Difference between revisions of "Antepartum Record"

From IHE Wiki
Jump to navigation Jump to search
Line 395: Line 395:
 
|Chief Complaint ||Chief Complaint ||
 
|Chief Complaint ||Chief Complaint ||
 
|-
 
|-
−
|Pregnancy History (Form A) ||Past Medical History ||
+
|Pregnancy History (Form A) ||Resolved Problems (Past Medical History) ||
 
|-
 
|-
−
|Menstrual/Gynecological History (Form A) ||Past Medical History ||
+
|Menstrual/Gynecological History (Form A) ||Resolved Problems (Past Medical History) ||
 
|-
 
|-
−
|Medical History (Form A) ||Past Medical History ||Exclude social and family history (included in other sections)
+
|Medical History (Form A) ||Resolved Problems (Past Medical History) ||Exclude social and family history (included in other sections)
 
|-
 
|-
 
|Medical History - Tobacco, Alcohol, Drugs (Form A) ||Social History ||
 
|Medical History - Tobacco, Alcohol, Drugs (Form A) ||Social History ||

Revision as of 12:54, 9 May 2008

Introduction

This is a draft of the Antepartum Record Profile (AR) supplement to the PCC Technical Framework. This draft is a work in progress, not the official supplement or profile.

Profile Abstract

The Antepartum Record Profile (AR)

The Antpartum Record continues the description of the content structures for the ACOG Antepartum Record Forms as begun in the Antepartum Summary Profile.

  1. Forms A&B - The initial assessment and physical
  2. Forms C&F&G - Update records and progress notes
  3. Form D - Laboratory Evaluations
  4. Form E - Education Assessment

The ACOG Form also includes:

  1. An Obstetric Medical History
  2. A Postpartum form

A sample may be found at target: http://www.acog.org/acb-custom/aa128.pdf

This profile defines the implementation of HL7 CDA documents to represent the data elements from forms A, B, D, and E, along with the XDS, XDR and XDM bindings. This profile also defines mechanisms to group them into a single logical folder.

Glossary

The following terms are found on Form A of the Antepartum Record:

AB, Induced
Number of induced abortions by patient
AB, Spontaneous
Number of spontaneous abortions by patient
Ectopics
Number of ectopic pregnancies by patient
Final EDD
Expected Date of Delivery; a fixed date determined by ultrasound measurements and/or last menstrual period. Also called EDC - Expected Date of Confinement
Full term
Number of babies the mother has delivered that were between 37 and 42 completed weeks of gestation.
Living
Number of living children of patient
Multiple births
Number of deliveries of more than one baby by patient
Premature
delivery between 20 and 36 6/7 weeks gestation
Total Preg
number of total pregnancies

Form A - Menstrual History

Frequency
Specify in days the duration of the patient's monthly cycle; from first day of menses to the first day of next menses
hCG+
Specify the date of the Human Chorionic Gonadotropin pregnancy test was positive
LMP (last menstrual period)
Date measured as the first day of the patient's most recent menstrual period.
  • Approximate (month known) - Patient is unsure of exact date but can offer an approximate date
  • Definite - Patient can say with certainty the date of her last menstrual period
  • Final - Finally agreed upon date of LMP
  • Unknown - Patient does not know the date of her last menstrual period
Menarche
Age at onset of initial menstrual period
Menses Monthly
Yes/No. Specify that the patient has or does not have a monthly period.
Normal Amount/duration
Yes/No. Specify that the patient's last menstrual was typical or not in amount and duration
On BCP at concept
Yes/No. Specify if the patient was on birth control pills at the time of conception
Prior Menses
Date of patient's latest period


Form A - Past Pregnancies

Anesthesia
Specify the type of labor and delivery anesthesia used in previous pregnancies.
ART Treatment
List any artificial reproductive technology treatments used previously.
Autoimmune disorder
List any autoimmune disorders.
Birth weight
Specify the weight of patient's previous babies at birth.
Date
Month/Year of birth of patient's previous babies.
D (Rh) sensitized
GA weeks
Specify gestational age in weeks at delivery of patient's previous pregnancies.
Infertility
Kidney disease/UTI
Length of labor
Specify the number of hours patient was in labor for previous pregnancies.
Place of Delivery
Specify the location patient delivered for previous pregnancies.
Preterm labor
Yes/No. Specify if the patient had preterm labor with previous pregnancies
Pulmonary (TB, Asthma)
Sex M/F
Specify sex of patient's previously delivered babies.
Type Delivery
Specify type of delivery for previous pregnancies: Vaginal (spontaneous, forceps,vacuum), Cesarean section (low-transverse, classical, low-vertical).
Uterine Anomaly/DES
Varicosities/Phlebitis

The following terms are found on Form B of the Antepartum Record:

