GZ: InhoudelijkeGegevens Integrale Zwangerschapskaart Echo: verschil tussen versies
Regel 4: | Regel 4: | ||
=Addenda voor inhoudelijke gegevens Integrale zwangerschapskaart 3.2=</noinclude> | =Addenda voor inhoudelijke gegevens Integrale zwangerschapskaart 3.2=</noinclude> | ||
− | ==Scenario | + | ==Scenario Echo casus 1== |
<section begin= /><section end= /> | <section begin= /><section end= /> | ||
=== Administratief === | === Administratief === | ||
Regel 105: | Regel 105: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Afdeling specialisme | |colspan="4"|Afdeling specialisme | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Echoscopie (code = '9018' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|<span id="HelmaGrootkaart8" title="Intern ID = HelmaGrootkaart8">Zorgverlener HelmaGrootkaart8</span> | |colspan="6"|<span id="HelmaGrootkaart8" title="Intern ID = HelmaGrootkaart8">Zorgverlener HelmaGrootkaart8</span> | ||
Regel 158: | Regel 158: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Zorgverlener | |colspan="2"|Zorgverlener | ||
− | |style="background-color: white;"|HelmaGrootkaart8 | + | |style="background-color: white;"|Zie [[#HelmaGrootkaart8|Zorgverlener: HelmaGrootkaart8]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Status zorgepisode | |colspan="3"|Status zorgepisode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Afgesloten (code = 'finished' in codeSystem '2.16.840.1.113883.4.642.1.649') |
|}<section end=zorgverlening_ /> | |}<section end=zorgverlening_ /> | ||
=== Zwangerschapsgegevens === | === Zwangerschapsgegevens === | ||
Regel 241: | Regel 241: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Observatie methode | |colspan="3"|Observatie methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Conclusie waarde | |colspan="3"|Conclusie waarde | ||
− | |style="background-color: white;"|2 | + | |style="background-color: white;"|Verdenking afwijking (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.56') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Verdenking afwijkingobv waarde | |colspan="3"|Verdenking afwijkingobv waarde | ||
− | |style="background-color: white;"|4 | + | |style="background-color: white;"|Afwijking sonomarker (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.200') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Advies waarde | |colspan="3"|Advies waarde | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Verwijzing GUO2 (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.57') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Biometrie | |colspan="5"|Biometrie | ||
Regel 261: | Regel 261: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Acwaarde | |colspan="2"|Acwaarde | ||
− | |style="background-color: white;"|151 | + | |style="background-color: white;"|151 mm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Acdatum begin tijd | |colspan="2"|Acdatum begin tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 570 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Foetale schedelomvang | |colspan="4"|Foetale schedelomvang | ||
Regel 274: | Regel 274: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Schedelomvang meetmethode | |colspan="2"|Schedelomvang meetmethode | ||
− | |style="background-color: white;"|2 | + | |style="background-color: white;"|Meten van schedelomvang m.b.v. echografisch onderzoek (code = '31561000146107' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Schedelomvang waarde | |colspan="2"|Schedelomvang waarde | ||
− | |style="background-color: white;"|168 | + | |style="background-color: white;"|168 mm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Schedelomvang datum tijd | |colspan="2"|Schedelomvang datum tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 570 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Foetale femurlengte fl meting | |colspan="4"|Foetale femurlengte fl meting | ||
Regel 287: | Regel 287: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Flwaarde | |colspan="2"|Flwaarde | ||
− | |style="background-color: white;"|31 | + | |style="background-color: white;"|31 mm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Fldatum begin tijd | |colspan="2"|Fldatum begin tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 570 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Foetale biparietale diameter bpd meting | |colspan="4"|Foetale biparietale diameter bpd meting | ||
Regel 300: | Regel 300: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Bpdwaarde | |colspan="2"|Bpdwaarde | ||
− | |style="background-color: white;"|49 | + | |style="background-color: white;"|49 mm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Bpddatum begin tijd | |colspan="2"|Bpddatum begin tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 570 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Foetaal longitudinale blaas diameter lbd meting | |colspan="4"|Foetaal longitudinale blaas diameter lbd meting | ||
Regel 313: | Regel 313: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lbdwaarde | |colspan="2"|Lbdwaarde | ||
− | |style="background-color: white;"|52 | + | |style="background-color: white;"|52 mm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Lbddatum begin tijd | |colspan="2"|Lbddatum begin tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 570 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Foetale transcerebellar diameter tcd meting | |colspan="4"|Foetale transcerebellar diameter tcd meting | ||
Regel 326: | Regel 326: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Tcdwaarde | |colspan="2"|Tcdwaarde | ||
− | |style="background-color: white;"|21 | + | |style="background-color: white;"|21 mm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Tcddatum begin tijd | |colspan="2"|Tcddatum begin tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 570 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Foetaal geschat gewicht efw meting | |colspan="4"|Foetaal geschat gewicht efw meting | ||
Regel 339: | Regel 339: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Efwwaarde | |colspan="2"|Efwwaarde | ||
− | |style="background-color: white;"|320 | + | |style="background-color: white;"|320 mm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Efwdatum begin tijd | |colspan="2"|Efwdatum begin tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 570 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Bevindingen | |colspan="5"|Bevindingen | ||
Regel 356: | Regel 356: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Beweging foetus datum tijd | |colspan="2"|Beweging foetus datum tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 570 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Beweging foetus waarde | |colspan="2"|Beweging foetus waarde | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|foetale bewegingen aanwezig (bevinding) (code = '289431008' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Observatie methode | |colspan="2"|Observatie methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Vruchtwater meting | |colspan="4"|Vruchtwater meting | ||
Regel 369: | Regel 369: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet datum tijd | |colspan="2"|Meet datum tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 570 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Hoeveelheid vruchtwater waarde | |colspan="2"|Hoeveelheid vruchtwater waarde | ||
