+
|colspan="6"|Perinatale sterfte groep
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="2"|
 
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Vermoeden intrauteriene vruchtdood?
+
|colspan="4"|Perinatale sterfte?
−
|style="background-color: white;"|
+
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Kindspecifieke maternale gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="19"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Tijdstip breken vliezen
 +
|style="background-color: white;"|3 aug 2014  07:04
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Kleur en consistentie vruchtwater
 +
|style="background-color: white;"|bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Tijdstip actief meepersen
 +
|style="background-color: white;"|4 aug 2014  22:15
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Episiotomie?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Locatie episiotomie
 +
|style="background-color: white;"|mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Ruggeprik gewenst niet gekregen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Pijnbestrijding?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Pijnbestrijding
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="9"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Methode
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="6"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Methode
 +
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Overig middel
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Middel
 +
|style="background-color: white;"|Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Toediening
 +
|style="background-color: white;"|Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Periode
 +
|style="background-color: white;"|tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Einde zwangerschap
+
|colspan="5"|Sedatie?
−
|style="background-color: white;"|
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="5"|Bevalling
+
|colspan="7"|Kindspecifieke uitkomstgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="21"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="13"|
+
|colspan="5"|Type partus
 +
|style="background-color: white;"|Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Pprom?
+
|colspan="5"|Ligging bij geboorte
−
|style="background-color: white;"|
+
|style="background-color: white;"|Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Prom?
+
|colspan="5"|Aanpakker kind - rol aanpakker kind
−
|style="background-color: white;"|
+
|style="background-color: white;"|co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Koorts?
+
|colspan="5"|Supervisor - rol supervisor
−
|style="background-color: white;"|
+
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Vaginale kunstverlossing groep
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Niet vorderende ontsluiting?
+
|rowspan="3"|
−
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Niet vorderende uitdrijving?
+
|colspan="4"|Vaginale kunstverlossing
−
|style="background-color: white;"|
+
|style="background-color: white;"|Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Verdenking foetale nood?
+
|colspan="4"|Succes vaginale kunstverlossing?
−
|style="background-color: white;"|
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="4"|Intrauteriene vruchtdood
+
|colspan="6"|Lichamelijk onderzoek kind
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="2"|
 
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Vermoeden intrauteriene vruchtdood?
+
|colspan="4"|Geboortegewicht
−
|style="background-color: white;"|
+
|style="background-color: white;"|4205 gram
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Congenitale afwijkingen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Problematiek kind?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Kinderarts betrokken?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Betrokkenheid kinderarts
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Datum betrokkenheid
 +
|style="background-color: white;"|4 aug 2014  00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Vastzittende placenta?
+
|colspan="4"|Reden betrokkenheid
−
|style="background-color: white;"|
+
|style="background-color: white;"|Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Conditie perineum postpartum
+
|colspan="4"|Type betrokkenheid
−
|style="background-color: white;"|
+
|style="background-color: white;"|consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Fluxus postpartum?
+
|colspan="4"|Zorginstelling lvrid
−
|style="background-color: white;"|
+
|style="background-color: white;"|0010
 +
|}<section end=uitkomst_per_kind_850810711 />
 +
=== Medisch onderzoek ===
 +
<section begin=medisch_onderzoek_850810711 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Medisch onderzoek
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="5"|Postnatale fase
+
|colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="2"|
 
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Pathologie vrouw
+
|colspan="2"|Irregulaire antistoffen?
−
|style="background-color: white;"|
+
|style="background-color: white;"|Nee
 +
|}<section end=medisch_onderzoek_850810711 />
 +
==Scenario 5. zorg volledig 2e lijn, vrouw overleden (voor vrouw met BSN: 912345676)==
 +
<section begin=912345676 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Vrouw
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Burgerservicenummer
 +
|style="background-color: white;"|912345676
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Overig
+
|colspan="2"|Lokale persoonsidentificatie
−
|style="background-color: white;"|
+
|style="background-color: white;"|* (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="5"|Van 2e naar 3e lijn
+
|colspan="2"|Geboortedatum
−
|style="background-color: white;"|
+
|style="background-color: white;"|4 mar 1993 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="5"|Van 2e naar 1e lijn
+
|colspan="2"|Adres - postcode
−
|style="background-color: white;"|
+
|style="background-color: white;"|9562 GF
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="5"|Van 3e naar 2e lijn
+
|colspan="2"|Etniciteit
−
|style="background-color: white;"|
+
|style="background-color: white;"|Latijns Amerikaans (code = '14' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Perinatale periode
+
|colspan="2"|Lengte gemeten
−
|style="background-color: white;"|voor 28e week (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52') - 2e t/m 7e dag (code = '92' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52')
+
|style="background-color: white;"|186 cm
−
|}<section end=zorgverlening_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />
+
|}<section end=912345676 />
−
=== Zorgverlenerzorginstelling ===
+
=== Anamnese ===
−
<section begin=zorgverlenerzorginstelling_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />
+
<section begin=anamnese_912345676 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
−
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Zorgverlenerzorginstelling
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Anamnese
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|colspan="3" width="25%"| Gegevenselement
 
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Onder behandeling geweest?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="4"|Zorginstelling
+
|colspan="4"|Algemene anamnese
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Cardiovasculaire aandoening
 +
|style="background-color: white;"|Hypertensive disorder, systemic arterial (disorder) (code = '38341003' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Diabetes mellitus?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Neurologische aandoening
 +
|style="background-color: white;"|Epilepsy (disorder) (code = '84757009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Longaandoening
 +
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Orthopedische afwijking
 +
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Type stollingsprobleem
 +
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Psychiatrie?
 +
|style="background-color: white;"|Ja
 +
|}<section end=anamnese_912345676 />
 +
=== Zorgverlening ===
 +
<section begin=zorgverlening_912345676 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgverlening
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum start zorgverantwoordelijkheid
 +
|style="background-color: white;"|9 dec 2013  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum einde zorgverantwoordelijkheid
 +
|style="background-color: white;"|4 aug 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="3"|
+
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="2"|Zorginstelling agbid
+
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
−
|style="background-color: white;"|12345678 (in identificerend systeem: 1)
+
|style="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Conclusie risicostatus na intake
 +
|style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
 +
|}<section end=zorgverlening_912345676 />
 +
=== Zorgverlenerzorginstelling ===
 +
<section begin=zorgverlenerzorginstelling_912345676 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgverlenerzorginstelling
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Zorginstelling lvrid
 
|colspan="2"|Zorginstelling lvrid
−
|style="background-color: white;"|1808 - 1504 - 0003 - 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
+
|style="background-color: white;"|0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
−
|}<section end=zorgverlenerzorginstelling_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />
+
|}<section end=zorgverlenerzorginstelling_912345676 />
 
=== Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
 
=== Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
−
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />
+
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
−
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="8" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
+
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="6" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
 
|-style="background-color: #1F497D;; color: white; text-align:left;"  
−
|colspan="7" width="25%"| Gegevenselement
+
|colspan="5" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Wijze einde zwangerschap
 +
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Definitieve a terme datum
 +
|style="background-color: white;"|5 jun 2012 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Diagnose
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="4"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Infectie
 +
|style="background-color: white;"|Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Zwangerschapscholestase?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Afwijkende groei foetus
 +
|style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Irregulaire antistoffen?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Eerdere bevalling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="11"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Placenta - geboorte placenta
 +
|style="background-color: white;"|spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Vorige uitkomst per kind - vorige baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="8"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Demografische gegevens - geboortedatum
 +
|style="background-color: white;"|9 jun 2012  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Kindspecifieke gegevens vorige uitkomsten
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Type partus
 +
|style="background-color: white;"|Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Percentiel van het geboortegewicht
 +
|style="background-color: white;"|10 ≤ P < 50 (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.50')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Apgarscore na 5 min
 +
|style="background-color: white;"|10
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Congenitale afwijkingen?
 +
|style="background-color: white;"|Nee
 +
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_912345676 />
 +
=== Zwangerschap ===
 +
<section begin=zwangerschap_912345676 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Zwangerschap
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 
|| Waarde
 
|| Waarde
  
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="7"|Wijze einde zwangerschap
+
|colspan="3"|Dossiernummer
−
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46') - Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
+
|style="background-color: white;"|68a34ee0-20a0-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Graviditeit
 +
|style="background-color: white;"|2
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pariteit voor deze zwangerschap
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Definitieve a terme datum
 +
|style="background-color: white;"|22 jul 2014 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voornemens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voorgenomen plaats baring tijdens zwangerschap type locatie
 +
|style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Prenatale controle
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="7"|Definitieve a terme datum
+
|rowspan="8"|
−
|style="background-color: white;"|1 dec 2011  - 5 jun 2013  - 5 jun 2012  - 1 feb 2017 
+
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum controle
 +
|style="background-color: white;"|9 jan 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zwangerschapsduur
 +
|style="background-color: white;"|86 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Leven voelen
 +
|style="background-color: white;"|Fetal movements absent (context-dependent category) (code = '289432001' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Rookgedrag
 +
|style="background-color: white;"|gestopt tijdens huidige zwangerschap (code = '6' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Alcoholgebruik
 +
|style="background-color: white;"|geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Drugsgebruik?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Gewicht gemeten
 +
|style="background-color: white;"|89 kg
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="8"|Diagnose
+
|colspan="4"|Diagnose
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum
 +
|style="background-color: white;"|9 jan 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zwangerschapsduur
 +
|style="background-color: white;"|86 dagen
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Afwijkende groei foetus
 +
|style="background-color: white;"|Large-for-dates fetus (disorder) (code = '199616008' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="13"|
+
|colspan="2"|Abruptio placentae?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Gynaecologische aandoening
+
|colspan="3"|Intrauteriene behandeling
−
|style="background-color: white;"|Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96')
+
|style="background-color: white;"|Selective destruction of fetus (procedure) (code = '265633004' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Bloedverlies?
+
|colspan="3"|Maternale sterfte?
 
|style="background-color: white;"|Ja
 
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Cervixinsufficientie?
+
|colspan="3"|Wijze einde zwangerschap
 +
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 +
|}<section end=zwangerschap_912345676 />
 +
=== Bevalling ===
 +
<section begin=bevalling_912345676 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Bevalling
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Partusnummer
 +
|style="background-color: white;"|000000
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Aantal geboren kinderen
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Risicostatus voor baring
 +
|style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Interventies begin baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Interventie begin baring
 +
|style="background-color: white;"|Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Indicatie interventie begin baring
 +
|style="background-color: white;"|acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Wijze waarop de baring begon
 +
|style="background-color: white;"|interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Medicatie nageboortetijdperk groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Medicatie nageboortetijdperk?
 
|style="background-color: white;"|Nee
 
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Infectie
+
|colspan="3"|Placenta - geboorte placenta
−
|style="background-color: white;"|Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96') - Intra-uterien (code = '301775005' in codeSystem 'Snomed CT')
+
|style="background-color: white;"|placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Hoeveelheid bloedverlies
 +
|style="background-color: white;"|1500 ml
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Conditie perineum postpartum
 +
|style="background-color: white;"|Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96')
 +
|}<section end=bevalling_912345676 />
 +
=== Uitkomst per kind ===
 +
<section begin=uitkomst_per_kind_912345676 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Uitkomst per kind
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="6" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="56"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Werkelijke plaats baring type locatie
 +
|style="background-color: white;"|Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Ziekenhuis baring
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Hyperemesis gravidarum?
+
|colspan="4"|Ziekenhuisnummer lvrid
−
|style="background-color: white;"|Ja - Nee
+
|style="background-color: white;"|0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Demografische gegevens
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Hypertensieve aandoening
+
|rowspan="10"|
−
|style="background-color: white;"|Zwangerschapshypertensie (code = '48194001' in codeSystem '2.16.840.1.113883.6.96')
+
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Identificaties kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Bsn kind
 +
|style="background-color: white;"|528741913
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geslacht medische observatie
 +
|style="background-color: white;"|twijfelachtig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Geboortedatum
 +
|style="background-color: white;"|24 jul 2014  02:30
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Rangnummer kind
 +
|style="background-color: white;"|1
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Perinatale sterfte groep
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Zwangerschapscholestase?
+
|rowspan="2"|
−
|style="background-color: white;"|Ja - Nee
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Diabetes gravidarum met insuline?
+
|colspan="3"|Perinatale sterfte?
 
|style="background-color: white;"|Nee
 
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Kindspecifieke maternale gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="12"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Afwijkende groei foetus
+
|colspan="4"|Kleur en consistentie vruchtwater
−
|style="background-color: white;"|Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') - Macrosomie (code = '199616008' in codeSystem 'Snomed CT')
+
|style="background-color: white;"|meconium (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Dreigende partus immaturus?
+
|colspan="4"|Episiotomie?
 
|style="background-color: white;"|Nee
 
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Dreigende partus prematurus?
+
|colspan="4"|Ruggeprik gewenst niet gekregen?
 
|style="background-color: white;"|Nee
 
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Abruptio placentae?
+
|colspan="4"|Pijnbestrijding?
 
