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| Line 2: |
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| {{TF-Vol-II-Supplement | | {{TF-Vol-II-Supplement |
| |templates-used= | | |bindings=none. |
| {{Content-Profile-Template-Identifier
| | |cda-r2-content-modules= |
| |template-name=Antepartum Summary Form A and B
| | {{:1.3.6.1.4.1.19376.1.5.3.1.1.11.1}} |
| |template-oid=1.3.6.1.4.1.19376.1.5.3.1.1.11.1
| |
| |tf-section=x.tbd
| |
| }}
| |
| {{Content-Profile-Template-Identifier
| |
| |template-name=Antepartum Summary Form C, F and G
| |
| |template-oid=1.3.6.1.4.1.19376.1.5.3.1.1.11.2
| |
| |tf-section=x.tbd
| |
| }}
| |
| {{Content-Profile-Template-Identifier
| |
| |template-name=Antepartum Summary Form D
| |
| |template-oid=1.3.6.1.4.1.19376.1.5.3.1.1.11.3
| |
| |tf-section=x.tbd
| |
| }}
| |
| {{Content-Profile-Template-Identifier
| |
| |template-name=Antepartum Summary Form E
| |
| |template-oid=1.3.6.1.4.1.19376.1.5.3.1.1.11.4
| |
| |tf-section=x.tbd
| |
| }}
| |
| |cda-r2-document-content-modules= | |
| {{CDA-R2-Document-Content-Module
| |
| |content-profile-name=Antepartum Summary Form C, F & G
| |
| |content-profile-oid=1.3.6.1.4.1.19376.1.5.3.1.1.11.2
| |
| |content-profile-parent-name=Medical Summary
| |
| |content-profile-parent-oid=1.3.6.1.4.1.19376.1.5.3.1.1.2
| |
| |content-profile-description=The Antepartum Summary Content Profile describes forms for antenatal care
| |
| |referenced-standards=
| |
| * ACOG Antepartum Record
| |
| * HL7 CDA release 2
| |
| * HL7 CCD implentation Guide
| |
| * IHE Medical Summary
| |
| |data-element-index-section=
| |
| {{Data-Element-Index-Section
| |
| |header=This section provides a map of the elements from the ACOG Antepartum Record, Form C to it's corresponding path in CDA-r2
| |
| |elements=
| |
| {{Document-Data-Element
| |
| |element-name=Allergies
| |
| |cda-r2-path=/structuredBody/section/code[code="10155-0"]
| |
| |template-name=Allergies
| |
| |template-oid=1.3.6.1.4.1.19376.1.5.3.1.3.13
| |
| |optionality=R
| |
| |comments=Must include observation of Latex Allergy
| |
| }}
| |
| {{Document-Data-Element
| |
| |element-name=Is Blood Transfusion Acceptable?
| |
| |cda-r2-path=/structuredBody/section/code[code="42348-3"]
| |
| |template-name=Advance Directives
| |
| |template-oid=1.3.6.1.4.1.19376.1.5.3.1.3.39
| |
| |optionality=R
| |
| |comments=Must include observation about blood transfusion acceptability.
| |
| }}
| |
| {{Document-Data-Element
| |
| |element-name=Antepartum Anesthesia Consult Planned
| |
| |cda-r2-path=/structuredBody/section/code[code="18776-5"]
| |
| |template-name=Care Plan
| |
| |template-oid=1.3.6.1.4.1.19376.1.5.3.1.3.31
| |
| |optionality=R
| |
| |comments=Must include observation about planned Anesthesia consult.
| |
| }}
| |
| {{Document-Data-Element
| |
| |element-name=Problems/Plans
| |
| |cda-r2-path=/structuredBody/section/code[code="11450-4"]
| |
| |template-name=Active Problems
| |
| |template-oid=1.3.6.1.4.1.19376.1.5.3.1.3.6
| |
| |optionality=R
| |
| |comments=Related plans should be included Care Plan Section.
