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:
| Code | Bezeichnung im Codesystem | Codesystem |
|---|---|---|
| 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 & WIEDERGABENAME | Code | BEZEICHNUNG IM CODESYSTEM | CODESYSTEM |
|---|---|---|---|
| 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 |
