Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2"

Revision as of 15:11, 30 May 2007

Development Only

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ACOG 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 ACOG Visit Summary Battery

Specification

ACOG 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'/>
    <activityTime value=' '/>
    <statusCode code='completed'/>
    <author typeCode='AUT'><reference value='#author-1'/></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 form C 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.

<activityTime value=' '/>

The <activityTime> element contains the date and time of the visit for which the battery is obtained.

<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'/>

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.

code	displayName	xsi:type	units
11884-4	GESTATIONAL AGE-TIME-PT-^FETUS-QN-CLINICAL.ESTIMATED	PQ	week
11881-0	FUNDAL HEIGHT-LEN-PT-UTERUS-QN-TAPE MEASURE	PQ	cm
18849-0 (by PE) or 18850-8 (by US)	FETAL PRESENTATION-TYPE-PT-PELVIS-NAR-PALPATION or FETAL PRESENTATION-TYPE-PT-PELVIS-NAR-US	ED
11948-7 or (xx-fetal-hr-ausc)	HEART RATE-NRAT-PT-^FETUS-QN-US.MEASURED or HEART RATE-NRAT-PT-^FETUS-QN-AUSCULTATION	RTO	min
(xx-fetal-movement)	MOVEMENT-FIND-PT-^FETUS-ORD-PATIENT REPORTED	ORD	N\|Reduced]
(xx-SS-Preterm-Labor)	PRETERM LABOR SYMPTOMS-FIND-PT-^PATIENT-QL-CLINICAL JUDGEMENT	BL
(xx-cerv-dil)	DILATION-LEN-PT-CERVIX-QN-PALPATION	PQ	cm
11867-9	EFFACEMENT-PRCTL-PT-CERVIX-ORD-PALPATION	CO	[0-100%]
11961-0	LONG AXIS-LEN-PT-CERVIX-QN-US.MEASURED	PQ	cm
8480-6	INTRAVASCULAR SYSTOLIC-PRES-PT-ARTERIAL SYSTEM-QN-	PQ	mm[Hg]
8462-4	INTRAVASCULAR DIASTOLIC-PRES-PT-ARTERIAL SYSTEM-QN-	PQ	mm[Hg]
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	[-,TRACE,+,2+,3+,4+]
2349-9 or 25428-4(test strip)	GLUCOSE-ACNC-PT-UR-ORD- or GLUCOSE-ACNC-PT-UR-ORD-TEST STRIP	CO	[-,TRACE,+,2+,3+,4+]
?44966-0 or 45700-2	(edema)	CO	[-,TRACE,+,2+,3+,4+]
38208-5	PAIN SEVERITY-FIND-PT-^PATIENT-ORD-REPORTED	CO	[0(no pain) -10(worst possible pain]
?(xx-next-appt:SNOMED)	TIME TO NEXT VISIT	PQ	day,week,mo
48767-8	(comment)	ED

@@ Line 74: / Line 74: @@
 |
 |-
-|11948-7
+|11948-7 or (xx-fetal-hr-ausc)
-|HEART RATE-NRAT-PT-^FETUS-QN-US.MEASURED
+|HEART RATE-NRAT-PT-^FETUS-QN-US.MEASURED<br/> or HEART RATE-NRAT-PT-^FETUS-QN-AUSCULTATION
 |RTO
 |min
 |-
-|?11632-7
+|(xx-fetal-movement)
-|?BIOPHYSICAL PROFILE.BODY MOVEMENT-FCN-PT-^FETUS-ORD-US
+|MOVEMENT-FIND-PT-^FETUS-ORD-PATIENT REPORTED
-|BL
+|ORD
-|
+|[Y|N|Reduced]
 |-
 |(xx-SS-Preterm-Labor)
@@ Line 97: / Line 97: @@
 |EFFACEMENT-PRCTL-PT-CERVIX-ORD-PALPATION
 |CO
-|?todo:value-set
+|[0-100%]
 |-
 |11961-0
@@ Line 114: / Line 114: @@
 |mm[Hg]
 |-
-|3141-9 (measured)<br/> or 3138-5(stated)<br/> or 29463-7(unstated)
+|3141-9
-|BODY WEIGHT-MASS-PT-^PATIENT-QN-MEASURED<br/> or BODY WEIGHT-MASS-PT-^PATIENT-QN-STATED<br/> or BODY WEIGHT-MASS-PT-^PATIENT-QN-
+|BODY WEIGHT-MASS-PT-^PATIENT-QN-MEASURED
 |PQ
 |g, kg, lb_av, or oz_av
@@ Line 122: / Line 122: @@
 |ALBUMIN-ACNC-PT-UR-ORD-
 |CO
-|?value-set
+|[-,TRACE,+,2+,3+,4+]
 |-
 |2349-9<br/> or 25428-4(test strip)
 |GLUCOSE-ACNC-PT-UR-ORD-<br/> or GLUCOSE-ACNC-PT-UR-ORD-TEST STRIP
 |CO
-|?value-set
+|[-,TRACE,+,2+,3+,4+]
 |-
 |?44966-0 or 45700-2
 |(edema)
 |CO
-|[+,2+,3+,4+]
+|[-,TRACE,+,2+,3+,4+]
 |-
 |38208-5
@@ Line 143: / Line 143: @@
 |PQ
 |day,week,mo
+|-
+|48767-8
+|(comment)
+|ED
+|
 |-
 |}