GZ: InhoudelijkeGegevens Integrale Zwangerschapskaart Echo: verschil tussen versies
(Inhoudelijke gegevens IZK Echo) |
(Volgorde kaarten aangepast) |
||
| Regel 461: | Regel 461: | ||
|style="background-color: white;"|4 | |style="background-color: white;"|4 | ||
|}<section end=medisch_onderzoek_ /> | |}<section end=medisch_onderzoek_ /> | ||
| − | ==Scenario | + | |
| + | ==Scenario Vrouw7-kaart9-Echo_gegevens== | ||
<section begin= /><section end= /> | <section begin= /><section end= /> | ||
=== Administratief === | === Administratief === | ||
| Regel 472: | Regel 473: | ||
|-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-119D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|Eind datum tijd | ||
| + | |style="background-color: white;"|T+246D | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|Verzekeringssoort | ||
| + | |style="background-color: white;"|1 | ||
| + | |-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;"|12346 | ||
| + | |-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 481: | Regel 512: | ||
|-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 494: | Regel 525: | ||
|-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 504: | Regel 535: | ||
|-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;"|1001 |
|-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 516: | Regel 547: | ||
|-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;"|Officieel adres (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="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;"|06-12345679 |
|-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;;" | ||
| + | |colspan="2"|Email adres | ||
| + | |style="background-color: white;"|l.osse@test.nl | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="2"| | + | |colspan="2"|Email soort |
| − | |style="background-color: white;"| | + | |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="3"| | |rowspan="3"| | ||
| Regel 554: | Regel 592: | ||
|style="background-color: white;"|457 | |style="background-color: white;"|457 | ||
|-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="14"| | |rowspan="14"| | ||
| Regel 594: | Regel 632: | ||
<section begin=zwangerschapsgegevens_ /> | <section begin=zwangerschapsgegevens_ /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="7" | Zwangerschapsgegevens |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| − | |colspan=" | + | |colspan="6" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="7"|Zwangerschap |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="8"| | |rowspan="8"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="5"|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=" | + | |colspan="5"|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=" | + | |colspan="6"|Aterme datum items |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="4"|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=" | + | |colspan="4"|Bepalings methode |
|style="background-color: white;"|aterme datum berekend door middel van diagnostische ultrasonografie (code = '31541000146106' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | |style="background-color: white;"|aterme datum berekend door middel van diagnostische ultrasonografie (code = '31541000146106' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="4"|Datum bepaling |
| − | |style="background-color: white;"|T - | + | |style="background-color: white;"|T - 207 dagen |
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="7"|Prenatale controle | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="16"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="6"|Uitwendig onderzoek | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="14"| | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Bevindingen foetus | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="12"| | ||
| + | |-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;;" | ||
| + | |colspan="4"|Foetale hartslag hartfrequentie | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="6"| | ||
| + | |-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;;" | ||
| + | |colspan="2"|Hartslag meet methode | ||
| + | |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="2"|Interpretatie frequentie | ||
| + | |style="background-color: white;"|normale basishartfrequentie van foetus (bevinding) (code = '278084002' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
|}<section end=zwangerschapsgegevens_ /> | |}<section end=zwangerschapsgegevens_ /> | ||