| |
| }}
| |
| {{Document-Data-Element
| |
| |element-name=Medication List
| |
| |cda-r2-path=/structuredBody/section/code[code="10160-0"]
| |
| |template-name=Current Medications
| |
| |template-oid=1.3.6.1.4.1.19376.1.5.3.1.3.19
| |
| |optionality=R
| |
| |comments=Must include start/stop dates if known.
| |
| }}
| |
| {{Document-Data-Element
| |
| |element-name=Estimated Due Dates
| |
| |cda-r2-path=/structuredBody/section/code[code="xx"]
| |
| |template-name=Estimated Due Dates
| |
| |template-oid=1.3.6.1.4.1.19376.1.5.3.1.11.2.1
| |
| |optionality=R
| |
| |comments=
| |
| }}
| |
| {{Document-Data-Element
| |
| |element-name=Prepregnancy Weight
| |
| |cda-r2-path=/structuredBody/section/code[code="xx"]
| |
| |template-name=Prepregnancy Weight
| |
| |template-oid=1.3.6.1.4.1.19376.1.5.3.1.11.2.2
| |
| |optionality=R
| |
| |comments=
| |
| }}
| |
| {{Document-Data-Element
| |
| |element-name=Visit Summary
| |
| |cda-r2-path=/structuredBody/section/code[code="xx"]
| |
| |template-name=ACOG Form C Visit Summary
| |
| |template-oid=1.3.6.1.4.1.19376.1.5.3.1.11.2.3
| |
| |optionality=R
| |
| |comments=
| |
| }}
| |
| }}
| |
| |additional-constraints=
| |
| * Latex Allergy SHALL be represented as a simple observation with <code code='' codeSystem=''/> and the negationInd attribute set to represent the presence or absence of the allergy.
| |
| * Blood Transfusion Acceptable SHALL be represented as a simple observation with the <code code='' codeSystem=''/> and the negationInd attribute of the observation set to true to represent "acceptable"
| |
| * Anesthesia consult planned SHALL be represented as a simple observation with the <code code='' codeSystem=''/> and the negationInd attribute of the observation set to true to indicate that a consult has been planned.
| |
| }}
| |
| |cda-r2-section-content-modules=
| |
| {{CDA-R2-Section-Content-Module
| |
| |section-name=Estimated Due Dates
| |
| |section-oid=1.3.6.1.4.1.19376.1.5.3.1.11.2.1
| |
| |status=draft
| |
| |description=This section contains initial and confirmation gestational dates
| |
| |section-codes=
| |
| {{CDA-R2-Valid-Section-Code
| |
| |loinc-code=xx-EDD-SECTION
| |
| |opt=R
| |
| |description=(requested from LOINC)
| |
| }}
| |
| |valid-subsections=
| |
| {{CDA Section Content
| |
| |section-name=None
| |
| |subsection-name
| |
| |opt
| |
| |oid
| |
| |comment
| |
| }}
| |
| |valid-entries=
| |
| {{Valid-Section-Entry
| |
| |entry-oid=1.3.6.1.4.1.19376.1.5.3.1.4.13
| |
| |entry-name=Simple Observation
| |
| |opt=R2
| |
| |description=This section will contain a list of simple observations using LOINC codes from the entry code table listed below
| |
| }}
| |
| |valid-LOINC-entry-codes=
| |
| {{LOINC-Entry-Code
| |
| |loinc-code=8655-2
| |
| |loinc-full-name=DATE LAST MENSTRUAL PERIOD^TMSTP^PT^PATIENT^QN^REPORTED
| |
| |type=TS
| |
| |units=
| |
| |reference-name=LMP
| |
| }}
| |
| {{LOINC-Entry-Code
| |
| |loinc-code=11779-6
| |
