Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1"

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EDD Observation 1.3.6.1.4.1.19376.1.5.3.1.11.2.3.1

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

EDD Observation Example

<observation classCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.11.2.3.1'>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <activityTime value=' '/>
 <author typeCode='AUT'><reference id=' '/></author>
 <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=' '/>
     <activityTime value=' '/>
     <author typeCode='AUT'><reference id=' '/></author>
     <code code='[11779-6|(xx-EDD-by-PE)|11781-2|(xx-EDD-by-Qck)|(xx-EDD-by-Fund)]'
           codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
     <value type='TS' value=' '>
     <entryRelationship typeCode='DRIV'>
       <observation  classCode='OBS' moodCode='EVN'>
         <id root=' ' extension=' '/>
         <statusCode code='completed'/>
         <effectiveTime value=' '/>
         <activityTime value=' '/>
         <author typeCode='AUT'><reference id=' '/></author>
         <informant><reference id=' '/></informant>
         <code code='[8655-2|(xx-ga-by-pe)|11888-5|(xx-date-of-qck)|(xx-date-of-fund-umb) ]' 
               codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
         <value type='[PQ|TS]' value=' ' units='week'/>
       </observation>
     </entryRelationship>
   </observation>
 </entryRelationship>
</observation>

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.11.2.3.1'/>

The <templateId> identifies the observation as a type of Estimated Due Date.

<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. It is good style to include the displayName and codeSystemName to help debugging.

<value xsi:type='TS' value=' '>

The value of the EDD is be represented as a point in time.

<author typeCode='AUT'>

If there are multiple clinicians following the patient, the author of the initial EDD may or may not be the author of the CDA. This may be clarified by inclusion of an author relationship.

<entryRelationship typeCode='SPRT'>

The <entryRelationship> element binds the 2 observations. The final clinically estimated delivery date is supported by other methods such as ultrasound, examination, or patient history.

<code code=' ' codeSystem='2.16.840.1.113883.6.1'/> [1st nesting]

Estimated Due Dates may be calculated by various different methods. The following table lists the relevant LOINC codes for methods used.

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^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