1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1: Difference between revisions

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{{HL7V3|EDD Observation|1.3.6.1.4.1.19376.1.5.3.1.11.2.3.1|draft|The EDD observation reflects the clinicians best judgement about the estimated delivery date of the patient.  It can be supported by patient history (eg last menses or quickening), physical examination findings (uterine size), or Ultrasound.  If present, ultrasound findings generally are the most accurate supporting evidence.  The observation is a {{ILink|1.3.6.1.4.1.19376.1.5.3.1.11.2.3.1|1.3.6.1.4.1.19376.1.5.3.1.4.13|Simple Observation}} with a supporting Simple Observation that represents the method and date derived from that method.
{{HL7V3|EDD Observation|1.3.6.1.4.1.19376.1.5.3.1.11.2.3.1|draft|The EDD observation reflects the clinicians best judgement about the estimated delivery date of the patient.  It can be supported by patient history (eg last menses or quickening), physical examination findings (uterine size), or Ultrasound.  If present, ultrasound findings generally are the most accurate supporting evidence.  The observation is a {{ILink|1.3.6.1.4.1.19376.1.5.3.1.11.2.3.1|1.3.6.1.4.1.19376.1.5.3.1.4.13|Simple Observation}} with a supporting entryRelation of another Observation.  The supporting observation may in turn have a entryRelation that gives the original observation as a gestational age or date from which the estimated due date is calculated.
|Parent=1.3.6.1.4.1.19376.1.5.3.1.4.13
|ParentName=Simple Observation
|Example=
|Example=
<no-include>
  TODO:
  {{V3-Observation-Example
    |parent-template-oid=
    |template-oid=
    |loinc-codes=
    |text=
    |value-type=
    |interpretation-code=
    |relations=
  }}
</no-include>
<br/>
<br/>
  <font style='color:#808080'><observation classCode='OBS' moodCode='EVN'>
  <font style='color:#808080'><observation classCode='OBS' moodCode='EVN'>
   <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'>
   <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><!-- a simpleObservation -->
   <font style='color:black'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.11.2.3.1'></font>
   <font style='color:black'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.11.2.3.1'></font>
  <statusCode code='completed'/>
  <effectiveTime value=' '/>
  <activityTime value=' '/>
  <author typeCode='AUT'>...</author>
   <id root=' ' extension=' '/>
   <id root=' ' extension=' '/>
   <font style='color:black'>&lt;code code='11778-8' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/></font>
   <font style='color:black'>&lt;code code='11778-8'  
        displayName='DELIVERY DATE^TMSTP^PT^PATIENT^QN^CLINICAL.ESTIMATED'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/></font>
   <text><reference value='id-foo'/></text>
   <text><reference value='id-foo'/></text>
  <statusCode code='completed'/>
   <font style='color:black'><value xsi:type='TS' value=' '/>
  <effectiveTime value=' '/>
   <font style='color:black'><value xsi:type='date'> </value>
   <entryRelationship typeCode='SPRT'>
   <entryRelationship typeCode='SPRT'>
     <observation classCode='OBS' moodCode='EVN'>
     <observation classCode='OBS' moodCode='EVN'>
      <!-- this is the EDD of the supporting observation such as ultrasound -->
       <id root=' ' extension=' '/>
       <id root=' ' extension=' '/>
       <statusCode code='completed'/>
       <statusCode code='completed'/>
       <effectiveTime value='[11779-6{{!}}11778-8{{!}}11781-2]'>
       <effectiveTime value=' '/>
      &lt;code code=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
      <activityTime value=' '/>
       <value xsi:type='date'>
      <author typeCode='AUT'>...</author>
      &lt;code code='[11779-6{{!}}(xx-EDD-by-PE){{!}}11781-2{{!}}(xx-EDD-by-Qck){{!}}(xx-EDD-by-Fund)]'
          codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
       <value type='TS' value=' '>
       <entryRelationship typeCode='DRIV'>
       <entryRelationship typeCode='DRIV'>
         <observation  classCode='OBS' moodCode='EVN'>
         <observation  classCode='OBS' moodCode='EVN'>
        <id root=' ' extension=' '/>
          <!-- this is the supporting observation as Gestational age -->
        <statusCode code='completed'/>
          <id root=' ' extension=' '/>
        <effectiveTime value='[11955-2{{!}}(loinc-exam){{!}}11887-7]'>
          <statusCode code='completed'/>
        &lt;code code=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
          <effectiveTime value=' '/>
        <value xsi:type='int'>
          <activityTime value=' '/>
<TODO:units=wks?>
          <author typeCode='AUT'>...</author>
          <informant>...</informant>
          &lt;code code='[8655-2{{!}}(xx-ga-by-pe){{!}}11888-5{{!}}(xx-date-of-qck){{!}}(xx-date-of-fund-umb) ]'  
            codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
          <value type='[PQ{{!}}TS]' value=' ' units='week'/>
        </observation>
       </entryRelationship>
       </entryRelationship>
     </observation>
     </observation>
Line 46: Line 45:


