Talk:Antepartum Record

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5/5/2009: applied CP-PCC-0048


Action Items

  • for Glossary terms:
    • Review terms and define as if being read outside of AR profile
    • Anne: Spell out abbreviations - is this done?
    • Review definitions for context definitions
    • Anne: Use consistent tense across all terms
  • for Volume I:
    • Anne: address "todo" labels
    • Anne: internationalize intro
    • Anne: Quick summary for use case at beginning of each
  • for Volume II:
    • Tone: add data type columns to data element tables this likely needs further analysis
    • Tone: restructure Medical History section to use the data element as the <value>
    • Keith/Larry/Tone: determine how to handle "not asked" for medical history (and other) elements. using negation indicator
    • Tone: determine which elements are required and which are optional for APH&P
    • Tone: Align APL with XD-LAB? may need some additional wording
    • Tone: Discuss and determine direction to go on APE - can we use the current PCC education structure?
    • Tone: Include additional psych-social coded elements in Social History (mental illness, homelessness, etc.)
    • Tone: Input Lab LOINC codes from spreadsheet
    • Tone: Input Education snomed codes from spreadsheet
    • Tone/Christine: Review and finalize snomed codes for APH&P
    • Tone/Christine: Review and finalize snomed codes for APE
    • Tone/Mike Jolley: Review and finalize LOINC codes for APL
    • Tone: move Gynelogical/Menstrual History to ROS
    • Tone: Finish examples for:
      • Medical History
      • Review of Systems
      • Physical Examination
      • Vital Signs
    • Tone: optional coded procedures in Medical History for Gyn Surgery and Operations/Hospitalizations
    • Tone: add raceCode in addition to ethnicityCode
    • Tone: Create new section for infection history/History of Infection
    • Tone: Move Genetic Screening out of ROS and into new section. this section was moved into Family History instead
    • Anne: Picture for process flow


Form A&B History and Physical

TODO:

  • Align PCC(CRS) Header with with CDA4CDT Header - i think it will be just the inclusion of a couple of nodes
  • Add discrete data elements in tables
  • Generate example xml

Spreadsheets and other files

Technical Notes/Questions

  • proposing to use CDA4CDT H&P for much of this
  • need to define Gynecological History
  • some LOINCs were found in last years work, but what about those fields which do not have LOINC codes? should we compose a list and submit for new codes?
  • (4/18 ts from discussion with Mike Jolley) Should we consider using Snomed codes here as there may be more codes available?
  • Alschuler Associates to review and provide feedback
  • (4/14 ts) - Remapped the ACOG data elements to CDA4CDT elements
  • (4/18 ts) I see 3 options here for the basic structure for basing this on CDA4CDT History & Physical:
    • Reference all CDA4CDT H&P sections and extend where necessary - this will have circular references - (i.e. CDA4CDT Review of Systems references IHE Review of Systems)
    • Reference CDA4CDT only where not found in IHE - and extend both the CDA4CDT and IHE sections where necessary
    • Mix and match CDA4CDT and IHE sections where appropriate
  • (4/18 ts) Is it ok to reference CDA4CDT piecemeal? (i.e. only reference sections applicable to APS)
  • (5/9 ts) There are 2 sections regarding Pregnancy History on Form A
    • Gravida Para Abortus (just above Menstrual History)
      • This is a summary of the past pregnancies and even though it may often be extracted from the Past Pregnancy Section, it needs its own section as many emr systems and clinics may not collect detailed Past Pregnancy History
      • Should add a data element here for Live Births
    • Past Pregnancy History
      • This is detailed information about the past pregnancies
      • Should be a Required if Known section as some emr systems and/or clinics will not capture this information


from T-Conn 4/18/08 (ts)
  • there should be 2 document specifications
    • the PCC generic History and Physical template
    • the APS specific History and Physical template that further constrains the generic one
  • The goal of this approach is to have a PCC document that is also compliant with the CDA4CDT H&P that is currently in DSTU
  • Need to be careful to avoid copyright issues
  • will include Medications and Allergies - from an APS perspective this means these sections will be in both this document and the Form C document, but that's ok.
  • This document needs to stand on its on and not be tied directly to the CDA4CDT - this is to facilitate an easier implementation

Clinical Questions

  • (4/25 ts) Are there any additional Genetic Screen/Teratology Counseling items other than what is on Form B to be considered?
from Clinical T-Conn 5/1/08 (ts)
  • Add these to the Genetic Screening/Teratology Counseling List:
    • Hydrocephaly
    • History of cleft Lip or palate
    • Polycystic kidney disease
    • PKU for infant is being considered, but since this is an antepartum (and not postpartum) record it does not really apply here
  • Mike Jolley has found some Snomed codes for Forms A&B
  • Be careful with Physical Education so that it is not constrained to "normal" and "abnormal" checkboxes as displayed on the form. Should allow for emr systems that do not capture data in this particular format



Form D Labs

Spreadsheets and other files

Technical Notes/Questions

  • using LOINC coding for this
  • (4/18 ts) Please advise which specific labs sample results are needed for and I can provide.
  • (4/18 ts) Mike Jolley has scheduled meeting with Intermountain folks to review LOINC codes
  • (5/8 ts) My thoughts are that we can only provide a "suggested use" list of loinc codes because of the variety of methods of administration and results. There does need to be a section code specifying this is an antepartum specific lab results document though.
  • (5/8 ts) After a discussion with Clem McDonald, I am thinking that a Survey Panel with an entry that can have multiple procedures should be used instead of just an entry with multiple procedures. This will allow for labs that are administered in panels.
  • (5/14 ts) Mike Jolley suggests: to allow for using proprietary codes and LOINC codes to aid in the transition to a standards only coding system