Abdomen
Area of the body that lies betweent he chest and the pelvis and encloses the stomach, intestines, liver, spleen and pancreas
Adnexa
Appendages of the uterus which include the fallopian tubes, the ovaries and the supporting ligaments of the uterus.
BMI
Measurement of the relative percentages of fat and muscle mass in the human body.
BP
Pressure exerted by the blood against the walls of the arteries, maintained by the contraction of the left ventricle, the resistance of the
Breasts
In humans, one of the paired regions in the anterior portion of the thorax. The breasts consists of mammary glands, the skin, the muscles, the adpose tissue and the connective tissue.
Cervix
The lower, narrow end of the uterus that forms a canal between the uterus and vagina.
Diagonal Conjugate
The distance from the promontory of the sacrum to the lower margin of the pubic symphysis
Extremities
Bodily limb
Fundi
Gynecoid pelvic type
Heart
Organ that maintains the circulation of the blood.
HEENT
Head, Eyes, Ears, Nose and Throat
Height
Measurement of stature
Lungs
Organs in the thorax that effect the aeration of the blood
Lymph nodes
Any of the accumulations of lymphoid tissue organized as definite lymphoid organs varying from 1 to 25 mm in diameter situated along the course of lymphatic vessels and consisting of an outer cortical and inner medullary part.
Rectum
The distal segment of the large intestine, between the sigmoid colon and the anal canal.
Sacrum
Triangular bone below the lumbar vertebrae.
Skin
Outer protective covering of the body
Spines
Series of articulated vertebrae, separated by intervertebral disks and held together by muscles and tendons, that extends from the cranium to the coccyx, encasing the spinal cord and forming the supporting axis of the body
Subpubic arch
Teeth
Thyroid
Uterus size
Vagina
Vulva
Weight

The following terms are found on Form D of the Antepartum Record:

1st Trimester Aneuploidy risk assessment
2nd Trimester serum screening
Amnio/CVS
Amniotic Fluid (AFP)
Antibody screen
Anti-D Immune Globulin (RHIG)
Blood type
Chlamydia
Cystic Fibrosis
D (Rh) Antibody screen
D (Rh) type
Diabetes screen
Familial Dysautonomia
Genetic Screening Test
Gonorrhea
Group B Strep
GTT (if screen abnormal)
HBsAg
HCT/HGB/MCV
Hemoglobin
Hemoglobin Electrophoresis
HIV
HIV Counseling/Testing
Karotype
MSAFP/Multiple markers
Pap test
PPD
Rubella
Tay-Sachs
Ultrasound
Urine Culture/Screen
Varicella
VDRL

The following terms are found on Form E of the Antepartum Record: First Trimester

Alcohol
Anticipated Course of prenatal care
Childbirth classes/hospital facilities
Domestic violence
Environmental/Work hazards
Exercise
Illicit/Recreational drugs
Indications for ultrasounds
Influenza vaccine
Nutrition and weight gain counseling, special diet
Risk factors identified by prenatal history
Seatbelt use
Sexual activity
Smoking counseling
Tobacco (Ask,advise,assess,assist,and arrange)
Toxoplasmosis precautions
Travel
Use of any medications (including supplements, vitamins, herbs or OTC drugs)

Second Trimester

Abnormal lab values
Domestic violence
Influenza vaccine
Postpartum family planning/tubal sterilization
Selecting a newborn care provider
Signs and symptoms of preterm labor
Smoking counseling

Third Trimester

Anesthesia/Analgesia plans
Breast or bottle feeding
Circumcision
Domestic violence
Family medical leave or disability forms
Fetal Movement monitoring
Influenza vaccine
Labor signs
Newborn education (Newborn screening, jaundice, SIDS, car seat)
Postpartum depression
Postterm counseling
Signs & Symptoms of Pregnancy-induced hypertension
Smoking counseling
VBAC counseling
History and physical have been sent to hospital
Tubal sterilization consent signed

Issue Log

Open Issues

  1. Issue
  2. Issue

Closed Issues

Volume I

Add the following bullet to the list of profiles
  • Antepartum Record - A folder of content profiles that contains the summarization record or the antepartum care delivery including initial patient history and physical, ambulatory checks of mother and fetus, laboratory studies, and patient education.

Dependencies

Add the following row(s) to the list of dependencies
Integration Profile Dependency Dependency Type Purpose
Antepartum Record A&B IHE History and Physical Child Initial Intake and Assessment for antepartum care
Antepartum Summary Form C&F&G Medical Summary Child Update and Progress Note
Antepartum Summary Form D XD-Lab Child Obstetric Lab Evaluation
Antepartum Summary Form E Obstetric Education Form

Profile Name

The Antepartum Record Profile (AR)

There are over 4 million births in the United States each year, including more than 1 million cesarean sections and more than 300,000 preterm or low birth weight babies. Obstetric patients in labor and admitted to Labor and Delivery must have a complete summary of their antepartum ambulatory care available at the time of admission to evaluate and / or ameliorate risk. This same data is required at any visit to Labor and Delivery for any other problems or special needs a patient may require. The antepartum record must be available in its entirety for appropriate care and legal concerns.

Practitioners who would use the aggregated record include: obstetricians, perinatologists, certified nurse midwives, family practice physicians, pediatricians, labor and delivery staff, emergency department staff, anesthesiologists, hospitalists, social workers, other medical specialists and patients.

