1.3.6.1.4.1.19376.1.5.3.1.1.16.1.3

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 Education Specification 1.3.6.1.4.1.19376.1.5.3.1.1.16.1.3

The Antepartum Education document contains a list of patient education activities that have occured, or have been planned to review with the patient.

Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:apr:2008

Parent Template

This document is an instance of the Medical Documents template.

LOINC Code

The LOINC code for this document is TBD Education Record

Standards

CDAR2

HL7 CDA Release 2.0

Specification

Data Element Name	Opt	Template ID
Coded Patient Education and Consents This section SHALL be the same as it is for History & Physical, and SHOULD use the codes available in the Antepartum Education Code table.	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.39

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 Documents 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.

Sample Antepartum Education Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.1.3'/>
  <id root=' ' extension=' '/>
  <code code='TBD' displayName='Education Record'
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Antepartum Education</title>
  <effectiveTime value='20240531012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.39'/>
        <!-- Required Coded Patient Education and Consents Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.16.1.3'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.16.1.3"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Antepartum Education can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.1"]'>
     Error: The parent template identifier for Antepartum Education is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "TBD"]'>
     Error: The document type code of a Antepartum Education must be TBD
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.9.39"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Education Document must contain a(n) Coded Patient Education and Consents Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.3 
   </assert> 
 </rule>
</pattern>

APR Education Value Set 1.3.6.1.4.1.19376.1.5.3.1.1.16.5.8

Name	Opt	Type	SNOMED CT
First Trimester
Risk factors identified by prenatal history	R2	CD	xx-edu-prenatalriskfactors
Anticipated course of prenatal care	R2	CD	17629007
Special Diet	R2	CD	171054004
Nutrition and weight gain counseling	R2	CD	429095004
Toxoplasmosis precautions (cats/raw meat)	R2	CD	xx-edu-toxoplasmosis
Sexual activity	R2	CD	162169002
Exercise	R2	CD	171056002
Influenza vaccine	R2	CD	xx-edu-influenza
Smoking/tobacco counseling	R2	CD	171055003
Environmental/work hazards	R2	CD	370995009
Travel	R2	CD	xx-edu-travel
Alcohol	R2	CD	171057006
Illicit/recreational drugs	R2	CD	171058001
Use of any medications	R2	CD	xx-edu-useofmeds
Indications for ultrasound	R2	CD	xx-edu-indicationsforultrasound
Domestic violence	R2	CD	413457006
Seatbelt use	R2	CD	xx-edu-seatbeltuse
Childbirth classes/hospital facilities	R2	CD	61324002
Second Trimester
Childbirth classes/hospital facilities	R2	CD	61324002
Signs and symptoms of preterm labor	R2	CD	xx-edu-pretermlaborsignssymptoms
Abnormal Lab Values	R2	CD	410299006
Influenza vaccine	R2	CD	xx-edu-fluvaccine
Selecting a newborn care provider	R2	CD	xx-edu-newborncareprovider
Postpartum family planning	R2	CD	54070000
Tubal sterilization	R2	CD	243064009
Third Trimester
Anesthesia/analgesia plans	R2	CD	243062008
Fetal movement monitoring	R2	CD	xx-edu-fetalmovement
Labor signs	R2	CD	xx-edu-sslabor
VBAC counseling	R2	CD	xx-edu-vbac
Signs & Symptoms of Pregnancy-induced hypertension	R2	CD	xx-edu-sspreclampsia
Postterm counseling	R2	CD	xx-edu-postterm
Circumcision	R2	CD	184002001
Bottle feeding	R2	CD	169644004
Breast feeding	R2	CD	169643005
Postpartum depression	R2	CD	xx-edu-ssppd
Newborn education (Newborn screening, jaundice, SIDS, car seat)	R2	CD	75461000
Family medical leave or disability forms	R2	CD	40791000
Tubal sterilazation consent signed	R2	CD	408835000