1.3.6.1.4.1.19376.1.5.3.1.1.21.1.1

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Labor and Delivery Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.21.1.1

The Labor and Delivery Summary represents...

The LDS profile is a medical summary and inherits all header constraints from Medical Summaries.

The use case for this document is described fully in the LDR Profile in PCC TF-1.

Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:ldr:lds:2009

Parent Template

This document is an instance of the Medical Summary template.

LOINC Code

The LOINC code for this document is XX-LDS Labor and Delivery Summary

Standards

CCD	ASTM/HL7 Continuity of Care Document
CDAR2	HL7 CDA Release 2.0
LOINC	Logical Observation Identifiers, Names and Codes
SNOMED	Systemized Nomenclature for Medicine

Data Element Index

This section will map something...

Data Element	CDA Section	Trial
Medication List	Active Medications

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. A CDA Document may conform to more than one template. This content module inherits from the Medical Summary content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Labor and Delivery Summary Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.21.1.1'/>
  <id root=' ' extension=' '/>
  <code code='XX-LDS' displayName='Labor and Delivery Summary'
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Labor and Delivery Summary</title>
  <effectiveTime value='20240418012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
       
  </structuredBody></component>
</ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.21.1.1'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.21.1.1"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Labor and Delivery Summary can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.2"]'>
     Error: The parent template identifier for Labor and Delivery Summary is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "XX-LDS"]'>
     Error: The document type code of a Labor and Delivery Summary must be XX-LDS
   </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> 
 </rule>
</pattern>