− | |style="background-color: white;"|1 | + | |style="background-color: white;"|normaal vruchtwatervolume (bevinding) (code = '278092006' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Vruchtwatercompartiment waarde | |colspan="2"|Vruchtwatercompartiment waarde | ||
− | |style="background-color: white;"|1 | + | |style="background-color: white;"|Geen bijzonderheden (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.55') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Placenta lokalisatie observatie | |colspan="4"|Placenta lokalisatie observatie | ||
Regel 385: | Regel 385: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Placenta lokalisatie datum tijd | |colspan="2"|Placenta lokalisatie datum tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 570 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Placentalokalisatie waarde | |colspan="2"|Placentalokalisatie waarde | ||
− | |style="background-color: white;"|1 | + | |style="background-color: white;"|rechts laterale positie van placenta (bevinding) (code = '7401000146107' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Observatie methode | |colspan="2"|Observatie methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Cervixlengte meting | |colspan="4"|Cervixlengte meting | ||
Regel 398: | Regel 398: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Cervixlengte waarde | |colspan="2"|Cervixlengte waarde | ||
− | |style="background-color: white;"|31 | + | |style="background-color: white;"|31 mm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Cervixlengte datum begin tijd | |colspan="2"|Cervixlengte datum begin tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 570 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Navelstreng observatie | |colspan="4"|Navelstreng observatie | ||
Regel 411: | Regel 411: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Navelstreng datum tijd | |colspan="2"|Navelstreng datum tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 570 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Navelstreng waarde | |colspan="2"|Navelstreng waarde | ||
− | |style="background-color: white;"|1 | + | |style="background-color: white;"|Geen bijzonderheden (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.55') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Navelstreng vaten waarde | |colspan="2"|Navelstreng vaten waarde | ||
− | |style="background-color: white;"|1 | + | |style="background-color: white;"|drie bloedvaten in navelstreng (bevinding) (code = '29691000146104' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Observatie methode | |colspan="2"|Observatie methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Orgaansysteem foetus observatie | |colspan="4"|Orgaansysteem foetus observatie | ||
Regel 427: | Regel 427: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Orgaansysteem foetus datum tijd | |colspan="2"|Orgaansysteem foetus datum tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 570 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Observatie naam | |colspan="2"|Observatie naam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|structuur van wervelkolom (lichaamsstructuur)+structuur van medulla spinalis (lichaamsstructuur) (code = '421060004+2748008' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Orgaansysteem foetus waarde | |colspan="2"|Orgaansysteem foetus waarde | ||
− | |style="background-color: white;"|2 | + | |style="background-color: white;"|Verdenking afwijking (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.55') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Observatie methode | |colspan="2"|Observatie methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Probleem wervelkolom ruggemerg | |colspan="4"|Probleem wervelkolom ruggemerg | ||
Regel 443: | Regel 443: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Probleem type | |colspan="2"|Probleem type | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Klinische bevinding (code = '404684003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Probleem naam | |colspan="2"|Probleem naam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|spina bifida occulta (aandoening) (code = '76916001' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Probleem begin datum | |colspan="2"|Probleem begin datum | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 570 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Probleem status | |colspan="2"|Probleem status | ||
− | |style="background-color: white;"|1 | + | |style="background-color: white;"|Actueel (code = '55561003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Verificatie status | |colspan="2"|Verificatie status | ||
− | |style="background-color: white;"|1 | + | |style="background-color: white;"|Werk (code = '415684004' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Sonomarkers observatie | |colspan="4"|Sonomarkers observatie | ||
Regel 462: | Regel 462: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Observatie datum tijd | |colspan="2"|Observatie datum tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 570 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Sonomarker naam | |colspan="2"|Sonomarker naam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echogeniciteit van foetale darmen bij obstetrische echografie (bevinding) (code = '698598000' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Sonomarker waarde | |colspan="2"|Sonomarker waarde | ||
− | |style="background-color: white;"|1 | + | |style="background-color: white;"|Geen sonomarker geconstateerd (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.54') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Observatie methode | |colspan="2"|Observatie methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Tekst uitslag | |colspan="5"|Tekst uitslag | ||
Regel 478: | Regel 478: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Tekst uitslag datum tijd | |colspan="3"|Tekst uitslag datum tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 570 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Verrichting | |colspan="4"|Verrichting | ||
Regel 485: | Regel 485: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Verrichting onderzoek | |colspan="2"|Verrichting onderzoek | ||
− | |style="background-color: white;"|ttseo | + | |style="background-color: white;"|Zie [[#ttseo|Verrichting onderzoek: ttseo]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Tekst uitslag status | |colspan="3"|Tekst uitslag status | ||
− | |style="background-color: white;"|3 | + | |style="background-color: white;"|Definitief (code = 'final' in codeSystem '<span title="2.16.840.1.113883.2.4.3.11.60.40.4.16.1">ZIB Laboratoriumuitslag Testuitslag ResultaatStatus</span>') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Tekst uitslag type | |colspan="3"|Tekst uitslag type | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografie (code = '16310003' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') |
|}<section end=medisch_onderzoek_ /> | |}<section end=medisch_onderzoek_ /> | ||
− | ==Scenario | + | ==Scenario Echo casus 2== |
<section begin= /><section end= /> | <section begin= /><section end= /> | ||