Clinical Questions

From Clem McDonald 4/4:

  • Presume that chlaymdyia and GC is asking for DNA testing for the presence of those organisme
  • And that the rubella and varicella is asking for the antibodies not the antigens
  • The triple screen is an old thing- and believe that most people now do a quad screen or better.
  • Don't understand hemoglobin as an optional test since it is included in the required tests HCT/Hgb/MCV (hgb is an abbreviation for hemoglobin)
  • am not sure what kind of test they are doing regarding cystic fibrosis, tay sachs familial dysautomina. Are those tests on mother or father?
  • Questions about family history or tests on the fetus s?


From Tone Southerland 4/8:

  • Need to discuss and understand why the lab results are split into groups to help determine appropriate way to represent the data in the CDA document.
    • Should it be a collection of panels - each panel representing a group (24-28 Weeks, etc.)? This approach is needed if the same lab can be administered at multiple times in a pregnancy with results that can be interpreted differently based on that administration time frame.
    • Or should they all be simple observations and let the implementers determine which group the lab belongs in based on the effectiveTime?
from Clinical T-Conn 5/1/08 (ts)
  • After much discussion it was decided to not use the ACOG lab groupings, but instead to specify in the PCC framework that the lab results are to be rendered by the content consumer in date order from earliest to latest to resemble the ACOG groupings. The ACOG groupings are laid out to guide the provider on when to perform the labs - so they are generally administered from earliest to latest date by weeks gestation.
  • Each lab result will have a verifier, or a signoff - if an EMR system uses a document or encounter level signoff then that provider is to also act as the signoff for the individual labs. To much degree this is up to the implementer - we just need to provide a method to implement this.
  • The date to be used for the lab tests is the order or sampling date - NOT the date the result was received
  • Mike Jolley is working on finalizing the LOINC codes and after review with Intermountain folks (and maybe others) will submit to the group for approval



Form E Education

Spreadsheets and other files

  • currently this spreadsheet does not have any codes:

media:APS_Field_Mapping_Form_E.xls

Technical Notes/Questions

  • proposing to use Snomed coding for this.
  • (4/11 ts) Keith is to write a new general education section (i think..) that APS Education can further constrain
from T-Conn 5/2/08 (ts)
  • Keith has not had time to write general education section so Tone is going to look into it
  • Tone mentioned that we should not use the ACOG trimester groupings and it was accepted that this is the way to go.
  • Keith mentioned not to use the existing Patient Education and Consents sections already written - Tone is still not sure why yet... need more discussion here
  • Should consents be lumped in with education?
  • Keith proposes to add a new section for education in either APH&P or APS profiles. Larry, Tone disagreed as this doesn't allow for reuse in other content profiles.


Clinical Questions

  • (4/18 ts - from discussion with Mike Jolley) The top of Form E states "Plans/Education" - Which are plans? Which are education? This is important as it will help to determine how to code these data elements.
from Clinical T-Conn 5/1/08 (ts)
  • This is an education list, and not a plan list. All plans should be listed in the APS document under Plan of Care
  • It was proposed to add Tubal Sterilization Consent to this document as well as other consents (circumcision, etc.). I disagree with this and think it needs further discussion. Two other options were mentioned:
    • Include with or near the Advanced Directives section in the APS document - this would be a change proposal
    • Create a separate Antepartum Consent document (another profile) - I don't think we have time this year
  • Mike Jolley will work on Snomed codes




UHIN Perinatal Data Elements

The link below contains a list of perinatal data elements identified as being important by UHIN, courtesy of Dr. Scott Williams of Hospital Corporation of America. media:UHIN Perinatal Data Elements.xls

The table below lists the data elements and maps them into the current work.