}}
}}
===== <templateId root='1.3.6.1.4.1.19376.1.5.3.1.11.2.3.1'/> =====
The <templateId> identifies the observation as a type of Estimated Due Date.
===== &lt;code code='11778-8' codeSystem='2.16.840.1.113883.6.1'/>=====
The &lt;code> element indicates that this is a "clinically estimated" estimated delivery date.  It is good style to include the displayName and codeSystemName to help debugging.
===== <value xsi:type='TS' value=' '> =====
The value of the EDD is be represented as a point in time.
===== <author typeCode='AUT'> =====
If there are multiple clinicians following the patient, the author of the initial EDD may or may not be the author of the CDA.  This may be clarified by inclusion of an author relationship.
===== <entryRelationship typeCode='SPRT'> =====
The <entryRelationship> element binds the 2 observations.  The final clinically estimated delivery date is supported by other methods such as ultrasound, examination, or patient history.
===== &lt;code code=' ' codeSystem='2.16.840.1.113883.6.1'/> [1 nesting] =====
Estimated Due Dates may be calculated by various different methods.  The following table lists the relevant LOINC codes for methods used.
{|border=1
|-bgcolor='#D9D9D9'
!Code
!Description
|-
|11779-6
|DELIVERY DATE^TMSTP^PT^PATIENT^QN^ESTIMATED FROM LAST MENSTRUAL PERIOD
|-
|(xx-EDD-by-PE)
|DELIVERY DATE^TMSTP^PT^PATIENT^QN^ESTIMATED FROM CLINICIANS PHYSICAL EXAM
|-
|11781-2
|DELIVERY DATE^TMSTP^PT^QN^US.COMPOSITE.ESTIMATED
|-
|(xx-EDD-by-Qck)
|DELIVERY DATE^TMSTP^PT^PATIENT^QN^ESTIMATED FROM DATE OF QUICKENING
|-
|(xx-EDD-by-Fund)
|DELIVERY DATE^TMSTP^PT^PATIENT^QN^ESTIMATED FROM DATE FUNDAL HEIGHT REACHES UMBILICUS
|-
|}
===== <entryRelationship typeCode='DRIV'> =====
===== &lt;code code=' ' codeSystem='2.16.840.1.113883.6.1'/> [2 nesting] =====
This code is used to represent the either the relevant date, or the gestational age observation from which the EDD is derived.  The following table lists the relevant LOINC codes for methods used.  For observations that record the gestational age the value is recorded as a physical quantity with the units of weeks and the activity time should be recorded to indicate the date at which the gestational age was observed.  For observations that simply record a date (eg LMP) the observation value is recorded as a point in time.
{|border=1
|-bgcolor='#D9D9D9'
!Code
!Description
!Type
|-
|8655-2
|DATE LAST MENSTRUAL PERIOD^TMSTP^PT^PATIENT^QN^REPORTED
|-
|(xx-ga-by-PE)
|GESTATIONAL AGE^TIME^PT^FETUS^QN^ESTIMATED FROM CLINICIANS PHYSICAL EXAM
|-
|11888-5
|GESTATIONAL AGE^TIME^PT^FETUS^QN^US.COMPOSITE.ESTIMATED
|-
|(xx-date-of-Qck)
|DATE OF QUICKENING^TMSTP^PT^PATIENT^QN^REPORTED
|-
|(xx-date-of-Fund-Umb)
|DATE FUNDAL HEIGHT REACHES UMBILICUS^TMSTP^PT^PATIENT^QN^CLINICIANS PHYSICAL EXAM
|-
|}

Revision as of 17:47, 28 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

EDD Observation 1.3.6.1.4.1.19376.1.5.3.1.11.2.3.1

The EDD observation reflects the clinicians best judgement about the estimated delivery date of the patient. It can be supported by patient history (eg last menses or quickening), physical examination findings (uterine size), or Ultrasound. If present, ultrasound findings generally are the most accurate supporting evidence. The observation is a Simple Observation with a supporting entryRelation of another Observation. The supporting observation may in turn have a entryRelation that gives the original observation as a gestational age or date from which the estimated due date is calculated.