=== Administratief === | === Administratief === | ||
Regel 504: | Regel 504: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|<span id=" | + | |colspan="6"|Betaler |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="11"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Verzekeraar | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="9"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Verzekering | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="4"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Begin datum tijd | ||
+ | |style="background-color: white;"|T - 119 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Eind datum tijd | ||
+ | |style="background-color: white;"|T + 246 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Verzekeringssoort | ||
+ | |style="background-color: white;"|Basis (code = 'B' in codeSystem '<span title="2.16.840.1.113883.2.4.3.11.60.101.5.1">ZIB Verzekeringssoort</span>') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Identificatie nummer | ||
+ | |style="background-color: white;"|1235 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Organisatie naam | ||
+ | |style="background-color: white;"|NN | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="3"|Verzekerde nummer | ||
+ | |style="background-color: white;"|123456 | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="6"|<span id="Leonie" title="Intern ID = Leonie">Patient Leonie</span> | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="30"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Naamgegevens | |colspan="5"|Naamgegevens | ||
Regel 513: | Regel 543: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Voornamen | |colspan="3"|Voornamen | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Leonie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Initialen | |colspan="3"|Initialen | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|L |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Naamgebruik | |colspan="3"|Naamgebruik | ||
Regel 526: | Regel 556: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Achternaam | |colspan="2"|Achternaam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|XXX_Osse |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Adresgegevens | |colspan="5"|Adresgegevens | ||
Regel 536: | Regel 566: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Huisnummer | |colspan="3"|Huisnummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1000 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Postcode | |colspan="3"|Postcode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|9999XA |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Woonplaats | |colspan="3"|Woonplaats | ||
Regel 548: | Regel 578: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Adres soort | |colspan="3"|Adres soort | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Woon-/verblijfadres (code = 'PHYS' in codeSystem '<span title="2.16.840.1.113883.5.1119">HL7 AddressUse</span>') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Contactgegevens | |colspan="5"|Contactgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="9"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Telefoonnummers | |colspan="4"|Telefoonnummers | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="3"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Telefoonnummer | |colspan="2"|Telefoonnummer | ||
− | |style="background-color: white;"|06- | + | |style="background-color: white;"|06-12345678 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Telecom type | |colspan="2"|Telecom type | ||
|style="background-color: white;"|Mobiel telefoonnummer (code = 'MC' in codeSystem '<span title="2.16.840.1.113883.5.1119">HL7 AddressUse</span>') | |style="background-color: white;"|Mobiel telefoonnummer (code = 'MC' in codeSystem '<span title="2.16.840.1.113883.5.1119">HL7 AddressUse</span>') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Email adressen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Email adres |
− | |style="background-color: white;"| | + | |style="background-color: white;"|l.osse@test.nl |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Email soort | ||
+ | |style="background-color: white;"|Privé e-mailadres (code = 'HP' in codeSystem '<span title="2.16.840.1.113883.5.1119">HL7 AddressUse</span>') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Identificatienummer | |colspan="4"|Identificatienummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|999901710 (in identificerend systeem: BSN) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geboortedatum | |colspan="4"|Geboortedatum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|13 jun 1998 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geslacht administratief | |colspan="4"|Geslacht administratief | ||
|style="background-color: white;"|Vrouw (code = 'F' in codeSystem '<span title="2.16.840.1.113883.5.1">HL7 AdministrativeGender</span>') | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem '<span title="2.16.840.1.113883.5.1">HL7 AdministrativeGender</span>') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|<span id=" | + | |colspan="6"|<span id="EchoGroei" title="Intern ID = EchoGroei">Zorgaanbieder EchoGroei</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
Regel 587: | Regel 624: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Afdeling specialisme | |colspan="4"|Afdeling specialisme | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Echoscopie (code = '9018' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|<span id=" | + | |colspan="6"|<span id="HelmaGroot" title="Intern ID = HelmaGroot">Zorgverlener HelmaGroot</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="10"| | |rowspan="10"| | ||
Regel 630: | Regel 667: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Begin datum | |colspan="2"|Begin datum | ||
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|T - 164 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Status zorgepisode | |colspan="2"|Status zorgepisode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Actief (code = 'active' in codeSystem '2.16.840.1.113883.4.642.1.649') |
|}<section end=zorgverlening_ /> | |}<section end=zorgverlening_ /> | ||
=== Zwangerschapsgegevens === | === Zwangerschapsgegevens === | ||
Regel 649: | Regel 686: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Pariteit | |colspan="3"|Pariteit | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Graviditeit | |colspan="3"|Graviditeit | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|2 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Aterme datum items | |colspan="4"|Aterme datum items | ||
Regel 659: | Regel 696: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Aterme datum | |colspan="2"|Aterme datum | ||
− | |style="background-color: white;"|T + | + | |style="background-color: white;"|T + 42 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Bepalings methode | |colspan="2"|Bepalings methode | ||
Regel 665: | Regel 702: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Datum bepaling | |colspan="2"|Datum bepaling | ||
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|T - 207 dagen |
|}<section end=zwangerschapsgegevens_ /> | |}<section end=zwangerschapsgegevens_ /> | ||
