Talk:Antepartum Summary Form C

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  1. Forms (A, B, C) can be covered by extending Medical Summary
  2. Form D can be covered by XD*-LAB
  3. Form E can be covered by an Education Plan
  4. Form F & G are simply extensions of C.
  5. Discharge Summary back to Ob.
  6. Post Partum Form

See example ACOG forms


The following terminologies were found by GE in their review of this data Media:GECodes.xls

March 23 Telcon

Attending
Anne Diamond - ACOG, Dr. Al Strunk, Tone Southerland - Digichart, James Scroggs - ACOG, Larry McKnight - Siemens, Keith W. Boone - GE Healthcare

Progress

TS: Has started an excel spreadsheet covering Form A, pulling out data elements, and identifying data types and LOINC codes.

See APS ACOG Field Mapping - Forms A & B.xls

See APS ACOG Field Mapping - Forms C, F & G.xls

IP Issues

LM: Does AGOC License the form? AS: ACOG does license the form itself. It is a non-exclusive license and has no cost associated with it.

KB: We should incorporate a statement about this in the profile. Would ACOG draft some text that we could include in the profile?

JS/AS: Yes.

Status

LM: Wiki updates were made recently.

LM: I've divided volume 2 into four parts: A and B; C, F and G; D; and E, is that OK?

Yes

LM: Do we have a volunteer to make sure the mood of the profile is rewrittent to be declaritive?

AD: Yes, we can do that.

LM: We need an Open Issues Log...

KB: Put that on the discussion page.

LM: So delete it ...

KB: Yes

LM: On the Actors and Transactions section, do we need this?

KB: I would ignore that for now. In the supplements, this is probably needed, but in the overall document it isn't.

LM: Does Radiology have a mechanism to deal with this?

KB: Probably not, since this seems to be a content profile issue.

LM: When Radiology included PIR, how did they handle this? Did they repeat pre-existing information or refer to existing material?

KB: I don't know.

LM: Can you take that as a to-do? To figure out our approach to this.

KB: Yes.

LM: Do you have any opinions about how to write the folder strategy?

KB: One of the things I'd like to do is to define the vocabulary used to identify the folder. This should be an update to the Bindings Section,

LM: Would this be the same for XD*

KB: I believe they all have folders.

We probably want to ask LOINC code for a new code for a SET of records that covers Antepartum Care, since these documents are not explicitely "LABOR AND DELIVERY RECORDS".

Claims Attachment ballot has listed in it a number of very usefull LOINC codes here: See Clinical Reports

Apr 4, Telcon

Attendance

Tone, Ann, Larry

Status report

  • Tone is working on loinc spreadsheet posted in discussion.
  • Ann has text, but to work with Tone on getting it into the wiki.
  • Larry still needs to fill in volume 2 templates that will later get expanded by Tone.

Action Items:

  • Larry to send LOINC spreadsheet to Clem after Tone finishes his review.

Apr 13, Telcon

Attendance

Tone, Keith, Larry, James

Status Report

  • Tone has finished LOINC spreadsheet.
  • Ann posted glossary.
  • Keith to review LOINC spreadsheet.
  • Larry has done nothing past week -- also busy this week, but will take action item to send LOINC to Clem.
  • James will get legal/copywright wording posted (~2weeks)
  • Link for VA/KP List ftp://ftp1.nci.nih.gov/pub/cacore/EVS/FDA/ProblemList/Browser/

4/20/07 t-conn

=

Issues

  • EDD is 2 sections or 2 panels?
  • How do you do panels?
  • EDD is an assessment scale? -> calculated EDD similar to APGAR
  • how to do entry constraints? Eg. Allergy requires Latex.
  • in CCD Allergen = obs value, not material?? I thought we were not going to do that?
  • upcoming meeting --
Ann making progress on edits to volume 1.
Tone no significant changes this week.
Larry

5/21/07 Form C Misc Notes (TS)

Form C - Flowsheet

  • Larry referred to part of Form C as the Visit Summary section. A better term may be Flowsheet as this is how this particular section is generally referred to among most (if not all) ob/gyn practices.


  • Example data values for flowsheet items:
    • Weeks Gestation
      • 0-46 weeks
      • Consider that different vendors report this different ways.
        • Ex1: 20.5 means 20 weeks, 5 days
        • Ex2: 20w5d means 20 weeks, 5 days
    • Fundal Height
      • < 100 cm
    • Presentation
      • breach, undetermined, vertex, etc.
    • FHR
      • < 300
      • Could be a range or a specific number
    • Fetal Movement
      • present/absent/reduced
    • Preterm Labor Signs/Symptoms
      • present/absent
    • Cervix Exam Ultrasound Length
      • Dilation: 0-10cm
      • Effacement: 0-100%
      • Station:
        • -2 -1 0 +1 +2 +3
        • Floating (-2 -1)
        • Engaged (+1 +2 +3)
    • Blood Pressure
      • Systolic: 0-300
      • Diastolic: 0-200
    • Weight
      • 0-1000 lbs
      • kg?
    • Urine
      • Albumin/Glucose: 0 Trace +1 +2 +3 +4
    • Edema
      • 0/none Trace +1 +2 +3
    • Pain Scale (0-10)
      • 0-10
    • Next Appointment
      • Days, weeks
      • How far out is next appointment?

Form C - Problems and Medications Section

Looking on Form C at the problems/plans section (above visit summary/flowsheet) consider the following:

  • There can be a medication listed that does not correlate with a problem
    • ex: prenatal vitamins - the problem is pregnancy, but it may not be listed
  • There can be a problem listed that does not correlate with a medication
    • ex: patient chose not to take medication
    • ex: no medications available for a particular problem
  • Both problems and medications will often be prefixed with an abbreviation to determine the type of problem/medication
    • ex: Hx, Rx, current, patient reported
  • The intent of this section is to collect all problems that are significant, to either the pregnancy or the patient
    • ex: tonsillectomy at age 10 IS NOT significant to either patient or pregnancy (and thus would not be collected)
    • ex: exposure to Rubella in a non-immune patient IS significant to the pregnancy, but not to the patient
    • ex: previous ectopic pregnancies IS significant to both pregnancy and patient
    • ex: blindness IS significant to the patient, but not to the pregnancy
  • The data collected here is usually done so by the ob-gyn practice and not from any outside sources - such as the patient's PCP