1.3.6.1.4.1.19376.1.5.3.1.4.13.5

From IHE Wiki
Jump to: navigation, search

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

Trial.gif Pregnancy Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.5

A pregnancy observation is a Simple Observation that uses a specific vocabulary to record observations about a patient's pregnancy history.


Parent Template

The parent of this template is Simple Observation.

Uses

See Templates using Pregnancy Observation

Specification
Pregnancy Observation Example

<observation classCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5'/>
 <id root=' ' extension=' '/>
 <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type=' ' .../>
 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
</observation>


<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5'/>

These <templateId> elements identify this <observation> as a pregnancy observation, allowing for validation of the content. The <templateId> elements shall be recorded as shown above.

<code code=' ' displayName=' '
  codeSystem='2.16.840.1.113883.6.1'
  codeSystemName='LOINC'/>

A pregnancy observation shall have a code describing what facet of patient's pregnancy history is being recorded. These codes should come from the list of codes shown below. Additional codes may be used to reflect additional information about the pregnancy history.

Pregnancy Observation Codes
LOINC CODE Description Type Units or Vocabulary
Summary over All Pregnancies
11636-8 BIRTHS LIVE (REPORTED) INT
N/A
11637-6 BIRTHS PRETERM (REPORTED)
11638-4 BIRTHS STILL LIVING (REPORTED)
11639-2 BIRTHS TERM (REPORTED)
11640-0 BIRTHS TOTAL (REPORTED)
11612-9 ABORTIONS (REPORTED)
11613-7 ABORTIONS INDUCED (REPORTED)
11614-5 ABORTIONS SPONTANEOUS (REPORTED)
33065-4 ECTOPIC PREGNANCY (REPORTED)
Detailed Pregnancy Data
11449-6 PREGNANCY STATUS CE SNOMED CT, ICD-9-CM (V22)
8678-5 MENSTRUAL STATUS SNOMED CT
8665-2 DATE LAST MENSTRUAL PERIOD TS
N/A
11778-8 DELIVERY DATE (CLINICAL ESTIMATE) TS
11779-6 DELIVERY DATE (ESTIMATED FROM LAST MENSTRUAL PERIOD)
11780-4 DELIVERY DATE (ESTIMATED FROM OVULATION DATE)
11884-4 FETUS, GESTATIONAL AGE (CLINICAL ESTIMATE) PQ d, wk or mo
11885-1 FETUS, GESTATIONAL AGE (ESTIMATED FROM LAST MENSTRUAL PERIOD)
11886-9 FETUS, GESTATIONAL AGE (ESTIMATED FROM OVULATION DATE)
11887-7 FETUS, GESTATIONAL AGE (ESTIMATED FROM SELECTED DELIVERY DATE)
45371‑2 MULTIPLE PREGNANCY
<repeatNumber value=' '/>

The <repeatNumber> element should not be present in a pregancy observation.

<value xsi:type=' ' .../>

The value of the observation shall be recording using a data type appropriate to the coded observation according to the table above.

<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <interpretationCode>, <methodCode>, and <targetSiteCode> should not be present in a pregnancy observation.