During the 40 weeks of a typical pregnancy duration, the patient will have an initial History and Physical Examination, followed by repetitive office visits with multiple laboratory studies, imaging (usually ultrasound) studies, and serial physical examinations with recordings of vital signs, fundal height, and the fetal heart rate. As the patient is seen over a finite period in the office, aggregation of specific relevant data important to the evaluation of the obstetric patient upon presentation to Labor and Delivery is captured on paper forms. The antepartum record contains the most critical information needed including the ongoing Medical Diagnoses, the Estimated Due Date, outcomes of any prior pregnancies, serial visit data on the appropriate growth of the uterus and assessments of fetal well being, authorizations, laboratory and imaging studies. This data must all be presented and evaluated upon entry to the Labor and Delivery Suite to ensure optimal care for the patient and the fetus.

Although the patient and her care provider may plan for a vaginal (natural) method of delivery, there is a substantive chance the delivery route may be surgical, requiring anesthesia and post-surgical care.

Current practice is to copy the patient's (paper) chart at various times during the pregnancy (as at 28 weeks and at 36 weeks of completed gestation), and transport the copies of the chart to the hospital the patient intends to use for delivery. Should the patient arrive prior to the chart copy arriving, or if the chart (or information within the chart) is missing on presentation of the patient to Labor and Delivery (a frequent occurrence), the staff or clinicians repeat laboratory or imaging studies. This results in unwarranted and duplicative tests, is wasteful of time and resources, and leads to dissatisfied patients. Further, missing or incomplete information about the patient’s clinical status may create a situation where critical information is unavailable to clinicians, which may ultimately result in an injury, inadequate aftercare or other undesirable outcome.

Significantly, a large portion of patients arrive in L&D without complete documentation. In one recent U.S. study , ~70% of patients (with paper charts) arrived in L&D without their current medical record being available. While only one hospital was involved in this study, one can see the extent of the issue, with pregnant patients possibly going to a different hospital than planned (preterm labor, rapid labor and unable to make it to the planned delivery hospital, or visiting a distant city), moving mid-care, or with a covering physician (rather than the primary obstetrician) on call.

In a Swedish study done in the 1990’s, critical data on paper records were incomplete from 45 to 87.5% of the time. Thus, availability of current medical records remains a significant problem for most hospital Labor and Delivery units; availability of key information electronically will significantly enhance patient safety.

Use Cases

Use Case: Basic Antepartum Record Summary Use Case

Pre-condition
The patient’s obstetrician sees the patient for her initial and subsequent prenatal visits. During the initial and/or subsequent prenatal visits information is collected and may be updated within the office Electronic Health Record (EHR), these include:

  • Patient demographics
  • Menstrual history
  • Obstetric history
  • Medical history including surgical history, psych-social history
  • Genetic history and screening/Teratology counseling
  • Infection history
  • Family history
  • Initial and subsequent physical examination
  • Medications
  • Problems and risk factors for preterm birth
  • Allergies
  • Prenatal visit information
  • Prenatal Laboratory results
  • Patient education information and plans for delivery if known

The information collected during the patient’s prenatal visits is the components which are included in the patient’s Antepartum Record Summary.

Event(s)
Scenario 1 - At a specified time an initial and/or subsequent patient Antepartum Record Summary is transmitted by the patient’s obstetrician EHR to the intended facility for delivery.

The intended facility of delivery health information system receives the transmitted initial and/or subsequent patient Antepartum Record Summary.

Scenario 2 - At a specified time the initial and/or subsequent patient Antepartum Record Summary registry information is transmitted by the patient’s obstetrician EHR to a registry.

The facility of delivery health information system queries the registry repository for the applicable patient’s Antepartum Record Summary(s). A request is made for the patient’s Antepartum Record Summary. The applicable system which contains the patient’s Antepartum Record Summary then makes available the patients Antepartum Record Summary information to the requesting facility of delivery.

Post-condition
The received patient Antepartum Record Summary can be viewed and/or imported into the facility for delivery health information system to facilitate patient care by healthcare professional at the time of delivery for the mother and newborn.

Use Case: Antepartum Care Delivery

Pre-condition
The patient’s obstetrician sees the patient for her pregnancy in the ambulatory (office) setting. During the pregnancy, the patient is noted to have a medical problem requiring consultation with a Maternal-Fetal Medicine specialist (perinatologist). The office obtains pre-authorization from the insurance payer for the consult, and for the intended or anticipated route of delivery, and transmits that information to both the consultant and to the hospital.

Events
The patient is seen in the obstetrician’s office where a complete medical and relevant social history are taken by the nurse and recorded in the office EHR, incorporating data from the perinatologist’s consultation report as appropriate. Laboratory and imaging reports ordered by the perinatologist as well as the perinatologist’s consultation report are displayed electronically to the obstetrician. The obstetrician reviews the consultation report from the perinatologist’s office and imaging studies ordered by the perinatologist along with data recorded by the nurse. Physical exam reveals some abnormalities. The obstetrician orders additional laboratory studies, and sends the patient to the hospital to Labor and Delivery.