Section Name Data Element Identifier Sub-Section Data element Usage Found in
APR/APS
Where?
Patient Demographics
PD1 Intake History Date
Date the patient first encountered the office for the index pregnancy.
Required
Repeat 1
APR serviceEvent/effectiveTime
PD2 Current Patient Name (Last, First, MI) - Name may change Required
Repeat n >=1
Please include all if there are more than one.
APR patient/name
PD3 Alias(s) Patient Name (Last, First, MI) - Name may change Optional
Repeat n >=1
APR patient/name
PD4 Maiden patient name Optional
Repeat 1
APR patient/name
PD5 Clinic medical record number
Specify Site (free text)
Optional
Repeat n >1
APR patientRole/id
PD6 Current Primary OB Provider
Primary OB Provider (keep a history; associated with primary OB provider)
Required
Repeat n >=1
Please include all if there are more than one.
APR performer/assignedPerson/name
Current Primary OB National Provider Identifier APR performer/id
PD7 Current Primary OB Provider Group Optional
Repeat n >=1
APR performer/representedOrganization
Other Previous Prenatial Provider(s) with Dates Optional
Repeat n>=1
performer/time
PD8 Newborn Physician Optional
Repeat n >=1
performer
PD9 Referred By Optional
Repeat 1
performer
PD10 Intended Facility For Delivery Optional
Repeat 1
PD11 Hospital medical record number
Specify Site (Free Text)
Optional
Repeat 1
PD12 Master patient index number (may be organization specific now) Optional
Repeat 1
PD13 Mothers Date of Birth Required
Repeat 1
patient/birthTime
PD14 Father's Date of Birth (MO/Day/Yr) Optional
Repeat 1
PD15 Mother of Baby Race Optional
Repeat n >=1
patient/raceCode
PD16 Father of Baby -Race Optional
Repeat n >=1
See XPHR for FH
PD18 Marital Status (S/M/W/D/SEP)
Keep history
Optional
Repeat n >=1
patient/maritalStatus
PD19 Mother of Baby- Occupation Optional
Repeat n >=1
See XPHR for FH
PD20 Father of Baby- Occupation Optional
Repeat n >=1
See XPHR for FH
PD21 Mother of Baby - Yrs of School Optional
Repeat 1
See XPHR for FH
PD22 Father of Baby - Yrs of School Optional
Repeat 1
See XPHR for FH
PD23 Mother of Baby Religion Optional
Repeat n >=1
patient/religiousPreferenceCode
PD24 Father of Baby Religion Optional
Repeat n >=1
See XPHR for FH
PD25 Mother's of Baby- Language Optional
Repeat n >=1
patient/languageCommunication
PD26 Husband/Domestic Partner Name (Last, First, Mi) Optional
Repeat 1
participant/participantRole/associatedPerson/name
PD27 Husband/Domestic Partner Phone Optional
Repeat n >=1
participant/participantRole/associatedPerson/name
PD28 Father of Baby (Last, First) Optional
Repeat 1
participant/participantRole/associatedPerson/name
PD29 Father of Baby Phone Optional
Repeat n >=1
participant/participantRole/associatedPerson/name
PD30 Maternal GrandMother's Name Optional
Repeat 1
See XPHR for FH
PD31 Maternal Grandmothers DOB Optional
Repeat 1
See XPHR for FH
PD32 Maternal Grandfather's Name Optional
Repeat 1
See XPHR for FH
PD33 Maternal Grandfather's DOB Optional
Repeat 1
See XPHR for FH
PD34 Paternal Grandmother's Name Optional
Repeat 1
See XPHR for FH
PD35 Paternal Grandmother's DOB Optional
Repeat 1
See XPHR for FH
PD36 Paternal Grandfather's Name Optional
Repeat 1
See XPHR for FH
PD37 Paternal Grandfaters DOB Optional
Repeat 1
See XPHR for FH
PD38 Patient Living Address Optional
Repeat n >=1
patientRole/addr
PD39 Patient Mailing Address Optional
Repeat n >=1
patientRole/addr
PD40 Patient State Optional
Repeat n >=1
patientRole/addr/state
PD41 Patient Zip Optional
Repeat n >=1
patientRole/addr/postalCode
PD42 Residence of mother - Country Optional
Repeat n >=1
patientRole/addr/country
PD43 Patient Home Phone Optional
Repeat n >=1
patientRole/telecom
PD44 Patient Cell Phone Optional
Repeat n >=1
patientRole/telecom
PD45 Patient Work Phone Optional
Repeat n >=1
patientRole/telecom
PD46 Insurance Carrier
Need a code for self-pay. Looping
Optional
Repeat n >=1
See XPHR for Payers
PD47 Policy Holder Name Optional
Repeat n >=1
See XPHR for Payers
PD48 Group Number Optional
Repeat n >=1
See XPHR for Payers
PD49 Policy Optional
Repeat n >=1
See XPHR for Payers
PD50 Emergency Contact Name Optional
Repeat n >=1
See XPHR for Contacts
PD51 Emergency Contact Phone Optional
Repeat n >=1
See XPHR for Contacts
PD52 "Did Mother get WIC food for herself" with the following qualifiers: Y, N, U Optional
Repeat n >=1
PERSONAL MEDICAL HISTORY Send only positive responses - otherwise do not send
All these should be in alphabetical order and include details for each disorder below in box
PMH1 Alcohol (amt/day pre preg; amt/day preg; years use, binge drinking (Y/N) freq) More than Y/N answer Optional
