1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1

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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 History and Physical Specification 1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1

The Antepartum History and Physical inherits all constraints from the IHE History and Physical and also requires the following additional constraints.


Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:apr:2008

Parent Template

This document is an instance of the History and Physical template.

LOINC Code

The LOINC code for this document is 34117-2 HISTORY AND PHYSICAL

Standards
CDAR2 HL7 CDA Release 2.0
CCD ASTM/HL7 Continuity of Care Document
CDTHP CDA for Common Document Types History and Physical Notes (DSTU)
Data Element Index
Data Element CDA Section Comments
Header Need to include Language, Ethnicity, Husband/Domestic Partner, Father of Baby; needs further analysis
Chief Complaint Chief Complaint
Pregnancy History Pregnancy History Summary (Gravida Para Abortus) and detailed history of pregnancies
Medical History Past Medical History Exclude social and family history (included in other sections)
Medical History - Tobacco, Alcohol, Drugs Social History
Medical History - Relevant Family History Family History
Medications Medications
Allergies Allergies and Other Adverse Reactions Section
Menstrual History/Symptoms Since LMP Review of Systems
Genetic Screening/Teratology Counseling Family History
Infection History History of Infection
Initial Physical Examination Physical Examination
Vital Signs Vital Signs subsection of Physical Examination
Diagnostic Findings This section is required by CDA4CDT H&P - The intent in the APR specification is to have the antepartum specific laboratory results in the APR Laboratory document. However, this type of data may also be included here.
Specification
Data Element Name Opt Template ID
Spouse R 1.3.6.1.4.1.19376.1.5.3.1.2.4.1
Natural Father of Fetus R 1.3.6.1.4.1.19376.1.5.3.1.2.4.2
Enthnicity
The enthnicity of the patient should be recorded 		R2
Chief Complaint R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
History of Present Illness R 1.3.6.1.4.1.19376.1.5.3.1.3.4
Past Medical History
This section is the same as it is for History and Physical, and it SHALL contain entries and SHOULD use the codes specified in the appropriate Antepartum Past Medical History Value Set.

There is currently a CP to change this section name from Resolved Problems to Past Medical History.

R 1.3.6.1.4.1.19376.1.5.3.1.3.8
History of Infection
This section SHALL contain coded entries for infection history and SHOULD use the codes as specified in the Antepartum Infection History Value Set. 		R 1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1
Pregnancy History
This section will consist of two entries, both of which will live under the existing Pregnancy History section.

Fields that don't exist in the current Pregnancy Observation list:' Summary - ectopics, multiple births Details - length of labor, birth weight, sex, type of delivery, anesthestics, place of delivery, preterm labor

R 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
Pregnancy Summary History
SHALL use the existing observation Pregnancy Observation and MAY use LOINC or SNOMED CT coded value sets 		R 1.3.6.1.4.1.19376.1.5.3.1.1.16.4.1
Pregnancy Detail History
Will contain the details of each pregnancy as specified in the Antepartum Pregnancy History Value Set. 		O 1.3.6.1.4.1.19376.1.5.3.1.1.16.4.2
Social History
This section is the same as it is for History & Physical, however it SHALL contain coded entries and SHOULD use the codes specified in the Antepartum Social History Value Set. 		R 1.3.6.1.4.1.19376.1.5.3.1.3.16
Coded Family Medical History
This section is the same as it is for History & Physical, however it SHALL contain Genetic Screening and Teratology Counseling information as specified in the Antepartum Family History and Genetic Screening Value Set. This section SHOULD also contain any additional relevant family history. 		R 1.3.6.1.4.1.19376.1.5.3.1.3.15
Review of Systems
This section is the same as it is for History & Physical, however it SHALL include organizers for Menstrual History and MAY include CDA entries for general review of systems data. The 'Menstrual History observations SHOULD use the codes specified in the Antepartum Menstrual History Value Set. The section code for the Menstrual History organizer SHALL be 49033-4 and the code system name is LOINC. 		R 1.3.6.1.4.1.19376.1.5.3.1.3.18
Physical Examination
This section is the same as it is for History & Physical, and if Vital Signs data are present it SHALL include a Vital Signs subsection. 		R 1.3.6.1.4.1.19376.1.5.3.1.1.9.15
Vital Signs
If Vital Signs data are present they SHALL be included as a subsection of Physical Examination. 		C 1.3.6.1.4.1.19376.1.5.3.1.3.25


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 History and Physical 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 History and Physical Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1'/>
  <id root=' ' extension=' '/>
  <code code='34117-2' displayName='HISTORY AND PHYSICAL'
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Antepartum History and Physical</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='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'/>
        <!-- Required Chief Complaint Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
        <!-- Required History of Present Illness Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required Past Medical History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1'/>
        <!-- Required History of Infection Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/>
        <!-- Required Pregnancy History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.4.1'/>
        <!-- Required Pregnancy Summary History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.4.2'/>
        <!-- Optional Pregnancy Detail History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16'/>
        <!-- Required Social History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.15'/>
        <!-- Required Coded Family Medical History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Required Review of Systems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.15'/>
        <!-- Required Physical Examination Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
        <!-- Conditional Vital Signs Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Antepartum History and Physical can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4"]'>
     Error: The parent template identifier for Antepartum History and Physical is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "34117-2"]'>
     Error: The document type code of a Antepartum History and Physical must be 34117-2
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.2.4.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) Spouse Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.4.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) Natural Father of Fetus Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Antepartum History and Physical Document should contain a(n) Enthnicity Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) Chief Complaint Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) History of Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) Past Medical History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) History of Infection Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) Pregnancy History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.16.4.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) Pregnancy Summary History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.16.4.2"]'> 
     <!-- Note any missing optional elements -->
     Note: This Antepartum History and Physical Document does not contain a(n) Pregnancy Detail History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.15"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) Coded Family Medical History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) Physical Examination Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Antepartum History and Physical Document does not contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
 </rule>
</pattern>
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