=== Medisch onderzoek === | === Medisch onderzoek === | ||
Regel 681: | Regel 718: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verrichting start datum | |colspan="5"|Verrichting start datum | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T-3D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verrichting type | |colspan="5"|Verrichting type | ||
− | |style="background-color: white;"|echografie | + | |style="background-color: white;"|echografie voor foetale presentatie (verrichting) (code = '169228004' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Locatie | |colspan="6"|Locatie | ||
Regel 691: | Regel 728: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorgaanbieder | |colspan="4"|Zorgaanbieder | ||
− | |style="background-color: white;"|Zie [[# | + | |style="background-color: white;"|Zie [[#EchoGroei|Zorgaanbieder: EchoGroei]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Uitvoerder | |colspan="6"|Uitvoerder | ||
Regel 698: | Regel 735: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorgverlener | |colspan="4"|Zorgverlener | ||
− | |style="background-color: white;"|Zie [[# | + | |style="background-color: white;"|Zie [[#HelmaGroot|Zorgverlener: HelmaGroot]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Foetusspecifieke onderzoeksgegevens | |colspan="7"|Foetusspecifieke onderzoeksgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="53"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Echoscopie | |colspan="6"|Echoscopie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="51"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Biometrie | |colspan="5"|Biometrie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="26"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Foetale buikomtrek ac meting | |colspan="4"|Foetale buikomtrek ac meting | ||
Regel 717: | Regel 754: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Acwaarde | |colspan="2"|Acwaarde | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|283 mm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Acdatum begin tijd | |colspan="2"|Acdatum begin tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 3 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Foetale schedelomvang | |colspan="4"|Foetale schedelomvang | ||
Regel 730: | Regel 767: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Schedelomvang meetmethode | |colspan="2"|Schedelomvang meetmethode | ||
− | |style="background-color: white;"|2 | + | |style="background-color: white;"|Meten van schedelomvang m.b.v. echografisch onderzoek (code = '31561000146107' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Schedelomvang waarde | |colspan="2"|Schedelomvang waarde | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|314 mm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Schedelomvang datum tijd | |colspan="2"|Schedelomvang datum tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 3 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Foetale femurlengte fl meting | |colspan="4"|Foetale femurlengte fl meting | ||
Regel 743: | Regel 780: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Flwaarde | |colspan="2"|Flwaarde | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|57 mm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Fldatum begin tijd | |colspan="2"|Fldatum begin tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 3 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Foetale biparietale diameter bpd meting | |colspan="4"|Foetale biparietale diameter bpd meting | ||
Regel 756: | Regel 793: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Bpdwaarde | |colspan="2"|Bpdwaarde | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|88 mm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Bpddatum begin tijd | |colspan="2"|Bpddatum begin tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 3 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Foetaal geschat gewicht efw meting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Efwwaarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2450 mm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Efwdatum begin tijd | ||
+ | |style="background-color: white;"|T - 3 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="5"|Bevindingen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="22"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Foetale hartslag hartfrequentie | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Hartfrequentie datum tijd | ||
+ | |style="background-color: white;"|T - 3 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Hartfrequentie waarde | ||
+ | |style="background-color: white;"|140 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Hartslag meet methode |
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|Echo (code = '408808009' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') |
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Hartslag regelmatigheid | ||
+ | |style="background-color: white;"|regelmatig hartritme van foetus (bevinding) (code = '289443009' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Ligging foetus meting | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |rowspan="3"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Ligging foetus waarde | ||
+ | |style="background-color: white;"|stuit (code = '6096002' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Meet datum begin tijd | ||
+ | |style="background-color: white;"|T - 3 dagen | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Beweging foetus observatie |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Beweging foetus datum tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 3 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Beweging foetus waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|zwakke foetale bewegingen (bevinding) (code = '276372004' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Observatie methode |
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="4"|Vruchtwater meting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |colspan="2"|Meet datum tijd |
+ | |style="background-color: white;"|T - 3 dagen | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="2"|Hoeveelheid vruchtwater waarde | ||
+ | |style="background-color: white;"|normaal vruchtwatervolume (bevinding) (code = '278092006' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Vruchtwatercompartiment waarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|Geen bijzonderheden (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.55') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Meet methode |
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|}<section end=medisch_onderzoek_ /> | |}<section end=medisch_onderzoek_ /> | ||
− | ==Scenario | + | ==Scenario Echo casus 3== |
<section begin= /><section end= /> | <section begin= /><section end= /> | ||
=== Administratief === | === Administratief === | ||
Regel 815: | Regel 884: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"| | + | |colspan="6"|<span id="Merthe" title="Intern ID = Merthe">Patient Merthe</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="27"| |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Naamgegevens | |colspan="5"|Naamgegevens | ||
