Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2"

Revision as of 23:53, 31 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'/>
    <statusCode code='completed'/>
    <author typeCode='AUT'>
       
       <assignedAuthor classCode=' '/>
          <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 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.

<author typeCode='AUT'/><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.

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	CO		Vertex Breech Transverse Oblique Compound Brow Face NULL^NOT LISTED NULL^UNKNOWN
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	CO		Yes No Reduced
(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	CO		0 10 20 30 40 50 60 70 80 90 100
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		None Trace 1+ 2+ 3+ 4+
2349-9 or 25428-4(test strip)	GLUCOSE-ACNC-PT-UR-ORD- or GLUCOSE-ACNC-PT-UR-ORD-TEST STRIP	CO		None Trace 1+ 2+ 3+ 4+
44966-0	EDEMA-FIND-PT-^PATIENT-ORD-	CO		None Trace 1+ 2+ 3+ 4+
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	(comment field)	ED

@@ Line 9: / Line 9: @@
       <statusCode code='completed'/>
       <author typeCode='AUT'>
-         <id root=' ' extension=' '/>
+         <time value=' '/>
+        <assignedAuthor classCode=' '/>
+           <id root=' ' extension=' '/>
+        </assignedAuthor>
       </author>
       <component>
@@ 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 typeCode='AUT'/><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 165: / Line 165: @@
 |48767-8
 |(comment field)
-|ED
-|
-|
-|-
-|34131-3
-|Subsequent evaluation note-FIND-PT-OUTPATIENT-DOC-{Provider}
 |ED
 |