Difference between revisions of "Antepartum Summary Form C"
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; Frequency : Length of duration for patient’s typical monthly period | ; Frequency : Length of duration for patient’s typical monthly period | ||
| − | ; Full Term : Number of | + | ; Full Term : Number of babies the mother has delivered between 37 and 42 weeks gestation |
; hCG + : Specify date of positive Human Chorionic Gonadotropin pregnancy test. | ; hCG + : Specify date of positive Human Chorionic Gonadotropin pregnancy test. | ||
| Line 94: | Line 94: | ||
; Birth Weight : Weight of baby at birth for previous pregnancies | ; Birth Weight : Weight of baby at birth for previous pregnancies | ||
| − | ; Date : Month/Year of delivery of previous pregnancies | + | ; Date : (Day)/Month/Year of delivery of previous pregnancies (day may be optionally recorded) |
; GA Weeks : Gestational age in weeks at delivery for previous pregnancies | ; GA Weeks : Gestational age in weeks at delivery for previous pregnancies | ||
Revision as of 15:45, 29 May 2007
Introduction
This is a draft of the Antepartum Summary Profile (APS) supplement to the Patient Care Coordination Technical Framework. This draft is a work in progress, not the official supplement or profile.
Profile Abstract
The Antepartum Summary Profile (APS) describes the content structures for the ACOG Antepartum Record Forms. It is divided into 4 content profiles:
- Forms A&B - The initial assessment and physical
- Form C&F&G - Update records and progress notes
- Form D - Laboratory Evaluations
- Form E - Education Assessment
The ACOG form also includes:
- An Obstetric Medical History
- A Postpartum Form
This profile defines the implementation of HL7 CDA documents to represent these forms, and the XDS, XDR, and XDM bindings to group them into a single logical folder.
Glossary
The following terms are found in Form C of the Antepartum Record.
- Antepartum
- Period of pregnancy between conception and onset of labor, referring to the mother.
- Cervix Exam (Dil/Eff/Sta)
- Examination to determine, Dilation, Effacement, and Station of the fetus.
- Dilation refers to the size of the opening in the cervix, usually recorded in centimeters (measured from 0[=closed] to 10 [=fully dialated or open]).
- Effacement refers to the thickness or thinness of the cervix (measured from 0% (or uneffaced, =thick) to 100% (completely thinned out).
- Station refers to the progress of the head (or presenting part) though the pelvis (measured in negative number, 0, and positive numbers, either in cms above or below the ischial spines or in relative distance to the introitus, (i.e., “thirds.”).
- EDD
- Expected Date of Delivery, a fixed date determined by ultrasound measurements and /or last menstrual period. Also called EDC - Expected Date of Confinement.
- Initial EDD
- Expected Date of Delivery, assuming 40 weeks or 280 days since last menstrual period.
- FHR
- Fetal Heart Rate. A measurement of the pulse of the fetus.
- Fetal Movement
- Maternal perception of movement by the fetus
- Fundal Height
- Measurement of the size of the uterus from the top of the pubic bone to the top of the uterus in centimeters. This measurement is used to assess fetal growth. This measurement should be done at every prenatal visit.
- LMP
- Last Menstrual Period: as measured from the first day of a woman’s last cycle prior to the pregnancy.
- Presentation
- Refers to the part of the fetus that is presenting first, i.e. breech, vertex, etc.
- Preterm Labor Signs/Symptoms
- Any sign or symptom suggesting possible labor, that occurs before 37 weeks of gestation. For example: regular or irregular contractions, ruptured membranes, abdominal cramps, low, dull backache, pelvic or abdominal pressure, change in type or increase of vaginal discharge.
- Quickening
- A woman’s initial awareness of movement of the fetus within the womb/uterus. Usually reported between 18 – 20 weeks gestation with a first pregnancy, often as early as 16 weeks with subsequent pregnancies.
- Ultrasound length
- Identifying the size and position of the fetus by ultrasound exam to estimate gestational age
- Weeks Gestation (Best est.)
- The best estimate of the length of time since conception.
The following terms are found in Form A of the Antepartum Record.
- AB Induced
- Number of induced abortions the mother has had
- AB Spontaneous
- Number of spontaneous abortions the patient has had
- Ectopics
- Number of ectopic pregnancies the patient has had
- Frequency
- Length of duration for patient’s typical monthly period
- Full Term
- Number of babies the mother has delivered between 37 and 42 weeks gestation
- hCG +
- Specify date of positive Human Chorionic Gonadotropin pregnancy test.
- Living
- Number of living children the mother has
- LMP (last menstrual period)
- measured from the first day of the patient’s cycle
- Definite - Patient is sure of the date of last menstrual period
- Approximate – Patient is unsure of exact date but can offer an approximate date
- Unknown – Patient does not know date of last menstrual period.
- Final – Finally agreed upon date of LMP after U/S measurements.
- Menarche (age onset)
- Age at onset of initial menstrual period
- Menses Monthly
- Specify that the patient has a monthly period or not.
- Multiple Births
- Number of multiple deliveries the mother has had.
- Normal Amount/Duration
- Specify that the last menstrual period was typical or not in amount and duration for this patient.
- On BCP Concept
- Specify if the patient was on birth control pills at conception
- Premature
- Number of premature babies the mother has delivered
- Prior Menses
- Date of patient’s prior period.
- Total Pregnancy
- Total number of times the patient has been pregnant
'Prior Pregnancies' Section:
- Anesthesia
- Specify the type of anesthesia used for previous pregnancy, i.e., epidural, etc.
- Birth Weight
- Weight of baby at birth for previous pregnancies
- Date
- (Day)/Month/Year of delivery of previous pregnancies (day may be optionally recorded)
- GA Weeks
- Gestational age in weeks at delivery for previous pregnancies
- Length of Labor
- Number of hours in labor for previous pregnancies
- Place of Delivery
- Specify where the previous babies were delivered.
- Preterm Labor
- Specify if the patient had preterm labor with the previous pregnancies.