When the laboratory results return, the physician completes the admission H&P, Allergies, Medications, includes the data prepared or ordered by the perinatologist, and makes it available to L&D. This data includes an assessment of the patient’s health status, and the requisite data summarized from the antepartum care given. The charge nurse for L&D documents that the complete collection of documents needed is available. The Post-Partum discharge planning is notified and assures that there is a suitable environment with appropriate support for post-delivery after-care.

Post-condition
The Pre-delivery H&P and Antepartum Summary with appropriate relationships to the Perinatologist Consultation, and all the antepartum laboratory and imaging studies are available to the obstetrician and the birthing center personnel for incorporation into their respective EHRs. The H&P is also available to the patient for viewing and incorporation into the patient’s PHR, and into the newborn baby’s PHR. For the APS profile, summary content is available to the obstetrician, with a plan for full content to be added in future years through other content profiles that share this use case.

Use Case Name 2

A pregnant diabetic patient is seen by her obstetrician in the office for a prenatal care. An ultrasound is performed to determine gestational age. The patient is sent for perinatology consult as a high-risk patient. Her obstetrician transmits preauthorization insurance information, labs and anticipated route of delivery to perinatologist and hospital.

The patient returns to her perinatologist biweekly for blood testing and ultrasounds when necessary in addition to regular ob visits. The perinatologist reports back to the obstetrician after each visit. Complete History and Physical, imaging and additional labs are performed during patient’s regular visit with her obstetrician.

The patient arrives at labor and delivery at the hospital. Obstetrician completes the admission H&P, Allergies, Medications, and includes the data prepared or ordered by the perinatologist, and makes it available to L&D. This data includes an assessment of the patient’s health status, and the requisite data summarized from the antepartum care given. The charge nurse for L&D documents that the complete collection of documents needed is available.

The patient’s obstetrician delivers by Cesarean Section after anesthesia. The post-partum discharge planning is notified and assures that there is a suitable environment with appropriate support for post-delivery after-care. Delivery information, i.e. birth weight, APGAR scores, type of delivery, etc is available for pediatrician. The patient can then incorporate H&P into her own and her newborn’s PHR.

Actors/Transaction

There are two actors in this profile, the Content Creator and the Content Consumer. Content is created by a Content Creator and is to be consumed by a Content Consumer. The sharing or transmission of content from one actor to the other is addressed by the appropriate use of IHE profiles described below, and is out of scope of this profile. A Document Source or a Portable Media Creator may embody the Content Creator Actor. A Document Consumer, a Document Recipient or a Portable Media Importer may embody the Content Consumer Actor. The sharing or transmission of content or updates from one actor to the other is addressed by the use of appropriate IHE profiles described by section 3.7 Content Bindings with XDS, XDM and XDR found in the Patient Care Coordination Technical Framework

Antepartum Record Actor Diagram

Options

Actor Option Section
Antepartum Record Options
Content Consumer View Option (1)

Document Import Option (1)
Section Import Option (1)
Discrete Data Import Option (1)

 PCC TF-1: 2.13.1

PCC TF-1: 2.13.2
PCC TF-1: 2.13.3
PCC TF-1: 2.13.4

Content Creator Referral Option (1)

Discharge Summary Option (1)

 PCC TF-1: 2.13.5

PCC TF-1: 2.13.6

Note 1: The Actor shall support at least one of these options.

Grouping

Content Bindings with XDS, XDM and XDR

It is expected that the transfers of care will occur in an environment where the physician offices and hospitals have a coordinated infrastructure that serves the information sharing needs of this community of care. Several mechanisms are supported by IHE profiles:

For more details on these profiles, see the IHE IT Infrastructure Technical Framework.

Content profiles may impose additional requirements on the transactions used when grouped with actors from other IHE Profiles.

Cross Enterprise Document Sharing, Media Interchange and Reliable Messages

Actors from the ITI XDS, XDM and XDR profiles embody the Content Creator and Content Consumer sharing function of this profile. A Content Creator or Content Consumer must be grouped with appropriate actors from the XDS, XDM or XDR profiles, and the metadata sent in the document sharing or interchange messages has specific relationships to the content of the clinical document described in the content profile.

Notification of Document Availability (NAV)

A Document Source should provide the capability to issue a Send Notification Transaction per the ITI Notification of Document Availability (NAV) Integration Profile in order to notify one or more Document Consumer(s) of the availability of one or more documents for retrieval. One of the Acknowledgement Request options may be used to request from a Document Consumer that an acknowledgement should be returned when it has received and processed the notification. A Document Consumer should provide the capability to receive a Receive Notification Transaction per the NAV Integration Profile in order to be notified by Document Sources of the availability of one or more documents for retrieval. The Send Acknowledgement option may be used to issue a Send Acknowledgement to a Document Source that the notification was received and processed.

Document Digital Signature (DSG)

When a Content Creator Actor needs to digitally sign a document in a submission set, it may support the Digital Signature (DSG) Content Profile as a Document Source. When a Content Consumer Actor needs to verify a Digital Signature, it may retrieve the digital signature document and may perform the verification against the signed document content.