Uses

See Templates using EDD Observation

Specification
EDD Observation Example

<observation classCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.11.2.3.1'>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <activityTime value=' '/>
 <author typeCode='AUT'>...</author>
 <id root=' ' extension=' '/>
 <code code='11778-8' 
       displayName='DELIVERY DATE^TMSTP^PT^PATIENT^QN^CLINICAL.ESTIMATED'
     codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
 <text><reference value='id-foo'/></text>
 <value xsi:type='TS' value=' '/>
 <entryRelationship typeCode='SPRT'>
   <observation classCode='OBS' moodCode='EVN'>
     <id root=' ' extension=' '/>
     <statusCode code='completed'/>
     <effectiveTime value=' '/>
     <activityTime value=' '/>
     <author typeCode='AUT'>...</author>
     <code code='[11779-6|(xx-EDD-by-PE)|11781-2|(xx-EDD-by-Qck)|(xx-EDD-by-Fund)]'
         codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
     <value type='TS' value=' '>
     <entryRelationship typeCode='DRIV'>
       <observation  classCode='OBS' moodCode='EVN'>
         <id root=' ' extension=' '/>
         <statusCode code='completed'/>
         <effectiveTime value=' '/>
         <activityTime value=' '/>
         <author typeCode='AUT'>...</author>
         <informant>...</informant>
         <code code='[8655-2|(xx-ga-by-pe)|11888-5|(xx-date-of-qck)|(xx-date-of-fund-umb) ]' 
            codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
         <value type='[PQ|TS]' value=' ' units='week'/>
       </observation>
     </entryRelationship>
   </observation>
 </entryRelationship>
</observation>


<templateId root='1.3.6.1.4.1.19376.1.5.3.1.11.2.3.1'/>

The <templateId> identifies the observation as a type of Estimated Due Date.

<code code='11778-8' codeSystem='2.16.840.1.113883.6.1'/>

The <code> element indicates that this is a "clinically estimated" estimated delivery date. It is good style to include the displayName and codeSystemName to help debugging.

<value xsi:type='TS' value=' '>

The value of the EDD is be represented as a point in time.

<author typeCode='AUT'>

If there are multiple clinicians following the patient, the author of the initial EDD may or may not be the author of the CDA. This may be clarified by inclusion of an author relationship.

<entryRelationship typeCode='SPRT'>

The <entryRelationship> element binds the 2 observations. The final clinically estimated delivery date is supported by other methods such as ultrasound, examination, or patient history.

<code code=' ' codeSystem='2.16.840.1.113883.6.1'/> [1 nesting]

Estimated Due Dates may be calculated by various different methods. The following table lists the relevant LOINC codes for methods used.

Code Description
11779-6 DELIVERY DATE^TMSTP^PT^PATIENT^QN^ESTIMATED FROM LAST MENSTRUAL PERIOD
(xx-EDD-by-PE) DELIVERY DATE^TMSTP^PT^PATIENT^QN^ESTIMATED FROM CLINICIANS PHYSICAL EXAM
11781-2 DELIVERY DATE^TMSTP^PT^QN^US.COMPOSITE.ESTIMATED
(xx-EDD-by-Qck) DELIVERY DATE^TMSTP^PT^PATIENT^QN^ESTIMATED FROM DATE OF QUICKENING
(xx-EDD-by-Fund) DELIVERY DATE^TMSTP^PT^PATIENT^QN^ESTIMATED FROM DATE FUNDAL HEIGHT REACHES UMBILICUS
<entryRelationship typeCode='DRIV'>
<code code=' ' codeSystem='2.16.840.1.113883.6.1'/> [2 nesting]

This code is used to represent the either the relevant date, or the gestational age observation from which the EDD is derived. The following table lists the relevant LOINC codes for methods used. For observations that record the gestational age the value is recorded as a physical quantity with the units of weeks and the activity time should be recorded to indicate the date at which the gestational age was observed. For observations that simply record a date (eg LMP) the observation value is recorded as a point in time.

Code Description Type
8655-2 DATE LAST MENSTRUAL PERIOD^TMSTP^PT^PATIENT^QN^REPORTED
(xx-ga-by-PE) GESTATIONAL AGE^TIME^PT^FETUS^QN^ESTIMATED FROM CLINICIANS PHYSICAL EXAM
11888-5 GESTATIONAL AGE^TIME^PT^FETUS^QN^US.COMPOSITE.ESTIMATED
(xx-date-of-Qck) DATE OF QUICKENING^TMSTP^PT^PATIENT^QN^REPORTED
(xx-date-of-Fund-Umb) DATE FUNDAL HEIGHT REACHES UMBILICUS^TMSTP^PT^PATIENT^QN^CLINICIANS PHYSICAL EXAM