- Sex
- Sex of babies for previous pregnancies
- Type Delivery
- Specify type of delivery for previous pregnancy, i.e. vaginal, cesarean
- ART Treatment
- Assisted Reproductive Technology Treatment
Volume I
Add the following bullet to the list of profiles
- Antepartum Summary - A folder of content profiles that contains the summarization record or the antepartum care delivery including initial patient history and physical, ambulatory checks of mother and fetus, laboratory studies, and patient education .
Dependencies
Add the following row(s) to the list of dependencies
| Integration Profile | Dependency | Dependency Type | Purpose |
|---|---|---|---|
| Antepartum Summary Form A&B | IHE History and Physical | Child | Initial Intake and Assessment for antepartum care |
| Antepartum Summary Form C&F&G | Medical Summary | Child | Update and Progress Note |
| Antepartum Summary Form D | XD-Lab | Child | Obstetric Lab Evaluation |
| Antepartum Summary Form E | Obstetric Education Form |
Because many document sections are shared with other Medical Summary document types, an Antepartum Ambulatory Prenatal Care Summary document would fit in nicely with the IHE collection of Medical Summary Documents. The ability for the IHE Medical Summary documents to incorporate the sections required for an Antepartum Summary as well as the inclusion or reference of imaging and laboratory reports and other clinical documents is an important consideration.
Specifically, this proposal is to publish content profiles for additional sections within the new Section Content Profile Framework being developed and then publish a medical summary document content profile for the full Antepartum Ambulatory Prenatal Care Summary document. The section unique to an Antepartum Ambulatory Prenatal Care Summary is the cumulative aggregation of office visits over the defined prenatal period, coupled with the similar requirements of the Pre-Procedure H&P documentation.
Profile Name
The Antepartum Summary Profile (APS)
Obstetric patients in labor and admitted to Labor and Delivery must have a complete summary of their antepartum ambulatory care available at the time of admission to evaluate and / or ameliorate risk. This same data is required at any visit to Labor and Delivery for any other problems or special needs a patient may require.
As the patient is seen over a finite period in the office, aggregation of specific relevant data is important to the evaluation of the obstetric patient upon presentation to Labor and Delivery. During the 40 weeks of a typical pregnancy duration, the patient will have an initial History and Physical Examination, followed by repetitive office visits with multiple laboratory studies, imaging (usually ultrasound) studies, and serial physical examinations with recordings of vital signs, fundal height, and the fetal heart rate. The original New OB History & Physical, ongoing Medical Diagnoses, the Estimated Due Date, outcomes of any prior pregnancies, serial visit data on the appropriate growth of the uterus and assessments of fetal well being, authorizations, laboratory and imaging studies must all be presented and evaluated upon entry to the Labor and Delivery Suite to ensure optimal care for the patient and the fetus.
Although the patient and her care provider may plan for a vaginal (natural) method of delivery, there is a substantive chance the delivery route may be surgical, requiring anesthesia and post-surgical care.
Current practice is to copy the patient's (paper) chart at various times during the pregnancy (as at 28 weeks and at 36 weeks of completed gestation), and transport the copies of the chart to the hospital the patient intends to use for delivery. Should the patient arrive prior to the chart copy arriving, or if the chart (or information within the chart) is missing on presentation of the patient to Labor and Delivery (a frequent occurrence), often the staff or clinicians repeat laboratory or imaging studies. This results in unwarranted and duplicative tests, is wasteful of time and resources, and leads to dissatisfied patients.
Further, missing or incomplete information about the patient’s clinical status may create a situation where critical information is unavailable to clinicians, which may ultimately result in an injury, inadequate aftercare or other undesirable outcome.
Significantly, a large portion of patients arrive in L&D without complete documentation. In one recent U.S. study , ~70% of patients (with paper charts) arrived in L&D without their current medical record being available. While in this study, only one hospital was involved, one can see the extent of the issue, with pregnant patients possibly going to a different hospital than planned (preterm labor, rapid labor and unable to make it to the planned delivery hospital, or visiting a distant city), moving mid-care, or with a covering physician (rather than the primary obstetrician) on call.
In a Swedish study done in the 1990’s, critical data on paper records were incomplete from 45 to 87.5% of the time. Thus, availability of current medical records remains a significant problem for most hospital Labor and Delivery units; availability of key information electronically will significantly enhance patient safety.
Technical Approach
The Antepartum Summary is a folder in XDS that defines a collection of documents. Several content profiles must be completed for the various kinds of documents that might be found in the Pre-Procedure Folder. These content profiles would include (existing and new):
- Pre-procedure patient questionnaire
- Pre-procedure H&P (including surgical and relevant social history)
- Summary of OB-specific Ambulatory Visit Data
- Laboratory Reports
- Imaging Reports
- Consultation Reports
- Diagnostic Imaging (Ultrasound) Images
- Non Stress Test (NST) Reports
- NST Waveforms (may be covered by DICOM)
- Patient Consent Forms for Performance of Procedures
- Payer Authorization Forms
Although the scope of this content profile is limited to the Antepartum Ambulatory Prenatal Care, this discussion illustrates the need to view the aggregation of documents for L&D as the center of multiple related documents and to include in the content profile the mechanisms for specifically referencing these document types.
Stakeholders
The stakeholders who use this document for decision making in the course of patient care include:
- Obstetrician
- Perinatologist
- Certified Nurse Midwives
- Anesthesiologist
- Labor and Delivery and Peri-operative personnel (L&D staff, surgical coordinator, scheduling, surgical nursing)
- Post-op and Post-Partum Nursing
- Social Work (discharge planning)
- Obstetrician (after discharge)
Use Cases
Use Case: Antepartum Care Delivery
- Pre-condition
- The patient’s obstetrician sees the patient for her pregnancy in the ambulatory (office) setting. During the pregnancy, the patient is noted to have a medical problem requiring consultation with a Maternal-Fetal Medicine specialist (perinatologist). The office obtains pre-authorization from the insurance payer for the consult, and for the intended or anticipated route of delivery, and transmits that information to both the consultant and to the hospital.