|style="background-color: white;"|Ja
 
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Pijnbestrijding
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Methode
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Methode
 +
|style="background-color: white;"|General anesthesia (procedure) (code = '50697003' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Periode
 +
|style="background-color: white;"|tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Sedatie?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Kindspecifieke uitkomstgegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="26"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Type partus
 +
|style="background-color: white;"|Emergency cesarian section (procedure) (code = '274130007' in codeSystem 'SNOMED CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Ligging bij geboorte
 +
|style="background-color: white;"|Onbekend (code = 'UNK' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Aanpakker kind - rol aanpakker kind
 +
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Supervisor - rol supervisor
 +
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Vaginale kunstverlossing groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="7"|Irregulaire antistoffen?
+
|colspan="3"|Vaginale kunstverlossing
−
|style="background-color: white;"|Nee - Ja
+
|style="background-color: white;"|Delivery by vacuum extraction (procedure) (code = '61586001' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Succes vaginale kunstverlossing?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Sectio caesarea group
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Beslismoment sectio caesarea
 +
|style="background-color: white;"|tijdens uitdrijving besloten (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.5')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Indicatie secundaire sectio
 +
|style="background-color: white;"|Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Lichamelijk onderzoek kind
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="2"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Geboortegewicht
 +
|style="background-color: white;"|3750 gram
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Congenitale afwijkingen?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="8"|Eerdere bevalling
+
|colspan="5"|Congenitale afwijkingen groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="19"|
+
|colspan="3"|Chromosomale afwijkingen?
 +
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="7"|Placenta
+
|colspan="4"|Specificatie chromosomale afwijking groep
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="2"|
 
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="5"|Geboorte placenta
+
|colspan="2"|Specificatie chromosomale afwijking
−
|style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - Placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
+
|style="background-color: white;"|Complete trisomy 21 syndrome (disorder) (code = '41040004' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="6"|Hoeveelheid bloedverlies
+
|colspan="4"|Problematiek kind?
−
|style="background-color: white;"|550 ml - 895 ml
+
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Problematiek kind
 +
|style="background-color: white;"|Congenital hearing disorder (disorder) (code = '95827002' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Kinderarts betrokken?
 +
|style="background-color: white;"|Nee
 +
|}<section end=uitkomst_per_kind_912345676 />
 +
=== Medisch onderzoek ===
 +
<section begin=medisch_onderzoek_912345676 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Medisch onderzoek
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="7"|Vorige uitkomst per kind
+
|colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="13"|
+
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Irregulaire antistoffen?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Welke irregulaire antistoffen vrouw aanwezig
 +
|style="background-color: white;"|Kell (code = '405844003' in codeSystem '2.16.840.1.113883.6.96')
 +
|}<section end=medisch_onderzoek_912345676 />
 +
=== Postnatale fase ===
 +
<section begin=postnatale_fase_912345676 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Postnatale fase
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="4" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
−
|colspan="6"|Vorige baring
+
|colspan="5"|Diagnoseinterventie postpartum
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Datum
 +
|style="background-color: white;"|24 jul 2014  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Pathologie vrouw
 +
|style="background-color: white;"|Postpartum deep phlebothrombosis (disorder) (code = '56272000' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="5"|Kindspecifieke gegevens
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="5"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Voeding kind groep
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="3"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Voeding kind datum
 +
|style="background-color: white;"|24 jul 2014 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Substantie voeding kind
 +
|style="background-color: white;"|kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')
 +
|}<section end=postnatale_fase_912345676 />
 +
==Scenario 6. 2e lijn (voor vrouw met BSN: 100202020)==
 +
<section begin=100202020 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Vrouw
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Burgerservicenummer
 +
|style="background-color: white;"|100202020
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Lokale persoonsidentificatie
 +
|style="background-color: white;"|987654321 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Geboortedatum
 +
|style="background-color: white;"|1 jan 1989 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Adres - postcode
 +
|style="background-color: white;"|1234 AB
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Etniciteit
 +
|style="background-color: white;"|Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Lengte gemeten
 +
|style="background-color: white;"|172 cm
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Vrouwelijke genitale verminking?
 +
|style="background-color: white;"|Nee
 +
|}<section end=100202020 />
 +
=== Anamnese ===
 +
<section begin=anamnese_100202020 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Anamnese
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="3" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="3"|Onder behandeling geweest?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="4"|Algemene anamnese
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="18"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Autoimmuun aandoening
 +
|style="background-color: white;"|Reuma (code = '396332003' in codeSystem 'Snomed CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Cardiovasculaire aandoening
 +
|style="background-color: white;"|Overig, niet nader omschreven Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Urogenitale aandoening
 +
|style="background-color: white;"|Pyelonefritis (code = '45816000' in codeSystem 'Snomed CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Oncologische aandoening
 +
|style="background-color: white;"|Overig, niet nader omschreven Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Schildklier aandoening
 +
|style="background-color: white;"|Hypothyreoidie (code = '40930008' in codeSystem 'Snomed CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Diabetes mellitus?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Neurologische aandoening
 +
|style="background-color: white;"|Hernia nuclei pulposi (code = '84857004' in codeSystem 'Snomed CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Neurologische aandoening
 +
|style="background-color: white;"|Overig, niet nader omschreven Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Mdl aandoening
 +
|style="background-color: white;"|M. Crohn (code = '34000006' in codeSystem 'Snomed CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Anemie
 +
|style="background-color: white;"|IJzergebrek (code = '87522002' in codeSystem 'Snomed CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Longaandoening
 +
|style="background-color: white;"|Astma (code = '195967001' in codeSystem 'Snomed CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Orthopedische afwijking
 +
|style="background-color: white;"|Trauma bekken (code = '282771003' in codeSystem 'Snomed CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Bloedtransfusie?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Type operatie
 +
|style="background-color: white;"|Sectio (code = '11466000' in codeSystem 'Snomed CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Type operatie
 +
|style="background-color: white;"|Rug (code = '129152004:260686004=129284003' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Psychiatrie?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Overige aandoening?
 +
|style="background-color: white;"|Nee
 +
|}<section end=anamnese_100202020 />
 +
=== Zorgverlening ===
 +
<section begin=zorgverlening_100202020 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgverlening
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum start zorgverantwoordelijkheid
 +
|style="background-color: white;"|1 mar 2019  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Datum einde zorgverantwoordelijkheid
 +
|style="background-color: white;"|15 oct 2019  00:00
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Eindverantwoordelijk in welke perinatale periode?
 +
|style="background-color: white;"|follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Conclusie risicostatus na intake
 +
|style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
 +
|}<section end=zorgverlening_100202020 />
 +
=== Zorgverlenerzorginstelling ===
 +
<section begin=zorgverlenerzorginstelling_100202020 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="3" | Zorgverlenerzorginstelling
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="2" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="2"|Zorginstelling lvrid
 +
|style="background-color: white;"|0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 +
|}<section end=zorgverlenerzorginstelling_100202020 />
 +
=== Obstetrische anamnese gegroepeerd per voorgaande zwangerschap ===
 +
<section begin=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_100202020 />
 +
{| class="wikitable" width="85%"
 +
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="7" | Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
 +
|-style="background-color: #1F497D;; color: white; text-align:left;"
 +
|colspan="6" width="25%"| Gegevenselement
 +
|| Waarde
 +
 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Wijze einde zwangerschap
 +
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Definitieve a terme datum
 +
|style="background-color: white;"|1 feb 2017 
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Diagnose
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="12"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Bloedverlies?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Cervixinsufficientie?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Infectie
 +
|style="background-color: white;"|Intra-uterien (code = '301775005' in codeSystem 'Snomed CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Hyperemesis gravidarum?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Hypertensieve aandoening
 +
|style="background-color: white;"|Zwangerschapshypertensie (code = '48194001' in codeSystem '2.16.840.1.113883.6.96')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Zwangerschapscholestase?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Diabetes gravidarum met insuline?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Afwijkende groei foetus
 +
|style="background-color: white;"|Macrosomie (code = '199616008' in codeSystem 'Snomed CT')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Dreigende partus immaturus?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Dreigende partus prematurus?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Abruptio placentae?
 +
|style="background-color: white;"|Ja
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="6"|Irregulaire antistoffen?
 +
|style="background-color: white;"|Nee
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="7"|Eerdere bevalling
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|rowspan="15"|
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Placenta - geboorte placenta
 +
|style="background-color: white;"|Placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="5"|Hoeveelheid bloedverlies
 +
|style="background-color: white;"|895 ml
 +
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 +
|colspan="6"|Vorige uitkomst per kind - vorige baring
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|rowspan="11"|
 
|rowspan="11"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="4"|Geboortedatum
+
|colspan="4"|Demografische gegevens - geboortedatum
−
|style="background-color: white;"|8 dec 2011  00:00 - 9 jun 2012  00:00 - 15 dec 2016   
+
|style="background-color: white;"|15 dec 2016   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Kindspecifieke gegevens vorige uitkomsten
 
|colspan="5"|Kindspecifieke gegevens vorige uitkomsten
Regel 525: Regel 3.377:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Type partus
 
|colspan="3"|Type partus
−
|style="background-color: white;"|Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT') - Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') - Secundair (code = '274130007' in codeSystem '2.16.840.1.113883.6.96')
+
|style="background-color: white;"|Secundair (code = '274130007' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Percentiel van het geboortegewicht
 
|colspan="3"|Percentiel van het geboortegewicht
−
|style="background-color: white;"|p50 tot p90 (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.50') - 10 ≤ P < 50 (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.50') - p2,3 tot p10 (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.50')
+
|style="background-color: white;"|p2,3 tot p10 (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.50')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Apgarscore na 5 min
 
|colspan="3"|Apgarscore na 5 min
−
|style="background-color: white;"|8 - 10
+
|style="background-color: white;"|8
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Congenitale afwijkingen?
 
|colspan="3"|Congenitale afwijkingen?
−
|style="background-color: white;"|Nee - Ja
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="4"|Congenitale afwijkingen groep
 
|colspan="4"|Congenitale afwijkingen groep
Regel 542: Regel 3.394:
 
|colspan="2"|Chromosomale afwijkingen?
 
|colspan="2"|Chromosomale afwijkingen?
 
|style="background-color: white;"|Nee
 
|style="background-color: white;"|Nee
−
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />
+
|}<section end=obstetrische_anamnese_gegroepeerd_per_voorgaande_zwangerschap_100202020 />
 
=== Zwangerschap ===
 
=== Zwangerschap ===
−
<section begin=zwangerschap_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />
+
<section begin=zwangerschap_100202020 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
 
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Zwangerschap
 
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Zwangerschap
Regel 551: Regel 3.403:
 
|| Waarde
 
|| Waarde
  
 +
|-style="vertical-align:top; background-color: #E3E3E3;;"
 +
|colspan="4"|Dossiernummer
 +
|style="background-color: white;"|0af1e5b1-bf99-40a2-ade9-728186c32f31 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Graviditeit
 
|colspan="4"|Graviditeit
−
|style="background-color: white;"|2 - 1
+
|style="background-color: white;"|2
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Pariteit voor deze zwangerschap
 
|colspan="4"|Pariteit voor deze zwangerschap
−
|style="background-color: white;"|1 - 0
+
|style="background-color: white;"|1
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Definitieve a terme datum
 
|colspan="4"|Definitieve a terme datum
−
|style="background-color: white;"|9 okt 2014  - 8 sep 2014  - 22 sep 2014  - 18 aug 2014  - 22 jul 2014  - 2 okt 2019   
+
|style="background-color: white;"|2 oct 2019   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Voornemens
 
|colspan="5"|Voornemens
Regel 566: Regel 3.421:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Voorgenomen plaats baring tijdens zwangerschap type locatie
 
|colspan="3"|Voorgenomen plaats baring tijdens zwangerschap type locatie
−
|style="background-color: white;"|Thuis (code = '169813005' in codeSystem '2.16.840.1.113883.6.96') - Nog niet bepaald (code = '05' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96') - Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008')
+
|style="background-color: white;"|Ziekenhuis (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Prenatale controle
 
|colspan="5"|Prenatale controle
Regel 573: Regel 3.428:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Datum controle
 
|colspan="3"|Datum controle
−
|style="background-color: white;"|2 mrt 2014  00:00 - 6 mei 2014  00:00 - 12 mei 2014  00:00 - 21 mei 2014  00:00 - 7 mei 2014  00:00 - 9 jan 2014  00:00 - 1 mrt 2019  00:00
+
|style="background-color: white;"|1 mar 2019  00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Zwangerschapsduur
 
|colspan="3"|Zwangerschapsduur
−
|style="background-color: white;"|59 dagen - 155 dagen - 161 dagen - 156 dagen - 149 dagen - 86 dagen - 56 dagen
+
|style="background-color: white;"|56 dagen
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Leven voelen
 
|colspan="3"|Leven voelen
−
|style="background-color: white;"|goed (code = '289431008' in codeSystem 'Snomed CT') - Weak fetal movements (finding) (code = '276372004' in codeSystem '2.16.840.1.113883.6.96') - Reduced fetal movement (finding) (code = '276369006' in codeSystem '2.16.840.1.113883.6.96') - Fetal movements absent (context-dependent category) (code = '289432001' in codeSystem '2.16.840.1.113883.6.96')
+
|style="background-color: white;"|geen (code = '289432001' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Rookgedrag
 
|colspan="3"|Rookgedrag
−
|style="background-color: white;"|niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58') - gestopt tijdens huidige zwangerschap (code = '6' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
+
|style="background-color: white;"|gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Alcoholgebruik
 
|colspan="3"|Alcoholgebruik
Regel 588: Regel 3.443:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Drugsgebruik?
 