Repeat 1
PMH2 Anesthesia Complications Optional
Repeat 1
See prior work on PPHP
PMH3 Autoimmune Disorder Optional
Repeat 1
PMH4 Breast Self Exam (yes or no) and freqency Optional
Repeat 1
PMH5 Blood Disorder Optional
Repeat 1
PMH6 Bladder Infections (1 or greater than 1) Optional
Repeat 1
PMH7 Breast disease/surgery Optional
Repeat 1
PMH8 Cancer/history of abnormal pap smear Optional
Repeat 1
PMH9 Cancer History Optional
Repeat n >=1
PMH10 Cardiac disease Optional
Repeat 1
PMH11 Chemical or radiation exposure history
Free Text 240 Characters
Optional
Repeat n >=1
PMH12 Depression Optional
Repeat 1
PMH13 Diabetes type 1 Optional
Repeat 1
PMH14 Diabetes type 2 Optional
Repeat 1
PMH15 Emotional and/or physical abuse Optional
Repeat 1
PMH16 Gastrointestinal disease Optional
Repeat 1
PMH17 GYN Surgery Optional
Repeat 1
PMH18 History Blood transfusion Optional
Repeat 1
PMH19 Infectious diseases Optional
Repeat 1
PMH20 Illicit/recreational drugs (amt/day pre preg; amt/day preg; years use) More than Y/N answer Optional
Repeat 1
PMH21 Infertility Optional
Repeat 1
PMH22 History of Eating Disorder
Dates
Optional
Repeat n >=1
PMH23 Hypertension Optional
Repeat 1
PMH24 Hypothyroid Optional
Repeat 1
PMH25 Hyperthyroid Optional
Repeat 1
PMH26 Kidney disease Optional
Repeat 1
PMH27 Known uterine malformation Optional
Repeat 1
PMH28 Liver disease Optional
Repeat 1
PMH29 Neurologic/Seizure Disorder Optional
Repeat 1
PMH30 Religious objections to medical treatment
Text
Optional
Repeat 1
PMH31 Special Diet Requirements
Text
Optional
Repeat 1
PMH32 Operations/hospitalizations (year & reason) Optional
Repeat 1
PMH33 Other psychiatric problems Optional
Repeat 1
PMH34 Organ transplant Optional
Repeat 1
PMH35 Previous uterine surgery (excludes previous C-section) (check box for yes or no) Optional
Repeat 1
PMH36 Pulmonary Disease Asthma Optional
Repeat 1
PMH37 Pulmonary Disease other than Asthma Optional
Repeat n >=1
PMH38 Stroke Optional
Repeat 1
PMH39 STD - All Optional
Repeat 1
PMH40 Thrombosis/varicosities/embolism/ phlebitis Optional
Repeat 1
PMH41 Tobacco Use
amt/day pre preg;
amt/day 1st Trimester
amt/day 2nd Trimester
amt/day 3rd Trimester
years use
stop date:___
Optional
Repeat 1
PMH42 Thyroid disease Optional
Repeat 1
PMH43 Unintentional injury Optional
Repeat 1
PMH44 Other _______________ Optional
Repeat 1
INFECTION HISTORY General Comment section for Infection History
(also include a comments field)
IH1 Gential herpes Optional
Repeat 1
IH2 Live with someone with TB or exposed to TB Optional
Repeat 1
IH3 Other Infections:______________ Optional
Repeat 1
IH3 Partner with genital herpes (Y) Optional
Repeat 1
IH4 Rash or viral illness since last menstrual period
(also include a comments field)
Optional
Repeat 1
ALLERGIES REACTIONS General Comment section for Allergies/Reactions
AR 1 Drug allergies/reactions Optional
Repeat 1
APS
AR 2 Food allergies Optional
Repeat 1
APS
AR 3 Latex allergies/reactions Optional
Repeat 0
APS
AR 4 Seasonal allergies Optional
Repeat 1
APS
AR 5 Other allergies/reactions Optional
Repeat 1
APS
Medication History Optional
Repeat n >=1
MH1 Medication Name
This includes vitamins or herbs
APS
MH2 Dose Optional
Repeat 1
APS
MH3 Start Optional
Repeat 1
APS
MN4 Stop Optional
Repeat 1
APS
MH5 Optional
Repeat n >=1
Anti-D immune globulin (RhIG) given or date refused and 28 wks date (Result column has signature __________ blank line space) Optional
Repeat n>=1
MH6 MMR (date) Optional
Repeat n >=1
See XPHR for Immunizations
MH7 Tetnus (date) Optional
Repeat n >=1
See XPHR for Immunizations
OBSTETRICAL HISTORY FOR EACH PAST PREGNANCY
OH1 Pregnancy Order Optional
Repeat 1
APR
OH2 Anesthesia Type:
None
Spinal
Epidural
General
Local
IV Sedation
Other
A,b,c,d,e for multiple births
Optional
Repeat n >=1
OH3 Date Month/Year
(none, epideral, general, narcotics, other ____
Optional
Repeat 1
APR
OH4 Delivery Type:
vag
operative vaginal
c-section - Scar Type+F182
Separate fields for day, month and year
Optional
Repeat n >=1
OH5 Birth Weight
Pounds and Ounces
Vaginial, c-section, vacuum, forceps (check all that apply)
Optional
Repeat 1
OH6 GA Weeks Optional
Repeat 1
OH7 Gender M/F/U Optional
Repeat 1
OH8 Labor Length Units are hours Optional
Repeat 1
OH9 Placed of Birth (Hospital, City/State)
(Hours)
Optional
Repeat 1
OH10 Pregnancy outcome:
liveborn
stillborn
miscarriage
abortion
Ectopic
Optional
Repeat 1
OH11
Still living (Y/N) If no death prior to 28 days.
live, stillbirth, miscarriage, ectopic,
Optional
Repeat 1
OH12 Previous cervical cerclage surgery Optional