- Events
- The patient is seen in the obstetrician’s office where a complete medical and relevant social history are taken by the nurse and recorded in the office EHR, incorporating data from the perinatologist’s consultation report as appropriate. Laboratory and imaging reports ordered by the perinatologist as well as the perinatologist’s consultation report are displayed electronically to the obstetrician. The obstetrician reviews the consultation report from the perinatologist’s office and imaging studies ordered by the perinatologist along with data recorded by the nurse. Physical exam reveals some abnormalities. The obstetrician orders additional laboratory studies, and sends the patient to the hospital to Labor and Delivery.
When the laboratory results return, the physician completes the admission H&P, Allergies, Medications, includes the data prepared or ordered by the perinatologist, and makes it available to L&D. This data includes an assessment of the patient’s health status, and the requisite data summarized from the antepartum care given. The charge nurse for L&D documents that the complete collection of documents needed is available. The Post-Partum discharge planning is notified and assures that there is a suitable environment with appropriate support for post-delivery after-care.
- Post-condition
- The Pre-delivery H&P and Antepartum Summary with appropriate relationships to the Perinatologist Consultation, and all the antepartum laboratory and imaging studies are available to the obstetrician and the birthing center personnel for incorporation into their respective EHRs. The H&P is also available to the patient for viewing and incorporation into the patient’s PHR, and into the newborn baby’s PHR.
Actors/Transaction
There are two actors in this profile, the Content Creator and the Content Consumer. Content is created by a Content Creator and is to be consumed by a Content Consumer. The sharing or transmission of content from one actor to the other is addressed by the appropriate use of IHE profiles described below, and is out of scope of this profile. A Document Source or a Portable Media Creator may embody the Content Creator Actor. A Document Consumer, a Document Recipient or a Portable Media Importer may embody the Content Consumer Actor. The sharing or transmission of content or updates from one actor to the other is addressed by the use of appropriate IHE profiles described by section 3.7 Content Bindings with XDS, XDM and XDR found in the Patient Care Coordination Technical Framework
Options
| Actor | Option | Section |
|---|---|---|
| Content Consumer | View Option (1) Document Import Option (1) |
PCC TF-1: 2.13.1 PCC TF-1: 2.13.2 |
| Content Creator | None Defined | N/A |
Note 1: The Actor shall support at least one of these options.
Grouping
Content Bindings with XDS, XDM and XDR
It is expected that the transfers of care will occur in an environment where the physician offices and hospitals have a coordinated infrastructure that serves the information sharing needs of this community of care. Several mechanisms are supported by IHE profiles:
- A registry/repository-based infrastructure is defined by the IHE Cross Enterprise Document Sharing (XDS) and other IHE Integration Profiles such as patient identification (PIX & PDQ), and notification of availability of documents (NAV).
- A media-based infrastructure is defined by the IHE Cross Enterprise Document Media Interchange (XDM) profile.
- A reliable messaging-based infrastructure is defined by the IHE Cross Enterprise Document Reliable Interchange (XDR) profile.
- All of these infrastructures support Security and privacy through the use of the Consistent Time (CT) and Audit Trail and Node Authentication (ATNA) profiles.
For more details on these profiles, see the IHE IT Infrastructure Technical Framework.
Content profiles may impose additional requirements on the transactions used when grouped with actors from other IHE Profiles.
Cross Enterprise Document Sharing, Media Interchange and Reliable Messages
Actors from the ITI XDS, XDM and XDR profiles embody the Content Creator and Content Consumer sharing function of this profile. A Content Creator or Content Consumer must be grouped with appropriate actors from the XDS, XDM or XDR profiles, and the metadata sent in the document sharing or interchange messages has specific relationships to the content of the clinical document described in the content profile.
Notification of Document Availability (NAV)
A Document Source should provide the capability to issue a Send Notification Transaction per the ITI Notification of Document Availability (NAV) Integration Profile in order to notify one or more Document Consumer(s) of the availability of one or more documents for retrieval. One of the Acknowledgement Request options may be used to request from a Document Consumer that an acknowledgement should be returned when it has received and processed the notification. A Document Consumer should provide the capability to receive a Receive Notification Transaction per the NAV Integration Profile in order to be notified by Document Sources of the availability of one or more documents for retrieval. The Send Acknowledgement option may be used to issue a Send Acknowledgement to a Document Source that the notification was received and processed.
Document Digital Signature (DSG)
When a Content Creator Actor needs to digitally sign a document in a submission set, it may support the Digital Signature (DSG) Content Profile as a Document Source. When a Content Consumer Actor needs to verify a Digital Signature, it may retrieve the digital signature document and may perform the verification against the signed document content.
Volume II
Volume II
KNOWN ISSUES
- LOINC requests
- (xx-Antepartum-Summary):ANTEPARTUM SUMMARY-^PATIENT-FIND-PT-DOC-
- (xx-edd-section):ESTIMATED DELIVERY DATE-^PATIENT-FIND-PT-NAR-
- (xx-acog-visit-sum-section):PREGNANCY VISIT SUMMARY-^PATIENT-FIND-PT-NAR
- (xx-EDD-by-PE):DELIVERY DATE^TMSTP^PT^PATIENT^QN^ESTIMATED FROM CLINICIANS PHYSICAL EXAM
- (xx-EDD-by-Qck):DELIVERY DATE^TMSTP^PT^PATIENT^QN^ESTIMATED FROM DATE OF QUICKENING
- (xx-EDD-by-Fund):DELIVERY DATE^TMSTP^PT^PATIENT^QN^ESTIMATED FROM DATE FUNDAL HEIGHT REACHES UMBILICUS
- (xx-ga-by-PE):GESTATIONAL AGE^TIME^PT^FETUS^QN^ESTIMATED FROM CLINICIANS PHYSICAL EXAM
- (xx-date-of-Qck):DATE OF QUICKENING^TMSTP^PT^PATIENT^QN^REPORTED
- (xx-date-of-Fund-Umb):DATE FUNDAL HEIGHT REACHES UMBILICUS^TMSTP^PT^PATIENT^QN^CLINICIANS PHYSICAL EXAM
- (xx-acog-visit-sum-battery):ACOG VISIT SUMMARY BATTERY--PT---
- (xx-SS-Preterm-Labor):PRETERM LABOR SYMPTOMS-FIND-PT-^PATIENT-QL-CLINICAL JUDGEMENT
- (xx-cerv-dil):DILATION-LEN-PT-CERVIX-QN-PALPATION
- (xx-time-to-next-appt):TIME TO NEXT VISIT-TIME-PT-^PATIENT-QN-
- (xx-fetal-hr-ausc):HEART RATE-NRAT-PT-^FETUS-QN-AUSCULTATION
- (xx-fetal-movement):MOVEMENT-FIND-PT-^FETUS-ORD-PATIENT REPORTED
- (xx-cerv-dil-us):DILATION-LEN-PT-CERVIX-QN-US
- (xx-bld-transf-ok):Blood Transfusion Preference-FIND-PT-^PATIENT-ORD-PATIENT REPORTED
- (xx-anest-cons-pland):Anesthesia Consult Status-FIND-PT-^PATIENT-ORD-
- Additional Work deferred until future years:
- Need to develop other forms in Antepartum Record (Form A/B, D, E, G)
- Folders to bind all related ACOG forms.
