Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2"

Latest revision as of 12:03, 5 May 2009

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

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>
       
       <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/><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

-->>TODO:<<--

@@ Line 1: / Line 1: @@
-{{HL7V3|ACOG Visit Summary Battery|1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2|draft|This entry describes a single row in the Visit Summary flowsheet.  The single observation date and provider is applied to all other observations.
+{{HL7V3|Antepartum Visit Summary Battery|1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2|Trial|This entry describes a single row in the Visit Summary flowsheet.  The single observation date and provider is applied to all other observations.
 |Example=<br/>
   <entry>
@@ Line 8: / Line 8: @@
             codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
       <statusCode code='completed'/>
-      <author typeCode='AUT'>
+      <author>
-         <id root=' ' extension=' '/>
+        <time value=' '/>
+         <assignedAuthor>
+           <id root=' ' extension=' '/>
+        </assignedAuthor>
       </author>
       <component>
@@ Line 33: / Line 36: @@
 ===== <organizer classCode='BATTERY' moodCode='EVN'> =====
-Each row in the visit Summary flowsheet of the Antepartum Summary form C SHALL be represented by an organizer with the classCode of 'BATTERY' and the moodCode of '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=' '/> =====
@@ Line 41: / Line 44: @@
 The &lt;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.
-===== <activityTime value=' '/> =====
+===== <author/><time/><assignedAuthor><id/></assignedAuthor></author> =====
-The <activityTime> element contains the date and time of the visit for which the battery is obtained.
+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.
-===== <author typeCode='AUT'/><reference value='#foo'/></author> =====
-The <author> element points at the author from the header that records the visit battery.  The reference value attribute points at the element with author element with the id='foo'.
 ===== <statusCode code='completed'/> =====
@@ Line 55: / Line 55: @@
 {|border=1
 |-bgcolor='#d9d9d9'
-!code
+!LOINC Code
 !displayName
 !xsi:type
@@ Line 62: / Line 62: @@
 |-
 |11884-4
-|GESTATIONAL AGE-TIME-PT-^FETUS-QN-CLINICAL.ESTIMATED
+|GESTATIONAL AGE-TIME-PT-<nowiki>^</nowiki>FETUS-QN-CLINICAL.ESTIMATED
-|PQ
+|align = "center"|PQ
 |week
-|
+|&nbsp;
 |-
 |11881-0
 |FUNDAL HEIGHT-LEN-PT-UTERUS-QN-TAPE MEASURE
-|PQ
+|align = "center"|PQ
 |cm
-|
+|&nbsp;
 |-
-|11876-0 (by PE)<br/> or<br/>11877-8 (by US)
+|11876-0 (by PE)<br>or<br>11877-8 (by US)
-|FETAL PRESENTATION-TYPE-PT-PELVIS-NOM-PALPATION<br/> or<br/>FETAL PRESENTATION-TYPE-PT-PELVIS-NOM-US
+|FETAL PRESENTATION-TYPE-PT-PELVIS-NOM-PALPATION<br>or<br>FETAL PRESENTATION-TYPE-PT-PELVIS-NOM-US
-|CO
+|align = "center"|CD
-|
+|&nbsp;
-|Vertex<br/>Breech<br/>Transverse<br/>Oblique<br/>Compound<br/>Brow<br/>Face<br/>NULL^NOT LISTED<br/>NULL^UNKNOWN<br/>
+|SNOMED CT<br>Vertex (70028003)<br>Breech (6096002)<br>Transverse (73161006)<br>Oblique (63750008)<br>Compound (124736009)<br>Brow (8014007)<br>Face (21882006)
 |-
-|11948-7<br/> or<br/>(xx-fetal-hr-ausc)
+|11948-7<br>or<br>(xx-fetal-hr-ausc)
-|HEART RATE-NRAT-PT-^FETUS-QN-US.MEASURED<br/> or<br/>HEART RATE-NRAT-PT-^FETUS-QN-AUSCULTATION
+|HEART RATE-NRAT-PT-<nowiki>^</nowiki>FETUS-QN-US.MEASURED<br>or<br>HEART RATE-NRAT-PT-<nowiki>^</nowiki>FETUS-QN-AUSCULTATION
-|RTO
+|align = "center"|PQ
 |/min
-|
+|&nbsp;
 |-
 |(xx-fetal-movement)
-|MOVEMENT-FIND-PT-^FETUS-ORD-PATIENT REPORTED
+|MOVEMENT-FIND-PT-<nowiki>^</nowiki>FETUS-ORD-PATIENT REPORTED
-|CO
+|align = "center"|CO
-|
+|&nbsp;
-|Yes<br/>No<br/>Reduced
+|SNOMED CT
+fetal movement activity (finding)  CID 364755008<br/>
+baby kicks a lot (finding)  CID 276368003<br/>
+baby not moving (finding)  CID 276370007<br/>