Regel 854: | Regel 893: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Voornamen | |colspan="3"|Voornamen | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Merthe |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Initialen | |colspan="3"|Initialen | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|M |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Naamgebruik | |colspan="3"|Naamgebruik | ||
Regel 867: | Regel 906: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Achternaam | |colspan="2"|Achternaam | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|XXX_Kooijman |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Adresgegevens | |colspan="5"|Adresgegevens | ||
Regel 877: | Regel 916: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Huisnummer | |colspan="3"|Huisnummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1002 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Postcode | |colspan="3"|Postcode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|9999ZZ |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Woonplaats | |colspan="3"|Woonplaats | ||
Regel 889: | Regel 928: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Adres soort | |colspan="3"|Adres soort | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Tijdelijk adres (code = 'TMP' in codeSystem '<span title="2.16.840.1.113883.5.1119">HL7 AddressUse</span>') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Contactgegevens | |colspan="5"|Contactgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="6"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Telefoonnummers | |colspan="4"|Telefoonnummers | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="4"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Telefoonnummer | |colspan="2"|Telefoonnummer | ||
− | |style="background-color: white;"|06- | + | |style="background-color: white;"|06-87654321 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Telecom type | |colspan="2"|Telecom type | ||
|style="background-color: white;"|Mobiel telefoonnummer (code = 'MC' in codeSystem '<span title="2.16.840.1.113883.5.1119">HL7 AddressUse</span>') | |style="background-color: white;"|Mobiel telefoonnummer (code = 'MC' in codeSystem '<span title="2.16.840.1.113883.5.1119">HL7 AddressUse</span>') | ||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="2"|Nummer soort | |
− | + | |style="background-color: white;"|Telefoonnummer thuis (code = 'HP' in codeSystem '<span title="2.16.840.1.113883.5.1119">HL7 AddressUse</span>') | |
− | |||
− | |||
− | |||
− | |colspan="2"| | ||
− | |style="background-color: white;"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Identificatienummer | |colspan="4"|Identificatienummer | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|999901734 (in identificerend systeem: BSN) |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geboortedatum | |colspan="4"|Geboortedatum | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|2 apr 2001 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Geslacht administratief | |colspan="4"|Geslacht administratief | ||
|style="background-color: white;"|Vrouw (code = 'F' in codeSystem '<span title="2.16.840.1.113883.5.1">HL7 AdministrativeGender</span>') | |style="background-color: white;"|Vrouw (code = 'F' in codeSystem '<span title="2.16.840.1.113883.5.1">HL7 AdministrativeGender</span>') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|<span id=" | + | |colspan="6"|<span id="PraktijkGroei" title="Intern ID = PraktijkGroei">Zorgaanbieder PraktijkGroei</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
Regel 935: | Regel 967: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Afdeling specialisme | |colspan="4"|Afdeling specialisme | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Echoscopie (code = '9018' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="6"|<span id=" | + | |colspan="6"|<span id="HelmaH" title="Intern ID = HelmaH">Zorgverlener HelmaH</span> |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="10"| | |rowspan="10"| | ||
Regel 978: | Regel 1.010: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Begin datum | |colspan="2"|Begin datum | ||
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|T - 13 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Status zorgepisode | |colspan="2"|Status zorgepisode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|Actief (code = 'active' in codeSystem '2.16.840.1.113883.4.642.1.649') |
|}<section end=zorgverlening_ /> | |}<section end=zorgverlening_ /> | ||
=== Zwangerschapsgegevens === | === Zwangerschapsgegevens === | ||
Regel 997: | Regel 1.029: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Pariteit | |colspan="3"|Pariteit | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|0 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="3"|Graviditeit | |colspan="3"|Graviditeit | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Aterme datum items | |colspan="4"|Aterme datum items | ||
Regel 1.007: | Regel 1.039: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Aterme datum | |colspan="2"|Aterme datum | ||
− | |style="background-color: white;"|T + | + | |style="background-color: white;"|T + 149 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Bepalings methode | |colspan="2"|Bepalings methode | ||
Regel 1.013: | Regel 1.045: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Datum bepaling | |colspan="2"|Datum bepaling | ||
− | |style="background-color: white;"|T - | + | |style="background-color: white;"|T - 13 dagen |
|}<section end=zwangerschapsgegevens_ /> | |}<section end=zwangerschapsgegevens_ /> | ||
=== Medisch onderzoek === | === Medisch onderzoek === | ||
Regel 1.029: | Regel 1.061: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verrichting start datum | |colspan="5"|Verrichting start datum | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T-13D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Verrichting type | |colspan="5"|Verrichting type | ||
− | |style="background-color: white;"|echografie | + | |style="background-color: white;"|echografie ter bepaling van geschatte datum van partus (verrichting) (code = '133601000146101' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Locatie | |colspan="6"|Locatie | ||
Regel 1.039: | Regel 1.071: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorgaanbieder | |colspan="4"|Zorgaanbieder | ||
− | |style="background-color: white;"|Zie [[# | + | |style="background-color: white;"|Zie [[#PraktijkGroei|Zorgaanbieder: PraktijkGroei]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Uitvoerder | |colspan="6"|Uitvoerder | ||
Regel 1.046: | Regel 1.078: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Zorgverlener | |colspan="4"|Zorgverlener | ||
− | |style="background-color: white;"|Zie [[# | + | |style="background-color: white;"|Zie [[#HelmaH|Zorgverlener: HelmaH]] |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="7"|Foetusspecifieke onderzoeksgegevens | |colspan="7"|Foetusspecifieke onderzoeksgegevens | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="41"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="6"|Echoscopie | |colspan="6"|Echoscopie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="39"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Biometrie | |colspan="5"|Biometrie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |rowspan=" | + | |rowspan="31"| |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Foetale buikomtrek ac meting | |colspan="4"|Foetale buikomtrek ac meting | ||