Repeat n >=1
OH13 How many months did it take you to achieve this pregnancy? (______months) (Please count the number of months in which intercourse occurred without using a contraceptive method. Also count months with any kind of medical treatment to get pregnant. If the pregnancy occurred while you were using a contraceptive method, answer 0.) Optional
Repeat n >=1
OH14 Did you utilize infertility treatments to achieve this pregnancy? If yes, choose all that apply from the following options:
oral ovulation induction drug - clomiphene citrate (Clomid, Serophene), letrazole (Femora), anastrazole (Arimidex)
insulin sensitizing agent metformin (Glucophage), roziglitazone (Avandia), pioglitazone (Actos)
an injectable fertility drug (gonadotropin) human menopausal gonadotropin (hMG), follicle stimulating hormone (FSH)
human chorionic gonadotropin (hCG) to trigger ovulation or support your early pregnancy?
progesterone supplementation (intramuscular [IM], vaginal, oral) during your attempt to become pregnant or during this pregnancy?
artificial insemination
In Vitro Fertilization (IVF)
In Vitro Fertilization (IVF) with intracytoplasmic sperm injection (ICSI)
Gamete Intrafallopian Transfer (GIFT)
Zygote Intrafallopian Transfer (ZIFT)
(You may choose as many treatments used specifically for this pregnancy. Do not include other treatments that occurred prior to this pregnancy.)
Optional
Repeat n >=1
COMPLICATION OF ANY PREGNANCY Newborn problems - when known to have occurred in any pregnancy - include preganacy number Include Pregnancy number and fetus number
CPN1 Newborn Problems Admit to NICU Optional
Repeat n >=1
CPN2 Newborn Problems Anemia Optional
Repeat n >=1
CPN3 Newborn Problems Anencephaly Optional
Repeat n >=1
CPN4 Newborn Problems Asphyxia, in liveborn infant Optional
Repeat n >=1
CPN5 Newborn Problems Aspiration - Meconium Optional
Repeat n >=1
CPN6 Newborn Problems Aspiration - Other Optional
Repeat n >=1
CPN7 Newborn Problems Birth Injury - Brachial Plexy Injury Optional
Repeat n >=1
CPN8 Newborn Problems Birth Injury - Cephalhematoma Optional
Repeat n >=1
CPN9 Newborn Problems Birth Injury - Other Optional
Repeat n >=1
CPN10 Newborn Problems Cardiac defect Optional
Repeat n >=1
CPN11 Newborn Problems Cerebral palsy Optional
Repeat n >=1
CPN12 Newborn Problems Congenital abnormality Optional
Repeat n >=1
CPN13 Newborn Problems Chromosomal abnormality Optional
Repeat n >=1
CPN14 Group B Strep Optional
Repeat 1
CPN15 Newborn Problems Hyperglycemia Optional
Repeat n >=1
CPN16 Newborn Problems Hypoglycemia Optional
Repeat n >=1
CPN17 Newborn Problems Hypovolemia Optional
Repeat n >=1
CPN18 Newborn Problems Immune/alloimmune Thrombocytopenia Optional
Repeat n >=1
CPN19 Newborn Problems Isoimmunization - ABO newborn Optional
Repeat n >=1
CPN20 Newborn Problems Isoimmunization - Rh Newborn Optional
Repeat n >=1
CPN21 Newborn Problems Isoimmunization - Other newborn Optional
Repeat n >=1
CPN22 Labor complications IUGR - move to past preg newborn problems Optional
Repeat 1
CPN23 Newborn Problems Jaundice Optional
Repeat n >=1
CPN24 Labor complications Previous infant with GBS infection - move to past preg newborn problems Optional
Repeat n >=1
CPN25 Newborn Problems Respiratory Distress Syndrome Optional
Repeat 1
CPN26 Newborn Problems Sepis Optional
Repeat 1
CPN27 Newborn Problems Thrombocytopenia Optional
Repeat 1
CPN28 Newborn Problems Transitory Tachypnea of newborn Optional
Repeat 1
CPN29 Newborn Problems Other newborn problems Optional
Repeat 1
COMPLICATION OF ANY PREGNANCY Fetal problems - when known to have occurred in any pregnancy - include preganacy number
CPF1 Anencephaly Optional
Repeat n >=1
CPF2 Fetal demise Optional
Repeat 1
CPF3 Fetal surgery Optional
Repeat 1
CPF4 Cardiac defect Optional
Repeat n >=1
CPF5 Congenital abnormality Optional
Repeat n >=1
CPF6 Chromosomal abnormality Optional
Repeat n >=1
CPF7 History of polyhydramnios - move to past preg newborn problems Optional
Repeat n >=1
CPF8 History of oligohydramnios - move to past preg newborn problems
CPF9 IUGR - move to past preg newborn problems Optional
Repeat 1
CPF10 Other fetal problems Optional
Repeat 1
CPF11 Macrosomia Optional
Repeat 1
CPF12 twin to twin transfusion Optional
Repeat 1
Maternal Complication of Past Pregnancies Maternal Problems Include when known to have occurred in any pregancy include pregancy number
MC1 Maternal Problems Bleeding requiring hospitalization
Required transfusion
Optional
Repeat 1
MC2 Maternal Problems Chorioamnionitis Optional
Repeat 1
MC3 Maternal Problems DES exposure Optional
