Talk:PCC TF-1/APS

Profile Abstract

The Antepartum Summary (APS) describes the content structures for the ACOG Antepartum Record Forms.

 It is divided into 4 content profiles:

1. Forms A&B - The initial assessment and physical
2. Form C&F - Update records and progress notes
3. Form D - Laboratory Evaluations
4. Form E - Education Assessment
5. Form G - Progress Notes

The ACOG form also includes:

1. An Obstetric Medical History
2. A Postpartum Form

A sample may be found at http://sales.acog.com/

This profile defines the implementation of HL7 CDA documents to represent Form C, along with the XDS, XDR, and XDM bindings. Future profiles will focus on other related forms along with mechanisms to group them into a single logical folder.

Glossary

The following terms are found in Form C of the Antepartum Record.

Antepartum

Period of pregnancy between conception and onset of labor, referring to the mother.

Cervix Exam (Dil/Eff/Sta)

Examination to determine, Dilation, Effacement, and Station of the fetus.

• Dilation refers to the size of the opening in the cervix, usually recorded in centimeters (measured from 0[=closed] to 10 [=fully dialated or open]).
• Effacement refers to the thickness or thinness of the cervix (measured from 0% (or uneffaced, =thick) to 100% (completely thinned out).
• Station refers to the progress of the head (or presenting part) though the pelvis (measured in negative number, 0, and positive numbers, either in cms above or below the ischial spines or in relative distance to the introitus, (i.e., “thirds.”).

EDD

Expected Date of Delivery, a fixed date determined by ultrasound measurements and /or last menstrual period. Also called EDC - Expected Date of Confinement.

Initial EDD

Expected Date of Delivery, assuming 40 weeks or 280 days since last menstrual period.

FHR

Fetal Heart Rate. A measurement of the pulse of the fetus.

Fetal Movement

Maternal perception of movement by the fetus

Fundal Height

Measurement of the size of the uterus from the top of the pubic bone to the top of the uterus in centimeters. This measurement is used to assess fetal growth. This measurement should be done at every prenatal visit.

Fundal Height at Umbilicus

The point in the pregnancy when the uterus is at the umbilicus (belly button), which usually corresponds to 20 weeks gestation (the half-way point of the pregnancy).

LMP

Last Menstrual Period: as measured from the first day of a woman’s last cycle prior to the pregnancy.

Presentation

Refers to the part of the fetus that is presenting first, i.e. breech, vertex, etc.

Preterm Labor Signs/Symptoms

Any sign or symptom suggesting possible labor, that occurs before 37 weeks of gestation. For example: regular or irregular contractions, ruptured membranes, abdominal cramps, low, dull backache, pelvic or abdominal pressure, change in type or increase of vaginal discharge.

Quickening

A woman’s initial awareness of movement of the fetus within the womb/uterus. Usually reported between 18 – 20 weeks gestation with a first pregnancy, often as early as 16 weeks with subsequent pregnancies.

Ultrasound length

Identifying the size and position of the fetus by ultrasound exam to estimate gestational age

Weeks Gestation (Best est.)

The best estimate of the length of time since conception.

The following terms are found in Form A of the Antepartum Record.

AB Induced

Number of induced abortions the mother has had

AB Spontaneous

Number of spontaneous abortions the patient has had

Ectopics

Number of ectopic pregnancies the patient has had

Frequency

Length of duration for patient’s typical monthly period

Full Term

Number of babies the mother has delivered between 37 and 42 weeks gestation

hCG +

Specify date of positive Human Chorionic Gonadotropin pregnancy test.

Living

Number of living children the mother has

LMP (last menstrual period)

measured from the first day of the patient’s cycle

• Definite - Patient is sure of the date of last menstrual period
• Approximate – Patient is unsure of exact date but can offer an approximate date
• Unknown – Patient does not know date of last menstrual period.
• Final – Finally agreed upon date of LMP after U/S measurements.

Menarche (age onset)

Age at onset of initial menstrual period

Menses Monthly

Specify that the patient has a monthly period or not.

Multiple Births

Number of multiple deliveries the mother has had.

Normal Amount/Duration

Specify that the last menstrual period was typical or not in amount and duration for this patient.

On BCP Concept

Specify if the patient was on birth control pills at conception

Premature

Number of premature babies the mother has delivered

Prior Menses

Date of patient’s prior period.

Total Pregnancy

Total number of times the patient has been pregnant

'Prior Pregnancies' Section:

Anesthesia

Specify the type of anesthesia used for previous pregnancy, i.e., epidural, etc.

Birth Weight

Weight of baby at birth for previous pregnancies

Date

(Day)/Month/Year of delivery of previous pregnancies (day may be optionally recorded)

GA Weeks

Gestational age in weeks at delivery for previous pregnancies

Length of Labor

Number of hours in labor for previous pregnancies

Place of Delivery

Specify where the previous babies were delivered.

Preterm Labor

Specify if the patient had preterm labor with the previous pregnancies.

Sex

Sex of babies for previous pregnancies

Type Delivery

Specify type of delivery for previous pregnancy, i.e. vaginal, cesarean

ART Treatment

Assisted Reproductive Technology Treatment

Volume I

Add the following bullet to the list of profiles

• Antepartum Summary - A folder of content profiles that contains the summarization record or the antepartum care delivery including initial patient history and physical, ambulatory checks of mother and fetus, laboratory studies, and patient education .

Dependencies

Add the following row(s) to the list of dependencies

Integration Profile	Dependency	Dependency Type	Purpose
Antepartum Summary Form A&B	IHE History and Physical	Child	Initial Intake and Assessment for antepartum care
Antepartum Summary Form C&F&G	Medical Summary	Child	Update and Progress Note
Antepartum Summary Form D	XD-Lab	Child	Obstetric Lab Evaluation
Antepartum Summary Form E			Obstetric Education Form

Because many document sections are shared with other Medical Summary document types, an Antepartum Ambulatory Prenatal Care Summary document would fit in nicely with the IHE collection of Medical Summary Documents. The ability for the IHE Medical Summary documents to incorporate the sections required for an Antepartum Summary as well as the inclusion or reference of imaging and laboratory reports and other clinical documents is an important consideration.

Specifically, this proposal is to publish content profiles for additional sections within the new Section Content Profile Framework being developed and then publish a medical summary document content profile for the full Antepartum Ambulatory Prenatal Care Summary document. The section unique to an Antepartum Ambulatory Prenatal Care Summary is the cumulative aggregation of office visits over the defined prenatal period, coupled with the similar requirements of the Pre-Procedure H&P documentation.