=== Medisch onderzoek === | === Medisch onderzoek === | ||
| Regel 637: | Regel 716: | ||
|-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 647: | Regel 726: | ||
|-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 654: | Regel 733: | ||
|-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="43"| |
|-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="41"| |
|-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 673: | Regel 752: | ||
|-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 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
| Regel 679: | Regel 758: | ||
|-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-3D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Foetale schedelomvang | |colspan="4"|Foetale schedelomvang | ||
| Regel 689: | Regel 768: | ||
|-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 |
|-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-3D |
|-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 699: | Regel 778: | ||
|-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 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
| Regel 705: | Regel 784: | ||
|-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-3D |
|-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 712: | Regel 791: | ||
|-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 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
| Regel 718: | Regel 797: | ||
|-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-3D |
|-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 |
|-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;"|6 | |style="background-color: white;"|6 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="2"| | + | |colspan="2"|Efwdatum begin tijd |
| − | |style="background-color: white;"|T- | + | |style="background-color: white;"|T-3D |
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="5"|Bevindingen | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |rowspan="12"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="4"| | + | |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;"|2 | + | |style="background-color: white;"|T-3D |
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|Beweging foetus waarde | ||
| + | |style="background-color: white;"|2 | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="2"| | + | |colspan="2"|Observatie methode |
|style="background-color: white;"|6 | |style="background-color: white;"|6 | ||
| − | |||
| − | |||
| − | |||
|-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-3D | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="2"| | + | |colspan="2"|Hoeveelheid vruchtwater waarde |
| − | |style="background-color: white;"| | + | |style="background-color: white;"|1 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan="2"| | + | |colspan="2"|Vruchtwatercompartiment waarde |
|style="background-color: white;"|1 | |style="background-color: white;"|1 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="2"|Meet methode | ||
| + | |style="background-color: white;"|6 | ||
|}<section end=medisch_onderzoek_ /> | |}<section end=medisch_onderzoek_ /> | ||
| − | ==Scenario | + | ==Scenario Vrouw8-kaart10-Echo_gegevens== |
<section begin= /><section end= /> | <section begin= /><section end= /> | ||
=== Administratief === | === Administratief === | ||
| Regel 771: | Regel 856: | ||
|-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"| |
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| − | |||
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="5"|Naamgegevens | |colspan="5"|Naamgegevens | ||
| Regel 810: | Regel 865: | ||
|-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 823: | Regel 878: | ||
|-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 833: | Regel 888: | ||
|-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 845: | Regel 900: | ||
|-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;"|Tijdelijk telefoonnummer (code = 'TMP' 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="3"| | |rowspan="3"| | ||
| Regel 890: | Regel 938: | ||
|style="background-color: white;"|457 | |style="background-color: white;"|457 | ||
|-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="14"| | |rowspan="14"| | ||
| Regel 930: | Regel 978: | ||
<section begin=zwangerschapsgegevens_ /> | <section begin=zwangerschapsgegevens_ /> | ||
{| class="wikitable" width="85%" | {| class="wikitable" width="85%" | ||
| − | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan=" | + | |style="background-color: #1F497D;; color: white; font-weight: bold; text-align:center;" colspan="5" | Zwangerschapsgegevens |
|-style="background-color: #1F497D;; color: white; text-align:left;" | |-style="background-color: #1F497D;; color: white; text-align:left;" | ||
| − | |colspan=" | + | |colspan="4" width="25%"| Gegevenselement |
|| Waarde | || Waarde | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="5"|Zwangerschap |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="8"| | |rowspan="8"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="3"|Pariteit |
| + | |style="background-color: white;"|0 | ||
| + | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| + | |colspan="3"|Graviditeit | ||
|style="background-color: white;"|1 | |style="background-color: white;"|1 | ||
| − | |||
| − | |||
| − | |||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="4"|Aterme datum items |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|rowspan="4"| | |rowspan="4"| | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="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=" | + | |colspan="2"|Bepalings methode |
|style="background-color: white;"|aterme datum berekend door middel van diagnostische ultrasonografie (code = '31541000146106' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | |style="background-color: white;"|aterme datum berekend door middel van diagnostische ultrasonografie (code = '31541000146106' in codeSystem '<span title="2.16.840.1.113883.6.96">SNOMED CT</span>') | ||
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="2"|Datum bepaling |
| − | |style="background-color: white;"|T - | + | |style="background-color: white;"|T - 13 dagen |
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|}<section end=zwangerschapsgegevens_ /> | |}<section end=zwangerschapsgegevens_ /> | ||
=== Medisch onderzoek === | === Medisch onderzoek === | ||
| Regel 1.014: | Regel 1.021: | ||
|-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 1.024: | Regel 1.031: | ||
|-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 1.031: | Regel 1.038: | ||
|-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 1.050: | Regel 1.057: | ||
|-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 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
| Regel 1.056: | Regel 1.063: | ||
|-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-13D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="4"|Foetale schedelomvang | |colspan="4"|Foetale schedelomvang | ||
| Regel 1.066: | Regel 1.073: | ||
|-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 |
|-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-13D |
|-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 1.076: | Regel 1.083: | ||
|-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 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
| Regel 1.082: | Regel 1.089: | ||
|-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-13D |
|-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 1.089: | Regel 1.096: | ||
|-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 |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
|colspan="2"|Meet methode | |colspan="2"|Meet methode | ||
| Regel 1.095: | Regel 1.102: | ||
|-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-13D |
|-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 |
|-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;"|6 | |style="background-color: white;"|6 | ||
|-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-13D |
|-style="vertical-align:top; background-color: #E3E3E3;;" | |-style="vertical-align:top; background-color: #E3E3E3;;" | ||
| − | |colspan=" | + | |colspan="4"|Foetale nekplooidikte nt 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"|Ntwaarde |
| − | |style="background-color: white;"| | + | |style="background-color: white;"|2.9 |
|-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;"|6 |
|-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-13D |
|-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;"| | + | |style="background-color: white;"|3 |
|-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;"|1 | ||
| − | |||
| − | |||
| − | |||
|}<section end=medisch_onderzoek_ /> | |}<section end=medisch_onderzoek_ /> | ||
Versie van 6 jun 2024 om 13:27
Inhoud
1 Addenda voor inhoudelijke gegevens Integrale zwangerschapskaart 3.2
