Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2"
| Line 72: | Line 72: | ||
| | | | ||
|- | |- | ||
| − | |11876-0 (by PE)<br/> or 11877-8 (by US) | + | |11876-0 (by PE)<br/> or<br/>11877-8 (by US) |
| − | |FETAL PRESENTATION-TYPE-PT-PELVIS-NOM-PALPATION <br/> or FETAL PRESENTATION-TYPE-PT-PELVIS-NOM-US | + | |FETAL PRESENTATION-TYPE-PT-PELVIS-NOM-PALPATION<br/> or<br/>FETAL PRESENTATION-TYPE-PT-PELVIS-NOM-US |
|CO | |CO | ||
| | | | ||
| − | | | + | |Vertex<br/>Breech<br/>Transverse<br/>Oblique<br/>Compound<br/>Brow<br/>Face<br/>NULL^NOT LISTED<br/>NULL^UNKNOWN<br/> |
|- | |- | ||
| − | |11948-7 or (xx-fetal-hr-ausc) | + | |11948-7<br/> or<br/>(xx-fetal-hr-ausc) |
| − | |HEART RATE-NRAT-PT-^FETUS-QN-US.MEASURED<br/> or HEART RATE-NRAT-PT-^FETUS-QN-AUSCULTATION | + | |HEART RATE-NRAT-PT-^FETUS-QN-US.MEASURED<br/> or<br/>HEART RATE-NRAT-PT-^FETUS-QN-AUSCULTATION |
|RTO | |RTO | ||
|/min | |/min | ||
| Line 88: | Line 88: | ||
|CO | |CO | ||
| | | | ||
| − | | | + | |Yes<br/>No<br/>Reduced |
|- | |- | ||
|(xx-SS-Preterm-Labor) | |(xx-SS-Preterm-Labor) | ||
| Line 96: | Line 96: | ||
| | | | ||
|- | |- | ||
| − | |(xx-cerv-dil-palp)<br/> or (xx-cerv-dil-us) | + | |(xx-cerv-dil-palp)<br/> or<br/>(xx-cerv-dil-us) |
| − | |DILATION-LEN-PT-CERVIX-QN-PALPATION<br/> or DILATION-LEN-PT-CERVIX-QN-US | + | |DILATION-LEN-PT-CERVIX-QN-PALPATION<br/> or<br/>DILATION-LEN-PT-CERVIX-QN-US |
|PQ | |PQ | ||
|cm | |cm | ||
| Line 106: | Line 106: | ||
|CO | |CO | ||
| | | | ||
| − | | | + | | 0<br/>10<br/>20<br/>30<br/>40<br/>50<br/>60<br/>70<br/>80<br/>90<br/>100 |
|- | |- | ||
|11961-0 | |11961-0 | ||
| Line 112: | Line 112: | ||
|PQ | |PQ | ||
|cm | |cm | ||
| + | | | ||
|- | |- | ||
|8480-6 | |8480-6 | ||
|INTRAVASCULAR SYSTOLIC-PRES-PT-ARTERIAL SYSTEM-QN- | |INTRAVASCULAR SYSTOLIC-PRES-PT-ARTERIAL SYSTEM-QN- | ||
|PQ | |PQ | ||
| − | | | + | |mmHg |
| | | | ||
|- | |- | ||
| Line 122: | Line 123: | ||
|INTRAVASCULAR DIASTOLIC-PRES-PT-ARTERIAL SYSTEM-QN- | |INTRAVASCULAR DIASTOLIC-PRES-PT-ARTERIAL SYSTEM-QN- | ||
|PQ | |PQ | ||
| − | | | + | |mmHg |
| | | | ||
|- | |- | ||
| Line 135: | Line 136: | ||
|CO | |CO | ||
| | | | ||
| − | | | + | |None<br/>Trace<br/>1+<br/>2+<br/>3+<br/>4+ |
|- | |- | ||
| − | |2349-9<br/> or 25428-4(test strip) | + | |2349-9<br/> or<br/>25428-4(test strip) |
| − | |GLUCOSE-ACNC-PT-UR-ORD-<br/> or GLUCOSE-ACNC-PT-UR-ORD-TEST STRIP | + | |GLUCOSE-ACNC-PT-UR-ORD-<br/> or<br/>GLUCOSE-ACNC-PT-UR-ORD-TEST STRIP |
|CO | |CO | ||
| | | | ||
| − | | | + | |None<br/>Trace<br/>1+<br/>2+<br/>3+<br/>4+ |
|- | |- | ||
|44966-0 | |44966-0 | ||
| Line 147: | Line 148: | ||
|CO | |CO | ||
| | | | ||
| − | | | + | |None<br/>Trace<br/>1+<br/>2+<br/>3+<br/>4+ |
|- | |- | ||
|38208-5 | |38208-5 | ||
| Line 153: | Line 154: | ||
|CO | |CO | ||
| | | | ||
| − | | | + | |0(no pain)<br/>:<br/>10(worst possible pain)<br/>Note: This observation should correspond to the functional status [[1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1|pain score observation]] |
|- | |- | ||
| − | |(xx-time-to-next-appt)or ?39165 | + | |(xx-time-to-next-appt)<br/> or<br/>?39165 |
| − | |TIME TO NEXT VISIT-<br/> or ?Date next screen visit-TmStp-PT-^PATIENT-QN-CPHS | + | |TIME TO NEXT VISIT-<br/> or<br/>?Date next screen visit-TmStp-PT-^PATIENT-QN-CPHS |
|PQ | |PQ | ||
|day,week,mo | |day,week,mo | ||
Revision as of 16:11, 30 May 2007
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
ACOG Visit Summary Battery 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2
This entry describes a single row in the Visit Summary flowsheet. The single observation date and provider is applied to all other observations.