Regel 1.065: | Regel 1.097: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Acwaarde | |colspan="2"|Acwaarde | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|49 mm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Acdatum begin tijd | |colspan="2"|Acdatum begin tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 13 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Foetale schedelomvang | |colspan="4"|Foetale schedelomvang | ||
Regel 1.078: | Regel 1.110: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Schedelomvang meetmethode | |colspan="2"|Schedelomvang meetmethode | ||
− | |style="background-color: white;"|2 | + | |style="background-color: white;"|Meten van schedelomvang m.b.v. echografisch onderzoek (code = '31561000146107' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Schedelomvang waarde | |colspan="2"|Schedelomvang waarde | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|74 mm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Schedelomvang datum tijd | |colspan="2"|Schedelomvang datum tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 13 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Foetale femurlengte fl meting | |colspan="4"|Foetale femurlengte fl meting | ||
Regel 1.091: | Regel 1.123: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Flwaarde | |colspan="2"|Flwaarde | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|7 mm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Fldatum begin tijd | |colspan="2"|Fldatum begin tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 13 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Foetale biparietale diameter bpd meting | |colspan="4"|Foetale biparietale diameter bpd meting | ||
Regel 1.104: | Regel 1.136: | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Bpdwaarde | |colspan="2"|Bpdwaarde | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|17 mm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Bpddatum begin tijd | |colspan="2"|Bpddatum begin tijd | ||
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 13 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="4"| | + | |colspan="4"|Foetale kruin romp lengte crl meting |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Crlwaarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|55 mm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Crldatum begin tijd |
− | |style="background-color: white;"|T- | + | |style="background-color: white;"|T - 13 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | + | |colspan="4"|Foetale nekplooidikte nt meting | |
− | |||
− | |||
− | |||
− | |colspan="4"|Foetale | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Ntwaarde |
− | |style="background-color: white;"| | + | |style="background-color: white;"|2.9 mm |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Meet methode |
− | |style="background-color: white;"| | + | |style="background-color: white;"|echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Ntdatum begin tijd |
− | |style="background-color: white;"| | + | |style="background-color: white;"|T - 13 dagen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan=" | + | |colspan="5"|Bevindingen |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="5"| | |rowspan="5"| | ||
+ | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
+ | |colspan="4"|Sonomarkers observatie | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | | | + | |rowspan="3"| |
− | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Sonomarker naam |
− | |style="background-color: white;"|1 | + | |style="background-color: white;"|verdikte nekplooi van foetus (bevinding) (code = '459053006' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
− | |colspan="2"| | + | |colspan="2"|Sonomarker waarde |
− | |style="background-color: white;"|1 | + | |style="background-color: white;"|Geen sonomarker geconstateerd (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.54') |
− | |||
− | |||
− | |||
|}<section end=medisch_onderzoek_ /> | |}<section end=medisch_onderzoek_ /> |
Huidige versie van 18 nov 2024 om 16:49
Inhoud
1 Addenda voor inhoudelijke gegevens Integrale zwangerschapskaart 3.2
1.1 Scenario Echo casus 1
1.1.1 Administratief
Administratief | |||||
Gegevenselement | Waarde | ||||
Patient | |||||
Naamgegevens | |||||
Voornamen | Leonie | ||||
Initialen | L | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem 'ZIB Naamgebruik') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Osse | ||||
Adresgegevens | |||||
Straat | Knolweg | ||||
Huisnummer | 1000 | ||||
Postcode | 9999XA | ||||
Woonplaats | STITSWERD | ||||
Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||||
Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | ||||
Contactgegevens | |||||
Telefoonnummers | |||||
Telefoonnummer | 06-12345678 | ||||
Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
Email adressen | |||||
Email adres | l.osse@test.nl | ||||
Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Identificatienummer | 999901710 (in identificerend systeem: BSN) | ||||
Geboortedatum | 13 jun 1998 | ||||
Geslacht administratief | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
Zorgaanbieder EchopraktijkGroei | |||||
Zorgaanbieder identificatienummer | 90012345 (in identificerend systeem: AGB-Z) | ||||
Organisatie naam | Echopraktijk Groei | ||||
Afdeling specialisme | Echoscopie (code = '9018' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | ||||
Zorgverlener HelmaGrootkaart8 | |||||
Zorgverlener identificatienummer | 8452962 (in identificerend systeem: UZI Personen) | ||||
Naamgegevens | |||||
Voornamen | Helma | ||||
Initialen | H | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem 'ZIB Naamgebruik') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Groot |
1.1.2 Zorgverlening
Zorgverlening | ||||
Gegevenselement | Waarde | |||
Zorg episode | ||||
Begin datum | T - 705 dagen | |||
Eind datum | T - 509 dagen | |||
Zorg episode verantwoordelijke | ||||
Zorgverlener | Zie Zorgverlener: HelmaGrootkaart8 | |||
Status zorgepisode | Afgesloten (code = 'finished' in codeSystem '2.16.840.1.113883.4.642.1.649') |
1.1.3 Zwangerschapsgegevens
Zwangerschapsgegevens | ||||
Gegevenselement | Waarde | |||
Zwangerschap | ||||
Pariteit | 0 | |||
Graviditeit | 1 | |||
Aterme datum items | ||||
Aterme datum | T - 509 dagen | |||
Bepalings methode | aterme datum berekend door middel van diagnostische ultrasonografie (code = '31541000146106' in codeSystem 'SNOMED CT') | |||
Datum bepaling | T - 649 dagen |
1.1.4 Medisch onderzoek
Medisch onderzoek | ||||||
Gegevenselement | Waarde | |||||
Verrichting onderzoek ttseo | ||||||
Verrichting start datum | T-570D | |||||
Verrichting type | structureel echoscopisch onderzoek tijdens tweede trimester (verrichting) (code = '143701000146108' in codeSystem 'SNOMED CT') | |||||
Locatie | ||||||
Zorgaanbieder | Zie Zorgaanbieder: EchopraktijkGroei | |||||
Uitvoerder | ||||||
Zorgverlener | Zie Zorgverlener: HelmaGrootkaart8 | |||||
Foetusspecifieke onderzoeksgegevens | ||||||
