Difference between revisions of "Antepartum Summary Volume 2"
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| Line 25: | Line 25: | ||
|cda-r2-content-modules= | |cda-r2-content-modules= | ||
{{CDA-r2-Content-Module | {{CDA-r2-Content-Module | ||
| − | |content-profile-name=Antepartum Summary Form C & G | + | |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-oid=1.3.6.1.4.1.19376.1.5.3.1.1.11.2 | ||
|content-profile-parent-name=Medical Summary | |content-profile-parent-name=Medical Summary | ||
| Line 39: | Line 39: | ||
|header=This section provides a map of the elements from the ACOG Antepartum Record, Form C to it's corresponding path in CDA-r2 | |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= | |elements= | ||
| − | {{Element | + | {{Document-Data-Element |
|element-name=Allergies | |element-name=Allergies | ||
|cda-r2-path=/structuredBody/section/code[code="10155-0"] | |cda-r2-path=/structuredBody/section/code[code="10155-0"] | ||
| Line 47: | Line 47: | ||
|comments=Must include observation of Latex Allergy | |comments=Must include observation of Latex Allergy | ||
}} | }} | ||
| − | {{Element | + | {{Document-Data-Element |
|element-name=Is Blood Transfusion Acceptable? | |element-name=Is Blood Transfusion Acceptable? | ||
|cda-r2-path=/structuredBody/section/code[code="42348-3"] | |cda-r2-path=/structuredBody/section/code[code="42348-3"] | ||
|template-name=Advance Directives | |template-name=Advance Directives | ||
| − | |template-oid=1.3.6.1.4.1.19376.1.5.3.1.3. | + | |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 | |optionality=R | ||
| − | |comments= | + | |comments= |
}} | }} | ||
}} | }} | ||
|additional-constraints= | |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. | * 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" | + | * 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. | ||
}} | }} | ||
}} | }} | ||
