1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1
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EDD Observation 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1
The EDD observation reflects the clinicians best judgement about the estimated delivery date of the patient. It can be supported by patient history (eg last menses or quickening), physical examination findings (uterine size), or Ultrasound. If present, ultrasound findings generally are the most accurate supporting evidence. The observation is a Simple Observation with a supporting entryRelation of another Observation. The supporting observation may in turn have a entryRelation that gives the original observation as a gestational age or date from which the estimated due date is calculated.
Uses
See Templates using EDD Observation
Specification
<observation classCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1'>
<statusCode code='completed'/>
<effectiveTime value=' '/>
<author typeCode='AUT'>
<id root=' ' extension=' '/>
<code code='11778-8'
displayName='DELIVERY DATE-TMSTP-PT-^PATIENT-QN-CLINICAL.ESTIMATED'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text><reference value='id-foo'/></text>
<value xsi:type='TS' value=' '/>
<entryRelationship typeCode='SPRT'>
<observation classCode='OBS' moodCode='EVN'>
<id root=' ' extension=' '/>
<statusCode code='completed'/>
<effectiveTime value=' '/>
<author typeCode='AUT'>
</observation>
|
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1'/>
The <templateId> identifies the observation as a type of Estimated Delivery Date Observation.
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
EDD observation SHALL comply with the restrictions of a [[1.3.6.1.4.1.19376.1.5.3.1.4.13|Simple Observation]. The observation SHALL NOT include repeatNumber, interpretationCode, methodCode, or targetSiteCode.
<code code='11778-8' codeSystem='2.16.840.1.113883.6.1'/>
The <code> element indicates that this is a "clinically estimated" estimated delivery date. This code SHALL be the LOINC code 11778-8. It is good style to include the displayName and codeSystemName to help debugging.
<value xsi:type='TS' value=' '>
The value of the EDD SHALL be represented as a point in time.
<author typeCode='AUT'><assignedAuthor><id root=' ' extension=' '/></assignedAuthor></author>
There may be multiple clinicians following the patient and authoring the overall document, however the EDD observation has an individual author. This author SHALL be listed in the CDA header and referenced from the entry by including the id element of the assignedAuthor.
<author typeCode='AUT'>
The author.time is used to record the time that the author recorded the observation. It SHALL be included.
<entryRelationship typeCode='SPRT'>
The <entryRelationship> element binds the clinicians estimated EDD to supporting observations by different methods. Supporting observations SHOULD be included. If included, the typeCode SHALL be 'SPRT'.
<observation><templateId root=' '/>...</observation> [1st nesting]
Supporting observations SHALL also conform to the simple observation template. Supporting observations MAY include a different effectiveTime, author, or informant. Supporting observations SHALL NOT include repeatNumber, interpretationCode, methodCode, or targetSiteCode.
<code code=' ' codeSystem='2.16.840.1.113883.6.1'/> [1st nesting]
Supporting observations SHALL include one of following LOINC values to indicate the method used to calculate the EDD.
| Code | Description |
|---|---|
| 11779-6 | DELIVERY DATE-TMSTP-PT-^PATIENT-QN-ESTIMATED FROM LAST MENSTRUAL PERIOD |
| (xx-EDD-by-PE) | DELIVERY DATE-TMSTP-PT-^PATIENT-QN-ESTIMATED FROM CLINICIANS PHYSICAL EXAM |
| 11781-2 | DELIVERY DATE-TMSTP-PT-^PATIENT-QN-US.COMPOSITE.ESTIMATED |
| (xx-EDD-by-Qck) | DELIVERY DATE-TMSTP-PT-^PATIENT-QN-ESTIMATED FROM DATE OF QUICKENING |
| (xx-EDD-by-Fund) | DELIVERY DATE-TMSTP-PT-^PATIENT-QN-ESTIMATED FROM DATE FUNDAL HEIGHT REACHES UMBILICUS |
<entryRelationship typeCode='DRIV'>
Observations of supporting EDD should provide observations from which they were derived such as the patients last menses, or gestational age value at a point in time.
<code code=' ' codeSystem='2.16.840.1.113883.6.1'/> [2nd nesting]
This code is used to represent the either the relevant date, or the gestational age observation from which the EDD is derived. The following table lists the relevant LOINC codes for methods used. For observations that record the gestational age the value is recorded as a physical quantity (PQ) with the units of weeks and the activity time should be recorded to indicate the date at which the gestational age was observed. For observations that simply record a date (eg LMP) the observation value is recorded as a point in time (TS).
| Code | Description | Type |
|---|---|---|
| 8655-2 | DATE LAST MENSTRUAL PERIOD-TMSTP-PT-^PATIENT-QN-REPORTED | TS |
| (xx-ga-by-PE) | GESTATIONAL AGE-TIME-PT-^FETUS-QN-ESTIMATED FROM CLINICIANS PHYSICAL EXAM | PQ |
| 11888-5 | GESTATIONAL AGE-TIME-PT-^FETUS-QN-US.COMPOSITE.ESTIMATED | PQ |
| (xx-date-of-Qck) | DATE OF QUICKENING-TMSTP-PT-^PATIENT-QN-REPORTED | TS |
| (xx-date-of-Fund-Umb) | DATE FUNDAL HEIGHT REACHES UMBILICUS-TMSTP-PT-^PATIENT-QN-CLINICIANS PHYSICAL EXAM | TS |
Schematron
TODO: must include templateID and simple obs templateID must include loinc 11778-8 must include author.assignedAuthor with Id valued must include author.time must have value xsi:type=ts must include text.reference.value may include effectiveTime warn should include sprt relation to simple obs assert must not include entryRelationship other than SPRT. must not include repeatNumber, interpretationCode, methodCode, or targetSiteCode if sprt relation included then must include obs.id must include includes obs.code=(one of loincs) may include obs.author may include obs.effectiveTime