Aps vol2 content-modules cda-r2-content-modules

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CDA Release 2 Content Modules

CDA Document Content Modules

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 A and B Specification 1.3.6.1.4.1.19376.1.5.3.1.1.11.1

Form A of the Antepartum Summary will be defined in future profile suppliments. This is a placeholder for that oid.




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

Specification
Data Element Name Opt Template ID
TBD R 1.3.6.1.4.1.19376.1.5.3.1.11.1.2.1


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 A and B Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.1'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Antepartum Summary Form A and B</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>

  

   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Antepartum Summary Form A and B 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>Form A,B

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 Specification 1.3.6.1.4.1.19376.1.5.3.1.1.11.2

The Antepartum Summary represents a summary of the most critical information to an antepartum care provider regarding the status of a patients pregnancy.

The APS document is a medical summary and inherits all header constraints from Medical Summaries.

The use case for this document is described fully in the APS Profile in PCC TF-1.


Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:aps:2007

Parent Template

This document is an instance of the Medical Summary template.

LOINC Code

The LOINC code for this document is XX-APS Antepartum Summary

Standards
CCD ASTM/HL7 Continuity of Care Document
CDAR2 HL7 CDA Release 2.0
ACOGAR American College of Obstretricians and Gynecologists (ACOG), Antepartum Record
LOINC Logical Observation Identifiers, Names and Codes
SNOMED Systemized Nomenclature for Medicine
Data Element Index

This section maps the ACOG Antepartum Record to corresponding CDA sections as constrained by IHE.

ACOG Antepartum Record Datum CDA Section Trial
Drug Allergy/Latex Allergy Allergies
Is Blood Transfusion Acceptable Advance Directives
Antepartum Anesthesia Consult Planned Plan of Care
Problems/Plans Problems Related plans should be listed in Plan of Care
Medication List Active Medications
EDD Confirmation/18-20 Week EDD Update Estimated Delivery Dates
Prepregnancy Weight Visit Summary Flowsheet
Visit Flowsheet Visit Summary Flowsheet
Specification
Data Element Name Opt Template ID
Allergies
This section is the same as for Medical Summary, however it SHALL include one observation of Latex Allergy which may be negated through the negationInd attribute. Latex Allergy is particularly relevant for Obstetrics because of the frequency of vaginal exams that might involve the use of latex gloves. 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 because the risk of massive hemorrhage during delivery is much higher. This observation SHALL be recorded in the Advance Directives section. APS Form C documents SHALL include a simple observation of "blood transfusion acceptable?" The observation value for this observation is '(xx-bld-transf-ok)'. The codeSystem is '2.16.840.1.113883.6.1'. The codeSystemName is 'LOINC' 		R 1.3.6.1.4.1.19376.1.5.3.1.3.34
Plan of Care
APS forms SHOULD include an observation stating if an anesthesia consult is planned. When present, the observation value for this observation is '(xx-anest-cons-pland)'. The codeSystem is '2.16.840.1.113883.6.1'. The codeSystemName is 'LOINC'.
If the type of anesthesia planned is known, systems SHOULD include an observation to represent that data using the LOINC code '(xx-type-of-anesth-pland)' with a CD value including one of the following values: ( General | Epidural | Spinal ) or a Null flavor to represent unknown or not listed. 		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 Delivery Dates R 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1
Antepartum Visit Summary Flowsheet R 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2


Note: The Antepartum summary is typically used as a 'living document' where the latest information is added to the end of the flowsheet at each visit. This is different than a typical Medical Summary which typically would not share information until document is complete. Although this pattern of updates is not prohibited by Medical Summary, it is also not typical. For APS documents may be published at the end of each visit, but subsequent updates with a pregnancy SHALL be represented as document replacement by including a <relatedDocument typeCode='REPL'> element as below. 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
    :
  <relatedDocument typeCode='REPL'>
    <parentDocument>
      <id root=' ' extension=' '/>
    </parentDocument>
  </relatedDocument>
    :
</ClinicalDocument>
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 Medical Summary 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 Summary Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2'/>
  <id root=' ' extension=' '/>
  <code code='XX-APS' displayName='Antepartum Summary'
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Antepartum Summary</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='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- 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 Delivery 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 Antepartum 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 can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.2"]'>
     Error: The parent template identifier for Antepartum Summary is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "XX-APS"]'>
     Error: The document type code of a Antepartum Summary must be XX-APS
   </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 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 = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary 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 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 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 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 Document must contain a(n) Estimated Delivery 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 Document must contain a(n) Antepartum 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> 
   <assert test="cda:entry/cda:observation/cda:value[@code='300916003']">
     Antepartum Summary Requires an observation of Latex Allergy to be
     asserted.  This may be negated via the negationInd attribute.
   </assert>
   <assert test="cda:entry/cda:observation/cda:value[@code='(xx-bld-transf-ok)']">
     Antepartum Summary Requires an observation of blood transfusion
     acceptability to be asserted.  This may be negated via the negationInd attribute.
   </assert>
   <assert test="cda:entry/cda:observation/cda:value[@code='(xx-anest-cons-pland)']">
     Antepartum Summary Requires an observation of anesthesia consult 
     planned to be asserted.  This may be negated via the negationInd attribute.
   </assert> 
 </rule>
</pattern>Form C,F,G

