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Risikomerkmale
In diesem Element können Befunde entsprechend den Vorgaben aus dem "Katalog B" im Mutterpass im Verlauf der Schwangerschaft erfasst werden.
Quelle: Anlage 3 (Mutterpass) zu den Mutterschafts-Richtlinien (Stand: Februar 2020), S.6 bzw. 8
https://www.g-ba.de/downloads/83-691-594/2020-02-20_G-BA_Mutterpass_web.pdf
Operationalisation: Es ist eine Auswahl mit den aufgeführten Punkten zu ermöglichen, aus der die Befunde ausgewählt werden können, die im Verlauf der Schwangerschaft festgestellt wurden.
FHIR®-Mapping:
Wert: Code
416471007 Family history of clinical finding (situation) SNOMED Clinical Terms 312850006 History of disorder (situation) SNOMED Clinical Terms 161460007 History of coagulation defect (situation) SNOMED Clinical Terms 609328004 Allergic disposition (finding) SNOMED Clinical Terms 161664006 History of blood transfusion (situation) SNOMED Clinical Terms 271596009 Mental distress (finding) SNOMED Clinical Terms 161152002 Social problem (finding) SNOMED Clinical Terms 312850006 : 246090004 = 44795003 History of disorder (situation) : Associated finding (attribute) = Rhesus isoimmunization affecting pregnancy (disorder) SNOMED Clinical Terms 73211009 Diabetes mellitus (disorder) SNOMED Clinical Terms 414916001 Obesity (disorder) SNOMED Clinical Terms 237836003 Short stature disorder (disorder) SNOMED Clinical Terms 8447006 Congenital anomaly of skeletal bone (disorder) SNOMED Clinical Terms 237240001 Teenage pregnancy (finding) SNOMED Clinical Terms 416413003 Advanced maternal age gravida (finding) SNOMED Clinical Terms 18656007 Grand multipara (finding) SNOMED Clinical Terms 443938003 : { 408731000 = 410513005 , 408730004 = 385658003 , 363589002 = 703145006 , 408732007 = 410604004 } Procedure carried out on subject (situation) : { Temporal context (attribute) = In the past (qualifier value) , Procedure context (attribute) = Done (qualifier value) , Associated procedure (attribute) = Sterilization procedure (procedure) , Subject relationship context (attribute) = Subject of record (person) } SNOMED Clinical Terms 161765003 History of premature delivery (situation) SNOMED Clinical Terms 726565008 Past history of small for gestational age baby (situation) SNOMED Clinical Terms 713651007 History of pregnancy with abortive outcome (situation) SNOMED Clinical Terms 161743003 History of stillbirth (situation) SNOMED Clinical Terms 417662000 : { 408731000 = 410513005 , 408729009 = 410515003, 246090004=199745000 , 408732007 = 410604004 } History of clinical finding in subject (situation) : { Temporal context (attribute) = In the past (qualifier value) , Finding context (attribute) = Known present (qualifier value) , Associated finding (attribute) = Complication occurring during labor and delivery (disorder), Subject relationship context (attribute) = Subject of record (person) } SNOMED Clinical Terms 417662000 : { 408731000 = 410513005 , 408729009 = 410515003 , 246090004 = 80113008 , 408732007 = 410604004 } History of clinical finding in subject (situation) : { Temporal context (attribute) = In the past (qualifier value) , Finding context (attribute) = Known present (qualifier value) , Associated finding (attribute) = Complication of the puerperium (disorder) , Subject relationship context (attribute) = Subject of record (person) } SNOMED Clinical Terms 161805006 History of cesarean section (situation) SNOMED Clinical Terms 272058002 : { 408730004 = 385658003 , 363589002 = 236974004 , 408731000 = 410513005 , 408732007 = 410604004 } History of past delivery (situation) : { Procedure context (attribute) = Done (qualifier value), Associated procedure (attribute) = Instrumental delivery (procedure) , Temporal context (attribute) = In the past (qualifier value) , Subject relationship context (attribute) = Subject of record (person)} SNOMED Clinical Terms 60001007 : 263502005 = 424572001 Not pregnant (finding) : Clinical course (attribute) = Clinical course with short duration (qualifier value) SNOMED Clinical Terms 418138009 Patient condition finding (finding) SNOMED Clinical Terms