Talk:Antepartum Summary Form C
- Forms (A, B, C) can be covered by extending Medical Summary
- Form D can be covered by XD*-LAB
- Form E can be covered by an Education Plan
- Form F & G are simply extensions of C.
- Discharge Summary back to Ob.
- Post Partum Form
The following terminologies were found by GE in their review of this data Media:GECodes.xls
March 23 Telcon
- Anne Diamond - ACOG, Dr. Al Strunk, Tone Southerland - Digichart, James Scroggs - ACOG, Larry McKnight - Siemens, Keith W. Boone - GE Healthcare
TS: Has started an excel spreadsheet covering Form A, pulling out data elements, and identifying data types and LOINC codes.
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?
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?
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 ...
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.
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
Tone, Ann, Larry
- 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.
- Larry to send LOINC spreadsheet to Clem after Tone finishes his review.
Apr 13, Telcon
Tone, Keith, Larry, James
- 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/
- 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
- breach, undetermined, vertex, etc.
- < 300
- Could be a range or a specific number
- Fetal Movement
- Preterm Labor Signs/Symptoms
- Cervix Exam Ultrasound Length
- Dilation: 0-10cm
- Effacement: 0-100%
- -2 -1 0 +1 +2 +3
- Floating (-2 -1)
- Engaged (+1 +2 +3)
- Blood Pressure
- Systolic: 0-300
- Diastolic: 0-200
- 0-1000 lbs
- Albumin/Glucose: 0 Trace +1 +2 +3 +4
- 0/none Trace +1 +2 +3
- Pain Scale (0-10)
- Next Appointment
- Days, weeks
- How far out is next appointment?
- Weeks Gestation
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