|colspan="3"|Drugsgebruik?
−
|style="background-color: white;"|Nee - Ja
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Gewicht gemeten
 
|colspan="3"|Gewicht gemeten
−
|style="background-color: white;"|70 kg - 85 kg - 67 kg - 82 kg - 89 kg - 68 kg
+
|style="background-color: white;"|68 kg
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Diagnose
 
|colspan="5"|Diagnose
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="22"|
+
|rowspan="18"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Datum
 
|colspan="3"|Datum
−
|style="background-color: white;"|2 mrt 2014  00:00 - 6 mei 2014  00:00 - 12 mei 2014  00:00 - 21 mei 2014  00:00 - 7 mei 2014  00:00 - 9 jan 2014  00:00 - 1 mrt 2019  00:00
+
|style="background-color: white;"|1 mar 2019  00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Zwangerschapsduur
 
|colspan="3"|Zwangerschapsduur
−
|style="background-color: white;"|59 dagen - 155 dagen - 161 dagen - 156 dagen - 149 dagen - 86 dagen - 56 dagen
+
|style="background-color: white;"|56 dagen
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Gynaecologische aandoening
 
|colspan="3"|Gynaecologische aandoening
−
|style="background-color: white;"|Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96') - Overig, niet nader gespecificeerd Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
+
|style="background-color: white;"|Overig, niet nader gespecificeerd Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Bloedverlies?
 
|colspan="3"|Bloedverlies?
−
|style="background-color: white;"|Ja - Nee
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Partiele mola?
 
|colspan="3"|Partiele mola?
−
|style="background-color: white;"|Ja - Nee
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Cervixinsufficientie?
 
|colspan="3"|Cervixinsufficientie?
 
|style="background-color: white;"|Nee
 
|style="background-color: white;"|Nee
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="3"|Infectie
 
−
|style="background-color: white;"|Urineweg infectie (code = '307534009' in codeSystem 'Snomed CT')
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Hyperemesis gravidarum?
 
|colspan="3"|Hyperemesis gravidarum?
 
|style="background-color: white;"|Nee
 
|style="background-color: white;"|Nee
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="3"|Hypertensieve aandoening
 
−
|style="background-color: white;"|Pregnancy-induced hypertension (disorder) (code = '48194001' in codeSystem '2.16.840.1.113883.6.96') - Pre-eclampsia (disorder) (code = '398254007' in codeSystem '2.16.840.1.113883.6.96')
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Zwangerschapscholestase?
 
|colspan="3"|Zwangerschapscholestase?
Regel 631: Regel 3.480:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Afwijkende groei foetus
 
|colspan="3"|Afwijkende groei foetus
−
|style="background-color: white;"|Small for gestational age fetus (disorder) (code = '267258002' in codeSystem '2.16.840.1.113883.6.96') - Large-for-dates fetus (disorder) (code = '199616008' in codeSystem '2.16.840.1.113883.6.96')
+
|style="background-color: white;"|Dysmaturiteit (code = '267258002' in codeSystem 'Snomed CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Dreigende partus immaturus?
 
|colspan="3"|Dreigende partus immaturus?
Regel 640: Regel 3.489:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Abruptio placentae?
 
|colspan="3"|Abruptio placentae?
−
|style="background-color: white;"|Ja - Nee
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Navelstrengprolaps?
 
|colspan="3"|Navelstrengprolaps?
 
|style="background-color: white;"|Nee
 
|style="background-color: white;"|Nee
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="3"|Liggingsafwijking
 
−
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="4"|Intrauteriene vruchtdood
 
|colspan="4"|Intrauteriene vruchtdood
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="3"|
+
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Vermoeden intrauteriene vruchtdood?
 
|colspan="2"|Vermoeden intrauteriene vruchtdood?
 
|style="background-color: white;"|Nee
 
|style="background-color: white;"|Nee
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="2"|Vermoeden iuvd op basis van
 
−
|style="background-color: white;"|
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="4"|Intrauteriene behandeling
 
−
|style="background-color: white;"|Selective destruction of fetus (procedure) (code = '265633004' in codeSystem '2.16.840.1.113883.6.96')
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Maternale sterfte?
 
|colspan="4"|Maternale sterfte?
−
|style="background-color: white;"|Nee - Ja
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Wijze einde zwangerschap
 
|colspan="4"|Wijze einde zwangerschap
 
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
 
|style="background-color: white;"|Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
−
|}<section end=zwangerschap_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />
+
|}<section end=zwangerschap_100202020 />
 
=== Bevalling ===
 
=== Bevalling ===
−
<section begin=bevalling_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />
+
<section begin=bevalling_100202020 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
 
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Bevalling
 
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Bevalling
Regel 677: Regel 3.517:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Partusnummer
 
|colspan="4"|Partusnummer
−
|style="background-color: white;"|000000 - 4567890123 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999​.60.7)
+
|style="background-color: white;"|4567890123 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999​.60.7)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Diagnose bevalling
 
|colspan="5"|Diagnose bevalling
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="13"|
+
|rowspan="12"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Pprom?
 
|colspan="3"|Pprom?
−
|style="background-color: white;"|Ja - Nee
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Prom?
 
|colspan="3"|Prom?
Regel 693: Regel 3.533:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Niet vorderende ontsluiting?
 
|colspan="3"|Niet vorderende ontsluiting?
−
|style="background-color: white;"|Ja - Nee
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Niet vorderende uitdrijving?
 
|colspan="3"|Niet vorderende uitdrijving?
−
|style="background-color: white;"|Ja - Nee
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Verdenking foetale nood?
 
|colspan="3"|Verdenking foetale nood?
−
|style="background-color: white;"|Ja - Nee
+
|style="background-color: white;"|Nee
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="4"|Intrauteriene vruchtdood
 
|colspan="4"|Intrauteriene vruchtdood
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="3"|
+
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Vermoeden intrauteriene vruchtdood?
 
|colspan="2"|Vermoeden intrauteriene vruchtdood?
 
|style="background-color: white;"|Nee
 
|style="background-color: white;"|Nee
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="2"|Vermoeden iuvd op basis van
 
−
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Vastzittende placenta?
 
|colspan="3"|Vastzittende placenta?
Regel 718: Regel 3.555:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Aantal geboren kinderen
 
|colspan="4"|Aantal geboren kinderen
−
|style="background-color: white;"|1 - 2
+
|style="background-color: white;"|1
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Risicostatus voor baring
 
|colspan="4"|Risicostatus voor baring
−
|style="background-color: white;"|1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25') - 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
+
|style="background-color: white;"|2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Interventies begin baring
 
|colspan="5"|Interventies begin baring
Regel 728: Regel 3.565:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Interventie begin baring
 
|colspan="3"|Interventie begin baring
−
|style="background-color: white;"|Strippen (code = '236960006' in codeSystem 'Snomed CT') - Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96') - Primen prostaglandine (code = '236966000' in codeSystem 'Snomed CT')
+
|style="background-color: white;"|Primen prostaglandine (code = '236966000' in codeSystem 'Snomed CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Indicatie interventie begin baring
 
|colspan="3"|Indicatie interventie begin baring
−
|style="background-color: white;"|wens patiënt (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') - acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7') - niet levensbedreigend (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7')
+
|style="background-color: white;"|niet levensbedreigend (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Wijze waarop de baring begon
 
|colspan="4"|Wijze waarop de baring begon
−
|style="background-color: white;"|Interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') - spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46') - Spontane weeën (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
+
|style="background-color: white;"|Spontane weeën (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Tijdstip begin actieve ontsluiting
 
|colspan="4"|Tijdstip begin actieve ontsluiting
−
|style="background-color: white;"|8 okt 2014  14:30 - 30 aug 2014  14:09 - 27 aug 2014  22:09 - 3 aug 2014  21:09 - 15 okt 2019  03:45
+
|style="background-color: white;"|15 oct 2019  03:45
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Medicatie nageboortetijdperk groep
 
|colspan="5"|Medicatie nageboortetijdperk groep
Regel 744: Regel 3.581:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Medicatie nageboortetijdperk?
 
|colspan="3"|Medicatie nageboortetijdperk?
−
|style="background-color: white;"|Ja - UNK - Nee
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Soort medicatie nageboortetijdperk
 
|colspan="3"|Soort medicatie nageboortetijdperk
−
|style="background-color: white;"|Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73') - Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73')
+
|style="background-color: white;"|Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73')
−
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 
−
|colspan="5"|Placenta
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|rowspan="2"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|colspan="3"|Geboorte placenta
+
|colspan="4"|Placenta - geboorte placenta
−
|style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19') - controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
+
|style="background-color: white;"|Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Hoeveelheid bloedverlies
 
|colspan="4"|Hoeveelheid bloedverlies
−
|style="background-color: white;"|615 ml - 980 ml - 1740 ml - 1120 ml - 1500 ml - 650 ml
+
|style="background-color: white;"|650 ml
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Conditie perineum postpartum
 
|colspan="4"|Conditie perineum postpartum
−
|style="background-color: white;"|1e graads perineumruptuur (code = '199916005' in codeSystem 'Snomed CT') - Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96') - Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96') - Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96')
+
|style="background-color: white;"|1e graads perineumruptuur (code = '199916005' in codeSystem 'Snomed CT')
−
|}<section end=bevalling_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />
+
|}<section end=bevalling_100202020 />
 
=== Uitkomst per kind ===
 
=== Uitkomst per kind ===
−
<section begin=uitkomst_per_kind_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />
+
<section begin=uitkomst_per_kind_100202020 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
 
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="8" | Uitkomst per kind
 
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="8" | Uitkomst per kind
Regel 773: Regel 3.606:
 
|colspan="8"|Baring
 
|colspan="8"|Baring
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="79"|
+
|rowspan="67"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="6"|Werkelijke plaats baring type locatie
 
|colspan="6"|Werkelijke plaats baring type locatie
−
|style="background-color: white;"|Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7') - Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
+
|style="background-color: white;"|Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="7"|Ziekenhuis baring
 
|colspan="7"|Ziekenhuis baring
Regel 783: Regel 3.616:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Ziekenhuisnummer lvrid
 
|colspan="5"|Ziekenhuisnummer lvrid
−
|style="background-color: white;"|0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6) - 0803 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
+
|style="background-color: white;"|0803 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="7"|Demografische gegevens
 
|colspan="7"|Demografische gegevens
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="12"|
+
|rowspan="10"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="6"|Identificaties kind
 
|colspan="6"|Identificaties kind
Regel 794: Regel 3.627:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Bsn kind
 
|colspan="4"|Bsn kind
−
|style="background-color: white;"|999910383 - 951847624 - 847035116 - 847035128 - 840736526 - 528741913
+
|style="background-color: white;"|847035116
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Geslacht medische observatie
 
|colspan="5"|Geslacht medische observatie
−
|style="background-color: white;"|vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21') - mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21') - twijfelachtig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
+
|style="background-color: white;"|mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Geboortedatum
 
|colspan="5"|Geboortedatum
−
|style="background-color: white;"|8 okt 2014  00:00 - 1 sep 2014  02:34 - 28 aug 2014  06:30 - 28 aug 2014  07:02 - 4 aug 2014  23:35 - 24 jul 2014  02:30 - 15 okt 2019   
+
|style="background-color: white;"|15 oct 2019   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Rangnummer kind
 
|colspan="5"|Rangnummer kind
−
|style="background-color: white;"|1 - 2
+
|style="background-color: white;"|1
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="6"|Perinatale sterfte groep
 
|colspan="6"|Perinatale sterfte groep
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="4"|
+
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Perinatale sterfte?
 
|colspan="4"|Perinatale sterfte?
−
|style="background-color: white;"|Nee - Ja
+
|style="background-color: white;"|Nee
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="4"|Fase perinatale sterfte
 
−
|style="background-color: white;"|Newborn death (event) (code = '276506001' in codeSystem '2.16.840.1.113883.6.96')
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="4"|Datumtijd vaststelling perinatale sterfte
 
−
|style="background-color: white;"|28 aug 2014  08:10
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="7"|Kindspecifieke maternale gegevens
 
|colspan="7"|Kindspecifieke maternale gegevens
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="21"|
+
|rowspan="20"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Bijstimulatie toegediend?
 
|colspan="5"|Bijstimulatie toegediend?
Regel 826: Regel 3.653:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Tijdstip breken vliezen
 
|colspan="5"|Tijdstip breken vliezen
−
|style="background-color: white;"|8 okt 2014  09:15 - 30 aug 2014  23:04 - 27 aug 2014  22:09 - 27 aug 2014  23:13 - 3 aug 2014  07:04 - 19 okt 2019  04:30
+
|style="background-color: white;"|19 oct 2019  04:30
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Kleur en consistentie vruchtwater
 
|colspan="5"|Kleur en consistentie vruchtwater
−
|style="background-color: white;"|Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18') - geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') - bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18') - meconium (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
+
|style="background-color: white;"|Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Tijdstip actief meepersen
 
|colspan="5"|Tijdstip actief meepersen
−
|style="background-color: white;"|8 okt 2014  12:13 - 27 aug 2014  23:49 - 28 aug 2014  06:45 - 4 aug 2014  22:15 - 19 okt 2019  05:00
+
|style="background-color: white;"|19 oct 2019  05:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Episiotomie?
 
