1.3.6.1.4.1.19376.1.5.3.1.1.11.2

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Antepartum Summary Form C, F & G Specification 1.3.6.1.4.1.19376.1.5.3.1.1.11.2

The Anetpartum Summary Form C represents a summary of the most critical information to Obstetrician regarding the status of the pregnancy.

Standards

• HL7 CDA Release 2
• HL7 CCD Implementation guide
• American College of Obstretricians and Gynecologists (ACOG), Antepartum Record
• LOINC
• SNOMED : Systemized Nomenclature for Medicine

Specification

Data Element Name	Opt	Template ID
Allergies This section is the same as for Medical Summary, however it must at least include one observation of Latex Allergy which may be negated through the negInd attribute. The observation value code for Latex Allergy is '300916003'. The codeSystem is '2.16.840.1.113883.6.96'. The codeSystemName is 'SNOMED CT'	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	1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1
ACOG Visit Summary Flowsheet	R	1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2

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='20260408012005'/> <confidentialityCode code='N' displayName='Normal' codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' /> <languageCode code='en-US'/>  : <component><structuredBody>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/> <!-- Required Allergies Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.39'/> <!-- Required Advance Directives Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/> <!-- Required Plan of Care Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/> <!-- Required Medications Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/> <!-- Required Problems Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1'/> <!-- Required Estimated Due Dates Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2'/> <!-- Required ACOG Visit Summary Flowsheet Section content --> </section> </component>     </structuredBody></component> </ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.11.2'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.11.2"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Antepartum Summary Form C, F & G can only be used on Clinical Documents.
   </assert> 
   <!-- 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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary Form C, F & G Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.39"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary Form C, F & G Document must contain a(n) Advance Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary Form C, F & G Document must contain a(n) Plan of Care Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary Form C, F & G Document must contain a(n) Medications Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary Form C, F & G Document must contain a(n) Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary Form C, F & G Document must contain a(n) Estimated Due Dates Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary Form C, F & G Document must contain a(n) ACOG Visit Summary Flowsheet Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2
   </assert> 
 </rule>
</pattern>