Uses
See Templates using ACOG Visit Summary Battery
Specification
<entry>
<organizer classCode='BATTERY' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2'/>
<id root=' ' extension=' '/>
<code code='(xx-acog-battery)' displayName='ACOG Summary Visit Battery---PT--'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<activityTime value=' '/>
<statusCode code='completed'/>
<author typeCode='AUT'><reference value='#author-1'/></author>
<component>
<observation classCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
...
</observation>
</component>
<component>
<observation classCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
...
</observation>
</component>
...
</organizer>
</entry>
|
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2'/>
The <templateId> element specifies that this organizer entry conforms to the APS profile Visit Summary Flowsheet battery. The root attribute SHALL contain the value "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2"
<organizer classCode='BATTERY' moodCode='EVN'>
Each row in the visit Summary flowsheet of the Antepartum Summary form C SHALL be represented by an organizer with the classCode of 'BATTERY' and the moodCode of 'EVN'
<id root=' ' extension=' '/>
Each battery SHALL have a globally unique identifier.
<code code='(xx-acog-battery)' codeSystem='2.16.840.1.113883.6.1'/>
The <code> element specifies the loinc code that represents the content of the battery. The codeSystem attribute SHALL contain the value '2.16.840.1.113883.6.1'. The code attribute SHALL contain the value='(xx-acog-battery)'. It is good practice to include displayName and codeSystemName for clarity and debugging. The corresponding values are 'ACOG VISIT SUMMARY BATTERY--PT--' and 'LOINC' respectively.
<activityTime value=' '/>
The <activityTime> element contains the date and time of the visit for which the battery is obtained.
<author typeCode='AUT'/><reference value='#foo'/></author>
The <author> element points at the author from the header that records the visit battery. The reference value attribute points at the element with author element with the id='foo'.
<statusCode code='completed'/>
The status code for all batteries SHALL be 'completed'
<component>
The battery is made of several component simple observations. The following table lists the allowable LOINC codes, displayNames, and observation types, and unit of measures for these observations.
| code | displayName | xsi:type | units | value set |
|---|---|---|---|---|
| 11884-4 | GESTATIONAL AGE-TIME-PT-^FETUS-QN-CLINICAL.ESTIMATED | PQ | week | |
| 11881-0 | FUNDAL HEIGHT-LEN-PT-UTERUS-QN-TAPE MEASURE | PQ | cm | |
| 11876-0 (by PE) or 11877-8 (by US) |
FETAL PRESENTATION-TYPE-PT-PELVIS-NOM-PALPATION or FETAL PRESENTATION-TYPE-PT-PELVIS-NOM-US |
CO | Vertex Breech Transverse Oblique Compound Brow Face NULL^NOT LISTED NULL^UNKNOWN | |
| 11948-7 or (xx-fetal-hr-ausc) |
HEART RATE-NRAT-PT-^FETUS-QN-US.MEASURED or HEART RATE-NRAT-PT-^FETUS-QN-AUSCULTATION |
RTO | /min | |
| (xx-fetal-movement) | MOVEMENT-FIND-PT-^FETUS-ORD-PATIENT REPORTED | CO | Yes No Reduced | |
| (xx-SS-Preterm-Labor) | PRETERM LABOR SYMPTOMS-FIND-PT-^PATIENT-QL-CLINICAL JUDGEMENT | BL | ||
| (xx-cerv-dil-palp) or (xx-cerv-dil-us) |
DILATION-LEN-PT-CERVIX-QN-PALPATION or DILATION-LEN-PT-CERVIX-QN-US |
PQ | cm | |
| 11867-9 | EFFACEMENT-PRCTL-PT-CERVIX-ORD-PALPATION | CO | 0 10 20 30 40 50 60 70 80 90 100 | |
| 11961-0 | LONG AXIS-LEN-PT-CERVIX-QN-US.MEASURED | PQ | cm | |
| 8480-6 | INTRAVASCULAR SYSTOLIC-PRES-PT-ARTERIAL SYSTEM-QN- | PQ | mmHg | |
| 8462-4 | INTRAVASCULAR DIASTOLIC-PRES-PT-ARTERIAL SYSTEM-QN- | PQ | mmHg | |
| 3141-9 | BODY WEIGHT-MASS-PT-^PATIENT-QN-MEASURED | PQ | g, kg, lb_av, or oz_av | |
| 1753-3 | ALBUMIN-ACNC-PT-UR-ORD- | CO | None Trace 1+ 2+ 3+ 4+ | |
| 2349-9 or 25428-4(test strip) |
GLUCOSE-ACNC-PT-UR-ORD- or GLUCOSE-ACNC-PT-UR-ORD-TEST STRIP |
CO | None Trace 1+ 2+ 3+ 4+ | |
| 44966-0 | EDEMA-FIND-PT-^PATIENT-ORD- | CO | None Trace 1+ 2+ 3+ 4+ | |
| 38208-5 | PAIN SEVERITY-FIND-PT-^PATIENT-ORD-REPORTED | CO | 0(no pain) : 10(worst possible pain) Note: This observation should correspond to the functional status pain score observation | |
| (xx-time-to-next-appt) or ?39165 |
TIME TO NEXT VISIT- or ?Date next screen visit-TmStp-PT-^PATIENT-QN-CPHS |
PQ | day,week,mo | |
| 48767-8 | (comment field) | ED |