1.3.6.1.4.1.19376.1.5.3.1.1.11.2

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Antepartum Summary Form C, F & G Specification 1.3.6.1.4.1.19376.1.5.3.1.1.11.2

The Anetpartum Summary Form C represents a summary of the most critical information to Obstetrician regarding the status of the pregnancy.

Standards

• HL7 CDA Release 2
• HL7 CCD Implementation guide
• American College of Obstretricians and Gynecologists (ACOG), Antepartum Record
• LOINC
• SNOMED : Systemized Nomenclature for Medicine

-->>Data<<--

Specification

Data Element Name	Opt	Template ID
Allergies Must include observation of Latex Allergy	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. This SHALL be recorded in the Advance Directives section. APS Form C documents SHALL include a simple observation of "blood transfusion acceptable?"	R	1.3.6.1.4.1.19376.1.5.3.1.3.39
Plan of Care Must include observation stating if an anesthesia consult is planned	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 Due Dates	R	1.3.6.1.4.1.19376.1.5.3.1.11.2.2.1
ACOG Visit Summary Flowsheet	R	1.3.6.1.4.1.19376.1.5.3.1.11.2.2.2

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='20240430012005'/> <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>