IHE Content Modules
Namespaces and Vocabulary
IHE PCC Template Identifiers
Editors Note: Please add the following templates to the PCC TF-2 Template Identifiers
| Root | Description |
|---|---|
| 1.3.6.1.4.1.19376.1.5.3.1.1.11.2 | Antepartum Summary Form C & F |
| 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1 | Estimated Delivery Date Section |
| 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2 | ACOG Visit Summary Flowsheet Section |
| 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1 | Estimated Delivery Date Observation |
| 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1 | ACOG Visit Summary Battery |
CDA Document Content Modules
Development Only
The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC
Antepartum Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.11.2
The Antepartum Summary represents a summary of the most critical information to an antepartum care provider regarding the status of a patients pregnancy.
The APS document is a medical summary and inherits all header constraints from Medical Summaries.
The use case for this document is described fully in the APS Profile in PCC TF-1.
Format Code
The XDSDocumentEntry format code for this content is urn:ihe:pcc:aps:2007
Parent Template
This document is an instance of the Medical Summary template.
LOINC Code
The LOINC code for this document is XX-APS Antepartum Summary
Standards
Data Element Index
This section maps the ACOG Antepartum Record to corresponding CDA sections as constrained by IHE.
| ACOG Antepartum Record Datum | CDA Section | Trial |
|---|---|---|
| Drug Allergy/Latex Allergy | Allergies | |
| Is Blood Transfusion Acceptable | Advance Directives | |
| Antepartum Anesthesia Consult Planned | Plan of Care | |
| Problems/Plans | Problems | Related plans should be listed in Plan of Care |
| Medication List | Active Medications | |
| EDD Confirmation/18-20 Week EDD Update | Estimated Delivery Dates | |
| Prepregnancy Weight | Visit Summary Flowsheet | |
| Visit Flowsheet | Visit Summary Flowsheet |
Specification
| Data Element Name | Opt | Template ID |
|---|---|---|
| Allergies This section is the same as for Medical Summary, however it SHALL include one observation of Latex Allergy which may be negated through the negationInd attribute. Latex Allergy is particularly relevant for Obstetrics because of the frequency of vaginal exams that might involve the use of latex gloves. The observation value code for Latex Allergy is '300916003'. The codeSystem is '2.16.840.1.113883.6.96'. The codeSystemName is 'SNOMED CT' |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.13 |
| Advance Directives APS includes an explicit check of patients preference for blood transfusion because the risk of massive hemorrhage during delivery is much higher. This observation SHALL be recorded in the Advance Directives section. APS Form C documents SHALL include a simple observation of "blood transfusion acceptable?" The observation value for this observation is '(xx-bld-transf-ok)'. The codeSystem is '2.16.840.1.113883.6.1'. The codeSystemName is 'LOINC' |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.34 |
| Plan of Care APS forms SHOULD include an observation stating if an anesthesia consult is planned. When present, the observation value for this observation is '(xx-anest-cons-pland)'. The codeSystem is '2.16.840.1.113883.6.1'. The codeSystemName is 'LOINC'. If the type of anesthesia planned is known, systems SHOULD include an observation to represent that data using the LOINC code '(xx-type-of-anesth-pland)' with a CD value including one of the following values: ( General | Epidural | Spinal ) or a Null flavor to represent unknown or not listed. |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.31 |
| Medications Medications should include start and stop date if known. |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.19 |
| Problems Related Plans should be included in the Plan of Care section. |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.6 |
| Estimated Delivery Dates | R | 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1 |
| Antepartum Visit Summary Flowsheet | R | 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2 |
| Note: | The Antepartum summary is typically used as a 'living document' where the latest information is added to the end of the flowsheet at each visit. This is different than a typical Medical Summary which typically would not share information until document is complete. Although this pattern of updates is not prohibited by Medical Summary, it is also not typical. For APS documents may be published at the end of each visit, but subsequent updates with a pregnancy SHALL be represented as document replacement by including a <relatedDocument typeCode='REPL'> element as below.
<ClinicalDocument xmlns='urn:hl7-org:v3'> : <relatedDocument typeCode='REPL'> <parentDocument> <id root=' ' extension=' '/> </parentDocument> </relatedDocument> : </ClinicalDocument> |
Conformance
CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown in the sample document below. A CDA Document may conform to more than one template. This content module inherits from the Medical Summary content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.
<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/> |
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.11.2'>
<rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.11.2"]'>
<!-- Verify that the template id is used on the appropriate type of object -->
<assert test='../cda:ClinicalDocument'>
Error: The Antepartum Summary can only be used on Clinical Documents.
</assert>
<!-- Verify that the parent templateId is also present. -->
<assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.2"]'>
Error: The parent template identifier for Antepartum Summary is not present.