Content Modules

Content modules describe the content of a payload found in an IHE transaction. Content profiles are transaction neutral. They do not have dependencies upon the transaction that they appear in.

Content Module 1

Process Flow

Antepartum Record Process Flow

More text about process flow

Actor Definitions

Actor
Definition

Transaction Definitions

Transaction
Definition

Volume II

Antepartum Record Content

Consists of the following documents:

  • Antepartum History and Physical (Forms A&B)
  • Antepartum Summary (Forms C&F)
  • Antepartum Laboratory (Form D)
  • Antepartum Education (Form E)

Standards

CDAR2
Clinical Document Architecture, Release 2, 2005 HL7
CRS
Implementation Guide for CDA Release 2 – Level 1 and 2 – Care Record Summary (US realm), 2006, HL7.
CCD
ASTM/HL7 Continuity of Care Document (Draft)

Antepartum History and Physical (APH&P)

The Antepartum History and Physical inherits all constraints from the IHE History and Physical and also requires the following additional constraints.

Data Element Index

Data Element CDA Section Comments
Antepartum History and Physical Data Elements
Header data Need to include Language, Ethnicity, Husband/Domestic Partner, Father of Baby; needs further analysis
Chief Complaint Chief Complaint
Pregnancy History (Form A) Resolved Problems (Past Medical History)
Menstrual/Gynecological History (Form A) Resolved Problems (Past Medical History)
Medical History (Form A) Resolved Problems (Past Medical History) Exclude social and family history (included in other sections)
Medical History - Tobacco, Alcohol, Drugs (Form A) Social History
Medical History - Relevant Family History (Form A) Family History
Medications Medications
Allergies Allergies and Other Adverse Reactions Section
Symptoms Since LMP (Form B) History of Present Illness
Genetic Screening/Teratology Counseling (Form B) Review of Systems
Infection History (Form B) Review of Systems
Initial Physical Examination (Form B) Physical Examination
Vital Signs Vital Signs will be a subsection of Physical Examination
Diagnostic Findings this section is required by CDA4CDT H&P - The intention for APR is to have the antepartum specific labs in the APL document. However, lab data may be put here as well.
Assessment and Plans this section is required by CDA4CDT H&P - The intention for APR is to have the antepartum specific education in the APE document. However, education data may be put here as well.

Document Specification

Data Element Opt Template ID Comments
Antepartum History and Physical Constraints
Header??
This section is the same as it is for history and physical, however it SHALL also include coded entries for husband/domestic partner and father of baby 		R -need to figure out how to specify header
Chief Complaint
 R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
History of Present Illness
This section will be the same as it is for History & Physical and SHOULD contain clinical statements regarding symptoms since the last menstrual period. 		R 1.3.6.1.4.1.19376.1.5.3.1.3.4
Resolved Problems
This section is the same as it is for History & Physical, however it SHALL include three coded entries (or organizers?) for gynecological history, pregnancy history and medical history. These entries SHOULD use the codes specified in the appropriate Antepartum Resolved Problems Entries tables		 R 1.3.6.1.4.1.19376.1.5.3.1.xyz

- need to find LOINC codes for the three sections
- can possibly use PCC Pregnancy History section and add observations for the extra data found on ACOG form.
- need to define structure, group the 3 types of history in organizers?

Social History
This section is the same as it is for History & Physical, however it SHALL contain coded entries as specified in the Antepartum Social History table. 		R 1.3.6.1.4.1.19376.1.5.3.1.3.16
Family History
This section is the same as it is for History & Physical, however it SHALL contain the coded entry as specified in the Antepartum Family History table. 		R 1.3.6.1.4.1.19376.1.5.3.1.3.14
Review of Systems
This section is the same as it is for History & Physical, however it SHALL include coded entries for genetic screening and infection history. These entries SHALL be grouped into organizers with LOINC codes. 		R 1.3.6.1.4.1.19376.1.5.3.1.3.18

- use organizers to group genetic screening and infection history? this should be same structure as Resolved Problems (PMH)

Physical Examination
This section is the same as it is for History & Physical, however it SHALL include coded entries for physical examinations related to antepartum care. 		R 1.3.6.1.4.1.19376.1.5.3.1.3.24

- need to find LOINC/Snomed codes

Vital Signs
 R 1.3.6.1.4.1.19376.1.5.3.1.3.25
Antepartum H&P Resolved Problems Entries
CDA Entry Code(s) Code System Opt Comments
Antepartum H&P Resolved Problems Entries - Pregnancy History
SNOMED CT R


CDA Entry Code(s) Code System Opt Comments
Antepartum H&P Resolved Problems Entries - Gynecological History
Date of Last Menstrual Period 21840007 SNOMED CT R
Menses Monthly SNOMED CT R
Prior Menses Date 84292000 SNOMED CT R
Duration of Menstrual Flow 161720007 SNOMED CT R Frequency
Oral Contraceptive Preparation 59261009 SNOMED CT R on BCP at conception
Menarche 20016009 SNOMED CT R
hCG+ SNOMED CT R several codes