|colspan="5"|Episiotomie?
−
|style="background-color: white;"|Nee - Ja
+
|style="background-color: white;"|Nee
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="5"|Indicatie episiotomie
 
−
|style="background-color: white;"|
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Locatie episiotomie
 
|colspan="5"|Locatie episiotomie
Regel 844: Regel 3.668:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Ruggeprik gewenst niet gekregen?
 
|colspan="5"|Ruggeprik gewenst niet gekregen?
−
|style="background-color: white;"|Nee - Ja
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Pijnbestrijding?
 
|colspan="5"|Pijnbestrijding?
−
|style="background-color: white;"|Nee - Ja
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="6"|Pijnbestrijding
 
|colspan="6"|Pijnbestrijding
Regel 858: Regel 3.682:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Methode
 
|colspan="3"|Methode
−
|style="background-color: white;"|Epidural anesthesia (procedure) (code = '18946005' in codeSystem '2.16.840.1.113883.6.96') - Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - General anesthesia (procedure) (code = '50697003' in codeSystem '2.16.840.1.113883.6.96')
+
|style="background-color: white;"|Overig middel (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="4"|Overig middel
 
|colspan="4"|Overig middel
Regel 865: Regel 3.689:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Middel
 
|colspan="2"|Middel
−
|style="background-color: white;"|Administration of morphinomimetic analgesic (procedure) (code = '52685006:363701004=404642006' in codeSystem '2.16.840.1.113883.6.96') - Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96')
+
|style="background-color: white;"|Entonox (code = '426060003' in codeSystem 'Snomed CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Toediening
 
|colspan="2"|Toediening
−
|style="background-color: white;"|Administration of substance via intravenous route (procedure) (code = '431215000' in codeSystem '2.16.840.1.113883.6.96') - Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96')
+
|style="background-color: white;"|Inhalatie (code = '241717009' in codeSystem 'Snomed CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Periode
 
|colspan="4"|Periode
−
|style="background-color: white;"|tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60') - tijdens ontsluitingsperiode > 3 cm (code = 'OntMt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
+
|style="background-color: white;"|tijdens ontsluitingsperiode > 3 cm (code = 'OntMt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Sedatie?
 
|colspan="5"|Sedatie?
−
|style="background-color: white;"|Nee - Ja
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="7"|Kindspecifieke uitkomstgegevens
 
|colspan="7"|Kindspecifieke uitkomstgegevens
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="38"|
+
|rowspan="29"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Type partus
 
|colspan="5"|Type partus
−
|style="background-color: white;"|Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT') - Cesarean section (procedure) (code = '11466000' in codeSystem 'SNOMED CT') - Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT') - Emergency cesarian section (procedure) (code = '274130007' in codeSystem 'SNOMED CT') - Spontaan (code = '177184002' in codeSystem '2.16.840.1.113883.6.96')
+
|style="background-color: white;"|Spontaan (code = '177184002' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Ligging bij geboorte
 
|colspan="5"|Ligging bij geboorte
−
|style="background-color: white;"|Achterhoofd-achter (code = '37235006' in codeSystem 'Snomed CT') - Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008') - Face presentation (finding) (code = '21882006' in codeSystem '2.16.840.1.113883.6.96') - Complete breech presentation (finding) (code = '49168004' in codeSystem '2.16.840.1.113883.6.96') - Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96') - Onbekend (code = 'UNK' in codeSystem '2.16.840.1.113883.5.1008') - Achterhoofd-voor (code = '70028003' in codeSystem 'Snomed CT')
+
|style="background-color: white;"|Achterhoofd-voor (code = '70028003' in codeSystem 'Snomed CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Aanpakker kind - rol aanpakker kind
 
|colspan="5"|Aanpakker kind - rol aanpakker kind
−
|style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111') - klinisch verloskundige (code = '25' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
+
|style="background-color: white;"|klinisch verloskundige (code = '25' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Supervisor - rol supervisor
 
|colspan="5"|Supervisor - rol supervisor
−
|style="background-color: white;"|1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59') - gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
+
|style="background-color: white;"|gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="6"|Vaginale kunstverlossing groep
 
|colspan="6"|Vaginale kunstverlossing groep
Regel 897: Regel 3.721:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Vaginale kunstverlossing
 
|colspan="4"|Vaginale kunstverlossing
−
|style="background-color: white;"|Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96') - Total breech extraction (procedure) (code = '416055001' in codeSystem '2.16.840.1.113883.6.96') - Delivery by vacuum extraction (procedure) (code = '61586001' in codeSystem '2.16.840.1.113883.6.96')
+
|style="background-color: white;"|Vacuüm (code = '61586001' in codeSystem 'Snomed CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Succes vaginale kunstverlossing?
 
|colspan="4"|Succes vaginale kunstverlossing?
−
|style="background-color: white;"|Ja - Nee
+
|style="background-color: white;"|Ja
−
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 
−
|colspan="6"|Sectio caesarea group
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|rowspan="4"|
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="4"|Beslismoment sectio caesarea
 
−
|style="background-color: white;"|tijdens uitdrijving besloten (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.5')
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="4"|Indicatie primaire sectio
 
−
|style="background-color: white;"|Suspected fetal distress (situation) (code = '444433005:246090004=130955003' in codeSystem '2.16.840.1.113883.6.96') - Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96')
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="4"|Indicatie secundaire sectio
 
−
|style="background-color: white;"|Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96')
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="5"|Overige interventies
 
−
|style="background-color: white;"|Maneuvers for delivery in shoulder dystocia (procedure) (code = '237008007' in codeSystem '2.16.840.1.113883.6.96')
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="6"|Lichamelijk onderzoek kind
 
|colspan="6"|Lichamelijk onderzoek kind
Regel 926: Regel 3.734:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Geboortegewicht
 
|colspan="4"|Geboortegewicht
−
|style="background-color: white;"|3450 gram - 3620 gram - 2040 gram - 1580 gram - 4205 gram - 3750 gram - 3550 gram
+
|style="background-color: white;"|3550 gram
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Congenitale afwijkingen?
 
|colspan="5"|Congenitale afwijkingen?
−
|style="background-color: white;"|Nee - Ja
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="6"|Congenitale afwijkingen groep
 
|colspan="6"|Congenitale afwijkingen groep
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="8"|
+
|rowspan="5"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Specificatie congenitale afwijking groep
 
|colspan="5"|Specificatie congenitale afwijking groep
Regel 940: Regel 3.748:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Specificatie congenitale afwijking
 
|colspan="3"|Specificatie congenitale afwijking
−
|style="background-color: white;"|Spina bifida occulta (disorder) (code = '76916001' in codeSystem '2.16.840.1.113883.6.96') - Multiple congenital cardiac defects (disorder) (code = '94702005' in codeSystem '2.16.840.1.113883.6.96') - overige congenitale huidafwijking (code = '74' in codeSystem '2.16.840.1.113883.2.4.4.13.8')
+
|style="background-color: white;"|overige congenitale huidafwijking (code = '74' in codeSystem '2.16.840.1.113883.2.4.4.13.8')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Chromosomale afwijkingen?
 
|colspan="4"|Chromosomale afwijkingen?
−
|style="background-color: white;"|Nee - Ja
+
|style="background-color: white;"|Nee
−
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 
−
|colspan="5"|Specificatie chromosomale afwijking groep
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|rowspan="2"|
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="3"|Specificatie chromosomale afwijking
 
−
|style="background-color: white;"|Complete trisomy 21 syndrome (disorder) (code = '41040004' in codeSystem '2.16.840.1.113883.6.96')
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Problematiek kind?
 
|colspan="5"|Problematiek kind?
−
|style="background-color: white;"|Nee - Ja
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Problematiek kind
 
|colspan="5"|Problematiek kind
−
|style="background-color: white;"|Birth trauma of fetus (disorder) (code = '56110009' in codeSystem '2.16.840.1.113883.6.96') - Subdural intracranial hemorrhage due to birth trauma (disorder) (code = '126941005' in codeSystem '2.16.840.1.113883.6.96') - Congenital hearing disorder (disorder) (code = '95827002' in codeSystem '2.16.840.1.113883.6.96')
+
|style="background-color: white;"|Geboortetrauma (code = '56110009' in codeSystem 'Snomed CT')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="5"|Kinderarts betrokken?
 
|colspan="5"|Kinderarts betrokken?
−
|style="background-color: white;"|Nee - Ja
+
|style="background-color: white;"|Ja
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="6"|Betrokkenheid kinderarts
 
|colspan="6"|Betrokkenheid kinderarts
Regel 966: Regel 3.767:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Datum betrokkenheid
 
|colspan="4"|Datum betrokkenheid
−
|style="background-color: white;"|1 sep 2014  00:00 - 28 aug 2014  00:00 - 4 aug 2014  00:00 - 15 okt 2019  00:00
+
|style="background-color: white;"|15 oct 2019  00:00
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Reden betrokkenheid
 
|colspan="4"|Reden betrokkenheid
−
|style="background-color: white;"|Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008') - Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96') - Finding of neonatal condition (finding) (code = '364737004' in codeSystem '2.16.840.1.113883.6.96') - kunstverlossing (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96')
+
|style="background-color: white;"|kunstverlossing (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Type betrokkenheid
 
|colspan="4"|Type betrokkenheid
−
|style="background-color: white;"|consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17') - overdracht (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
+
|style="background-color: white;"|Consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="4"|Zorginstelling lvrid
 
|colspan="4"|Zorginstelling lvrid
−
|style="background-color: white;"|0003 - 9999 - 0001 - 0010 - 0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
+
|style="background-color: white;"|0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
−
|}<section end=uitkomst_per_kind_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />
+
|}<section end=uitkomst_per_kind_100202020 />
 
=== Medisch onderzoek ===
 
=== Medisch onderzoek ===
−
<section begin=medisch_onderzoek_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />
+
<section begin=medisch_onderzoek_100202020 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
 
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Medisch onderzoek
 
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="4" | Medisch onderzoek
Regel 988: Regel 3.789:
 
|colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
 
|colspan="4"|Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
−
|rowspan="3"|
+
|rowspan="2"|
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Irregulaire antistoffen?
 
|colspan="2"|Irregulaire antistoffen?
−
|style="background-color: white;"|Nee - Ja
+
|style="background-color: white;"|Nee
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
+
|}<section end=medisch_onderzoek_100202020 />
−
|colspan="2"|Welke irregulaire antistoffen vrouw aanwezig
 
−
|style="background-color: white;"|Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96') - Kell (code = '405844003' in codeSystem '2.16.840.1.113883.6.96')
 
−
|}<section end=medisch_onderzoek_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />
 
 
=== Postnatale fase ===
 
=== Postnatale fase ===
−
<section begin=postnatale_fase_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />
+
<section begin=postnatale_fase_100202020 />
 
{| class="wikitable" width="85%"
 
{| class="wikitable" width="85%"
 
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Postnatale fase
 
|style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;"  colspan="5" | Postnatale fase
Regel 1.004: Regel 3.802:
 
|| Waarde
 
|| Waarde
  
−
|-style="vertical-align:top; background-color: #E3E3E3;;" 
 
−
|colspan="5"|Diagnoseinterventie postpartum
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|rowspan="3"|
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="3"|Datum
 
−
|style="background-color: white;"|3 sep 2014  00:00 - 8 aug 2014  00:00 - 24 jul 2014  00:00
 
−
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
−
|colspan="3"|Pathologie vrouw
 
−
|style="background-color: white;"|Urinary tract infectious disease (disorder) (code = '68566005' in codeSystem '2.16.840.1.113883.6.96') - Embolism (disorder) (code = '414086009' in codeSystem '2.16.840.1.113883.6.96') - Episiotomy infection (disorder) (code = '300927001' in codeSystem '2.16.840.1.113883.6.96') - Postpartum deep phlebothrombosis (disorder) (code = '56272000' in codeSystem '2.16.840.1.113883.6.96')
 
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="5"|Kindspecifieke gegevens
 
|colspan="5"|Kindspecifieke gegevens
Regel 1.020: Regel 3.808:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="3"|Rangnummer kind
 
|colspan="3"|Rangnummer kind
−
|style="background-color: white;"|
+
|style="background-color: white;"|1
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"   
 
|colspan="4"|Voeding kind groep
 
|colspan="4"|Voeding kind groep
Regel 1.027: Regel 3.815:
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Voeding kind datum
 
|colspan="2"|Voeding kind datum
−
|style="background-color: white;"|12 okt 2014  - 7 okt 2014  - 3 sep 2014  - 15 sep 2014  - 24 jul 2014  - 15 okt 2019   
+
|style="background-color: white;"|15 oct 2019   
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|-style="vertical-align:top; background-color: #E3E3E3;;"
 
|colspan="2"|Substantie voeding kind
 
|colspan="2"|Substantie voeding kind
−
|style="background-color: white;"|borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8') - kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')
+
|style="background-color: white;"|borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')
−
|}<section end=postnatale_fase_999910413 - 961921821 - 961921821 - 895623146 - 850810711 - 850810711 - 912345676 - 100202020 />        
+
|}<section end=postnatale_fase_100202020 />
 
[[Categorie:Kwalificatie]]
 
[[Categorie:Kwalificatie]]