Die verwendeten Code-Systeme finden sie hier: Verwendete Code-Systeme, Phase I.KONZEPT & WIEDERGABENAME CODE BEZEICHNUNG IM CODESYSTEM CODESYSTEM (1) Familiäre Belastung (z.B. Diabetes, Hypertonie, Fehlbildungen, genetische Krankheiten, psychische Krankheiten) (2) Frühere eigene schwere Erkrankungen (z.B. Herz, Lunge, Leber, Nieren, ZNS, Psyche) (3) Blutungs-/Thromboseneigung (4) Allergie, z.B. gegen Medikamente (5) Frühere Bluttransfusionen (6) Besondere psychische Belastung (z.B. familiäre oder berufliche) (7) Besondere soziale Belastung (z.B. Integrationsprobleme, wirtschaftliche Probleme) (8) Rhesus-Inkompatibilität (bei vorangegangenen Schwangerschaften) (9) Diabetes mellitus (10) Adipositas (11) Kleinwuchs (12) Skelettanomalien (13) Schwangere unter 18 Jahren (14) Schwangere über 35 Jahren (15) Vielgebärende (mehr als 4 Kinder) (16) Zustand nach Sterilitätsbehandlung (17) Zustand nach Frühgeburt (vor Ende der 37. SSW) (18) Zustand nach Mangelgeburt (19) Zustand nach 2 oder mehr Fehlgeburten/Abbrüchen (20) Totes/geschädigtes Kind in der Anamnese (21) Komplikationen bei vorausgegangenen Entbindungen (22) Komplikationen post partum (23) Zustand nach Sectio (24) Zustand nach anderen Uterusoperationen (25) Rasche Schwangerschaftsfolge (weniger als 1 Jahr) (26) Andere Besonderheiten
27624003 Chronic disease (disorder) SNOMED Clinical Terms 710814002 Long-term current use of drug therapy (situation) SNOMED Clinical Terms 66214007 Substance abuse (disorder) SNOMED Clinical Terms 271596009 Mental distress (finding) SNOMED Clinical Terms 161152002 Social problem (finding) SNOMED Clinical Terms 723665008 Vaginal bleeding complicating early pregnancy (disorder) SNOMED Clinical Terms 427139004 Third trimester bleeding (disorder) SNOMED Clinical Terms 36813001 Placenta previa (disorder) SNOMED Clinical Terms 16356006 Multiple pregnancy (disorder) SNOMED Clinical Terms 86203003 Polyhydramnios (disorder) SNOMED Clinical Terms 59566000 Oligohydramnios (disorder) SNOMED Clinical Terms 237238006 Pregnancy with uncertain dates (finding) SNOMED Clinical Terms 237292005 Placental insufficiency (disorder) SNOMED Clinical Terms 17382005 Cervical incompetence (disorder) SNOMED Clinical Terms 6383007 Premature labor (finding) SNOMED Clinical Terms 199246003 Anemia during pregnancy - baby not yet delivered (disorder) SNOMED Clinical Terms 307534009 Urinary tract infection in pregnancy (disorder) SNOMED Clinical Terms 165775009 Indirect Coombs test positive (finding) SNOMED Clinical Terms 47200007 : 418775008 = 312404004 High risk pregnancy (finding) : Finding method (attribute) = Antenatal blood tests (procedure) SNOMED Clinical Terms 82771000119102 Hypertension complicating pregnancy (disorder) SNOMED Clinical Terms 29738008 Proteinuria (finding) SNOMED Clinical Terms 698632006 : 263502005 = 371924009 Pregnancy induced edema (disorder) : Clinical course (attribute) = Moderate to severe (qualifier value) SNOMED Clinical Terms 45007003 Low blood pressure (disorder) SNOMED Clinical Terms 11687002 Gestational diabetes mellitus (disorder) SNOMED Clinical Terms 289365005 Finding of malposition of fetus (finding) SNOMED Clinical Terms 118185001 Finding related to pregnancy (finding) SNOMED Clinical Terms Die verwendeten Code-Systeme finden sie hier: Verwendete Code-Systeme, Phase I.Konzept & Wiedergabename Code Bezeichnung im Codesystem Codesystem (27) Behandlungsbedürftige Allgemeinerkrankungen (28) Dauermedikation (29) Abusus (30) Besondere psychische Belastung (31) Besondere soziale Belastung (32) Blutungen vor der 28. SSW (33) Blutungen nach der 28. SSW (34) Placenta praevia (35) Mehrlingsschwangerschaft (36) Hydramnion (37) Oligohydramnie (38) Terminunklarheit (39) Placenta-Insuffizienz (40) Isthmozervikale Insuffizienz (41) Vorzeitige Wehentätigkeit (42) Anämie (43) Harnwegsinfekt (44) Indirekter Coombstest positiv (45) Risiko aus anderen serologischen Befunden (46) Hypertonie (Blutdruck über 140/90) (47) pathologische Eiweißausscheidung (48) Mittelgradige - schwere Ödeme (49) Hypotonie (50) Gestationsdiabetes (51) Einstellungsanomalie (52) Andere Besonderheiten