CDA Entry Code(s) Code System Opt Comments
Antepartum H&P Resolved Problems Entries - Medical History
Diabetes 161445009 / 266991009 SNOMED CT R diabetes mellitus / metabolic disorder?
Hypertension 161501007 SNOMED CT R
Heart Disease 275544003 SNOMED CT R
Autoimmune Disorder SNOMED CT R
Kidney Disease 275552000 SNOMED CT R
UTI 267002001 SNOMED CT R
Neurologic/Epilepsy 161480008 SNOMED CT R
Psychiatric 161464003 SNOMED CT R
Depression/Postpartum Depression 161469008 SNOMED CT R
Hepatitis/Liver Disease 161535005 SNOMED CT R
Varicosities/Phlebitis 413154005 SNOMED CT R
Thyroid Dysfunction 275536003 SNOMED CT R
Trauma/Violence 161472001 SNOMED CT R
History of Blood Transfusion 161664006 SNOMED CT R
D(Rh) Sensitized SNOMED CT R
Pulmonary 161523006 SNOMED CT R
Seasonal Allergies 161524000 SNOMED CT R
Drug/Latex Allergy/Reactions 161611007 SNOMED CT R
Breast 429087003 SNOMED CT R H/O malignant neoplasm of breast?
Gyn Surgery 271902005 SNOMED CT R H/O gynecological disorder?
Operations/Hospitalizations 161615003 SNOMED CT R
Anesthetic Complications 161593001 SNOMED CT R
History of Abnormal Pap 271902005 SNOMED CT R H/O gynecological disorder?
Uterine Anomaly/DES 267016006 SNOMED CT R H/O abnormal uterine bleeding?
Infertility 169589005 SNOMED CT R
Art Treatment SNOMED CT R
Antepartum H&P Social History Entries
CDA Entry Code(s) Code System Opt Comments
Antepartum H&P Social History Entries
Tobacco Use 365981007 SNOMED CT R includes amount per day pre-preg, preg and # years use
Alcohol Use 228273003 / 427013000 SNOMED CT R includes amount per day pre-preg, preg and # years use
Illicit/Recreational Drugs 361055000 / 199254001 SNOMED CT R includes amount per day pre-preg, preg and # years use
Antepartum H&P Family History Entries
CDA Entry Code(s) Code System Opt Comments
Antepartum H&P Family History Entries
Relevant Family History 57177007 SNOMED CT R need to specify specific structure here? also have codes for Date(410671006) and Treatment(182991002)


Antepartum H&P Review of Systems - Genetic Screening Entries
CDA Entry Code(s) Code System Opt Comments
Antepartum H&P Review of Systems - Genetic Screening Entries
Thalassemia 40108008 SNOMED CT R
Neural Tube Defect 253098009 SNOMED CT R
Congenital Heart Defect 59494005 SNOMED CT R
Down Syndrome 41040004 SNOMED CT R
Tay-Sachs 111385000 SNOMED CT R
Canavan Disease 80544005 SNOMED CT R
Familial Dysautonomia 29159009 SNOMED CT R
Sick Cell Disease 417357006 SNOMED CT R
Sick Cell Trait 16402000 SNOMED CT R
Hemophilia 90935002 SNOMED CT R
Blood Disorders 266992002 SNOMED CT R
Muscular Dystrophy 58795000 SNOMED CT R
Cystic Fibrosis 190905008 SNOMED CT R
Huntington's Chorea 58756001 SNOMED CT R
Mental Retardation 91138005 SNOMED CT R
Autism 408856003 SNOMED CT R
Chrosomosal Disorder 409709004 SNOMED CT R Other inherited genetic or chromosomal disorder
Maternal Metabolic Disorder SNOMED CT R metabolic disorder following molar and/or ectopic pregnancies
Dysmorphism (Birth Defect) 276720006 SNOMED CT R Patient or baby's father has a child with birth defects
Stillbirth 161743003 SNOMED CT R Recurrent pregnancy loss/stillbirth
Counseling 409063005 SNOMED CT R


Antepartum H&P Review of Systems - Infection History Entries
CDA Entry Code(s) Code System Opt Comments
Antepartum H&P Review of Systems - Infection History Entries
Tuberculosis 161414005 SNOMED CT R
Genital Herpes 402888002 SNOMED CT R
Viral Exanthem (Viral Rash) 49882001 SNOMED CT R Rash or viral illness since LMP
Hepatitis B SNOMED CT R
Viral Hepatitis C 50711007 SNOMED CT R
History of STD 275881005 SNOMED CT R
History of Gonorrhea 274118001 SNOMED CT R Venereal Disease in Pregnancy
History of Chlamydia SNOMED CT R
History of HPV SNOMED CT R
History of HIV SNOMED CT R
History of Syphilis SNOMED CT R


