1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2

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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

Trial.gif 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
Antepartum Visit Summary Battery Example

<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>
       <time value=' '/>
       <assignedAuthor>
          <id root=' ' extension=' '/>
       </assignedAuthor>
    </author>
    <component>
       <observation classCode='OBS' moodCode='EVN'>
          <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
          :
       </observation>
    </component>
    <component>
       <observation classCode='OBS' moodCode='EVN'>
          <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
           :
       </observation>
    </component>
    :
  </organizer>
</entry>



<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/><time/><assignedAuthor><id/></assignedAuthor></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
baby kicks a lot (finding) CID 276368003
baby not moving (finding) CID 276370007
reduced fetal movement (finding) CID 276369006
fetal movements present (finding) CID 289431008
fetal movements felt (finding) CID 268470003
fetal movements seen (finding) CID 169731002

(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
Trace (finding) CID 167274008
1+ (finding) CID 167275009
2+ (finding) CID 167276005
3+ (finding) CID 167277001
4+ (finding) CID 167278006

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
Trace (finding) CID 167262009
1+ (finding) CID 167264005
2+ (finding) CID 167265006
3+ (finding) CID 167266007
4+ (finding) CID 167267003

44966-0 EDEMA-FIND-PT-^PATIENT-ORD- CO   SNOMED CT

trace edema 44996-0
1+ pitting edema 420829009
2+ pitting edema 421605005
3+ pitting edema 421346005
4+ pitting edema 421129002

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
This text needs to be fixed-->>TODO:<<--