1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1

Development Only

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Antepartum Record History and Physical Specification 1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1

The Antepartum Record History and Physical inherits all constraints from the IHE History and Physical and also requires the following additional constraints.

Format Code

The XDSDocumentEntry format code for this content is formatCode

Parent Template

This document is an instance of the History and Physical template.

LOINC Code

The LOINC code for this document is LOINC TBD TBD

Standards

CDAR2	HL7 CDA Release 2.0
CCD	ASTM/HL7 Continuity of Care Document
CDTHP	CDA for Common Document Types History and Physical Notes (DSTU)

Data Element Index

Data Element	CDA Section	Comments
Header	Need to include Language, Ethnicity, Husband/Domestic Partner, Father of Baby; needs further analysis
Chief Complaint	Chief Complaint
Pregnancy History	Pregnancy History	Summary (Gravida Para Abortus) and detailed history of pregnancies
Medical History	Past Medical History	Exclude social and family history (included in other sections)
Medical History - Tobacco, Alcohol, Drugs	Social History
Medical History - Relevant Family History	Family History
Medications	Medications
Allergies	Allergies and Other Adverse Reactions Section
Menstrual History/Symptoms Since LMP	Review of Systems
Genetic Screening/Teratology Counseling	Family History
Infection History	History of Infection
Initial Physical Examination	Physical Examination
Vital Signs	Vital Signs	subsection of Physical Examination
Diagnostic Findings	This section is required by CDA4CDT H&P - The intent in the APR specification is to have the antepartum specific laboratory results in the APR Laboratory document. However, this type of data may also be included here.

Specification

Data Element Name	Opt	Template ID
Spouse	R	1.3.6.1.4.1.19376.1.5.3.1.2.4.1
Natural Father of Fetus	R	1.3.6.1.4.1.19376.1.5.3.1.2.4.2
Enthnicity The enthnicity of the patient should be recorded	R2
Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4	C	R
Section	C	R
Section	C	O
Section 1.3.6.1.4.1.19376.1.5.3.1.3.16	C	R
Section 1.3.6.1.4.1.19376.1.5.3.1.3.15	C	R
Section 1.3.6.1.4.1.19376.1.5.3.1.3.18	C	R
Section 1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1	C	R
Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.15	C	R
Section 1.3.6.1.4.1.19376.1.5.3.1.3.25	C	C
[[{{{83}}}|{{{81}}}]] {{{84}}}	C	{{{83}}} [[Category:Templates using {{{83}}}]]

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. A CDA Document may conform to more than one template. This content module inherits from the History and Physical content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Antepartum Record History and Physical Document

<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root='ParentOID'/>  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1'/> <id root=' ' extension=' '/> <code code='LOINC TBD' displayName='TBD' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Antepartum Record History and Physical</title> <effectiveTime value='20260408012005'/> <confidentialityCode code='N' displayName='Normal' codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' /> <languageCode code='en-US'/>  : <component><structuredBody>     </structuredBody></component> </ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Antepartum Record History and Physical can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="ParentOID"]'>
     Error: The parent template identifier for Antepartum Record History and Physical is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "LOINC TBD"]'>
     Error: The document type code of a Antepartum Record History and Physical must be LOINC TBD
   </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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.4.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Record History and Physical Document must contain a(n) Spouse Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.4.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Record History and Physical Document must contain a(n) Natural Father of Fetus Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Antepartum Record History and Physical Document should contain a(n) Enthnicity Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "R"]'>
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "R"]'>
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "O"]'>
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "R"]'>
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "R"]'>
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "R"]'>
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "R"]'>
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "R"]'>
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "C"]'>
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "{{{83}}}"]'>
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
 </rule>
</pattern>