Antepartum H&P Physical Examination Entries
CDA Entry Code(s) Code System Opt Comments
Antepartum H&P Physical Examination Entries
HEENT 162824006(head)
271894002(eyes)
271896000(ent)		 SNOMED CT R
FUNDI SNOMED CT R
Teeth 270479002 SNOMED CT R
Thyroid 162836000 SNOMED CT R
Breasts 163433006 SNOMED CT R
Lungs 423649001 SNOMED CT R
Heart 309652009 SNOMED CT R
Abdomen 271911005 SNOMED CT R
Extremeties 164443003 SNOMED CT R
Skin 271303006 SNOMED CT R
Lymph Nodes 284427004 SNOMED CT R
Vulva 275961008 SNOMED CT R
Vagina 274297000 SNOMED CT R
Cervix 309668003 SNOMED CT R
Uterus Size 163509002(fundus = term size)
163498004(gravid uterus size)		 SNOMED CT R
Adnexa SNOMED CT R
Rectum SNOMED CT R
Diagonal Conjugate SNOMED CT R
Spines 163576005 SNOMED CT R
Sacrum 164565001 SNOMED CT R
Subpubic Arch SNOMED CT R
Gynecoid Pelvic Type 163555000 SNOMED CT R


Antepartum H&P Vital Signs Entries
CDA Entry Code(s) Code System Opt Comments
Antepartum H&P Vital Signs Entries
Weight 424927000(w/shoes)
425024002(w/o shoes)		 SNOMED CT R
Height 24833004 SNOMED CT R
BMI 60621009 SNOMED CT R
Blood Pressure 75367002 SNOMED CT R




Antepartum Laboratory (APL)

Data Element Index

Data Element CDA Section Comments
Antepartum Laboratory Data Elements
Antepartum Laboratory Results Survey Panel SHALL use LOINC code xx-APL for the section

Document Specification

Data Element Opt Section Template ID
Antepartum Laboratory Constraints
Survey Panel
This section SHALL contain one or more Coded Results Sections and SHOULD use LOINC codes from the antepartum laboratory LOINC code list when possible. A document consumer SHOULD render these data in ascending date order. This ascending date order offers a visual representation that aids in the understanding of the course of care for antepartum laboratory tests. 		R 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.7

Sample LOINC Code List

Lab LOINC Code Comments
Antepartum Laboratory LOINC Codes - (not complete)
Antibody Screen 890-4
Blood Type 883-9/10331-7/14578-9
HBsAg 5195-3/5196-1/5197-9/7905-3
HCT_HGB 718-7/4544-3/30350-3
Pap Test 21440-3/21441-1/10524-7/18500-9/19765-7/19766-5
Rubella 5334-8/25514-1/40667-8/8014-3
etc.

Sample Antepartum Laboratory Document

<!-- Survey Panel  -->
<organizer classCode="CLUSTER" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.20.1.32"/>
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.12.3.7"/>
  <id root="" extension=""/>
  <code code=" " displayName=" " codeSystem=" " codeSystemName=" "/>
  <statusCode code="completed"/>
  <effectiveTime value=""/>
  <!-- one or more survey observations -->
  <component typeCode="COMP">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.12.3.6"/>
      <!-- Coded Results -->
      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.28"/>
      <id root=" " extension=" "/>
      <code code="30954-2" displayName="STUDIES SUMMARY" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
      <text>Text as described above</text>
      <entry>
        <procedure classCode="PROC" moodCode="EVN|INT">
          <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.19"/>
          <templateId root="2.16.840.1.113883.10.20.1.29"/>
          <!-- see text of section 0 -->
          <templateId root="2.16.840.1.113883.10.20.1.25"/>
          <!-- see text of section 0 -->
          <id root="" extension=""/>
          <code code="890-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Antibody screen"/>
          <text>
            <reference value="#xxx"/>
          </text>
          <statusCode code="completed|active|aborted|cancelled"/>
          <effectiveTime>
            <low value=""/>
            <high value=""/>
          </effectiveTime>
          <priorityCode code=""/>
          <approachSiteCode code="" displayName="" codeSystem="" codeSystemName=""/>
          <targetSiteCode code="" displayName="" codeSystem="" codeSystemName=""/>
          <author/>
          <informant/>
          <entryRelationship typeCode="REFR">
            <encounter classCode="ENC" moodCode="">
              <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.4.1"/>
              <id root="" extension=""/>
            </encounter>
          </entryRelationship>
          <entryRelationship typeCode="RSON">
            <act classCode="ACT" moodCode="EVN">
              <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.4.1"/>
              <id root="" extension=""/>
            </act>
          </entryRelationship>
        </procedure>
      </entry>
    </observation>
  </component>
</organizer>

Antepartum Education (APE)

Data Element Index

Data Elements CDA Section Comments
Antepartum Education Data Elements
Antepartum Education and Consents Coded Patient Education and Consents SHALL use LOINC code xx-APE for the section

Document Specification

Data Element Opt Section Template ID
Antepartum Education Constraints
Coded Patient Education and Consents R 1.3.6.1.4.1.19376.1.5.3.1.1.9.39

Sample Snomed CT Code List

Lab LOINC Code Comments
Antepartum Education Snomed CT Codes - (not complete)
Risk factors identified by prenatal history xxxxa
Anticipated course of prenatal care xxxxb
Nutrition and weight gain counseling; special diet xxxxc
Toxoplasmosis precautions (cats/raw meat) xxxxd
Sexual activity xxxxe
etc.