</assert>
<!-- Verify the document type code -->
<assert test='cda:code[@code = "XX-APS"]'>
Error: The document type code of a Antepartum Summary must be XX-APS
</assert>
<assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'>
Error: The document type code must come from the LOINC code
system (2.16.840.1.113883.6.1).
</assert>
<assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'>
<!-- Verify that all required data elements are present -->
Error: The Antepartum Summary Document must contain a(n) Allergies Section.
See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2
</assert>
<assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'>
<!-- Verify that all required data elements are present -->
Error: The Antepartum Summary Document must contain a(n) Advance Directives Section.
See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2
</assert>
<assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'>
<!-- Verify that all required data elements are present -->
Error: The Antepartum Summary Document must contain a(n) Plan of Care Section.
See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2
</assert>
<assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'>
<!-- Verify that all required data elements are present -->
Error: The Antepartum Summary Document must contain a(n) Medications Section.
See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2
</assert>
<assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'>
<!-- Verify that all required data elements are present -->
Error: The Antepartum Summary Document must contain a(n) Problems Section.
See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2
</assert>
<assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1"]'>
<!-- Verify that all required data elements are present -->
Error: The Antepartum Summary Document must contain a(n) Estimated Delivery Dates Section.
See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2
</assert>
<assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2"]'>
<!-- Verify that all required data elements are present -->
Error: The Antepartum Summary Document must contain a(n) Antepartum Visit Summary Flowsheet Section.
See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2
</assert>
<assert test="cda:entry/cda:observation/cda:value[@code='300916003']">
Antepartum Summary Requires an observation of Latex Allergy to be
asserted. This may be negated via the negationInd attribute.
</assert>
<assert test="cda:entry/cda:observation/cda:value[@code='(xx-bld-transf-ok)']">
Antepartum Summary Requires an observation of blood transfusion
acceptability to be asserted. This may be negated via the negationInd attribute.
</assert>
<assert test="cda:entry/cda:observation/cda:value[@code='(xx-anest-cons-pland)']">
Antepartum Summary Requires an observation of anesthesia consult
planned to be asserted. This may be negated via the negationInd attribute.
</assert>
</rule>
</pattern>
CDA Header Content Modules
CDA Section Content Modules
Development Only
The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at https://www.ihe.net/resources/technical_frameworks/#pcc
Estimated Delivery Dates Section
| Template ID | 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1 | |
|---|---|---|
| General Description |
This section houses the physicians best estimate of the patients due date. This is generally done both on an initial evaluation, and later confirmed at 18-20 weeks. The date is supported by evidence such as the patients history of last menstral period, a physical examination, or ultrasound measurements. If an gestational age based on ultrasound is present, it is generally considered the most accurate measurement and so that date would be chosen. | |
| LOINC Code | Opt | Description |
| (xx-edd-section) | R | ESTIMATED DELIVERY DATE-^PATIENT-FIND-PT-NAR- |
| Entries | Opt | Description |
| 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1 | R | Estimated Due Date Observation This is a simple observation to represent the estimated due date with a supporting observation or observations that state the method used and date implied by that method. If one observation is present, then it is to be interpreted as the initial EDD. If the initial observation dates indicate the EDD is within the 18 to 20 weeks completed gestation, that observation will also populate the 18-20 week update. If the initial observation indicates an EDD of more than 20 weeks EGA, then no value will be placed in the 18-20 week update field. |
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1'/>
<id root=' ' extension=' '/>
<code code='(xx-edd-section)' displayName='ESTIMATED DELIVERY DATE-^PATIENT-FIND-PT-NAR-'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Estimated Due Date Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1'/>
:
</entry>
</section>
</component>
|
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1'>
<rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1"]'>
<!-- Verify that the template id is used on the appropriate type of object -->
<assert test='../cda:section'>
Error: The Estimated Delivery Dates can only be used on sections.
</assert>
<!-- Verify the section type code -->
<assert test='cda:code[@code = "(xx-edd-section)"]'>
Error: The section type code of a Estimated Delivery Dates must be (xx-edd-section)
</assert>
<assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'>
Error: The section type code must come from the LOINC code
system (2.16.840.1.113883.6.1).
</assert>
<assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1"]'>
<!-- Verify that all required data elements are present -->
Error: The Estimated Delivery Dates Section must contain a(n) Estimated Due Date Observation Entry.
See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1
</assert>
</rule>
</pattern>
Uses
See Templates using the Estimated Delivery Dates Section
Development Only
The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at https://www.ihe.net/resources/technical_frameworks/#pcc
Visit Summary Section
| Template ID | 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2 | |
|---|---|---|
| General Description |
This section is a running history of the most important elements noted for a pregnant woman. | |
| LOINC Code | Opt | Description |
| (xx-acog-visit-sum-section) | R | PREGNANCY VISIT SUMMARY-^PATIENT-FIND-PT-NAR |
| Entries | Opt | Description |
| 1.3.6.1.4.1.19376.1.5.3.1.4.13 | R | Simple Observation The flowsheet contains one simple observation to represent the Prepregancy Weight. This observation SHALL be valued with the LOINC code 8348-5, BODY WEIGHT^PRE PREGNANCY-MASS-PT-QN-MEASURED. The value SHALL be of type PQ. The units may be either "lb_av" or "kg". |
| 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2 | R | Antepartum Flowsheet Panel Other entries on the flowsheet are "batteries" which represent a single visit. |
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2'/>
<id root=' ' extension=' '/>
<code code='(xx-acog-visit-sum-section)' displayName='PREGNANCY VISIT SUMMARY-^PATIENT-FIND-PT-NAR'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Simple Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
:
</entry>
<entry>
:
<!-- Required Antepartum Flowsheet Panel element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2'/>
:
</entry>
</section>
</component>
|
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2'>
<rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2"]'>
<!-- Verify that the template id is used on the appropriate type of object -->
<assert test='../cda:section'>
Error: The Visit Summary can only be used on sections.