+reduced fetal movement (finding)  CID 276369006<br/>
+fetal movements present (finding)  CID 289431008<br/>
+fetal movements felt (finding)  CID 268470003<br/>
+fetal movements seen (finding)  CID 169731002
 |-
 |(xx-SS-Preterm-Labor)
-|PRETERM LABOR SYMPTOMS-FIND-PT-^PATIENT-QL-CLINICAL JUDGEMENT
+|PRETERM LABOR SYMPTOMS-FIND-PT-<nowiki>^</nowiki>PATIENT-QL-CLINICAL JUDGEMENT
-|BL
+|align = "center"|BL
-|
+|&nbsp;
-|
+|&nbsp;
 |-
-|(xx-cerv-dil-palp)<br/> or<br/>(xx-cerv-dil-us)
+|(xx-cerv-dil-palp)<br>or<br>(xx-cerv-dil-us)
-|DILATION-LEN-PT-CERVIX-QN-PALPATION<br/> or<br/>DILATION-LEN-PT-CERVIX-QN-US
+|DILATION-LEN-PT-CERVIX-QN-PALPATION<br/>or<br/>DILATION-LEN-PT-CERVIX-QN-US
-|PQ
+|align = "center"|PQ
 |cm
-|
+|&nbsp;
 |-
 |11867-9
 |EFFACEMENT-PRCTL-PT-CERVIX-ORD-PALPATION
-|CO
+|align = "center"|PQ
-|
+|percent
-| 0<br/>10<br/>20<br/>30<br/>40<br/>50<br/>60<br/>70<br/>80<br/>90<br/>100
+|&nbsp;
 |-
 |11961-0
 |LONG AXIS-LEN-PT-CERVIX-QN-US.MEASURED
-|PQ
+|align = "center"|PQ
 |cm
-|
+|&nbsp;
 |-
 |8480-6
 |INTRAVASCULAR SYSTOLIC-PRES-PT-ARTERIAL SYSTEM-QN-
-|PQ
+|align = "center"|PQ
 |mmHg
-|
+|&nbsp;
 |-
 |8462-4
 |INTRAVASCULAR DIASTOLIC-PRES-PT-ARTERIAL SYSTEM-QN-
-|PQ
+|align = "center"|PQ
 |mmHg
-|
+|&nbsp;
 |-
 |3141-9
-|BODY WEIGHT-MASS-PT-^PATIENT-QN-MEASURED
+|BODY WEIGHT-MASS-PT-<nowiki>^</nowiki>PATIENT-QN-MEASURED
-|PQ
+|align = "center"|PQ
 |g, kg, lb_av, or oz_av
-|
+|&nbsp;
 |-
 |1753-3
 |ALBUMIN-ACNC-PT-UR-ORD-
-|CO
+|align = "center"|CO
-|
+|&nbsp;
-|None<br/>Trace<br/>1+<br/>2+<br/>3+<br/>4+
+|SNOMED CT<br/>
+Negative (finding) CID 167273002<br/>
+Trace (finding) CID 167274008<br/>
+<nowiki>+</nowiki> (finding) CID 167275009<br/>
+<nowiki>+</nowiki> (finding) CID 167276005<br/>
+<nowiki>+</nowiki> (finding) CID 167277001<br/>
+<nowiki>+</nowiki> (finding) CID 167278006
 |-
-|2349-9<br/> or<br/>25428-4(test strip)
+|2349-9<br>or<br>25428-4(test strip)
-|GLUCOSE-ACNC-PT-UR-ORD-<br/> or<br/>GLUCOSE-ACNC-PT-UR-ORD-TEST STRIP
+|GLUCOSE-ACNC-PT-UR-ORD-<br>or<br>GLUCOSE-ACNC-PT-UR-ORD-TEST STRIP
-|CO
+|align = "center"|CO
-|
+|&nbsp;
-|None<br/>Trace<br/>1+<br/>2+<br/>3+<br/>4+
+|SNOMED CT<br/>
+Negative (finding) CID 167261002<br/>
+Trace (finding) CID 167262009<br/>
+<nowiki>+</nowiki> (finding) CID 167264005<br/>
+<nowiki>+</nowiki> (finding) CID 167265006<br/>
+<nowiki>+</nowiki> (finding) CID 167266007<br/>
+<nowiki>+</nowiki> (finding) CID 167267003<br/>
 |-
 |44966-0
-|EDEMA-FIND-PT-^PATIENT-ORD-
+|EDEMA-FIND-PT-<nowiki>^</nowiki>PATIENT-ORD-
-|CO
+|align = "center"|CO
-|
+|&nbsp;
-|None<br/>Trace<br/>1+<br/>2+<br/>3+<br/>4+
+|SNOMED CT<br/>
+trace edema 44996-0<br/>
+<nowiki>+</nowiki> pitting edema 420829009<br/>
+<nowiki>+</nowiki> pitting edema 421605005<br/>
+<nowiki>+</nowiki> pitting edema 421346005<br/>
+<nowiki>+</nowiki> pitting edema 421129002
 |-
 |38208-5
-|PAIN SEVERITY-FIND-PT-^PATIENT-ORD-REPORTED
+|PAIN SEVERITY-FIND-PT-<nowiki>^</nowiki>PATIENT-ORD-REPORTED
-|CO
+|align = "center"|CO
-|
+|&nbsp;
-|0(no pain)<br/>:<br/>10(worst possible pain)<br/>Note: This observation should correspond to the functional status [[1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1|pain score observation]]
+|0 (no pain)<br>:<br>10 (worst possible pain)<br>Note: This observation should correspond to the functional status [http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1 pain score observation]
 |-
-|(xx-time-to-next-appt)<br/> or<br/>?39165
+|(xx-time-to-next-appt)<br>or<br>?39165
-|TIME TO NEXT VISIT-<br/> or<br/>?Date next screen visit-TmStp-PT-^PATIENT-QN-CPHS
+|TIME TO NEXT VISIT-<br>or<br>?Date next screen visit-TmStp-PT-<nowiki>^</nowiki>PATIENT-QN-CPHS
-|PQ
+|align = "center"|PQ
 |day,week,mo
-|
+|&nbsp;
 |-
 |48767-8
-|(comment field)
+|ANNOTATION COMMENT-FIND-PT-<nowiki>^</nowiki>PATIENT-NAR-
-|ED
+|align = "center"|ED
-|
+|&nbsp;
-|
+|&nbsp;
-|-
-|34131-3
-|Subsequent evaluation note-FIND-PT-OUTPATIENT-DOC-{Provider}
-|ED
-|
-|
 |-
 |}
+===== Schematron =====
+ {{Fixme|TODO:}}