Antepartum Education Sample

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.38'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.39'/>
    <id root=' ' extension=' '/>
    <code code='34895-3' displayName='EDUCATION NOTE'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
      <!-- Required Procedure Entry element -->
      <procedure classCode='PROC' moodCode='EVN|INT'>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.19'/>
        <templateId root='2.16.840.1.113883.10.20.1.29'/><!-- see text of section 0 -->
        <templateId root='2.16.840.1.113883.10.20.1.25'/><!-- see text of section 0 -->
        <id root='' extension=''/>
        <code code='xxxxxa' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMEDCT'
          displayName='Risk factors'/>
        <text><reference value='#xxx'/></text>
        <statusCode code='completed|active|aborted|cancelled'/>
        <effectiveTime>
          <low value=''/>
          <high value=''/>
        </effectiveTime>
        <priorityCode code=''/>
        <approachSiteCode code='' displayName='' codeSystem='' codeSystemName=''/>
        <targetSiteCode code='' displayName='' codeSystem='' codeSystemName=''/>
        <author />
        <informant />
        <entryRelationship typeCode='REFR'>
          <encounter classCode='ENC' moodCode=''>
            <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
            <id root='' extension=''/>
          </encounter>
        </entryRelationship>
        <entryRelationship typeCode='RSON'>
          <act classCode='ACT' moodCode='EVN'>
            <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
            <id root='' extension=''/>
          </act>
        </entryRelationship>
      </procedure>
      <procedure classCode='PROC' moodCode='EVN|INT'>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.19'/>
        <templateId root='2.16.840.1.113883.10.20.1.29'/><!-- see text of section 0 -->
        <templateId root='2.16.840.1.113883.10.20.1.25'/><!-- see text of section 0 -->
        <id root='' extension=''/>
        <code code='xxxxb' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMEDCT'
          displayName='Anticipated course of care'/>
        <text><reference value='#xxx'/></text>
        <statusCode code='completed|active|aborted|cancelled'/>
        <effectiveTime>
          <low value=''/>
          <high value=''/>
        </effectiveTime>
        <priorityCode code=''/>
        <approachSiteCode code='' displayName='' codeSystem='' codeSystemName=''/>
        <targetSiteCode code='' displayName='' codeSystem='' codeSystemName=''/>
        <author />
        <informant />
        <entryRelationship typeCode='REFR'>
          <encounter classCode='ENC' moodCode=''>
            <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
            <id root='' extension=''/>
          </encounter>
        </entryRelationship>
        <entryRelationship typeCode='RSON'>
          <act classCode='ACT' moodCode='EVN'>
            <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
            <id root='' extension=''/>
          </act>
        </entryRelationship>
      </procedure>
    </entry> 
    <entry>
      <!-- Required if known Simple Observations element -->
      <observation typeCode='OBS' moodCode='EVN'>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
        <id root='' extension=''/>
        <code code='' displayName='' codeSystem='' codeSystemName=''/>
        <!-- for CDA -->
        <text><reference value='#xxx'/></text>
        <!-- For HL7 Version 3 Messages
        <text>text</text> 
        -->
        <statusCode code='completed'/>
        <effectiveTime value=''/>
        <repeatNumber value=''/>
        <value xsi:type='' …/>
        <interpretationCode code='' codeSystem='' codeSystemName=''/>
        <methodCode code='' codeSystem='' codeSystemName=''/>
        <targetSiteCode code='' codeSystem='' codeSystemName=''/>
        <author typeCode='AUT'>
          <assignedAuthor typeCode='ASSIGNED'><id></assignedAuthor> <!-- for CDA -->
          <!-- For HL7 Version 3 Messages 
          <assignedEntity typeCode='ASSIGNED'>
            <Person classCode='PSN'>
              <determinerCode root=''>
                <name>…</name>
            </Person>
          <assignedEntity>
          -->
        </author>
      </observation>
    </entry> 
    <entry>
      <!-- Required if known External References element -->
      <entry>
        <act classCode='ACT' moodCode='EVN'> 
          <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
          <id root='' extension=''/>
          <code nullFlavor='NA' />
          <text><reference value='#study-1'/></text>
          <!-- For CDA -->
          <reference typeCode='REFR|SPRT'>
            <externalDocument classCode='DOC' moodCode='EVN'>
              <id extension='' root=''/>
              <text><reference value='http://foo..'/></text>
            </externalDocument>
          </reference>
          <!-- For HL7 Version 3 Messages
          <sourceOf typeCode='REFR|SPRT'>
            <act classCode='DOC' moodCode='EVN'>
              <id extension='' root=''/>
              <text><reference value='http://foo…'</text>
            </act>
          </sourceOf>
          -->
        </act>
      </entry>
    </entry>       
  </section>
</component>


Retrieved from "http://wiki.ihe.net/index.php?title=Antepartum_Record&oldid=17663"