</assert>
<!-- Verify the section type code -->
<assert test='cda:code[@code = "(xx-acog-visit-sum-section)"]'>
Error: The section type code of a Visit Summary must be (xx-acog-visit-sum-section)
</assert>
<assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'>
Error: The section type code must come from the LOINC code
system (2.16.840.1.113883.6.1).
</assert>
<assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.13"]'>
<!-- Verify that all required data elements are present -->
Error: The Visit Summary Section must contain a(n) Simple Observation Entry.
See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2
</assert>
<assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2"]'>
<!-- Verify that all required data elements are present -->
Error: The Visit Summary Section must contain a(n) Antepartum Flowsheet Panel Entry.
See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2
</assert>
<assert test='.//cda:observation/cda:code[@code="8348-5"]'>
Error: The Visit Summary must have at least one simple observation with the LOINC
code 8348-5 to represent the prepregnancy weight.
See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2
</assert>
<assert test='.//cda:observation[cda:code/@code='8348-5']/cda:value[@unit='kg' or @unit='lb_av']">
Error: The prepregnancy weight shall record the units in kg or lbs
See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2
</assert>
</rule>
</pattern>
Uses
See Templates using the Visit Summary Section
CDA Entry Content Modules
Development Only
The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC
EDD Observation 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1
The EDD observation reflects the clinicians best judgement about the estimated delivery date of the patient. It can be supported by patient history (eg last menses or quickening), physical examination findings (uterine size), or Ultrasound. If present, ultrasound findings generally are the most accurate supporting evidence. The observation is a Simple Observation with a supporting entryRelation of another Observation. The supporting observation may in turn have a entryRelation that gives the original observation as a gestational age or date from which the estimated due date is calculated.
Uses
See Templates using EDD Observation
Specification
<observation classCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1'>
<statusCode code='completed'/>
<effectiveTime value=' '/>
<author typeCode='AUT'>
<id root=' ' extension=' '/>
<code code='11778-8'
displayName='DELIVERY DATE-TMSTP-PT-^PATIENT-QN-CLINICAL.ESTIMATED'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text><reference value='id-foo'/></text>
<value xsi:type='TS' value=' '/>
<entryRelationship typeCode='SPRT'>
<observation classCode='OBS' moodCode='EVN'>
<id root=' ' extension=' '/>
<statusCode code='completed'/>
<effectiveTime value=' '/>
<author typeCode='AUT'>
</observation>
|
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1'/>
The <templateId> identifies the observation as a type of Estimated Delivery Date Observation. The root attribute SHALL be valued with '1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1'.
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
EDD observation SHALL comply with the restrictions of the Simple Observation entry. The observation SHALL NOT include repeatNumber, interpretationCode, methodCode, or targetSiteCode as listed below.
<code code='11778-8' codeSystem='2.16.840.1.113883.6.1'/>
The <code> element indicates that this is a "clinically estimated" estimated delivery date (for example, this code is used to represent the field on the last line of the EDD section of the ACOG form). This code SHALL be the LOINC code 11778-8. It is good style to include the displayName and codeSystemName to help debugging.
<value xsi:type='TS' value=' '>
The value of the EDD SHALL be represented as a point in time.
<author typeCode='AUT'><assignedAuthor><id root=' ' extension=' '/></assignedAuthor></author>
There may be multiple clinicians following the patient and authoring the overall document, however the EDD observation has an individual author. For CDA based content, this author SHALL be listed in the CDA header and referenced from the entry by including the id element of the assignedAuthor. For HL7 Version 3 Messages based content, the author SHALL be included in full through this element.
<author typeCode='AUT'>
The author.time is used to record the time that the author recorded the observation. It SHALL be included.
<entryRelationship typeCode='SPRT'>
The <entryRelationship> element binds the clinicians estimated EDD to supporting observations by different methods. Supporting observations SHOULD be included. If included, the typeCode SHALL be 'SPRT'. For HL7 Version 3 Messages based content, the element name is <sourceOf> rather than <entryRelationship>, however the semantics, typeCode, and nested elements remain unchanged.
<observation>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
:
</observation> [1st nesting]
Observations that support the clinical observation SHALL be included if known. These observations are the supporting calculated dates from various methods such as ultrasound dates or dates calculated from LMP (i.e., the left column of fields on the ACOG form). Supporting observations SHALL also conform to the simple observation template. Supporting observations MAY include a different effectiveTime, author, or informant. Supporting observations SHALL NOT include repeatNumber, interpretationCode, methodCode, or targetSiteCode. (Method is implied by the LOINC code). The templateId SHALL be valued as ‘1.3.6.1.4.1.19376.1.5.3.1.4.13’
<code code=' ' codeSystem='2.16.840.1.113883.6.1'/> [1st nesting]
Supporting observations SHALL include one of following LOINC values to indicate the method used to calculate the EDD.
| Code | Description |
|---|---|
| 11779-6 | DELIVERY DATE-TMSTP-PT-^PATIENT-QN-ESTIMATED FROM LAST MENSTRUAL PERIOD |
| (xx-EDD-by-PE) | DELIVERY DATE-TMSTP-PT-^PATIENT-QN-ESTIMATED FROM CLINICIANS PHYSICAL EXAM |
| 11781-2 | DELIVERY DATE-TMSTP-PT-^PATIENT-QN-US.COMPOSITE.ESTIMATED |
| (xx-EDD-by-Qck) | DELIVERY DATE-TMSTP-PT-^PATIENT-QN-ESTIMATED FROM DATE OF QUICKENING |
| (xx-EDD-by-Fund) | DELIVERY DATE-TMSTP-PT-^PATIENT-QN-ESTIMATED FROM DATE FUNDAL HEIGHT REACHES UMBILICUS |
<entryRelationship typeCode='DRIV'>
Observations of supporting EDD should provide observations from which they were derived such as the patients last menses, or gestational age value at a point in time.
For HL7 Version 3 Messages based content, the element name is <sourceOf> rather than <entryRelationship>, however the semantics, typeCode, and nested elements remain unchanged.
