Antepartum Summary Volume 2

Volume II

KNOWN ISSUES

• LOINC requests
  • (xx-edd-section):ESTIMATED DELIVERY DATE-^PATIENT-FIND-PT-NAR-
  • (xx-acog-visit-sum-section):PREGNANCY VISIT SUMMARY-^PATIENT-FIND-PT-NAR
  • (xx-EDD-by-PE):DELIVERY DATE^TMSTP^PT^PATIENT^QN^ESTIMATED FROM CLINICIANS PHYSICAL EXAM
  • (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
  • (xx-ga-by-PE):GESTATIONAL AGE^TIME^PT^FETUS^QN^ESTIMATED FROM CLINICIANS PHYSICAL EXAM
  • (xx-date-of-Qck):DATE OF QUICKENING^TMSTP^PT^PATIENT^QN^REPORTED
  • (xx-date-of-Fund-Umb):DATE FUNDAL HEIGHT REACHES UMBILICUS^TMSTP^PT^PATIENT^QN^CLINICIANS PHYSICAL EXAM
  • (xx-acog-visit-sum-battery):
  • (xx-SS-Preterm-Labor):PRETERM LABOR SYMPTOMS-FIND-PT-^PATIENT-QL-CLINICAL JUDGEMENT
  • (xx-cerv-dil):DILATION-LEN-PT-CERVIX-QN-PALPATION
• SNOMED requests
  • (xx-next-appt):TIME TO NEXT VISIT
• Additional Work:
  • Need to develop other forms in Antepartum Record (Form A/B, D, E)

QUESTIONS FOR COMMENT

• Clinical Questions
  • Is Latex Allergy negation observation a requirement for all viewers of the document (ie R) or speed aid to aid entry (ie R2)
  • Is anesthesia consult planned observation a requirement for all viewers (ie R) or speed aid (R2).
  • Is blood transfusion observation a requirement for all viewers of the document (ie R) or speed aid (R2)
  • Is Fetal movememnt always by US. If not we need an additional LOINC code.
  • Is Fetal heart rate always by US. If not we need an additional LOINC code.