Talk:Antepartum Summary Form C

1. Forms (A, B, C) can be covered by extending Medical Summary
2. Form D can be covered by XD*-LAB
3. Form E can be covered by an Education Plan
4. Form F & G are simply extensions of C.
5. Discharge Summary back to Ob.
6. Post Partum Form

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See example ACOG forms

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The following terminologies were found by GE in their review of this data Media:GECodes.xls

March 23 Telcon

Attending

Anne Diamond - ACOG, Dr. Al Strunk, Tone Southerland - Digichart, James Scroggs - ACOG, Larry McKnight - Siemens, Keith W. Boone - GE Healthcare

Progress

TS: Has started an excel spreadsheet covering Form A, pulling out data elements, and identifying data types and LOINC codes.

See APS ACOG Field Mapping - Forms A & B.xls

See APS ACOG Field Mapping - Forms C, F & G.xls

IP Issues

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?

JS/AS: Yes.

Status

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?

Yes

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 ...

KB: Yes

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.

KB: Yes.

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

Attendance

Tone, Ann, Larry

Status report

• 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.

Action Items:

• Larry to send LOINC spreadsheet to Clem after Tone finishes his review.

Apr 13, Telcon

Attendance

Tone, Keith, Larry, James

Status Report

• 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/

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Issues

• 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
  • Presentation
    • breach, undetermined, vertex, etc.
  • FHR
    • < 300
    • Could be a range or a specific number
  • Fetal Movement
    • present/absent/reduced
  • Preterm Labor Signs/Symptoms
    • present/absent
  • Cervix Exam Ultrasound Length
    • Dilation: 0-10cm
    • Effacement: 0-100%
    • Station:
      • -2 -1 0 +1 +2 +3
      • Floating (-2 -1)
      • Engaged (+1 +2 +3)
  • Blood Pressure
    • Systolic: 0-300
    • Diastolic: 0-200
  • Weight
    • 0-1000 lbs
    • kg?
  • Urine
    • Albumin/Glucose: 0 Trace +1 +2 +3 +4
  • Edema
    • 0/none Trace +1 +2 +3
  • Pain Scale (0-10)
    • 0-10
  • Next Appointment
    • Days, weeks
    • How far out is next appointment?

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