1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2
Development Only
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Antepartum 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 Antepartum 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'/> <statusCode code='completed'/> <author> |
<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 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.
<author/>
The <author> relation element points at the author that records the visit battery. This assignedAuthor may be different than the author of the document. The time element is used to record when the assigned author recorded the battery.
<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.
LOINC 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 |
CD | SNOMED CT Vertex (70028003) Breech (6096002) Transverse (73161006) Oblique (63750008) Compound (124736009) Brow (8014007) Face (21882006) | |
11948-7 or (xx-fetal-hr-ausc) |
HEART RATE-NRAT-PT-^FETUS-QN-US.MEASURED or HEART RATE-NRAT-PT-^FETUS-QN-AUSCULTATION |
PQ | /min | |
(xx-fetal-movement) | MOVEMENT-FIND-PT-^FETUS-ORD-PATIENT REPORTED | CO | SNOMED CT
fetal movement activity (finding) CID 364755008 | |
(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 | PQ | percent | |
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 | SNOMED CT Negative (finding) CID 167273002 | |
2349-9 or 25428-4(test strip) |
GLUCOSE-ACNC-PT-UR-ORD- or GLUCOSE-ACNC-PT-UR-ORD-TEST STRIP |
CO | SNOMED CT Negative (finding) CID 167261002 | |
44966-0 | EDEMA-FIND-PT-^PATIENT-ORD- | CO | SNOMED CT trace edema 44996-0 | |
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 | ANNOTATION COMMENT-FIND-PT-^PATIENT-NAR- | ED |
Schematron
-->>TODO:<<--