1.3.6.1.4.1.19376.1.5.3.1.1.11.2

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Antepartum Summary Form C & F 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 a patients 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

Conformance

An Antepartum Summary is a type of Medical Summary and incorporates the constraints defined for Medical Summaries found in the PCC TF-2 Medical Summary Module (templateID='1.3.6.1.4.1.19376.1.5.3.1.1.2').

Documents Conforming to the requirements of the APS form C content module shall indicate their conformance by the inclusion of the appropriate <templateId> element in the header of the document. This is shown in the figure below.

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension='  ' root=' '/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2'/>
   :

Data Element Index

ACOG Element	CDA Section	Comment
Drug Allergy/Latex Allergy	Allergies
Is Blood Transfusion Acceptable	Advance Directives
Antepartum Anesthesia Consult Planned	Plan of Care
Problems/Plans	Problems	Related plans should be listed in Plan of Care
Medication List	Active Medications
EDD Confirmation/18-20 Week EDD Update	Estimated Delivery Dates
Prepregnancy Weight	ACOG Visit Summary Flowsheet
Visit Flowsheet	ACOG Visit Summary Flowsheet

Specification

Data Element Name	Opt	Template ID
Allergies This section is the same as for Medical Summary, however it SHALL include one observation of Latex Allergy which may be negated through the negationInd attribute. Latex Allergy is particularly relevant for Obstetrics because of the frequency of vaginal exams that might involve the use of latex gloves. The observation value code for Latex Allergy is '300916003'. The codeSystem is '2.16.840.1.113883.6.96'. The codeSystemName is 'SNOMED CT'	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 because the risk of massive hemorrhage during delivery is much higher. This observation SHALL be recorded in the Advance Directives section. APS Form C documents SHALL include a simple observation of "blood transfusion acceptable?" The observation value for this observation is '(xx-bld-transf-ok)'. The codeSystem is '2.16.840.1.113883.6.'. The codeSystemName is 'LOINC'	R	1.3.6.1.4.1.19376.1.5.3.1.3.34
Plan of Care APS forms SHOULD include an observation stating if an anesthesia consult is planned. When present, the observation value for this observation is '(xx-anest-cons-pland)'. The codeSystem is '2.16.840.1.113883.6.'. The codeSystemName is 'LOINC'. If the type of anesthesia planned is known, systems SHOULD include an observation to represent that data using the LOINC code '(xx-type-of-anesth-pland)' with a CD value including one of the following values: ( General | Epidural | Spinal ) or a Null flavor to represent unknown or not listed.	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 Delivery Dates	R	1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1
ACOG Visit Summary Flowsheet	R	1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2

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 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</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>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/> <!-- Required Allergies Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/> <!-- Required Advance Directives Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/> <!-- Required Plan of Care Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/> <!-- Required Medications Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/> <!-- Required Problems Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1'/> <!-- Required Estimated Delivery Dates Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2'/> <!-- Required ACOG Visit Summary Flowsheet Section content --> </section> </component>     </structuredBody></component> </ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.11.2'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.11.2"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Antepartum Summary Form C & F can only be used on Clinical Documents.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Antepartum Summary Form C & F 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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary Form C & F Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary Form C & F Document must contain a(n) Advance Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary Form C & F Document must contain a(n) Plan of Care Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary Form C & F Document must contain a(n) Medications Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary Form C & F Document must contain a(n) Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary Form C & F Document must contain a(n) Estimated Delivery Dates Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary Form C & F Document must contain a(n) ACOG Visit Summary Flowsheet Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2
   </assert> 
 </rule>
</pattern>

-->>please insert schematron parameter and conformance parameter into CDA Document template<<--

Additional Schematron patterns:

<pattern name='Latex Allergy Observation Present'>
  <rule context="templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.3.13']">
    <assert test="entry/observation/value[@code='300916003']">
     Antepartum Summary Requires an observation of Latex Allergy to be asserted.  This may be negated via the negationInd attribute.
    </assert>
  </rule>
</pattern>
<pattern name='Blood Transfusion Acceptable Observation Present'>
  <rule context="templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.3.34']">
    <assert test="entry/observation/value[@code='(xx-bld-transf-ok)']">
     Antepartum Summary Requires an observation of blood transfusion acceptability to be asserted.  This may be negated via the negationInd attribute.
    </assert>
  </rule>
</pattern>
<pattern name='Anesthesia Consult Planned Observation Present'>
  <rule context="templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.3.31']">
    <assert test="entry/observation/value[@code='(xx-anest-cons-pland)']">
     Antepartum Summary Requires an observation of anesthesia consult planned to be asserted.  This may be negated via the negationInd attribute.
    </assert>
  </rule>
</pattern>