1.3.6.1.4.1.19376.1.5.3.1.1.11.2: Difference between revisions

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{{CDA Document|Antepartum Summary Form C, F & G|1.3.6.1.4.1.19376.1.5.3.1.1.11.2|draft|what is param 4?
{{CDA Document|Antepartum Summary Form C, F & G|1.3.6.1.4.1.19376.1.5.3.1.1.11.2|draft|
The APS Form C represents a summary of the most critical information to Obstritrician regarding the status of hte pregnancy.
|Data=
|Data=
  {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.3.13|Allergies|R|1.3.6.1.4.1.19376.1.5.3.1.3.13|Must include observation of Latex Allergy}}
  {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.3.13|Allergies|R|1.3.6.1.4.1.19376.1.5.3.1.3.13|Must include observation of Latex Allergy}}
  {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.3.39|Advance Directives|R|1.3.6.1.4.1.19376.1.5.3.1.3.39|Must include observation of blood transfusion acceptable?}}
  {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.3.39|Advance Directives|R|1.3.6.1.4.1.19376.1.5.3.1.3.39|APS includes an explicit check of patients preference for blood transfusion.  This SHALL be recorded in the Advance Directives section.  APS Form C documents SHALL include a simple observation of "blood transfusion acceptable?" }}
  {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.3.31|Plan of Care|R|1.3.6.1.4.1.19376.1.5.3.1.3.31|Must include observation stating if an anesthesia consult is planned}}
  {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.3.31|Plan of Care|R|1.3.6.1.4.1.19376.1.5.3.1.3.31|Must include observation stating if an anesthesia consult is planned}}
  {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.3.19|Medications|R|1.3.6.1.4.1.19376.1.5.3.1.3.19|Medications should include start and stop date if known.}}
  {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.3.19|Medications|R|1.3.6.1.4.1.19376.1.5.3.1.3.19|Medications should include start and stop date if known.}}
  {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.3.6|Problems|R|1.3.6.1.4.1.19376.1.5.3.1.3.6|Related Plans should be included in the Plan of Care section.}}
  {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.3.6|Problems|R|1.3.6.1.4.1.19376.1.5.3.1.3.6|Related Plans should be included in the Plan of Care section.}}
  {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.11.2.1|Estimated Due Dates|1.3.6.1.4.1.19376.1.5.3.1.11.2.1|}}
  {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.11.2.1|Estimated Due Dates|R|1.3.6.1.4.1.19376.1.5.3.1.11.2.1|}}
  {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.11.2.2|ACOG Visit Summary|1.3.6.1.4.1.19376.1.5.3.1.11.2.2|}}
  {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.11.2.2|ACOG Visit Summary|R|1.3.6.1.4.1.19376.1.5.3.1.11.2.2|}}
}}
}}

Revision as of 11:09, 26 May 2007

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 Summary Form C, F & G Specification 1.3.6.1.4.1.19376.1.5.3.1.1.11.2

The APS Form C represents a summary of the most critical information to Obstritrician regarding the status of hte pregnancy.




Transition to new CDA Document template to support schematron-->>Data<<--

Specification
Data Element Name Opt Template ID
Allergies
Must include observation of Latex Allergy 		R 1.3.6.1.4.1.19376.1.5.3.1.3.13
Advance Directives
APS includes an explicit check of patients preference for blood transfusion. This SHALL be recorded in the Advance Directives section. APS Form C documents SHALL include a simple observation of "blood transfusion acceptable?" 		R 1.3.6.1.4.1.19376.1.5.3.1.3.39
Plan of Care
Must include observation stating if an anesthesia consult is planned 		R 1.3.6.1.4.1.19376.1.5.3.1.3.31
Medications
Medications should include start and stop date if known. 		R 1.3.6.1.4.1.19376.1.5.3.1.3.19
Problems
Related Plans should be included in the Plan of Care section. 		R 1.3.6.1.4.1.19376.1.5.3.1.3.6
Estimated Due Dates R 1.3.6.1.4.1.19376.1.5.3.1.11.2.1
ACOG Visit Summary R 1.3.6.1.4.1.19376.1.5.3.1.11.2.2


Conformance

CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown in the sample document below.

Sample Antepartum Summary Form C, F & G Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Antepartum Summary Form C, F & G</title>
  <effectiveTime value='20260407012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
       
  </structuredBody></component>
</ClinicalDocument>

  

   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Antepartum Summary Form C, F & G must be {{{LOINC}}}
   </assert>
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'>
     Error: The document type code must come from the LOINC code 
     system (2.16.840.1.113883.6.1).
   </assert>
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