===== <observation>
<templateId root=' '/>
:
</observation> [2st nesting]
Observations that support the calculation of supporting observation SHALL be included if known. These observations are the supporting dates or ages from various methods such as ultrasound gestational age or the date of last Menses (for example, the right column of fields on the ACOG form). Supporting observations SHALL also conform to the simple observation template. Supporting observations MAY include a different effectiveTime, author, or informant. Supporting observations SHALL NOT include repeatNumber, interpretationCode, methodCode, or targetSiteCode. (Method is implied by the LOINC code)
<code code=' ' codeSystem='2.16.840.1.113883.6.1'/> [2nd nesting]
This code is used to represent the either the relevant date, or the gestational age observation from which the EDD is derived. The following table lists the relevant LOINC codes for methods used. For observations that record the gestational age the value is recorded as a physical quantity (PQ) with the units of weeks and the activity time should be recorded to indicate the date at which the gestational age was observed. For observations that simply record a date (eg LMP) the observation value is recorded as a point in time (TS).
| Code | Description | Type |
|---|---|---|
| 8655-2 | DATE LAST MENSTRUAL PERIOD-TMSTP-PT-^PATIENT-QN-REPORTED | TS |
| (xx-ga-by-PE) | GESTATIONAL AGE-TIME-PT-^FETUS-QN-ESTIMATED FROM CLINICIANS PHYSICAL EXAM | PQ |
| 11888-5 | GESTATIONAL AGE-TIME-PT-^FETUS-QN-US.COMPOSITE.ESTIMATED | PQ |
| (xx-date-of-Qck) | DATE OF QUICKENING-TMSTP-PT-^PATIENT-QN-REPORTED | TS |
| (xx-date-of-Fund-Umb) | DATE FUNDAL HEIGHT REACHES UMBILICUS-TMSTP-PT-^PATIENT-QN-CLINICIANS PHYSICAL EXAM | TS |
<repeatNumber value=' '/>
<interpretationCode code=' ' codeSystem=' '/>
<targetSiteCode code=' ' codeSystem=' '/>
<interpretationCode code=' ' codeSystem=' '/>
<targetSiteCode code=' ' codeSystem=' '/>
The <repeatNumber> <interpretationCode>, and <targetSiteCode> elements should not be present in a EDD observation.
Schematron
-->>TODO:<<--
must include templateID and simple obs templateID
must include loinc 11778-8
must include author.assignedAuthor with Id valued
must include author.time
must have value xsi:type=ts
must include text.reference.value
may include effectiveTime
warn should include sprt relation to simple obs
assert must not include entryRelationship other than SPRT.
must not include repeatNumber, interpretationCode, methodCode, or targetSiteCode
if sprt relation included then
must include obs.id
must include includes obs.code=(one of loincs)
may include obs.author
may include obs.effectiveTime
Development Only
The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC
Antepartum Visit Summary Battery 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2
This entry describes a single row in the Visit Summary flowsheet. The single observation date and provider is applied to all other observations.
Uses
See Templates using Antepartum Visit Summary Battery
Specification
<entry>
<organizer classCode='BATTERY' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2'/>
<id root=' ' extension=' '/>
<code code='(xx-acog-battery)' displayName='ACOG Summary Visit Battery---PT--'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<statusCode code='completed'/>
<author>
|
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2'/>
The <templateId> element specifies that this organizer entry conforms to the APS profile Visit Summary Flowsheet battery. The root attribute SHALL contain the value "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2"
<organizer classCode='BATTERY' moodCode='EVN'>
Each row in the visit Summary flowsheet of the Antepartum Summary SHALL be represented by an organizer with the classCode of 'BATTERY' and the moodCode of 'EVN'
<id root=' ' extension=' '/>
Each battery SHALL have a globally unique identifier.
<code code='(xx-acog-battery)' codeSystem='2.16.840.1.113883.6.1'/>
The <code> element specifies the loinc code that represents the content of the battery. The codeSystem attribute SHALL contain the value '2.16.840.1.113883.6.1'. The code attribute SHALL contain the value='(xx-acog-battery)'. It is good practice to include displayName and codeSystemName for clarity and debugging. The corresponding values are 'ACOG VISIT SUMMARY BATTERY--PT--' and 'LOINC' respectively.
<author/>
The <author> relation element points at the author that records the visit battery. This assignedAuthor may be different than the author of the document. The time element is used to record when the assigned author recorded the battery.
<statusCode code='completed'/>
The status code for all batteries SHALL be 'completed'
<component>
The battery is made of several component simple observations. The following table lists the allowable LOINC codes, displayNames, and observation types, and unit of measures for these observations.
