Hinweistext aus der Papierversion des U-Heftes: Zutreffendes bitte ankreuzen!

Die Schwangerschaftsanamnese im Kinderuntersuchungsheft ist eine Familienanamnese mit Bezug auf die Schwangerschaft der Mutter. Dementsprechend wurde semantisch und syntaktisch der Bezug zur Mutter hergestellt. Das U-Heft sieht eine Prüfung und ggf. Nachtragung der U1-Schwangerschaftsanamnese im Rahmen der U2 und U3 vor. 

Operationalisierung: Hier enthaltende Informationen sind teilweise deckungsgleich mit Informationen in Katalog A und B im Mutterpass (siehe dazu 5.2.1 Anamneseerhebung, Phase I und 9. Besondere Befunde, Phase I).

Terminologie-Assoziation: 

CodeBezeichnung im CodesystemCodesystem
160427003 Family history with explicit context pertaining to mother (situation)SNOMED Clinical Terms

FHIR®-Mapping: KBV_PR_MIO_CMR_Observation_U1_U3_Pregnancy_History.code

Wert: Code

KONZEPT & WIEDERGABENAMECodeBEZEICHNUNG IM CODESYSTEMCODESYSTEM
Gestationsdiabetes

721151003

Maternal history of gestational diabetes (situation)

SNOMED Clinical Terms

Diabetes mellitus

704144000

Maternal history of diabetes mellitus (situation)

SNOMED Clinical Terms

Dauermedikation

410684002 : { 408731000 = 410512000 , 363589002 = 416608005 , 408730004 = 385651009 , 408732007 = 444301002 }

Drug therapy status (situation) : { Temporal context (attribute) = Current or specified time (qualifier value), Associated procedure (attribute) = Drug therapy (procedure)| , Procedure context (attribute) = In progress (qualifier value) , Subject relationship context (attribute) = Mother of subject (person) }

SNOMED Clinical Terms

akute oder chronische Infektionen in der Schwangerschaft

160427003 : 246090004 = 40609001

Family history with explicit context pertaining to mother (situation) : Associated finding (attribute) = Infectious disease in mother complicating pregnancy, childbirth AND/OR puerperium (disorder)

SNOMED Clinical Terms

Antikörper-Suchtest positiv

160427003 : 246090004 = 165775009

Family history with explicit context pertaining to mother (situation) : Associated finding (attribute) = Indirect Coombs test positive (finding)

SNOMED Clinical Terms

B-Streptokokken-Status der Mutter positiv

160427003 : 246090004 = 120001000119107

Family history with explicit context pertaining to mother (situation) : Associated finding (attribute) = Group B streptococcus infection in mother complicating childbirth (disorder)

SNOMED Clinical Terms

Mehrlingsschwangerschaft

160427003 : 246090004 = 288259000

Family history with explicit context pertaining to mother (situation) : Associated finding (attribute) = Born after multiple pregnancy (disorder)

SNOMED Clinical Terms

(Poly-)Hydramnion

413350009 : { 246090004 = 199646006 , 408732007 = 444301002 }

Finding with explicit context (situation) : { Associated finding (attribute) = Polyhydramnios - delivered (disorder), Subject relationship context (attribute) = Mother of subject (person) }

SNOMED Clinical Terms

Oligohydramnion

413350009 : { 246090004 = 59566000 , 408732007 = 444301002 }

Finding with explicit context (situation) : { Associated finding (attribute) = Oligohydramnios (disorder) , Subject relationship context (attribute) = Mother of subject (person) }

SNOMED Clinical Terms

besondere psychische Belastungen

288256007

History of maternal psychiatric problem (situation)

SNOMED Clinical Terms

besondere soziale Belastungen

413350009 : { 246090004 = 284465006 , 408732007 = 59566000 }

Finding with explicit context (situation) : { Associated finding (attribute) = Finding relating to psychosocial functioning (finding), Subject relationship context (attribute) = Mother of subject (person) }

SNOMED Clinical Terms

Abusus

442080007

Drug misuse by mother (situation)

SNOMED Clinical Terms


Kommentierungen

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