Versie van 12 feb 2019 om 17:12

{{#customtitle:Kernset Geboortezorg 2.3 - inhoud kwalificatie}}

Issue icon.png

Deze pagina is nog in bewerking

Naar nictiz.nl

Inhoud

1 Addenda voor inhoudelijke gegevens Kernset Geboortezorg 2.3

1.1 Scenario 1. Zorg volledig 1e lijn, herpes, strippen, gezonde eenling (voor vrouw met BSN: 999910413)

Vrouw
Gegevenselement Waarde
Burgerservicenummer 999910413
Lokale persoonsidentificatie 000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
Geboortedatum 2 may 1976
Adres - postcode 4563 AB
Etniciteit Turks (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
Lengte gemeten 170 cm

1.1.1 Anamnese

Anamnese
Gegevenselement Waarde
Onder behandeling geweest? Ja
Algemene anamnese
Cardiovasculaire aandoening Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Oncologische aandoening Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Infectieziekte Herpes (code = '23513009' in codeSystem '2.16.840.1.113883.6.96')
Type operatie Orthopedisch (code = '112697007' in codeSystem 'Snomed CT')

1.1.2 Zorgverlening

Zorgverlening
Gegevenselement Waarde
Datum start zorgverantwoordelijkheid 1 mar 2014 00:00
Datum einde zorgverantwoordelijkheid 12 nov 2014 00:00
Eindverantwoordelijk in welke perinatale periode? start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Conclusie risicostatus na intake 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26')

1.1.3 Zorgverlenerzorginstelling

Zorgverlenerzorginstelling
Gegevenselement Waarde
Zorginstelling lvrid 1808

1.1.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap

Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Gegevenselement Waarde
Wijze einde zwangerschap Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
Definitieve a terme datum 1 dec 2011
Irregulaire antistoffen? Nee
Eerdere bevalling
Placenta - geboorte placenta Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
Hoeveelheid bloedverlies 550 ml
Vorige uitkomst per kind - vorige baring
Demografische gegevens - geboortedatum 8 dec 2011 00:00
Kindspecifieke gegevens vorige uitkomsten
Type partus Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT')
Percentiel van het geboortegewicht p50 tot p90 (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.50')
Apgarscore na 5 min 8
Congenitale afwijkingen? Nee

1.1.5 Zwangerschap

Zwangerschap
Gegevenselement Waarde
Dossiernummer 0cbda760-1fdd-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
Graviditeit 2
Pariteit voor deze zwangerschap 1
Definitieve a terme datum 9 oct 2014
Voornemens
Voorgenomen plaats baring tijdens zwangerschap type locatie Thuis (code = '169813005' in codeSystem '2.16.840.1.113883.6.96')
Prenatale controle
Datum controle 2 mar 2014 00:00
Zwangerschapsduur 59 dagen
Leven voelen goed (code = '289431008' in codeSystem 'Snomed CT')
Rookgedrag niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
Alcoholgebruik geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
Drugsgebruik? Nee
Gewicht gemeten 70 kg
Diagnose
Datum 2 mar 2014 00:00
Zwangerschapsduur 59 dagen
Infectie Urineweg infectie (code = '307534009' in codeSystem 'Snomed CT')
Maternale sterfte? Nee
Wijze einde zwangerschap Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')

1.1.6 Bevalling

Bevalling
Gegevenselement Waarde
Partusnummer 000000
Aantal geboren kinderen 1
Risicostatus voor baring 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
Interventies begin baring
Interventie begin baring Strippen (code = '236960006' in codeSystem 'Snomed CT')
Indicatie interventie begin baring wens patiënt (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7')
Wijze waarop de baring begon Interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
Tijdstip begin actieve ontsluiting 8 oct 2014 14:30
Medicatie nageboortetijdperk groep
Medicatie nageboortetijdperk? Ja
Soort medicatie nageboortetijdperk Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73')
Placenta - geboorte placenta Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
Hoeveelheid bloedverlies 615 ml
Conditie perineum postpartum 1e graads perineumruptuur (code = '199916005' in codeSystem 'Snomed CT')

1.1.7 Uitkomst per kind

Uitkomst per kind
Gegevenselement Waarde
Baring
Werkelijke plaats baring type locatie Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7')
Demografische gegevens
Identificaties kind
Bsn kind 999910383
Geslacht medische observatie vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
Geboortedatum 8 oct 2014 00:00
Rangnummer kind 1
Perinatale sterfte groep
Perinatale sterfte? Nee
Kindspecifieke maternale gegevens
Tijdstip breken vliezen 8 oct 2014 09:15
Kleur en consistentie vruchtwater Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
Tijdstip actief meepersen 8 oct 2014 12:13
Episiotomie? Nee
Ruggeprik gewenst niet gekregen? Nee
Pijnbestrijding? Nee
Sedatie? Nee
Kindspecifieke uitkomstgegevens
Type partus Normal delivery procedure (procedure) (code = '177184002' in codeSystem 'SNOMED CT')
Ligging bij geboorte Achterhoofd-achter (code = '37235006' in codeSystem 'Snomed CT')
Aanpakker kind - rol aanpakker kind 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
Supervisor - rol supervisor 1e lijns verloskundige (code = '11' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
Lichamelijk onderzoek kind
Geboortegewicht 3450 gram
Congenitale afwijkingen? Nee
Problematiek kind? Nee
Kinderarts betrokken? Nee

1.1.8 Medisch onderzoek

Medisch onderzoek
Gegevenselement Waarde
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
Irregulaire antistoffen? Nee

1.1.9 Postnatale fase

Postnatale fase
Gegevenselement Waarde
Kindspecifieke gegevens
Voeding kind groep
Voeding kind datum 12 oct 2014
Substantie voeding kind borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')
Substantie voeding kind kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')

1.2 Scenario 2. 1e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)

Vrouw
Gegevenselement Waarde
Burgerservicenummer 961921821
Lokale persoonsidentificatie * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
Geboortedatum 11 sep 1974
Adres - postcode 5689 CZ
Etniciteit Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
Lengte gemeten 184 cm

1.2.1 Anamnese

Anamnese
Gegevenselement Waarde
Onder behandeling geweest? Nee

1.2.2 Zorgverlening

Zorgverlening
Gegevenselement Waarde
Datum start zorgverantwoordelijkheid 28 aug 2018
Datum einde zorgverantwoordelijkheid 28 nov 2018
Eindverantwoordelijk in welke perinatale periode? start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Conclusie risicostatus na intake 1e lijn (VIL A) (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
Verwijsdetails
Datum verwijzing 6 may 2014 00:00
Verwijzing van
Zorginstelling
Zorgaanbieder identificatie nummer 1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Verwijzing naar
Zorginstelling
Specialisme Gynaecoloog 2e lijn (code = '02' in codeSystem 'Specialisme, specifiek voor perinatologie.')
Redenen van verwijzing
Van 1e naar 2e lijn
Zwangerschap
Hypertensieve aandoening Zwangerschapshypertensie (code = '48194001' in codeSystem 'SNOMED CT')
Perinatale periode voor 28e week (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52')

1.2.3 Zorgverlenerzorginstelling

Zorgverlenerzorginstelling
Gegevenselement Waarde
Zorginstelling lvrid 1504

1.2.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap

Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Gegevenselement Waarde
Wijze einde zwangerschap Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
Definitieve a terme datum 5 jun 2013
Diagnose
Bloedverlies? Ja
Hyperemesis gravidarum? Ja
Irregulaire antistoffen? Ja

1.2.5 Zwangerschap

Zwangerschap
Gegevenselement Waarde
Dossiernummer 5460cff0-2089-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
Graviditeit 2
Pariteit voor deze zwangerschap 0
Definitieve a terme datum 8 sep 2014
Voornemens
Voorgenomen plaats baring tijdens zwangerschap type locatie Nog niet bepaald (code = '05' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7')
Prenatale controle
Datum controle 6 may 2014 00:00
Zwangerschapsduur 155 dagen
Leven voelen Weak fetal movements (finding) (code = '276372004' in codeSystem '2.16.840.1.113883.6.96')
Rookgedrag gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
Alcoholgebruik geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
Drugsgebruik? Nee
Gewicht gemeten 85 kg
Diagnose
Datum 6 may 2014 00:00
Zwangerschapsduur 155 dagen
Hypertensieve aandoening Pregnancy-induced hypertension (disorder) (code = '48194001' in codeSystem '2.16.840.1.113883.6.96')
Maternale sterfte? Nee

1.3 Scenario 2. 2e lijn. Zorg begonnen 1e lijn, bevallen 2e lijn, gezonde eenling (voor vrouw met BSN: 961921821)

Vrouw
Gegevenselement Waarde
Burgerservicenummer 961921821
Lokale persoonsidentificatie * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
Geboortedatum 11 sep 1974
Adres - postcode 5689 CZ
Etniciteit Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
Lengte gemeten 184 cm

1.3.1 Anamnese

Anamnese
Gegevenselement Waarde
Onder behandeling geweest? Nee

1.3.2 Zorgverlening

Zorgverlening
Gegevenselement Waarde
Datum start zorgverantwoordelijkheid 12 may 2014 00:00
Datum einde zorgverantwoordelijkheid 9 oct 2014 00:00
Eindverantwoordelijk in welke perinatale periode? zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Verwijsdetails
Verwijzing van
Zorginstelling
Zorgaanbieder identificatie nummer 1504 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Verwijzing naar
Zorginstelling
Zorgaanbieder identificatie nummer 0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Redenen van verwijzing
Van 1e naar 2e lijn
Zwangerschap
Hypertensieve aandoening Preeclampsie (code = '398254007' in codeSystem 'SNOMED CT')

1.3.3 Zorgverlenerzorginstelling

Zorgverlenerzorginstelling
Gegevenselement Waarde
Zorginstelling lvrid 0003

1.3.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap

Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Gegevenselement Waarde
Wijze einde zwangerschap Miskraam (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
Definitieve a terme datum 5 jun 2013
Diagnose
Gynaecologische aandoening Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96')
Bloedverlies? Ja
Hyperemesis gravidarum? Ja
Irregulaire antistoffen? Ja

1.3.5 Zwangerschap

Zwangerschap
Gegevenselement Waarde
Dossiernummer c2204d20-209a-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
Graviditeit 2
Pariteit voor deze zwangerschap 0
Definitieve a terme datum 8 sep 2014
Voornemens
Prenatale controle
Datum controle 12 may 2014 00:00
Zwangerschapsduur 161 dagen
Leven voelen Reduced fetal movement (finding) (code = '276369006' in codeSystem '2.16.840.1.113883.6.96')
Rookgedrag gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
Alcoholgebruik geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
Drugsgebruik? Nee
Gewicht gemeten 85 kg
Diagnose
Datum 12 may 2014 00:00
Zwangerschapsduur 161 dagen
Gynaecologische aandoening Congenital uterine anomaly (disorder) (code = '37849005' in codeSystem '2.16.840.1.113883.6.96')
Partiele mola? Ja
Hypertensieve aandoening Pre-eclampsia (disorder) (code = '398254007' in codeSystem '2.16.840.1.113883.6.96')
Maternale sterfte? Nee
Wijze einde zwangerschap Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')

1.3.6 Bevalling

Bevalling
Gegevenselement Waarde
Partusnummer 000000
Aantal geboren kinderen 1
Risicostatus voor baring 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
Interventies begin baring
Interventie begin baring Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96')
Indicatie interventie begin baring acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7')
Wijze waarop de baring begon interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
Tijdstip begin actieve ontsluiting 30 aug 2014 14:09
Medicatie nageboortetijdperk groep
Medicatie nageboortetijdperk? UNK
Placenta - geboorte placenta placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
Hoeveelheid bloedverlies 980 ml
Conditie perineum postpartum Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96')

1.3.7 Uitkomst per kind

Uitkomst per kind
Gegevenselement Waarde
Baring
Werkelijke plaats baring type locatie Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
Ziekenhuis baring
Ziekenhuisnummer lvrid 0003 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Demografische gegevens
Identificaties kind
Bsn kind 951847624
Geslacht medische observatie mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
Geboortedatum 1 sep 2014 02:34
Rangnummer kind 1
Perinatale sterfte groep
Perinatale sterfte? Nee
Kindspecifieke maternale gegevens
Tijdstip breken vliezen 30 aug 2014 23:04
Kleur en consistentie vruchtwater geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008')
Ruggeprik gewenst niet gekregen? Nee
Pijnbestrijding? Ja
Pijnbestrijding
Methode
Methode Epidural anesthesia (procedure) (code = '18946005' in codeSystem '2.16.840.1.113883.6.96')
Periode tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
Sedatie? Ja
Kindspecifieke uitkomstgegevens
Type partus Cesarean section (procedure) (code = '11466000' in codeSystem 'SNOMED CT')
Ligging bij geboorte Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008')
Aanpakker kind - rol aanpakker kind gynaecoloog in opleiding (code = '22' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
Supervisor - rol supervisor gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
Sectio caesarea group
Indicatie primaire sectio Suspected fetal distress (situation) (code = '444433005:246090004=130955003' in codeSystem '2.16.840.1.113883.6.96')
Indicatie primaire sectio Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96')
Lichamelijk onderzoek kind
Geboortegewicht 3620 gram
Congenitale afwijkingen? Nee
Problematiek kind? Nee
Kinderarts betrokken? Ja
Betrokkenheid kinderarts
Datum betrokkenheid 1 sep 2014 00:00
Reden betrokkenheid Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Type betrokkenheid consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
Zorginstelling lvrid 0003