Repeat 1
MC4 Depression/Postpartum (check box for yes or no) Optional
Repeat 1
MC5 Maternal Problems Endometritis Optional
Repeat n >=1
MC6 Maternal Problems GBS Carrier Optional
Repeat n >=1
MC7 Maternal Problems Gestational Diabetes Optional
Repeat n >=1
MC8 Maternal Problems Hyperemesis Gravidarum Optional
Repeat n >=1
MC9 Maternal Problems Incompetent cervix Optional
Repeat n >=1
MC10 Maternal Problems PROM (>+37 wks) Optional
Repeat 1
MC11 Maternal Problems P-PROM (<37 wks) Optional
Repeat 1
MC12 Maternal Problems Placenta Accreta Optional
Repeat 1
MC13 Maternal Problems Placental Abruption - antepartum Optional
Repeat 1
MC14 Maternal Problems Placenta previa Optional
Repeat 1
MC15 Maternal Problems Postpartum hemorrhage
Required transfusion
Optional
Repeat 1
MC16 Maternal Problems Preeclampsia Optional
Repeat n >=1
MC17 HELLP Syndorme Optional
Repeat n >=2
MC18 Maternal Problems Preterm labor symptoms Optional
Repeat n >=1
MC19 Maternal Problems Pulmonary embolism Optional
Repeat n >=1
MC20 Maternal Problems Pyelonephritis Optional
Repeat n >=1
MC21 Maternal Problems Trauma during pregnancy Optional
Repeat n >=1
MC22 Maternal Problems Urinary Tract infection Optional
Repeat n >=1
MC23 Maternal Problems Uterine atony Optional
Repeat n >=1
MC24 Maternal Problems Uterine Inversion Optional
Repeat n >=1
MC25 Maternal Problems Vaginal infection Optional
Repeat n >=1
MC26 Maternal Problems Other maternal problems Optional
Repeat n >=1
Labor complications of any past pregnancy Labor complications Include when known to have occurred in any pregancy
include pregancy number
LC1 Labor complications Amniotic fluid embolism Optional
Repeat n >=1
LC2 Labor complications Cord prolapse Optional
Repeat n >=1
LC3 Labor complications Elevated maternal temperature Optional
Repeat n >=1
LC4 Labor complications Failed forceps delivery Optional
Repeat n >=1
LC5 Labor complications Failed vacuum delivery Optional
Repeat n >=1
LC6 Labor complications Inadvertant Cystomy Optional
Repeat n >=1
LC7 Labor complications Labor Dystocia (failure to progress) Optional
Repeat n >=1
LC8 Labor complications Non- reassuring fetal heart rate Optional
Repeat n >=1
LC9 Labor complications Placental Abruption intrapartum Optional
Repeat n >=1
LC10 Labor complications Post-partum hemorrhage Optional
Repeat n >=1
LC11 Labor complications Precipitous delivery Optional
Repeat n >=1
LC12 Labor complications Shoulder dystocia Optional
Repeat 1
LC13 Labor complications Uterine Rupture Optional
Repeat 1
LC14 Labor complications Vasa Previa Optional
Repeat 1
LC15 Labor complications 4th degree Vaginal laceration Optional
Repeat n >=1
LC16 Labor complications Other labor complications Optional
Repeat n >=1
RISK FACTORS For preterm birth
(also include a comments field)
Other risk factors need to be pulleed in here for presentation
RFP1 2 or more abortions requiring D & C Optional
Repeat 1
RFP2 Labor complications Age less than 18 or greater than 35 Optional
Repeat 1
RFP3 Labor complications Black race Optional
Repeat 1
RFP4 Labor complications Cervical insufficiency Optional
Repeat 1
RFP5 History of STDs Optional
Repeat 1
RFP6 Prior preterm birth (less than 37 weeks) Optional
Repeat 1
RFP7 Weight less than 120 pounds Optional
Repeat 1
RISK FACTORS For general adverse pregnancy Outcomes Need to pull items from other sections for presentation
RFG1 Labor complications Infertility greater than one year
RFG2 Labor complications Infertility: Asst. Rep. Technology
RFG3 Labor complications Morbid Obesity
Also include a comments field
RFG4 Labor complications Other Risk Factors:_______________ Optional
Repeat n >=1
Menstrual History
MNH1 Menarche (Age onset) Optional
Repeat 1
MNH2 Menses Regular (Y/N); Optional
Repeat 1
MNH3 Usual Duration of the Cycle (days) Optional
Repeat 1
MNH4 Usual Duration of the Bleeding (days) Optional
Repeat 1
Gestational Age Determinants
GAD1 LMP Last Menstrual Period Date
Definite
Approximate
Unknown
Optional
Repeat 1
GAD2 Normal amount/duration of LMP (Y/N) Optional
Repeat 1
GAD3 Hormonal contraceptive at conception (Y/N) Optional
Repeat 1
GAD4 Estimated gestational age by LMP Optional
Repeat 1
GAD5 Estimated due date by LMP Optional
Repeat n >1
GAD6 PG Test Positive (Date) Optional
Repeat 1
GAD7 1st Visit Optional
Repeat 1
GAD8 Date of Ultrasound Optional
Repeat n >=1
GAD9 Estimated gestational age by ultrasound Optional
Repeat n >=1
GAD10 Estimated due date by ultrasound Optional
Repeat n >=1
GAD11 gestational age
calculated field based on EDD
GAD12 Quickening - date
GAD13 fundal height at umbilicus - date
