Aps vol2 content-modules cda-r2-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 C, F & G Specification 1.3.6.1.4.1.19376.1.5.3.1.1.11.2

-->>Data<<--

Specification

Data Element Name	Opt	Template ID
Allergies Must include observation of Latex Allergy	R
Advance Directives Must include observation of blood transfusion acceptable?	R
Plan of Care Must include observation stating if an anesthesia consult is planned	R
Medications	R
Problems	R

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>     </structuredBody></component> </ClinicalDocument>

 

   <!-- 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>

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

docname2 Specification did2

desc2

-->>Data<<--

Specification

Data Element Name	Opt	Template ID
sect1	R	sid1

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 docname2 Document

<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root='did2'/> <id root=' ' extension=' '/> <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>docname2</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 docname2 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>

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 Due Dates Section

Template ID	1.2.6.1.4.1.19376.1.5.3.1.1.11.2.1
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 Codes	Opt	Description
(LOINC-requested)	R	EntryName1
Entries	Opt	Description
1.2.6.1.4.1.19376.1.5.3.1.1.11.2.1	R	entN if one observation is present, then it is to be interpreted as the initial EDD. If observations dates indicate the EDD is within 20 weeks, the most recent observation will also be interpreted as the 18-20 week update.

Sample Estimated Due Dates Section

<component> <section> <templateId root='1.2.6.1.4.1.19376.1.5.3.1.1.11.2.1'/> <id root=' ' extension=' '/> <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text> <entry> Required and optional entries as described above </entry>     </section> </component>

Uses

See Templates using the Estimated Due Dates Section