1.3.8 Medisch onderzoek

Medisch onderzoek
Gegevenselement Waarde
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
Irregulaire antistoffen? Ja
Welke irregulaire antistoffen vrouw aanwezig Rhesus D (code = '112162009' in codeSystem '2.16.840.1.113883.6.96')

1.3.9 Postnatale fase

Postnatale fase
Gegevenselement Waarde
Diagnoseinterventie postpartum
Datum 3 sep 2014 00:00
Pathologie vrouw Urinary tract infectious disease (disorder) (code = '68566005' in codeSystem '2.16.840.1.113883.6.96')
Kindspecifieke gegevens
Voeding kind groep
Voeding kind datum 7 oct 2014
Substantie voeding kind kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')

1.4 Scenario 3. zorg volledig in 2e lijn, meerling, 1 kind overleden (voor vrouw met BSN: 895623146)

Vrouw
Gegevenselement Waarde
Burgerservicenummer 895623146
Lokale persoonsidentificatie 000000 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
Geboortedatum 5 aug 1985
Adres - postcode 5421 JG
Etniciteit Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
Lengte gemeten 167 cm
Vrouwelijke genitale verminking? Ja
Type vrouwelijke genitale verminking Female genital mutilation type 2 (disorder) (code = '130621000119105' in codeSystem '2.16.840.1.113883.6.96')

1.4.1 Anamnese

Anamnese
Gegevenselement Waarde
Onder behandeling geweest? Ja
Algemene anamnese
Cardiovasculaire aandoening Cardiac arrhythmia (disorder) (code = '698247007' in codeSystem '2.16.840.1.113883.6.96')
Schildklier aandoening Hyperthyroidism (disorder) (code = '34486009' in codeSystem '2.16.840.1.113883.6.96')
Anemie Iron deficiency anemia (disorder) (code = '87522002' in codeSystem '2.16.840.1.113883.6.96')
Bloedtransfusie? Ja
Type operatie Operation on heart (procedure) (code = '64915003' in codeSystem '2.16.840.1.113883.6.96')

1.4.2 Zorgverlening

Zorgverlening
Gegevenselement Waarde
Datum start zorgverantwoordelijkheid 10 mar 2014 00:00
Datum einde zorgverantwoordelijkheid 3 nov 2014 00:00
Eindverantwoordelijk in welke perinatale periode? start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Conclusie risicostatus na intake 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26')

1.4.3 Zorgverlenerzorginstelling

Zorgverlenerzorginstelling
Gegevenselement Waarde
Zorginstelling lvrid 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)

1.4.4 Zwangerschap

Zwangerschap
Gegevenselement Waarde
Dossiernummer ad9c3280-209d-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
Graviditeit 1
Pariteit voor deze zwangerschap 0
Definitieve a terme datum 22 sep 2014
Voornemens
Voorgenomen plaats baring tijdens zwangerschap type locatie Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
Prenatale controle
Datum controle 21 may 2014 00:00
Zwangerschapsduur 156 dagen
Leven voelen Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96')
Rookgedrag niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
Alcoholgebruik geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
Drugsgebruik? Nee
Gewicht gemeten 67 kg
Diagnose
Datum 21 may 2014 00:00
Zwangerschapsduur 156 dagen
Bloedverlies? Ja
Infectie Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96')
Afwijkende groei foetus Small for gestational age fetus (disorder) (code = '267258002' in codeSystem '2.16.840.1.113883.6.96')
Abruptio placentae? Ja
Maternale sterfte? Nee
Wijze einde zwangerschap Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')

1.4.5 Bevalling

Bevalling
Gegevenselement Waarde
Partusnummer 000000
Diagnose bevalling
Pprom? Ja
Verdenking foetale nood? Ja
Aantal geboren kinderen 2
Risicostatus voor baring 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
Wijze waarop de baring begon spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
Tijdstip begin actieve ontsluiting 27 aug 2014 22:09
Medicatie nageboortetijdperk groep
Medicatie nageboortetijdperk? Nee
Placenta - geboorte placenta controlled cord traction (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
Hoeveelheid bloedverlies 1740 ml
Conditie perineum postpartum Episiotomy wound (morphologic abnormality) (code = '609344008' in codeSystem '2.16.840.1.113883.6.96')

1.4.6 Uitkomst per kind

Uitkomst per kind
Gegevenselement Waarde
Baring
Werkelijke plaats baring type locatie Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
Ziekenhuis baring
Ziekenhuisnummer lvrid 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Demografische gegevens
Identificaties kind
Bsn kind 847035116
Geslacht medische observatie vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
Geboortedatum 28 aug 2014 06:30
Rangnummer kind 1
Perinatale sterfte groep
Perinatale sterfte? Nee
Kindspecifieke maternale gegevens
Tijdstip breken vliezen 27 aug 2014 22:09
Kleur en consistentie vruchtwater kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
Tijdstip actief meepersen 27 aug 2014 23:49
Episiotomie? Ja
Locatie episiotomie mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60')
Ruggeprik gewenst niet gekregen? Nee
Pijnbestrijding? Ja
Pijnbestrijding
Methode
Methode Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Overig middel
Middel Administration of morphinomimetic analgesic (procedure) (code = '52685006:363701004=404642006' in codeSystem '2.16.840.1.113883.6.96')
Toediening Administration of substance via intravenous route (procedure) (code = '431215000' in codeSystem '2.16.840.1.113883.6.96')
Periode tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
Sedatie? Nee
Kindspecifieke uitkomstgegevens
Type partus Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
Ligging bij geboorte Face presentation (finding) (code = '21882006' in codeSystem '2.16.840.1.113883.6.96')
Aanpakker kind - rol aanpakker kind arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
Supervisor - rol supervisor gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
Vaginale kunstverlossing groep
Vaginale kunstverlossing Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96')
Succes vaginale kunstverlossing? Ja
Lichamelijk onderzoek kind
Geboortegewicht 2040 gram
Congenitale afwijkingen? Nee
Problematiek kind? Ja
Problematiek kind Birth trauma of fetus (disorder) (code = '56110009' in codeSystem '2.16.840.1.113883.6.96')
Kinderarts betrokken? Ja
Betrokkenheid kinderarts
Datum betrokkenheid 28 aug 2014 00:00
Reden betrokkenheid Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96')
Type betrokkenheid consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
Zorginstelling lvrid 9999

1.4.7 Uitkomst per kind

Uitkomst per kind
Gegevenselement Waarde
Baring
Werkelijke plaats baring type locatie Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
Ziekenhuis baring
Ziekenhuisnummer lvrid 9999 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Demografische gegevens
Identificaties kind
Bsn kind 847035128
Geslacht medische observatie mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
Geboortedatum 28 aug 2014 07:02
Rangnummer kind 2
Perinatale sterfte groep
Perinatale sterfte? Ja
Fase perinatale sterfte Newborn death (event) (code = '276506001' in codeSystem '2.16.840.1.113883.6.96')
Datumtijd vaststelling perinatale sterfte 28 aug 2014 08:10
Kindspecifieke maternale gegevens
Tijdstip breken vliezen 27 aug 2014 23:13
Kleur en consistentie vruchtwater kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
Tijdstip actief meepersen 28 aug 2014 06:45
Episiotomie? Ja
Locatie episiotomie mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60')
Ruggeprik gewenst niet gekregen? Nee
Pijnbestrijding? Ja
Pijnbestrijding
Methode
Methode Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Overig middel
Middel Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96')
Toediening Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96')
Periode tijdens uitdrijving (code = 'Uitdr' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
Sedatie? Nee
Kindspecifieke uitkomstgegevens
Type partus Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
Ligging bij geboorte Complete breech presentation (finding) (code = '49168004' in codeSystem '2.16.840.1.113883.6.96')
Aanpakker kind - rol aanpakker kind arts-assistent (code = '24' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
Supervisor - rol supervisor gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
Vaginale kunstverlossing groep
Vaginale kunstverlossing Total breech extraction (procedure) (code = '416055001' in codeSystem '2.16.840.1.113883.6.96')
Succes vaginale kunstverlossing? Ja
Overige interventies Maneuvers for delivery in shoulder dystocia (procedure) (code = '237008007' in codeSystem '2.16.840.1.113883.6.96')
Lichamelijk onderzoek kind
Geboortegewicht 1580 gram
Congenitale afwijkingen? Ja
Congenitale afwijkingen groep
Specificatie congenitale afwijking groep
Specificatie congenitale afwijking Spina bifida occulta (disorder) (code = '76916001' in codeSystem '2.16.840.1.113883.6.96')
Specificatie congenitale afwijking groep
Specificatie congenitale afwijking Multiple congenital cardiac defects (disorder) (code = '94702005' in codeSystem '2.16.840.1.113883.6.96')
Chromosomale afwijkingen? Nee
Problematiek kind? Ja
Problematiek kind Subdural intracranial hemorrhage due to birth trauma (disorder) (code = '126941005' in codeSystem '2.16.840.1.113883.6.96')
Kinderarts betrokken? Ja
Betrokkenheid kinderarts
Datum betrokkenheid 28 aug 2014 00:00
Reden betrokkenheid Finding of neonatal condition (finding) (code = '364737004' in codeSystem '2.16.840.1.113883.6.96')
Type betrokkenheid overdracht (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
Zorginstelling lvrid 0001

1.4.8 Medisch onderzoek

Medisch onderzoek
Gegevenselement Waarde
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
Irregulaire antistoffen? Nee

1.4.9 Postnatale fase

Postnatale fase
Gegevenselement Waarde
Kindspecifieke gegevens
Rangnummer kind
Voeding kind groep
Voeding kind datum 3 sep 2014
Substantie voeding kind borstmelk (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')

1.5 Scenario 4. 1e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)

Vrouw
Gegevenselement Waarde
Burgerservicenummer 850810711
Lokale persoonsidentificatie * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
Geboortedatum 6 aug 1987
Adres - postcode 4589 BA
Etniciteit Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
Lengte gemeten 162 cm
Vrouwelijke genitale verminking? Ja
Type vrouwelijke genitale verminking Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96')

1.5.1 Anamnese

Anamnese
Gegevenselement Waarde
Onder behandeling geweest? Ja
Algemene anamnese
Autoimmuun aandoening Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96')
Urogenitale aandoening Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96')
Diabetes mellitus? Ja
Mdl aandoening Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96')
Longaandoening Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96')
Type operatie Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96')
Type operatie Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96')
Type operatie Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')

1.5.2 Zorgverlening

Zorgverlening
Gegevenselement Waarde
Datum start zorgverantwoordelijkheid 7 aug 2014 00:00
Datum einde zorgverantwoordelijkheid 15 sep 2014 00:00
Eindverantwoordelijk in welke perinatale periode? 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Conclusie risicostatus na intake 3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
Verwijsdetails
Verwijzing van
Zorginstelling
Zorgaanbieder identificatie nummer 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Verwijzing naar
Zorginstelling
Zorgaanbieder identificatie nummer 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Redenen van verwijzing
Redenen van verwijzing

1.5.3 Zorgverlenerzorginstelling

Zorgverlenerzorginstelling
Gegevenselement Waarde
Zorginstelling lvrid 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)

1.5.4 Zwangerschap

Zwangerschap
Gegevenselement Waarde
Dossiernummer 05e54070-209f-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
Graviditeit 1
Pariteit voor deze zwangerschap 0
Definitieve a terme datum 18 aug 2014
Maternale sterfte? Ja
Wijze einde zwangerschap Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')

1.5.5 Bevalling

Bevalling
Gegevenselement Waarde
Aantal geboren kinderen 1
Risicostatus voor baring 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
Wijze waarop de baring begon spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
Tijdstip begin actieve ontsluiting 3 aug 2014 21:09
Medicatie nageboortetijdperk groep
Medicatie nageboortetijdperk? Ja
Soort medicatie nageboortetijdperk Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73')
Placenta - geboorte placenta spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
Hoeveelheid bloedverlies 1120 ml
Conditie perineum postpartum Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96')

1.5.6 Uitkomst per kind

Uitkomst per kind
Gegevenselement Waarde
Baring
Werkelijke plaats baring type locatie Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
Ziekenhuis baring
Ziekenhuisnummer lvrid 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Demografische gegevens
Identificaties kind
Bsn kind 840736526
Geslacht medische observatie vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
Geboortedatum 4 aug 2014 23:35
Rangnummer kind 1
Perinatale sterfte groep
Perinatale sterfte? Nee
Kindspecifieke maternale gegevens
Tijdstip breken vliezen 3 aug 2014 07:04
Kleur en consistentie vruchtwater bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
Tijdstip actief meepersen 4 aug 2014 22:15
Episiotomie? Ja
Locatie episiotomie mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60')
Ruggeprik gewenst niet gekregen? Nee
Pijnbestrijding? Ja
Pijnbestrijding
Methode
Methode Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Overig middel
Middel Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96')
Toediening Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96')
Periode tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
Sedatie? Nee
Kindspecifieke uitkomstgegevens
Type partus Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
Ligging bij geboorte Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96')
Aanpakker kind - rol aanpakker kind co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
Supervisor - rol supervisor gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
Vaginale kunstverlossing groep
Vaginale kunstverlossing Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96')
Succes vaginale kunstverlossing? Ja
Lichamelijk onderzoek kind
Geboortegewicht 4205 gram
Congenitale afwijkingen? Nee
Problematiek kind? Nee
Kinderarts betrokken? Ja
Betrokkenheid kinderarts
Datum betrokkenheid 4 aug 2014 00:00
Reden betrokkenheid Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96')
Type betrokkenheid consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
Zorginstelling lvrid 0010