Echoscopie | ||||||
Echografiche bevindingen algemeen observatie | ||||||
Observatie methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Conclusie waarde | Verdenking afwijking (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.56') | |||||
Verdenking afwijkingobv waarde | Afwijking sonomarker (code = '4' in codeSystem '2.16.840.1.113883.2.4.3.22.1.2.200') | |||||
Advies waarde | Verwijzing GUO2 (code = '4' in codeSystem '2.16.840.1.113883.2.4.4.13.57') | |||||
Biometrie | ||||||
Foetale buikomtrek ac meting | ||||||
Acwaarde | 151 mm | |||||
Meet methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Acdatum begin tijd | T - 570 dagen | |||||
Foetale schedelomvang | ||||||
Schedelomvang meetmethode | Meten van schedelomvang m.b.v. echografisch onderzoek (code = '31561000146107' in codeSystem 'SNOMED CT') | |||||
Schedelomvang waarde | 168 mm | |||||
Schedelomvang datum tijd | T - 570 dagen | |||||
Foetale femurlengte fl meting | ||||||
Flwaarde | 31 mm | |||||
Meet methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Fldatum begin tijd | T - 570 dagen | |||||
Foetale biparietale diameter bpd meting | ||||||
Bpdwaarde | 49 mm | |||||
Meet methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Bpddatum begin tijd | T - 570 dagen | |||||
Foetaal longitudinale blaas diameter lbd meting | ||||||
Lbdwaarde | 52 mm | |||||
Meet methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Lbddatum begin tijd | T - 570 dagen | |||||
Foetale transcerebellar diameter tcd meting | ||||||
Tcdwaarde | 21 mm | |||||
Meet methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Tcddatum begin tijd | T - 570 dagen | |||||
Foetaal geschat gewicht efw meting | ||||||
Efwwaarde | 320 mm | |||||
Meet methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Efwdatum begin tijd | T - 570 dagen | |||||
Bevindingen | ||||||
Beweging foetus observatie | ||||||
Beweging foetus datum tijd | T - 570 dagen | |||||
Beweging foetus waarde | foetale bewegingen aanwezig (bevinding) (code = '289431008' in codeSystem 'SNOMED CT') | |||||
Observatie methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Vruchtwater meting | ||||||
Meet datum tijd | T - 570 dagen | |||||
Hoeveelheid vruchtwater waarde | normaal vruchtwatervolume (bevinding) (code = '278092006' in codeSystem 'SNOMED CT') | |||||
Vruchtwatercompartiment waarde | Geen bijzonderheden (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.55') | |||||
Meet methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Placenta lokalisatie observatie | ||||||
Placenta lokalisatie datum tijd | T - 570 dagen | |||||
Placentalokalisatie waarde | rechts laterale positie van placenta (bevinding) (code = '7401000146107' in codeSystem 'SNOMED CT') | |||||
Observatie methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Cervixlengte meting | ||||||
Cervixlengte waarde | 31 mm | |||||
Meet methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Cervixlengte datum begin tijd | T - 570 dagen | |||||
Navelstreng observatie | ||||||
Navelstreng datum tijd | T - 570 dagen | |||||
Navelstreng waarde | Geen bijzonderheden (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.55') | |||||
Navelstreng vaten waarde | drie bloedvaten in navelstreng (bevinding) (code = '29691000146104' in codeSystem 'SNOMED CT') | |||||
Observatie methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Orgaansysteem foetus observatie | ||||||
Orgaansysteem foetus datum tijd | T - 570 dagen | |||||
Observatie naam | structuur van wervelkolom (lichaamsstructuur)+structuur van medulla spinalis (lichaamsstructuur) (code = '421060004+2748008' in codeSystem 'SNOMED CT') | |||||
Orgaansysteem foetus waarde | Verdenking afwijking (code = '2' in codeSystem '2.16.840.1.113883.2.4.4.13.55') | |||||
Observatie methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Probleem wervelkolom ruggemerg | ||||||
Probleem type | Klinische bevinding (code = '404684003' in codeSystem 'SNOMED CT') | |||||
Probleem naam | spina bifida occulta (aandoening) (code = '76916001' in codeSystem 'SNOMED CT') | |||||
Probleem begin datum | T - 570 dagen | |||||
Probleem status | Actueel (code = '55561003' in codeSystem 'SNOMED CT') | |||||
Verificatie status | Werk (code = '415684004' in codeSystem 'SNOMED CT') | |||||
Sonomarkers observatie | ||||||
Observatie datum tijd | T - 570 dagen | |||||
Sonomarker naam | echogeniciteit van foetale darmen bij obstetrische echografie (bevinding) (code = '698598000' in codeSystem 'SNOMED CT') | |||||
Sonomarker waarde | Geen sonomarker geconstateerd (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.54') | |||||
Observatie methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Tekst uitslag | ||||||
Tekst uitslag datum tijd | T - 570 dagen | |||||
Verrichting | ||||||
Verrichting onderzoek | Zie Verrichting onderzoek: ttseo | |||||
Tekst uitslag status | Definitief (code = 'final' in codeSystem 'ZIB Laboratoriumuitslag Testuitslag ResultaatStatus') | |||||
Tekst uitslag type | echografie (code = '16310003' in codeSystem 'SNOMED CT') |
1.2 Scenario Echo casus 2
1.2.1 Administratief
Administratief | |||||
Gegevenselement | Waarde | ||||
Betaler | |||||
Verzekeraar | |||||
Verzekering | |||||
Begin datum tijd | T - 119 dagen | ||||
Eind datum tijd | T + 246 dagen | ||||
Verzekeringssoort | Basis (code = 'B' in codeSystem 'ZIB Verzekeringssoort') | ||||
Identificatie nummer | 1235 | ||||
Organisatie naam | NN | ||||
Verzekerde nummer | 123456 | ||||
Patient Leonie | |||||
Naamgegevens | |||||
Voornamen | Leonie | ||||
Initialen | L | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem 'ZIB Naamgebruik') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Osse | ||||
Adresgegevens | |||||
Straat | Knolweg | ||||
Huisnummer | 1000 | ||||
Postcode | 9999XA | ||||
Woonplaats | STITSWERD | ||||
Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||||
Adres soort | Woon-/verblijfadres (code = 'PHYS' in codeSystem 'HL7 AddressUse') | ||||
Contactgegevens | |||||
Telefoonnummers | |||||
Telefoonnummer | 06-12345678 | ||||
Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
Email adressen | |||||
Email adres | l.osse@test.nl | ||||
Email soort | Privé e-mailadres (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Identificatienummer | 999901710 (in identificerend systeem: BSN) | ||||
Geboortedatum | 13 jun 1998 | ||||
Geslacht administratief | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
Zorgaanbieder EchoGroei | |||||
Zorgaanbieder identificatienummer | 90012345 (in identificerend systeem: AGB-Z) | ||||
Organisatie naam | Echopraktijk Groei | ||||
Afdeling specialisme | Echoscopie (code = '9018' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | ||||
Zorgverlener HelmaGroot | |||||
Zorgverlener identificatienummer | 654321 (in identificerend systeem: UZI Personen) | ||||
Naamgegevens | |||||
Voornamen | Helma | ||||
Initialen | H | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem 'ZIB Naamgebruik') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Groot |
1.2.2 Zorgverlening
Zorgverlening | |||
Gegevenselement | Waarde | ||
Zorg episode | |||
Begin datum | T - 164 dagen | ||
Status zorgepisode | Actief (code = 'active' in codeSystem '2.16.840.1.113883.4.642.1.649') |
1.2.3 Zwangerschapsgegevens
