Antepartum Summary Volume 2

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Draft.gif Volume II

Contents

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

Trial.gif 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
CCD ASTM/HL7 Continuity of Care Document
CDAR2 HL7 CDA Release 2.0
ACOGAR American College of Obstretricians and Gynecologists (ACOG), Antepartum Record
LOINC Logical Observation Identifiers, Names and Codes
SNOMED Systemized Nomenclature for Medicine
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.

Sample Antepartum Summary Document
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2'/> <id root=' ' extension=' '/> <code code='XX-APS' displayName='Antepartum Summary' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Antepartum Summary</title> <effectiveTime value='20200712012005'/> <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='1.3.6.1.4.1.19376.1.5.3.1.3.13'/> <!-- Required Allergies Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/> <!-- Required Advance Directives Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/> <!-- Required Plan of Care Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/> <!-- Required Medications Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/> <!-- Required Problems Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1'/> <!-- Required Estimated Delivery Dates Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2'/> <!-- Required Antepartum Visit Summary Flowsheet Section content --> </section> </component>
    </structuredBody></component> </ClinicalDocument>
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 http://www.ihe.net/Technical_Framework/index.cfm#PCC

Trial.gif 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.



Sample Estimated Delivery Dates Section
<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 http://www.ihe.net/Technical_Framework/index.cfm#PCC

Trial.gif 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.



Sample Visit Summary Section
<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

Trial.gif 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
EDD Observation Example

<observation classCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1'>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <author typeCode='AUT'>
   <time value=' '/>
   <assignedAuthor>
     <id root=' ' extension=' '/>
   </assignedAuthor>
 </author>
 <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'>
        <time value=' '/>
        <assignedAuthor classCode=' '>
          <id root=' ' extension=' '/>
        </assignedAuthor>
     </author>
     <code code='[11779-6|(xx-EDD-by-PE)|11781-2|(xx-EDD-by-Qck)|(xx-EDD-by-Fund)]'
           codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
     <value type='TS' value=' '>
     <entryRelationship typeCode='DRIV'>
       <observation  classCode='OBS' moodCode='EVN'>
         <id root=' ' extension=' '/>
         <statusCode code='completed'/>
         <effectiveTime value=' '/>
         <author typeCode='AUT'>
           <time value=' '/>
           <assignedAuthor>
             <id root=' ' extension=' '/>
           </assignedAuthor>
         </author>
         <informant typeCode='INF'>
           <relatedEntity classCode=' '>
             <id root=' ' extension=' '/>
           </relatedEntity>
         </informant>
         <code code='[8655-2|(xx-ga-by-pe)|11888-5|(xx-date-of-qck)|(xx-date-of-fund-umb) ]' 
               codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
         <value type='[PQ|TS]' value=' ' units='week'/>
       </observation>
     </entryRelationship>
   </observation>
 </entryRelationship>
</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'><time value=' '/></author>

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=' '/>

The <repeatNumber> <interpretationCode>, and <targetSiteCode> elements should not be present in a EDD observation.

Schematron
This text needs to be fixed-->>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

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:<<--

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 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
Simple Observations Example
<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.