1.5.7 Postnatale fase

Postnatale fase
Gegevenselement Waarde
Diagnoseinterventie postpartum
Datum 8 aug 2014 00:00
Pathologie vrouw Embolism (disorder) (code = '414086009' in codeSystem '2.16.840.1.113883.6.96')
Diagnoseinterventie postpartum
Datum 8 aug 2014 00:00
Pathologie vrouw Episiotomy infection (disorder) (code = '300927001' in codeSystem '2.16.840.1.113883.6.96')
Kindspecifieke gegevens
Voeding kind groep
Voeding kind datum 15 sep 2014
Substantie voeding kind kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')

1.6 Scenario 4. 2e lijn zorg begonnen 2e lijn, bevallen in 2e lijn, gezonde eenling, kraambed 1e lijn, vrouw overleden (voor vrouw met BSN: 850810711)

Vrouw
Gegevenselement Waarde
Burgerservicenummer 850810711
Lokale persoonsidentificatie * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
Geboortedatum 6 aug 1987
Adres - postcode 4589 BA
Etniciteit Overig Afrikaans (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
Lengte gemeten 162 cm
Vrouwelijke genitale verminking? Ja
Type vrouwelijke genitale verminking Female genital mutilation type 1 (disorder) (code = '130631000119108' in codeSystem '2.16.840.1.113883.6.96')

1.6.1 Anamnese

Anamnese
Gegevenselement Waarde
Onder behandeling geweest? Ja
Algemene anamnese
Autoimmuun aandoening Rheumatism (disorder) (code = '396332003' in codeSystem '2.16.840.1.113883.6.96')
Urogenitale aandoening Bacteriuria (finding) (code = '61373006' in codeSystem '2.16.840.1.113883.6.96')
Diabetes mellitus? Ja
Mdl aandoening Chronic liver disease (disorder) (code = '328383001' in codeSystem '2.16.840.1.113883.6.96')
Longaandoening Asthma (disorder) (code = '195967001' in codeSystem '2.16.840.1.113883.6.96')
Type operatie Operation on musculoskeletal system (procedure) (code = '112697007' in codeSystem '2.16.840.1.113883.6.96')
Type operatie Appendectomy (procedure) (code = '80146002' in codeSystem '2.16.840.1.113883.6.96')
Type operatie Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')

1.6.2 Zorgverlening

Zorgverlening
Gegevenselement Waarde
Datum start zorgverantwoordelijkheid 3 feb 2014 00:00
Datum einde zorgverantwoordelijkheid 6 aug 2014 00:00
Eindverantwoordelijk in welke perinatale periode? zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Conclusie risicostatus na intake 3e lijns zorg (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.26')
Verwijsdetails
Datum verwijzing 6 aug 2014 00:00
Verwijzing van
Zorginstelling
Zorgaanbieder identificatie nummer 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Verwijzing naar
Zorginstelling
Zorgaanbieder identificatie nummer 1410 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Redenen van verwijzing
Perinatale periode 2e t/m 7e dag (code = '92' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.52')

1.6.3 Zorgverlenerzorginstelling

Zorgverlenerzorginstelling
Gegevenselement Waarde
Zorginstelling lvrid 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)

1.6.4 Zwangerschap

Zwangerschap
Gegevenselement Waarde
Dossiernummer e1691540-209f-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
Graviditeit 1
Pariteit voor deze zwangerschap 0
Definitieve a terme datum 18 aug 2014
Voornemens
Voorgenomen plaats baring tijdens zwangerschap type locatie Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
Prenatale controle
Datum controle 7 may 2014 00:00
Zwangerschapsduur 149 dagen
Leven voelen Fetal movements present (finding) (code = '289431008' in codeSystem '2.16.840.1.113883.6.96')
Rookgedrag niet gerookt (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
Alcoholgebruik geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
Drugsgebruik? Nee
Gewicht gemeten 82 kg
Diagnose
Datum 7 may 2014 00:00
Zwangerschapsduur 149 dagen
Infectie Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96')
Maternale sterfte? Nee
Wijze einde zwangerschap Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')

1.6.5 Bevalling

Bevalling
Gegevenselement Waarde
Diagnose bevalling
Niet vorderende ontsluiting? Ja
Niet vorderende uitdrijving? Ja
Aantal geboren kinderen 1
Risicostatus voor baring 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
Wijze waarop de baring begon spontane vliesscheur (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
Tijdstip begin actieve ontsluiting 3 aug 2014 21:09
Medicatie nageboortetijdperk groep
Medicatie nageboortetijdperk? Ja
Soort medicatie nageboortetijdperk Prostaglandins (code = 'G02AD' in codeSystem '2.16.840.1.113883.6.73')
Placenta - geboorte placenta spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
Hoeveelheid bloedverlies 1120 ml
Conditie perineum postpartum Third degree perineal tear during delivery - delivered (disorder) (code = '199930000' in codeSystem '2.16.840.1.113883.6.96')

1.6.6 Uitkomst per kind

Uitkomst per kind
Gegevenselement Waarde
Baring
Werkelijke plaats baring type locatie Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
Ziekenhuis baring
Ziekenhuisnummer lvrid 0010 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Demografische gegevens
Identificaties kind
Bsn kind 840736526
Geslacht medische observatie vrouwelijk (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
Geboortedatum 4 aug 2014 23:35
Rangnummer kind 1
Perinatale sterfte groep
Perinatale sterfte? Nee
Kindspecifieke maternale gegevens
Tijdstip breken vliezen 3 aug 2014 07:04
Kleur en consistentie vruchtwater bloederig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
Tijdstip actief meepersen 4 aug 2014 22:15
Episiotomie? Ja
Locatie episiotomie mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60')
Ruggeprik gewenst niet gekregen? Nee
Pijnbestrijding? Ja
Pijnbestrijding
Methode
Methode Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Overig middel
Middel Nitrous oxide and oxygen gas analgesia in labor (procedure) (code = '426060003' in codeSystem '2.16.840.1.113883.6.96')
Toediening Inhalational analgesia (procedure) (code = '241717009' in codeSystem '2.16.840.1.113883.6.96')
Periode tijdens ontsluitingsperiode <= 3 cm (code = 'OntLt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
Sedatie? Nee
Kindspecifieke uitkomstgegevens
Type partus Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
Ligging bij geboorte Fontanelles presenting (finding) (code = '249079005' in codeSystem '2.16.840.1.113883.6.96')
Aanpakker kind - rol aanpakker kind co-assistent (code = '13' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
Supervisor - rol supervisor gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
Vaginale kunstverlossing groep
Vaginale kunstverlossing Forceps delivery (procedure) (code = '302383004' in codeSystem '2.16.840.1.113883.6.96')
Succes vaginale kunstverlossing? Ja
Lichamelijk onderzoek kind
Geboortegewicht 4205 gram
Congenitale afwijkingen? Nee
Problematiek kind? Nee
Kinderarts betrokken? Ja
Betrokkenheid kinderarts
Datum betrokkenheid 4 aug 2014 00:00
Reden betrokkenheid Fetal or neonatal effect of assisted delivery (disorder) (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96')
Type betrokkenheid consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
Zorginstelling lvrid 0010

1.6.7 Medisch onderzoek

Medisch onderzoek
Gegevenselement Waarde
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
Irregulaire antistoffen? Nee

1.7 Scenario 5. zorg volledig 2e lijn, vrouw overleden (voor vrouw met BSN: 912345676)

Vrouw
Gegevenselement Waarde
Burgerservicenummer 912345676
Lokale persoonsidentificatie * (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
Geboortedatum 4 mar 1993
Adres - postcode 9562 GF
Etniciteit Latijns Amerikaans (code = '14' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
Lengte gemeten 186 cm

1.7.1 Anamnese

Anamnese
Gegevenselement Waarde
Onder behandeling geweest? Ja
Algemene anamnese
Cardiovasculaire aandoening Hypertensive disorder, systemic arterial (disorder) (code = '38341003' in codeSystem '2.16.840.1.113883.6.96')
Diabetes mellitus? Ja
Neurologische aandoening Epilepsy (disorder) (code = '84757009' in codeSystem '2.16.840.1.113883.6.96')
Longaandoening Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Orthopedische afwijking Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Type stollingsprobleem Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Psychiatrie? Ja

1.7.2 Zorgverlening

Zorgverlening
Gegevenselement Waarde
Datum start zorgverantwoordelijkheid 9 dec 2013 00:00
Datum einde zorgverantwoordelijkheid 4 aug 2014 00:00
Eindverantwoordelijk in welke perinatale periode? start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Conclusie risicostatus na intake 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26')

1.7.3 Zorgverlenerzorginstelling

Zorgverlenerzorginstelling
Gegevenselement Waarde
Zorginstelling lvrid 0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)

1.7.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap

Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Gegevenselement Waarde
Wijze einde zwangerschap Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
Definitieve a terme datum 5 jun 2012
Diagnose
Infectie Urinary tract infection in pregnancy (disorder) (code = '307534009' in codeSystem '2.16.840.1.113883.6.96')
Zwangerschapscholestase? Ja
Afwijkende groei foetus Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008')
Irregulaire antistoffen? Ja
Eerdere bevalling
Placenta - geboorte placenta spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
Vorige uitkomst per kind - vorige baring
Demografische gegevens - geboortedatum 9 jun 2012 00:00
Kindspecifieke gegevens vorige uitkomsten
Type partus Assisted delivery of fetus (procedure) (code = '3311000146109' in codeSystem 'SNOMED CT')
Percentiel van het geboortegewicht 10 ≤ P < 50 (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.50')
Apgarscore na 5 min 10
Congenitale afwijkingen? Nee

1.7.5 Zwangerschap

Zwangerschap
Gegevenselement Waarde
Dossiernummer 68a34ee0-20a0-11e9-b56e-0800200c9a66 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
Graviditeit 2
Pariteit voor deze zwangerschap 1
Definitieve a terme datum 22 jul 2014
Voornemens
Voorgenomen plaats baring tijdens zwangerschap type locatie Geen informatie (code = 'NI' in codeSystem '2.16.840.1.113883.5.1008')
Prenatale controle
Datum controle 9 jan 2014 00:00
Zwangerschapsduur 86 dagen
Leven voelen Fetal movements absent (context-dependent category) (code = '289432001' in codeSystem '2.16.840.1.113883.6.96')
Rookgedrag gestopt tijdens huidige zwangerschap (code = '6' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
Alcoholgebruik geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
Drugsgebruik? Ja
Gewicht gemeten 89 kg
Diagnose
Datum 9 jan 2014 00:00
Zwangerschapsduur 86 dagen
Afwijkende groei foetus Large-for-dates fetus (disorder) (code = '199616008' in codeSystem '2.16.840.1.113883.6.96')
Abruptio placentae? Ja
Intrauteriene behandeling Selective destruction of fetus (procedure) (code = '265633004' in codeSystem '2.16.840.1.113883.6.96')
Maternale sterfte? Ja
Wijze einde zwangerschap Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')

1.7.6 Bevalling

Bevalling
Gegevenselement Waarde
Partusnummer 000000
Aantal geboren kinderen 1
Risicostatus voor baring 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
Interventies begin baring
Interventie begin baring Elective caesarean section (procedure) (code = '177141003' in codeSystem '2.16.840.1.113883.6.96')
Indicatie interventie begin baring acuut levensbedreigend (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7')
Wijze waarop de baring begon interventie om baring op gang te brengen (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
Medicatie nageboortetijdperk groep
Medicatie nageboortetijdperk? Nee
Placenta - geboorte placenta placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
Hoeveelheid bloedverlies 1500 ml
Conditie perineum postpartum Perineum intact (finding) (code = '289854007' in codeSystem '2.16.840.1.113883.6.96')

1.7.7 Uitkomst per kind

Uitkomst per kind
Gegevenselement Waarde
Baring
Werkelijke plaats baring type locatie Hospital (environment) (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
Ziekenhuis baring
Ziekenhuisnummer lvrid 0179 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Demografische gegevens
Identificaties kind
Bsn kind 528741913
Geslacht medische observatie twijfelachtig (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
Geboortedatum 24 jul 2014 02:30
Rangnummer kind 1
Perinatale sterfte groep
Perinatale sterfte? Nee
Kindspecifieke maternale gegevens
Kleur en consistentie vruchtwater meconium (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
Episiotomie? Nee
Ruggeprik gewenst niet gekregen? Nee
Pijnbestrijding? Ja
Pijnbestrijding
Methode
Methode General anesthesia (procedure) (code = '50697003' in codeSystem '2.16.840.1.113883.6.96')
Periode tijdens sectio (code = 'Sectio' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
Sedatie? Ja
Kindspecifieke uitkomstgegevens
Type partus Emergency cesarian section (procedure) (code = '274130007' in codeSystem 'SNOMED CT')
Ligging bij geboorte Onbekend (code = 'UNK' in codeSystem '2.16.840.1.113883.5.1008')
Aanpakker kind - rol aanpakker kind gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
Supervisor - rol supervisor gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
Vaginale kunstverlossing groep
Vaginale kunstverlossing Delivery by vacuum extraction (procedure) (code = '61586001' in codeSystem '2.16.840.1.113883.6.96')
Succes vaginale kunstverlossing? Nee
Sectio caesarea group
Beslismoment sectio caesarea tijdens uitdrijving besloten (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.5')
Indicatie secundaire sectio Patient condition finding (finding) (code = '418138009' in codeSystem '2.16.840.1.113883.6.96')
Lichamelijk onderzoek kind
Geboortegewicht 3750 gram
Congenitale afwijkingen? Ja
Congenitale afwijkingen groep
Chromosomale afwijkingen? Ja
Specificatie chromosomale afwijking groep
Specificatie chromosomale afwijking Complete trisomy 21 syndrome (disorder) (code = '41040004' in codeSystem '2.16.840.1.113883.6.96')
Problematiek kind? Ja
Problematiek kind Congenital hearing disorder (disorder) (code = '95827002' in codeSystem '2.16.840.1.113883.6.96')
Kinderarts betrokken? Nee