| |loinc-full-name=DELIVERY DATE^TMSTP^PT^PATIENT^QN^ESTIMATED FROM LAST MENSTRUAL PERIOD
| |
| |type=TS
| |
| |units=
| |
| |reference-name=EDD from LMP
| |
| }}
| |
| {{LOINC-Entry-Code
| |
| |loinc-code=xx-GA-BY-PE
| |
| |loinc-full-name=TBD (Gestational Age based on physical examination)
| |
| |type=TS
| |
| |units=
| |
| |reference-name=Initial Exam Wks, Fundal Height
| |
| }}
| |
| {{LOINC-Entry-Code
| |
| |loinc-code=xx-EDD-BY-PE
| |
| |loinc-full-name=TBD (Estimated Due Date base on Physical Exam)
| |
| |type=TS
| |
| |units=
| |
| |reference-name=EDD from Inital Exam
| |
| }}
| |
| {{LOINC-Entry-Code
| |
| |loinc-code=11888-5
| |
| |loinc-full-name=GESTATIONAL AGE^TIME^PT^FETUS^QN^US.COMPOSITE.ESTIMATED
| |
| |type=TS
| |
| |units=
| |
| |reference-name=Ultrasound Wks
| |
| }}
| |
| {{LOINC-Entry-Code
| |
| |loinc-code=11781-2
| |
| |loinc-full-name=DELIVERY DATE^TMSTP^PT^QN^US.COMPOSITE.ESTIMATED
| |
| |type=TS
| |
| |units=
| |
| |reference-name=Ultrasound Wks
| |
| }}
| |
| {{LOINC-Entry-Code
| |
| |loinc-code=xx-QUICKENING-DATE
| |
| |loinc-full-name=TBD(Quickening Date)
| |
| |type=TS
| |
| |units=
| |
| |reference-name=Quickening Date
| |
| }}
| |
| {{LOINC-Entry-Code
| |
| |loinc-code=xx-EDD-BY-QUICKENING-DATE
| |
| |loinc-full-name=TBD(Estimated Due Date based on Quickening Date)
| |
| |type=TS
| |
| |units=
| |
| |reference-name=EDD by Quickening Date
| |
| }}
| |
| {{LOINC-Entry-Code
| |
| |loinc-code=11778-8
| |
| |loinc-full-name=DELIVERY DATE^TMSTP^PT^PATIENT^QN^CLINICAL.ESTIMATED
| |
| |type=TS
| |
| |units=
| |
| |reference-name=Initial EDD, Final EDD
| |
| }}
| |
| |notes=
| |
| * Initial and Final EDD may be distinquished by observation activity time.
| |
| }}
| |
| {{CDA-R2-Section-Content-Module
| |
| |section-name=Prepregnancy Weight
| |
| }}
| |
| {{CDA-R2-Section-Content-Module
| |
| |section-name=Visit Summary
| |
| |section-oid=1.3.6.1.4.1.19376.1.5.3.1.11.2.3
| |
| |status=draft
| |
| |description=
| |
| |section-codes=
| |
| {{CDA-R2-Valid-Section-Code
| |
| |loinc-code=xx-VISIT-SUM
| |
| |opt=R
| |
| |description=(requested from LOINC)
| |
| }}
| |
| |valid-subsections=
| |
| {{CDA Section Content
| |
| |section-name=None
| |
| |subsection-name=
| |
| |opt=
| |
| |oid=
| |
| |comment=
| |
| }}
| |
| |valid-entries=
| |
| {{Valid-Section-Entry
| |
| |entry-oid=1.3.6.1.4.1.19376.1.5.3.1.4.13
| |
| |entry-name=Simple Observation
| |
| |opt=R2
| |
| |description=This section will contain a list of simple observations using LOINC codes from the entry code table listed below
| |
| }}
| |
| |valid-LOINC-entry-codes=
| |
| {{LOINC-Entry-Code
| |
| |loinc-code=11881-0
| |
| |loinc-full-name=FUNDAL HEIGHT^LEN^PT^UTERUS^QN^TAPE MEASURE
| |
| |type=
| |
| |units=
| |
| |reference-name=Fundal Height(cm)
| |
| }}
| |
| {{LOINC-Entry-Code
| |
| |loinc-code=
| |
| |loinc-full-name=
| |
| |type=
| |
| |units=
| |
| |reference-name=
| |
| }}
| |
| }}
| |
| }} | | }} |
