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. Hier enthaltende Informationen sind teilweise deckungsgleich mit Informationen in Katalog A und B im Mutterpass.
Kardinalität und Konformität:
SZENARIO | KARDINALITÄT | KONFORMITÄT |
---|---|---|
U1 dokumentieren (Kindervorsorgeuntersuchungen) | 0...* | R |
U2 dokumentieren (Kindervorsorgeuntersuchungen) | 0...* | O |
U3 dokumentieren (Kindervorsorgeuntersuchungen) | 0...* | O |
Terminologie-Assoziation:
CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
---|---|---|
160427003 | Family history with explicit context pertaining to mother (situation) | SNOMED CT®, 2021-01-31 |
FHIR®-Mapping:
- KBV_PR_MIO_CMR_Observation_U1_U3_Pregnancy_History
- KBV_PR_MIO_CMR_Composition_U1.section:scwangerschaftsanamnese
- KBV_PR_MIO_CMR_Composition_U2.section:scwangerschaftsanamnese
- KBV_PR_MIO_CMR_Composition_U3.section:scwangerschaftsanamnese
Wert: Code
KONZEPT UND WIEDERGABENAME | CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
---|---|---|---|
Gestationsdiabetes | 721151003 | Maternal history of gestational diabetes (situation) | SNOMED CT®, 2021-01-31 |
Diabetes mellitus | 704144000 | Maternal history of diabetes mellitus (situation) | SNOMED CT®, 2021-01-31 |
Dauermedikation | 417451006 + 410684002 : {408731000 = 410512000 , 363589002 = 416608005 , 408730004 = 410525008 , 408732007 = 444301002} | Procedure needed (situation) + Drug therapy status (situation) : { Temporal context (attribute) = Current or specified time (qualifier value) , Associated procedure (attribute) = Drug therapy (procedure) , Procedure context (attribute) = Needed (qualifier value) , Subject relationship context (attribute) = Mother of subject (person) } | SNOMED CT®, 2021-01-31 |
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 CT®, 2021-01-31 |
Antikörper-Suchtest positiv | 160427003 : 246090004 = 165775009 | Family history with explicit context pertaining to mother (situation) : Associated finding (attribute) = Indirect Coombs test positive (finding) | SNOMED CT®, 2021-01-31 |
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 CT®, 2021-01-31 |
Mehrlingsschwangerschaft | 160427003 : 246090004 = 16356006 | Family history with explicit context pertaining to mother (situation) : Associated finding (attribute) = Multiple pregnancy (disorder) | SNOMED CT®, 2021-01-31 |
(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 CT®, 2021-01-31 |
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 CT®, 2021-01-31 |
besondere psychische Belastungen | 288256007 | History of maternal psychiatric problem (situation) | SNOMED CT®, 2021-01-31 |
besondere soziale Belastungen | 413350009 : {246090004 = 284465006 , 408732007 = 444301002} | Finding with explicit context (situation) : { Associated finding (attribute) = Finding relating to psychosocial functioning (finding), Subject relationship context (attribute) = Mother of subject (person) } | SNOMED CT®, 2021-01-31 |
Abusus | 442080007 | Drug misuse by mother (situation) | SNOMED CT®, 2021-01-31 |