Zwangerschapsgegevens | ||||
Gegevenselement | Waarde | |||
Zwangerschap | ||||
Pariteit | 1 | |||
Graviditeit | 2 | |||
Aterme datum items | ||||
Aterme datum | T + 42 dagen | |||
Bepalings methode | aterme datum berekend door middel van diagnostische ultrasonografie (code = '31541000146106' in codeSystem 'SNOMED CT') | |||
Datum bepaling | T - 207 dagen |
1.2.4 Medisch onderzoek
Medisch onderzoek | ||||||
Gegevenselement | Waarde | |||||
Verrichting onderzoek | ||||||
Verrichting start datum | T-3D | |||||
Verrichting type | echografie voor foetale presentatie (verrichting) (code = '169228004' in codeSystem 'SNOMED CT') | |||||
Locatie | ||||||
Zorgaanbieder | Zie Zorgaanbieder: EchoGroei | |||||
Uitvoerder | ||||||
Zorgverlener | Zie Zorgverlener: HelmaGroot | |||||
Foetusspecifieke onderzoeksgegevens | ||||||
Echoscopie | ||||||
Biometrie | ||||||
Foetale buikomtrek ac meting | ||||||
Acwaarde | 283 mm | |||||
Meet methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Acdatum begin tijd | T - 3 dagen | |||||
Foetale schedelomvang | ||||||
Schedelomvang meetmethode | Meten van schedelomvang m.b.v. echografisch onderzoek (code = '31561000146107' in codeSystem 'SNOMED CT') | |||||
Schedelomvang waarde | 314 mm | |||||
Schedelomvang datum tijd | T - 3 dagen | |||||
Foetale femurlengte fl meting | ||||||
Flwaarde | 57 mm | |||||
Meet methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Fldatum begin tijd | T - 3 dagen | |||||
Foetale biparietale diameter bpd meting | ||||||
Bpdwaarde | 88 mm | |||||
Meet methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Bpddatum begin tijd | T - 3 dagen | |||||
Foetaal geschat gewicht efw meting | ||||||
Efwwaarde | 2450 mm | |||||
Meet methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Efwdatum begin tijd | T - 3 dagen | |||||
Bevindingen | ||||||
Foetale hartslag hartfrequentie | ||||||
Hartfrequentie datum tijd | T - 3 dagen | |||||
Hartfrequentie waarde | 140 | |||||
Hartslag meet methode | Echo (code = '408808009' in codeSystem 'SNOMED CT') | |||||
Hartslag regelmatigheid | regelmatig hartritme van foetus (bevinding) (code = '289443009' in codeSystem 'SNOMED CT') | |||||
Ligging foetus meting | ||||||
Ligging foetus waarde | stuit (code = '6096002' in codeSystem 'SNOMED CT') | |||||
Meet datum begin tijd | T - 3 dagen | |||||
Beweging foetus observatie | ||||||
Beweging foetus datum tijd | T - 3 dagen | |||||
Beweging foetus waarde | zwakke foetale bewegingen (bevinding) (code = '276372004' in codeSystem 'SNOMED CT') | |||||
Observatie methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Vruchtwater meting | ||||||
Meet datum tijd | T - 3 dagen | |||||
Hoeveelheid vruchtwater waarde | normaal vruchtwatervolume (bevinding) (code = '278092006' in codeSystem 'SNOMED CT') | |||||
Vruchtwatercompartiment waarde | Geen bijzonderheden (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.55') | |||||
Meet methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') |
1.3 Scenario Echo casus 3
1.3.1 Administratief
Administratief | |||||
Gegevenselement | Waarde | ||||
Patient Merthe | |||||
Naamgegevens | |||||
Voornamen | Merthe | ||||
Initialen | M | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem 'ZIB Naamgebruik') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Kooijman | ||||
Adresgegevens | |||||
Straat | Knolweg | ||||
Huisnummer | 1002 | ||||
Postcode | 9999ZZ | ||||
Woonplaats | STITSWERD | ||||
Land | Nederland (code = 'NL' in codeSystem 'ISO 3166-1 (alpha-2)') | ||||
Adres soort | Tijdelijk adres (code = 'TMP' in codeSystem 'HL7 AddressUse') | ||||
Contactgegevens | |||||
Telefoonnummers | |||||
Telefoonnummer | 06-87654321 | ||||
Telecom type | Mobiel telefoonnummer (code = 'MC' in codeSystem 'HL7 AddressUse') | ||||
Nummer soort | Telefoonnummer thuis (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
Identificatienummer | 999901734 (in identificerend systeem: BSN) | ||||
Geboortedatum | 2 apr 2001 | ||||
Geslacht administratief | Vrouw (code = 'F' in codeSystem 'HL7 AdministrativeGender') | ||||
Zorgaanbieder PraktijkGroei | |||||
Zorgaanbieder identificatienummer | 90012345 (in identificerend systeem: AGB-Z) | ||||
Organisatie naam | Echopraktijk Groei | ||||
Afdeling specialisme | Echoscopie (code = '9018' in codeSystem 'COD016-VEKT Vektis Zorgverlenersspecificatie (subberoepsgroep)') | ||||
Zorgverlener HelmaH | |||||
Zorgverlener identificatienummer | 654321 (in identificerend systeem: UZI Personen) | ||||
Naamgegevens | |||||
Voornamen | Helma | ||||
Initialen | H | ||||
Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem 'ZIB Naamgebruik') | ||||
Geslachtsnaam | |||||
Achternaam | XXX_Groot |
1.3.2 Zorgverlening
Zorgverlening | |||
Gegevenselement | Waarde | ||
Zorg episode | |||
Begin datum | T - 13 dagen | ||
Status zorgepisode | Actief (code = 'active' in codeSystem '2.16.840.1.113883.4.642.1.649') |
1.3.3 Zwangerschapsgegevens
Zwangerschapsgegevens | ||||
Gegevenselement | Waarde | |||
Zwangerschap | ||||
Pariteit | 0 | |||
Graviditeit | 1 | |||
Aterme datum items | ||||
Aterme datum | T + 149 dagen | |||
Bepalings methode | aterme datum berekend door middel van diagnostische ultrasonografie (code = '31541000146106' in codeSystem 'SNOMED CT') | |||
Datum bepaling | T - 13 dagen |
1.3.4 Medisch onderzoek
Medisch onderzoek | ||||||
Gegevenselement | Waarde | |||||
Verrichting onderzoek | ||||||
Verrichting start datum | T-13D | |||||
Verrichting type | echografie ter bepaling van geschatte datum van partus (verrichting) (code = '133601000146101' in codeSystem 'SNOMED CT') | |||||
Locatie | ||||||
Zorgaanbieder | Zie Zorgaanbieder: PraktijkGroei | |||||
Uitvoerder | ||||||
Zorgverlener | Zie Zorgverlener: HelmaH | |||||
Foetusspecifieke onderzoeksgegevens | ||||||
Echoscopie | ||||||
Biometrie | ||||||
Foetale buikomtrek ac meting | ||||||
Acwaarde | 49 mm | |||||
Meet methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Acdatum begin tijd | T - 13 dagen | |||||
Foetale schedelomvang | ||||||
Schedelomvang meetmethode | Meten van schedelomvang m.b.v. echografisch onderzoek (code = '31561000146107' in codeSystem 'SNOMED CT') | |||||
Schedelomvang waarde | 74 mm | |||||
Schedelomvang datum tijd | T - 13 dagen | |||||
Foetale femurlengte fl meting | ||||||
Flwaarde | 7 mm | |||||
Meet methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Fldatum begin tijd | T - 13 dagen | |||||
Foetale biparietale diameter bpd meting | ||||||
Bpdwaarde | 17 mm | |||||
Meet methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Bpddatum begin tijd | T - 13 dagen | |||||
Foetale kruin romp lengte crl meting | ||||||
Crlwaarde | 55 mm | |||||
Meet methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Crldatum begin tijd | T - 13 dagen | |||||
Foetale nekplooidikte nt meting | ||||||
Ntwaarde | 2.9 mm | |||||
Meet methode | echografische beeldvorming (kwalificatiewaarde) (code = '278292003' in codeSystem 'SNOMED CT') | |||||
Ntdatum begin tijd | T - 13 dagen | |||||
Bevindingen | ||||||
Sonomarkers observatie | ||||||
Sonomarker naam | verdikte nekplooi van foetus (bevinding) (code = '459053006' in codeSystem 'SNOMED CT') | |||||
Sonomarker waarde | Geen sonomarker geconstateerd (code = '1' in codeSystem '2.16.840.1.113883.2.4.4.13.54') |