1.7.8 Medisch onderzoek

Medisch onderzoek
Gegevenselement Waarde
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
Irregulaire antistoffen? Ja
Welke irregulaire antistoffen vrouw aanwezig Kell (code = '405844003' in codeSystem '2.16.840.1.113883.6.96')

1.7.9 Postnatale fase

Postnatale fase
Gegevenselement Waarde
Diagnoseinterventie postpartum
Datum 24 jul 2014 00:00
Pathologie vrouw Postpartum deep phlebothrombosis (disorder) (code = '56272000' in codeSystem '2.16.840.1.113883.6.96')
Kindspecifieke gegevens
Voeding kind groep
Voeding kind datum 24 jul 2014
Substantie voeding kind kunstvoeding (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')

1.8 Scenario 6. 2e lijn (voor vrouw met BSN: 100202020)

Vrouw
Gegevenselement Waarde
Burgerservicenummer 100202020
Lokale persoonsidentificatie 987654321 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.6)
Geboortedatum 1 jan 1989
Adres - postcode 1234 AB
Etniciteit Kaukasisch (code = '12' in codeSystem '2.16.840.1.113883.2.4.4.13.28')
Lengte gemeten 172 cm
Vrouwelijke genitale verminking? Nee

1.8.1 Anamnese

Anamnese
Gegevenselement Waarde
Onder behandeling geweest? Ja
Algemene anamnese
Autoimmuun aandoening Reuma (code = '396332003' in codeSystem 'Snomed CT')
Cardiovasculaire aandoening Overig, niet nader omschreven Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Urogenitale aandoening Pyelonefritis (code = '45816000' in codeSystem 'Snomed CT')
Oncologische aandoening Overig, niet nader omschreven Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Schildklier aandoening Hypothyreoidie (code = '40930008' in codeSystem 'Snomed CT')
Diabetes mellitus? Nee
Neurologische aandoening Hernia nuclei pulposi (code = '84857004' in codeSystem 'Snomed CT')
Neurologische aandoening Overig, niet nader omschreven Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Mdl aandoening M. Crohn (code = '34000006' in codeSystem 'Snomed CT')
Anemie IJzergebrek (code = '87522002' in codeSystem 'Snomed CT')
Longaandoening Astma (code = '195967001' in codeSystem 'Snomed CT')
Orthopedische afwijking Trauma bekken (code = '282771003' in codeSystem 'Snomed CT')
Bloedtransfusie? Nee
Type operatie Sectio (code = '11466000' in codeSystem 'Snomed CT')
Type operatie Rug (code = '129152004:260686004=129284003' in codeSystem '2.16.840.1.113883.6.96')
Psychiatrie? Nee
Overige aandoening? Nee

1.8.2 Zorgverlening

Zorgverlening
Gegevenselement Waarde
Datum start zorgverantwoordelijkheid 1 mar 2019 00:00
Datum einde zorgverantwoordelijkheid 15 oct 2019 00:00
Eindverantwoordelijk in welke perinatale periode? start /intake zwangerschapszorg (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? zwangerschap vervolg (code = '2' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? start baring/ontsluiting (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? uitdrijving (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? nageboortetijdperk (code = '5' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 1e 24 uur postpartum (code = '6' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? 2e - 7e dag postpartum (code = '7' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Eindverantwoordelijk in welke perinatale periode? follow-up eerste 6 wkn postpartum (code = '8' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.20')
Conclusie risicostatus na intake 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.4.13.26')

1.8.3 Zorgverlenerzorginstelling

Zorgverlenerzorginstelling
Gegevenselement Waarde
Zorginstelling lvrid 0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)

1.8.4 Obstetrische anamnese gegroepeerd per voorgaande zwangerschap

Obstetrische anamnese gegroepeerd per voorgaande zwangerschap
Gegevenselement Waarde
Wijze einde zwangerschap Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')
Definitieve a terme datum 1 feb 2017
Diagnose
Bloedverlies? Ja
Cervixinsufficientie? Nee
Infectie Intra-uterien (code = '301775005' in codeSystem 'Snomed CT')
Hyperemesis gravidarum? Nee
Hypertensieve aandoening Zwangerschapshypertensie (code = '48194001' in codeSystem '2.16.840.1.113883.6.96')
Zwangerschapscholestase? Nee
Diabetes gravidarum met insuline? Nee
Afwijkende groei foetus Macrosomie (code = '199616008' in codeSystem 'Snomed CT')
Dreigende partus immaturus? Nee
Dreigende partus prematurus? Nee
Abruptio placentae? Ja
Irregulaire antistoffen? Nee
Eerdere bevalling
Placenta - geboorte placenta Placentaverwijdering bij SC (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
Hoeveelheid bloedverlies 895 ml
Vorige uitkomst per kind - vorige baring
Demografische gegevens - geboortedatum 15 dec 2016
Kindspecifieke gegevens vorige uitkomsten
Type partus Secundair (code = '274130007' in codeSystem '2.16.840.1.113883.6.96')
Percentiel van het geboortegewicht p2,3 tot p10 (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.50')
Apgarscore na 5 min 8
Congenitale afwijkingen? Ja
Congenitale afwijkingen groep
Chromosomale afwijkingen? Nee

1.8.5 Zwangerschap

Zwangerschap
Gegevenselement Waarde
Dossiernummer 0af1e5b1-bf99-40a2-ade9-728186c32f31 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999.60.4)
Graviditeit 2
Pariteit voor deze zwangerschap 1
Definitieve a terme datum 2 oct 2019
Voornemens
Voorgenomen plaats baring tijdens zwangerschap type locatie Ziekenhuis (code = '22232009' in codeSystem '2.16.840.1.113883.6.96')
Prenatale controle
Datum controle 1 mar 2019 00:00
Zwangerschapsduur 56 dagen
Leven voelen geen (code = '289432001' in codeSystem '2.16.840.1.113883.6.96')
Rookgedrag gestopt vóór huidige zwangerschap (code = '5' in codeSystem '2.16.840.1.113883.2.4.4.13.58')
Alcoholgebruik geen (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.59')
Drugsgebruik? Nee
Gewicht gemeten 68 kg
Diagnose
Datum 1 mar 2019 00:00
Zwangerschapsduur 56 dagen
Gynaecologische aandoening Overig, niet nader gespecificeerd Overig (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Bloedverlies? Nee
Partiele mola? Nee
Cervixinsufficientie? Nee
Hyperemesis gravidarum? Nee
Zwangerschapscholestase? Nee
Diabetes gravidarum met insuline? Nee
Afwijkende groei foetus Dysmaturiteit (code = '267258002' in codeSystem 'Snomed CT')
Dreigende partus immaturus? Nee
Dreigende partus prematurus? Nee
Abruptio placentae? Nee
Navelstrengprolaps? Nee
Intrauteriene vruchtdood
Vermoeden intrauteriene vruchtdood? Nee
Maternale sterfte? Nee
Wijze einde zwangerschap Partus (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.46')

1.8.6 Bevalling

Bevalling
Gegevenselement Waarde
Partusnummer 4567890123 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.999​.60.7)
Diagnose bevalling
Pprom? Nee
Prom? Nee
Koorts? Nee
Niet vorderende ontsluiting? Nee
Niet vorderende uitdrijving? Nee
Verdenking foetale nood? Nee
Intrauteriene vruchtdood
Vermoeden intrauteriene vruchtdood? Nee
Vastzittende placenta? Nee
Fluxus postpartum? Ja
Aantal geboren kinderen 1
Risicostatus voor baring 2e lijn (VIL C) (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.25')
Interventies begin baring
Interventie begin baring Primen prostaglandine (code = '236966000' in codeSystem 'Snomed CT')
Indicatie interventie begin baring niet levensbedreigend (code = '3' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.7')
Wijze waarop de baring begon Spontane weeën (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.46')
Tijdstip begin actieve ontsluiting 15 oct 2019 03:45
Medicatie nageboortetijdperk groep
Medicatie nageboortetijdperk? Ja
Soort medicatie nageboortetijdperk Oxytocine (code = 'H01BB02' in codeSystem '2.16.840.1.113883.6.73')
Placenta - geboorte placenta Spontaan (code = '0' in codeSystem '2.16.840.1.113883.2.4.4.13.19')
Hoeveelheid bloedverlies 650 ml
Conditie perineum postpartum 1e graads perineumruptuur (code = '199916005' in codeSystem 'Snomed CT')

1.8.7 Uitkomst per kind

Uitkomst per kind
Gegevenselement Waarde
Baring
Werkelijke plaats baring type locatie Geboortecentrum (code = '23' in codeSystem '2.16.840.1.113883.2.4.3.22.1.8.7')
Ziekenhuis baring
Ziekenhuisnummer lvrid 0803 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)
Demografische gegevens
Identificaties kind
Bsn kind 847035116
Geslacht medische observatie mannelijk (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.21')
Geboortedatum 15 oct 2019
Rangnummer kind 1
Perinatale sterfte groep
Perinatale sterfte? Nee
Kindspecifieke maternale gegevens
Bijstimulatie toegediend? Ja
Tijdstip breken vliezen 19 oct 2019 04:30
Kleur en consistentie vruchtwater Kleurloos (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.18')
Tijdstip actief meepersen 19 oct 2019 05:00
Episiotomie? Nee
Locatie episiotomie mediolaterale episiotomie (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.3.60')
Ruggeprik gewenst niet gekregen? Ja
Pijnbestrijding? Ja
Pijnbestrijding
Methode
Methode Overig middel (code = 'OTH' in codeSystem '2.16.840.1.113883.5.1008')
Overig middel
Middel Entonox (code = '426060003' in codeSystem 'Snomed CT')
Toediening Inhalatie (code = '241717009' in codeSystem 'Snomed CT')
Periode tijdens ontsluitingsperiode > 3 cm (code = 'OntMt3' in codeSystem '2.16.840.1.113883.2.4.4.13.60')
Sedatie? Ja
Kindspecifieke uitkomstgegevens
Type partus Spontaan (code = '177184002' in codeSystem '2.16.840.1.113883.6.96')
Ligging bij geboorte Achterhoofd-voor (code = '70028003' in codeSystem 'Snomed CT')
Aanpakker kind - rol aanpakker kind klinisch verloskundige (code = '25' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.59')
Supervisor - rol supervisor gynaecoloog (code = '01.046' in codeSystem '2.16.840.1.113883.2.4.15.111')
Vaginale kunstverlossing groep
Vaginale kunstverlossing Vacuüm (code = '61586001' in codeSystem 'Snomed CT')
Succes vaginale kunstverlossing? Ja
Lichamelijk onderzoek kind
Apgarscore na 5 min 9
Geboortegewicht 3550 gram
Congenitale afwijkingen? Ja
Congenitale afwijkingen groep
Specificatie congenitale afwijking groep
Specificatie congenitale afwijking overige congenitale huidafwijking (code = '74' in codeSystem '2.16.840.1.113883.2.4.4.13.8')
Chromosomale afwijkingen? Nee
Problematiek kind? Ja
Problematiek kind Geboortetrauma (code = '56110009' in codeSystem 'Snomed CT')
Kinderarts betrokken? Ja
Betrokkenheid kinderarts
Datum betrokkenheid 15 oct 2019 00:00
Reden betrokkenheid kunstverlossing (code = '8571000146103' in codeSystem '2.16.840.1.113883.6.96')
Type betrokkenheid Consultatie (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.17')
Zorginstelling lvrid 0110 (in identificerend systeem: 2.16.840.1.113883.2.4.3.22.96.6)

1.8.8 Medisch onderzoek

Medisch onderzoek
Gegevenselement Waarde
Maternale onderzoeksgegevens - urine bloed en aanvullende onderzoeken - PSIE
Irregulaire antistoffen? Nee

1.8.9 Postnatale fase

Postnatale fase
Gegevenselement Waarde
Kindspecifieke gegevens
Rangnummer kind 1
Voeding kind groep
Voeding kind datum 15 oct 2019
Substantie voeding kind borstvoeding (code = '1' in codeSystem '2.16.840.1.113883.2.4.3.22.1.4.8')
Overgenomen van "https://informatiestandaarden.nictiz.nl/index.php?title=Gebz:Vdraft_AddendaKwalificatieKernsetGeboortezorg23&oldid=17869"