GAD14 Final EDD (Date) Current Optional
Repeat n >=1
GAD15 Final EDD Method based on
Options listed LMP,
Ultrasound,
Positive PG test,
Quickening (Fetal Movement)
Optional
Repeat n >=1
GAD16 Date of Last Revision Optional
Repeat n >=1
Genetic/Teratology Screening Check box throughout for Patient and baby's father and any family members from either mother or father - send if known to be present
radiation exposure in 1st trimester
Also include a comments field for each field below
GTS1 Prescription drugs, supplements, vitamins, herbs, OTC drugs)/illicit/recreational drugs/alcohol since last menstrual period
List all
Optional
Repeat n >=1
GTS2 Family Hx of birth defects Optional
Repeat n >=1
GTS3 Tay sachs (check if positive or abnormal) Optional
Repeat n >=1
GTS4 Sickle cell trait/disease (check if positive or abnormal) Optional
Repeat n >=1
GTS5 Thalassemia (check if positive or abnormal) Optional
Repeat n >=1
GTS6 Huntington chorea Optional
Repeat n >=1
GTS7 Cystic Fibrosis Optional
Repeat n >=1
GTS8 Muscular Dystrophy Optional
Repeat n >=1
GTS9 Hemophilia or other blood disorders Optional
Repeat n >=1
GTS10 Neural tube defect (meningomyelocele, spina bifida, or anencephaly) Optional
Repeat n >=1
GTS11 Down syndrome Optional
Repeat n >=1
GTS12 Hydrocephaly Optional
Repeat n >=1
GTS13 Congenital heart defect Optional
Repeat n >=1
GTS14 Is there a family hisotry Mental retardation/autism Optional
Repeat n >=1
GTS15 Is there a f+E313amily history of fragile X? Optional
Repeat n >=1
GTS16 Other inherited genetic or chromosomal disorder (check yes or no)
metabolic disorder (eg, type 1 diabetes, pku) (check yes or no)
Optional
Repeat n >=1
GTS17 Maternal metabolic disorder (eg, type 1 diabetes, pku) Optional
Repeat n >=1
GTS18 Any other Please list: Optional
Repeat n >=1
GTS19 Canavan disease
GTS20 Familial Dysautonomia
chicken pox or immunization (yes or no)
GTS21 Maternal history of chicken pox during this pregnancy Optional
Repeat n >=1
GTS DES exposure (yes or no) Optional
Repeat 1
GTS PKU (yes/ no ) Mother Optional
Repeat n >=1
GTS DES exposure (yes or no) Optional
Repeat 1
GTS PKU (yes/ no ) Other Child Optional
Repeat n >=0
Physical Examination Send all elements with value of
Normal = N
Abnormal = A
Not Performed = NP
Optional
Repeat n>=1
PE1 Additional physical Exam Date Optional
Repeat n >=1
PE2 Mother's Height
PE3 Mother's current weight"
PE4 Mother's Prepregnancy weight Optional
Repeat 1
PE5 BP ____, Temp ____ Optional
Repeat n >=1
APS Flowsheet
PE6 HEENT (check box for normal or abnormal)
Allow Text for abnormal result
Optional
Repeat 1
APR Physical Exam
PE7 BREASTS (check box for normal or abnormal)
Allow Text for abnormal result
Optional
Repeat 1
APR Physical Exam
PE8 LUNGS (check box for normal or abnormal)
Allow Text for abnormal result
Optional
Repeat 1
APR Physical Exam
PE9 HEART (check box for normal or abnormal)
Allow Text for abnormal result
Optional
Repeat 1
APR Physical Exam
PE10 ABDOMEN (check box for normal or abnormal)
Allow Text for abnormal result
Optional
Repeat 1
APR Physical Exam
PE11 EXTREMITIES (check box for normal or abnormal)
Allow Text for abnormal result
Optional
Repeat 1
APR Physical Exam
PE12 SKIN (check box for normal or abnormal)
Allow Text for abnormal result
Optional
Repeat 1
APR Physical Exam
PE13 LYMPH NODES (check box for normal or abnormal)
Allow Text for abnormal result
Optional
Repeat 1
APR Physical Exam
PE14 Rectum (check box for normal or abnormal)
Allow Text for abnormal result
Optional
Repeat 1
APR Physical Exam
PE15 Other physical findings: Optional
Repeat n >=1
APR Physical Exam
PE16 Examiner's Signature ____________ Optional
Repeat 1
PE17 Pelvic Exam Pelvic exam date Optional
Repeat n>=1
PE18 VULVA Normal Abnormal or Not Done
List Abnormalities
Optional
Repeat 1
PE19 VAGINA Normal Abnormal or Not Done
List Abnormalities
Optional
Repeat 1
PE20 CERVIX Normal Abnormal or Not Done
List Abnormalities
Optional
Repeat 1
PE21 UTERUS Size (____ Weeks Optional
Repeat 1
PE22 UTERUS Normal Abnormal or Not Done
List Abnormalities
Optional
Repeat 1
PE23 ADNEXA Normal Abnormal or Not Done
List Abnormalities
Optional
Repeat 1
PE24 Pelvic Dimensions (Adequate, Borderline, Contracted) Optional
Repeat 1
PE25 Diagonal Conjugate Reached, Not Reached or ________CM Optional
Repeat 1
PE26 Spines (check box for Average, prominent or blunt)
List Abnormalities
Optional
Repeat 1
PE27 Sacrum (check box for concave, straight or anterior)
List Abnormalities
Optional
Repeat 1
PE28 Subpubic Arch (check box for normal,wide, or narrow)
List Abnormalities
Optional
Repeat 1