1.3.6.1.4.1.19376.1.5.3.1.1.11.3Form D 1.3.6.1.4.1.19376.1.5.3.1.1.11.4Form E

CDA Header Content Modules

CDA Section Content Modules

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 https://www.ihe.net/resources/technical_frameworks/#pcc

Estimated Delivery Dates Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1
General Description

This section houses the physicians best estimate of the patients due date. This is generally done both on an initial evaluation, and later confirmed at 18-20 weeks. The date is supported by evidence such as the patients history of last menstral period, a physical examination, or ultrasound measurements. If an gestational age based on ultrasound is present, it is generally considered the most accurate measurement and so that date would be chosen.

LOINC Code Opt Description
(xx-edd-section) R ESTIMATED DELIVERY DATE-^PATIENT-FIND-PT-NAR-
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1 R Estimated Due Date Observation
This is a simple observation to represent the estimated due date with a supporting observation or observations that state the method used and date implied by that method. If one observation is present, then it is to be interpreted as the initial EDD. If the initial observation dates indicate the EDD is within the 18 to 20 weeks completed gestation, that observation will also populate the 18-20 week update. If the initial observation indicates an EDD of more than 20 weeks EGA, then no value will be placed in the 18-20 week update field.



Sample Estimated Delivery Dates Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1'/>
    <id root=' ' extension=' '/>
    <code code='(xx-edd-section)' displayName='ESTIMATED DELIVERY DATE-^PATIENT-FIND-PT-NAR-'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Estimated Due Date Observation element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Estimated Delivery Dates can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "(xx-edd-section)"]'> 
     Error: The section type code of a Estimated Delivery Dates must be (xx-edd-section) 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Estimated Delivery Dates Section must contain a(n) Estimated Due Date Observation Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Estimated Delivery Dates Section


EDD section

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 https://www.ihe.net/resources/technical_frameworks/#pcc

Visit Summary Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2
General Description

This section is a running history of the most important elements noted for a pregnant woman.

LOINC Code Opt Description
(xx-acog-visit-sum-section) R PREGNANCY VISIT SUMMARY-^PATIENT-FIND-PT-NAR
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.13 R Simple Observation
The flowsheet contains one simple observation to represent the Prepregancy Weight. This observation SHALL be valued with the LOINC code 8348-5, BODY WEIGHT^PRE PREGNANCY-MASS-PT-QN-MEASURED. The value SHALL be of type PQ. The units may be either "lb_av" or "kg".
1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2 R Antepartum Flowsheet Panel
Other entries on the flowsheet are "batteries" which represent a single visit.



Sample Visit Summary Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2'/>
    <id root=' ' extension=' '/>
    <code code='(xx-acog-visit-sum-section)' displayName='PREGNANCY VISIT SUMMARY-^PATIENT-FIND-PT-NAR'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Simple Observation element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
         :
    </entry> 
    <entry>
         :
      <!-- Required Antepartum Flowsheet Panel element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Visit Summary can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "(xx-acog-visit-sum-section)"]'> 
     Error: The section type code of a Visit Summary must be (xx-acog-visit-sum-section) 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Visit Summary Section must contain a(n) Simple Observation Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Visit Summary Section must contain a(n) Antepartum Flowsheet Panel Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2 
   </assert> 
   <assert test='.//cda:observation/cda:code[@code="8348-5"]'>
     Error: The Visit Summary must have at least one simple observation with the LOINC
     code 8348-5 to represent the prepregnancy weight.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2
   </assert>
   <assert test='.//cda:observation[cda:code/@code='8348-5']/cda:value[@unit='kg' or @unit='lb_av']">
     Error: The prepregnancy weight shall record the units in kg or lbs
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Visit Summary Section


Visit summary

CDA Entry Content Modules

1.2.6.1.4.1.19376.1.5.3.1.1.11.2.3.1EDD observation 1.2.6.1.4.1.19376.1.5.3.1.1.11.2.3.2Visit Summary observation

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