1.1 Scenario Vrouw7-kaart8-Echo_gegevens
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 | SITSWERD | ||||
| Land | Nederland (code = '6030' in codeSystem 'GBA Tabel 34 Landen') | ||||
| Adres soort | Officieel adres (code = 'HP' 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 | |||||
| Organisatie naam | Echopraktijk Groei | ||||
| Afdeling specialisme | 457 | ||||
| Zorgverlener HelmaGrootkaart8 | |||||
| Zorgverlener identificatienummer | 654321 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.31.5.1) | ||||
| Naamgegevens | |||||
| Voornamen | Helma | ||||
| Initialen | H | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem 'ZIB Naamgebruik') | ||||
| Geslachtsnaam | |||||
| Achternaam | Groot | ||||
| Geslachtsnaam partner | |||||
| Voorvoegsels partner | de | ||||
| Achternaam partner | Vries | ||||
1.1.2 Zwangerschapsgegevens
| Zwangerschapsgegevens | |||
| Gegevenselement | Waarde | ||
| Zwangerschap | |||
| Pariteit | 0 | ||
| Graviditeit | 1 | ||
1.1.3 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 | 7 | |||||
| Conclusie waarde | 2 | |||||
| Verdenking afwijkingobv waarde | 4 | |||||
| Advies waarde | 5 | |||||
| Biometrie | ||||||
| Foetale buikomtrek ac meting | ||||||
| Acwaarde | 151 | |||||
| Meet methode | 6 | |||||
| Acdatum begin tijd | T-570D | |||||
| Foetale schedelomvang | ||||||
| Schedelomvang meetmethode | 2 | |||||
| Schedelomvang waarde | 168 | |||||
| Schedelomvang datum tijd | T-570D | |||||
| Foetale femurlengte fl meting | ||||||
| Flwaarde | 31 | |||||
| Meet methode | 6 | |||||
| Fldatum begin tijd | T-570D | |||||
| Foetale biparietale diameter bpd meting | ||||||
| Bpdwaarde | 49 | |||||
| Meet methode | 6 | |||||
| Bpddatum begin tijd | T-570D | |||||
| Foetaal longitudinale blaas diameter lbd meting | ||||||
| Lbdwaarde | 52 | |||||
| Meet methode | 6 | |||||
| Lbddatum begin tijd | T-570D | |||||
| Foetale transcerebellar diameter tcd meting | ||||||
| Tcdwaarde | 21 | |||||
| Meet methode | 6 | |||||
| Tcddatum begin tijd | T-570D | |||||
| Foetaal geschat gewicht efw meting | ||||||
| Efwwaarde | 320 | |||||
| Meet methode | 6 | |||||
| Efwdatum begin tijd | T-570D | |||||
| Bevindingen | ||||||
| Ligging foetus meting | ||||||
| Beweging foetus observatie | ||||||
| Beweging foetus datum tijd | T-570D | |||||
| Beweging foetus waarde | 1 | |||||
| Observatie methode | 6 | |||||
| Vruchtwater meting | ||||||
| Meet datum tijd | T-570D | |||||
| Hoeveelheid vruchtwater waarde | 1 | |||||
| Vruchtwatercompartiment waarde | 1 | |||||
| Meet methode | 6 | |||||
| Placenta lokalisatie observatie | ||||||
| Placenta lokalisatie datum tijd | T-570D | |||||
| Placentalokalisatie waarde | 1 | |||||
| Observatie methode | 6 | |||||
| Cervixlengte meting | ||||||
| Cervixlengte waarde | 31 | |||||
| Meet methode | 7 | |||||
| Cervixlengte datum begin tijd | T-570D | |||||
| Navelstreng observatie | ||||||
| Navelstreng datum tijd | T-570D | |||||
| Navelstreng waarde | 1 | |||||
| Navelstreng vaten waarde | 1 | |||||
| Observatie methode | 6 | |||||
| Orgaansysteem foetus observatie | ||||||
| Orgaansysteem foetus datum tijd | T-570D | |||||
| Observatie naam | 3 | |||||
| Orgaansysteem foetus waarde | 2 | |||||
| Observatie methode | 6 | |||||
| Probleem wervelkolom ruggemerg | ||||||
| Probleem type | 3 | |||||
| Probleem naam | 4 | |||||
| Probleem begin datum | T-570D | |||||
| Probleem status | 1 | |||||
| Verificatie status | 1 | |||||
| Sonomarkers observatie | ||||||
| Observatie datum tijd | T-570D | |||||
| Sonomarker naam | 4 | |||||
| Sonomarker waarde | 2 | |||||
| Observatie methode | 6 | |||||
| Tekst uitslag | ||||||
| Tekst uitslag datum tijd | T-570D | |||||
| Verrichting | ||||||
| Verrichting onderzoek | ttseo | |||||
| Tekst uitslag status | 3 | |||||
| Tekst uitslag type | 4 | |||||
1.2 Scenario Vrouw7-kaart9-Echo_gegevens
1.2.1 Administratief
| Administratief | |||||
| Gegevenselement | Waarde | ||||
| Betaler | |||||
| Verzekeraar | |||||
| Verzekering | |||||
| Begin datum tijd | T-119D | ||||
| Eind datum tijd | T+246D | ||||
| Verzekeringssoort | 1 | ||||
| Identificatie nummer | 1235 | ||||
| Organisatie naam | NN | ||||
| Verzekerde nummer | 12346 | ||||
| Patient Leonie | |||||
| Naamgegevens | |||||
| Voornamen | Leonie | ||||
| Initialen | L | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem 'ZIB Naamgebruik') | ||||
| Geslachtsnaam | |||||