PE29 Gynecoid Pelvic Type
Gynecoid
Anthropoid
Android
Platypoid
Optional
Repeat 1
PE30 Other physical findings: Optional
Repeat n >=1
PE31 Pain Scale
Scale 1-10
Optional
Repeat 1
PE32 Examiner's Name Optional
Repeat 1
PE33 National Provider Identifier Optional
Repeat 2
Prenatal Examinations
PNE1 45 available rows columns include: weeks gest (best est),
fundal height (CM),
presentation,
FHR,
fetal movement,
Cervix exam (dil./eff. Sta.)
ultrasound cervical length,
blood pressure (2 fields) ,
weight,
next appointment date (mm/dd/yy)
heart rate,
fetal movement,
contractions
comments
Separate all elements
Optional
Repeat n>=1
APS Flowsheet
Laboratory
L1 Blood type, (Patient) A B AB O Optional
Repeat 1
APR
L2 Blood type, (Father of the baby, if known) A B AB O Optional
Repeat 1
L3 D (Rh) Type (patient) Optional
Repeat 1
APR
L4 D (Rh) Type (Father of the baby, if known) Optional
Repeat 1
L5 2 sections for Antibody Screen (check box for pos, neg and space for the titer) Optional
Repeat n >=1
L6 beta-hCG Optional
Repeat n >=1
L7 HGB, (Result)___g/dl Optional
Repeat n >=1
L8 HCT (Result) ___% Optional
Repeat n >=1
L9 Pap Test, (Result) Normal/abnormal/__ Optional
Repeat n >=1
L10 Rubella (check box for IMM, N-Imm and _______(blank space)). Optional
Repeat n >=1
L11 VDRL Optional
Repeat n >=1
L12 RPR Optional
Repeat n >=1
L13 Urinalysis Optional
Repeat n >=1
L14 Urine Culture (check box for pos, neg and __________(blank space)) Optional
Repeat n >=1
L15 Hepatitis B s AG Optional
Repeat n >=1
L16 HIV Counsel/Testing, (Result) POS NEG Declined (***Check state requirements before recording results**) Optional
Repeat 1
L17 HIV Counseling Optional
Repeat 1
L17 HIV (check box for Offer/Date Optional
Repeat 1
L18 HIV Decline/Date Optional
Repeat 1
L18 Chlamydia Optional
Repeat n >=1
L19 Gonorrhea Optional
Repeat n >=1
L20 Aneuploidy screening Optional
Repeat n >=1
L21 HGB Electrophoresis, (Result) AA AS SS AC SC AF A2 Optional
Repeat n >=1
L22 PPD Optional
Repeat n >=1
L23 Genetic Screening Tests Optional
Repeat n >=1
L24 First Trimester Screeingin with nuchal translucency and maternal serum. (Check box for normal, abnormal?) Optional
Repeat n >=1
L25 Other Optional
Repeat n >=1
L26 Ultrasound Optional
Repeat n >=1
L27 Amnios Optional
Repeat n >=1
L28 MSAFP/Multiple Markers Optional
Repeat n >=1
L29 Chorionic villus sampling Optional
Repeat n >=1
L30 Karyotype ____________ (blank line space) Optional
Repeat n >=1
L31 Amniotic Fluid (AFP) Include Value and Reference Range Optional
Repeat n >=1
L32 Individual columns for: 24-28-week labs, date (common throughout), result (common throughout), reviewed (common throughout);
L33 Maternal Serum Quad Screen (check box for Offer, Decline, Abn and NL) Optional
Repeat n >=1
L34 Maternal Serum Triple Screen (check box for Offer, Decline, Abn and NL) Optional
Repeat n >=1
L35 Diabetes Screen (Result column has 1 hour __________(blank line space)) space for
High end cutoff value
Optional
Repeat n >=1
L36 GTT (if screen abnormal) (Result column has ___FBS, ___1 hour, ___ 2 hour, ___ 3 hour) Optional
Repeat n >=1
L37 Strep Type
B
A
G
C
F
Optional
Repeat n >=1
L38 TSH __________(blank space) Optional
Repeat n >=1
L39 Thryoid
Free T3
Free T4
L40 VZV Ab (check box Pos and Neg) Optional
Repeat 1
L41 CF Counseling/Screening (check box for Offer, Decline, Pos and Neg) Optional
Repeat 1
L42 Comments/additional Labs blank space section Optional
Repeat n >=1
L43 Influenza vaccine provided
If yes - date and dose
Optional
Repeat n>=1


consider adding back:

Physical Exam

  • Adnexa || ||SNOMED CT ||R || ||BL || ||normal
    abnormal
  • Diagonal Conjugate || ||SNOMED CT ||O || ||CD || ||reached
    not reached
    length
  • Spines ||163576005 ||SNOMED CT ||O || ||CD || ||average
    prominent
    blunt
  • Sacrum ||164565001 ||SNOMED CT ||O || ||CD || ||concave
    straight
    anterior
  • Subpubic Arch || ||SNOMED CT ||O || ||CD || ||normal
    wide
    narrow
  • Gynecoid Pelvic Type ||163555000 ||SNOMED CT ||O || ||BL || ||yes
    no
  • Cervix ||309668003 ||SNOMED CT ||R || ||BL || ||normal
    abnormal
  • Uterus Size ||163509002(fundus = term size)
    163498004(gravid uterus size) ||SNOMED CT ||R ||weeks gestation, fibroids determined from ultrasound ||BL || ||
  • All values SHALL have a normal/abnormal (BL) value and a text narrative with related comments. The elements with value sets other than normal/abnormal (e.g. vulva, vagina) have value sets that may change and therefore should not be coded to a specific value set.
  • |Funduscopic Examination || ||LOINC ||O || || || ||