| LOINC Code | displayName | xsi:type | units | value set |
|---|---|---|---|---|
| 11884-4 | GESTATIONAL AGE-TIME-PT-^FETUS-QN-CLINICAL.ESTIMATED | PQ | week | |
| 11881-0 | FUNDAL HEIGHT-LEN-PT-UTERUS-QN-TAPE MEASURE | PQ | cm | |
| 11876-0 (by PE) or 11877-8 (by US) |
FETAL PRESENTATION-TYPE-PT-PELVIS-NOM-PALPATION or FETAL PRESENTATION-TYPE-PT-PELVIS-NOM-US |
CD | SNOMED CT Vertex (70028003) Breech (6096002) Transverse (73161006) Oblique (63750008) Compound (124736009) Brow (8014007) Face (21882006) | |
| 11948-7 or (xx-fetal-hr-ausc) |
HEART RATE-NRAT-PT-^FETUS-QN-US.MEASURED or HEART RATE-NRAT-PT-^FETUS-QN-AUSCULTATION |
PQ | /min | |
| (xx-fetal-movement) | MOVEMENT-FIND-PT-^FETUS-ORD-PATIENT REPORTED | CO | SNOMED CT
fetal movement activity (finding) CID 364755008 | |
| (xx-SS-Preterm-Labor) | PRETERM LABOR SYMPTOMS-FIND-PT-^PATIENT-QL-CLINICAL JUDGEMENT | BL | ||
| (xx-cerv-dil-palp) or (xx-cerv-dil-us) |
DILATION-LEN-PT-CERVIX-QN-PALPATION or DILATION-LEN-PT-CERVIX-QN-US |
PQ | cm | |
| 11867-9 | EFFACEMENT-PRCTL-PT-CERVIX-ORD-PALPATION | PQ | percent | |
| 11961-0 | LONG AXIS-LEN-PT-CERVIX-QN-US.MEASURED | PQ | cm | |
| 8480-6 | INTRAVASCULAR SYSTOLIC-PRES-PT-ARTERIAL SYSTEM-QN- | PQ | mmHg | |
| 8462-4 | INTRAVASCULAR DIASTOLIC-PRES-PT-ARTERIAL SYSTEM-QN- | PQ | mmHg | |
| 3141-9 | BODY WEIGHT-MASS-PT-^PATIENT-QN-MEASURED | PQ | g, kg, lb_av, or oz_av | |
| 1753-3 | ALBUMIN-ACNC-PT-UR-ORD- | CO | SNOMED CT Negative (finding) CID 167273002 | |
| 2349-9 or 25428-4(test strip) |
GLUCOSE-ACNC-PT-UR-ORD- or GLUCOSE-ACNC-PT-UR-ORD-TEST STRIP |
CO | SNOMED CT Negative (finding) CID 167261002 | |
| 44966-0 | EDEMA-FIND-PT-^PATIENT-ORD- | CO | SNOMED CT trace edema 44996-0 | |
| 38208-5 | PAIN SEVERITY-FIND-PT-^PATIENT-ORD-REPORTED | CO | 0 (no pain) : 10 (worst possible pain) Note: This observation should correspond to the functional status pain score observation | |
| (xx-time-to-next-appt) or ?39165 |
TIME TO NEXT VISIT- or ?Date next screen visit-TmStp-PT-^PATIENT-QN-CPHS |
PQ | day,week,mo | |
| 48767-8 | ANNOTATION COMMENT-FIND-PT-^PATIENT-NAR- | ED |
Schematron
-->>TODO:<<--
Development Only
The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC
Simple Observations 1.3.6.1.4.1.19376.1.5.3.1.4.13
The simple observation entry is meant to be an abstract representation of many of the observations used in this specification. It can be made concrete by the specification of a few additional constraints, namely the vocabulary used for codes, and the value representation. A simple observation may also inherit constraints from other specifications (e.g., ASTM/HL7 Continuity of Care Document).
Uses
See Templates using Simple Observations
Specification
<observation classCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<id root='' extension=''/>
<code code='' displayName='' codeSystem='' codeSystemName=''/>
<!-- for CDA -->
<text><reference value='#xxx'/></text>
<!-- For HL7 Version 3 Messages
<text>text</text>
-->
<statusCode code='completed'/>
<effectiveTime value=''/>
<repeatNumber value=''/>
<value xsi:type='' …/>
<interpretationCode code='' codeSystem='' codeSystemName=''/>
<methodCode code='' codeSystem='' codeSystemName=''/>
<targetSiteCode code='' codeSystem='' codeSystemName=''/>
<author typeCode='AUT'>
<assignedAuthor typeCode='ASSIGNED'><id ... /></assignedAuthor> <!-- for CDA -->
<!-- For HL7 Version 3 Messages
<assignedEntity typeCode='ASSIGNED'>
<Person classCode='PSN'>
<determinerCode root=''>
<name>…</name>
</Person>
<assignedEntity>
-->
</author>
</observation>
|
<observation classCode='OBS' moodCode='EVN'>
These acts are simply observations that have occurred, and so are recored using the <observation> element as shown above.
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
The <templateId> element identifies this <observation> as a simple observation, allowing for validation of the content. The templateId must appear as shown above.
<id root=' ' extension=' '/>
Each observation shall have an identifier.
<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>
Observations shall have a code describing what was measured. The code system used is determined by the vocabulary constraints on the types of measurements that might be recorded in a section. Content modules that are derived from the Simple Observation content module may restrict the code system and code values used for the observation.
<text><reference value='#xxx'/></text> -OR- <text>text</text>
Each observation measurement entry may contain a <text> element providing the free text that provides the same information as the observation within the narrative portion of the document with a <text> element. For CDA based uses of Simple Observations, this element SHALL be present, and SHALL contain a <reference> element that points to the related string in the narrative portion of the document. For HL7 Version 3 based uses, the <text> element MAY be included.
<statusCode code='completed'/>
The status code of all observations shall be completed.
<effectiveTime value=' '/>
The <effectiveTime> element shall be present in standalone observations , and shall record the date and time when the measurement was taken. This element should be precise to the day. If the date and time is unknown, this element should record that using the nullFlavor attribute.
<value xsi:type=' ' …/>
The value of the observation shall be recording using a data type appropriate to the observation. Content modules derived from the Simple Observation content module may restrict the allowable data types used for the observation.
<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
If there is an interpretation that can be performed using an observation result (e.g., high, borderline, normal, low), these may be recorded within the interpretationCode element.
<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
The methodCode element may be used to record the specific method used to make an observation when this information is not already pre-coordinated with the observation code .
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
The targetSiteCode may be used to record the target site where an observation is made when this information is not already pre-coordinated with the observation code.
<author><assignedAuthor classCode='ASSIGNED'>...<assignedAuthor></author>
In CDA uses, SimpleObservations are assumed to be authored by the same author as the document through context conduction. However specific authorship of observation may be represented by listing the author in the header and referencing the author in a <author> relationship. If authors are explicitly listed in documents, an <id> element SHOULD reference the ID of the author in the header through an assignedAuthor Role. If the author of the observation is not an author of the document the <person> object including a name and ID SHALL be included.
For HL7 Version 3 purposes, the <author> element SHOULD be present unless it can be determined by conduction from organizers or higher level structures. When used for HL7 Version 3 the role element name is <assignedEntity> and the author is represented a <assignedPerson> element.
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