| Achternaam | XXX_Osse | ||||
| Adresgegevens | |||||
| Straat | Knolweg | ||||
| Huisnummer | 1001 | ||||
| Postcode | 9999XA | ||||
| Woonplaats | STITSWERD | ||||
| Land | Nederland (code = '6030' in codeSystem 'GBA Tabel 34 Landen') | ||||
| Adres soort | Officieel adres (code = 'HP' in codeSystem 'HL7 AddressUse') | ||||
| Contactgegevens | |||||
| Telefoonnummers | |||||
| Telefoonnummer | 06-12345679 | ||||
| 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 | |||||
| Organisatie naam | Echopraktijk Groei | ||||
| Afdeling specialisme | 457 | ||||
| Zorgverlener HelmaGroot | |||||
| Zorgverlener identificatienummer | 654321 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.31.5.1) | ||||
| Naamgegevens | |||||
| Voornamen | Helma | ||||
| Initialen | H | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem 'ZIB Naamgebruik') | ||||
| Geslachtsnaam | |||||
| Achternaam | Groot | ||||
| Geslachtsnaam partner | |||||
| Voorvoegsels partner | de | ||||
| Achternaam partner | Vries | ||||
1.2.2 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 | |||||
| Prenatale controle | ||||||
| Uitwendig onderzoek | ||||||
| Bevindingen foetus | ||||||
| Ligging foetus meting | ||||||
| Ligging foetus waarde | stuit (code = '6096002' in codeSystem 'SNOMED CT') | |||||
| Meet datum begin tijd | T - 3 dagen | |||||
| 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') | |||||
| Interpretatie frequentie | normale basishartfrequentie van foetus (bevinding) (code = '278084002' in codeSystem 'SNOMED CT') | |||||
1.2.3 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 | |||||
| Meet methode | 6 | |||||
| Acdatum begin tijd | T-3D | |||||
| Foetale schedelomvang | ||||||
| Schedelomvang meetmethode | 2 | |||||
| Schedelomvang waarde | 314 | |||||
| Schedelomvang datum tijd | T-3D | |||||
| Foetale femurlengte fl meting | ||||||
| Flwaarde | 57 | |||||
| Meet methode | 6 | |||||
| Fldatum begin tijd | T-3D | |||||
| Foetale biparietale diameter bpd meting | ||||||
| Bpdwaarde | 88 | |||||
| Meet methode | 6 | |||||
| Bpddatum begin tijd | T-3D | |||||
| Foetaal geschat gewicht efw meting | ||||||
| Efwwaarde | 2450 | |||||
| Meet methode | 6 | |||||
| Efwdatum begin tijd | T-3D | |||||
| Bevindingen | ||||||
| Beweging foetus observatie | ||||||
| Beweging foetus datum tijd | T-3D | |||||
| Beweging foetus waarde | 2 | |||||
| Observatie methode | 6 | |||||
| Vruchtwater meting | ||||||
| Meet datum tijd | T-3D | |||||
| Hoeveelheid vruchtwater waarde | 1 | |||||
| Vruchtwatercompartiment waarde | 1 | |||||
| Meet methode | 6 | |||||
1.3 Scenario Vrouw8-kaart10-Echo_gegevens
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 = '6030' in codeSystem 'GBA Tabel 34 Landen') | ||||
| 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 | Tijdelijk telefoonnummer (code = 'TMP' 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 | |||||
| Organisatie naam | Echopraktijk Groei | ||||
| Afdeling specialisme | 457 | ||||
| Zorgverlener HelmaH | |||||
| Zorgverlener identificatienummer | 654321 (in identificerend systeem: 2.16.840.1.113883.2.4.3.11.31.5.1) | ||||
| Naamgegevens | |||||
| Voornamen | Helma | ||||
| Initialen | H | ||||
| Naamgebruik | Eigen geslachtsnaam (code = 'NL1' in codeSystem 'ZIB Naamgebruik') | ||||
| Geslachtsnaam | |||||
| Achternaam | Groot | ||||
| Geslachtsnaam partner | |||||
| Voorvoegsels partner | de | ||||
| Achternaam partner | Vries | ||||
1.3.2 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 | |||
1.3.3 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 | |||||
| Meet methode | 6 | |||||
| Acdatum begin tijd | T-13D | |||||
| Foetale schedelomvang | ||||||
| Schedelomvang meetmethode | 2 | |||||
| Schedelomvang waarde | 74 | |||||
| Schedelomvang datum tijd | T-13D | |||||
| Foetale femurlengte fl meting | ||||||
| Flwaarde | 7 | |||||
| Meet methode | 6 | |||||
| Fldatum begin tijd | T-13D | |||||
| Foetale biparietale diameter bpd meting | ||||||
| Bpdwaarde | 17 | |||||
| Meet methode | 6 | |||||
| Bpddatum begin tijd | T-13D | |||||
| Foetale kruin romp lengte crl meting | ||||||
| Crlwaarde | 55 | |||||
| Meet methode | 6 | |||||
| Crldatum begin tijd | T-13D | |||||
| Foetale nekplooidikte nt meting | ||||||
| Ntwaarde | 2.9 | |||||
| Meet methode | 6 | |||||
| Ntdatum begin tijd | T-13D | |||||
| Bevindingen | ||||||
| Sonomarkers observatie | ||||||
| Sonomarker naam | 3 | |||||
| Sonomarker waarde | 1 | |||||