Difference between revisions of "Antepartum Record"

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|Sacrum ||164565001 ||SNOMED CT ||O || ||CD || ||concave<br/>straight<br/>anterior
 
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Revision as of 10:25, 20 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 Antepartum Record Profile extends the description of the content structures for the Antepartum Summary (APS), and is based on the data elements from prenatal records currently in common use. The Antepartum Record includes the following additional documents:

  1. Antepartum History & Physical - The initial assessment and physical
  2. Antepartum Laboratory - Laboratory Evaluations
  3. Antepartum Education - Education Record

Additional commonly used forms not included in this profile are:

  1. A patient generated obstetric medical history
  2. A postpartum form

A sample form showing the data elements may be found at: http://www.acog.org/acb-custom/aa128.pdf

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

Glossary

The following elements are found in the Antepartum History & Physical document of the Antepartum Record:

Abortion, Induced (AB, Induced)
Number of induced abortions by patient. An induced abortion is a deliberate termination of pregnancy.
Abortion Spontaneous (AB, Spontaneous)
Number of spontaneous abortions by patient. A spontaneous abortion is a natural loss of the products of conception.
Ectopic pregnancy
Number of ectopic pregnancies by patient. An ectopic pregnancy is the development of a fertilized ovum outside the uterus, as in a Fallopian tube.
Estimated Date of Delivery(EDD)/Estimated Date of Confinement(EDC)
Date of anticipated delivery (confinement).
Final/Corrected Estimated Date of Delivery (EDD)
Corrected EDD/EDC based upon parameters such as ultrasound, first auscultation of fetal heart tones, etc.
Full term
Number of babies the mother has delivered that were between 37 and 42 completed weeks of gestation.
Living Children
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 Pregnancies
Number of total pregnancies


Antepartum History & Physical - 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+
Human Chorionic Gonadotropin pregnancy test.
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 whether the patient's last menstrual was typical or not in amount and duration.
On Birth Control Pills (BCP) at conception
Yes/No. Specify if the patient was on birth control pills at the time of conception.
Prior Menses
Date of patient's latest period.


Antepartum History & Physical - Past Pregnancies

Anesthesia
Specify the type of labor and delivery anesthesia used in previous pregnancies.
Artificial Reproductive Technology (ART) Treatment
List any artificial reproductive technology treatments used previously.
Autoimmune disorder
List any autoimmune disorders. An autoimmune disorder is a condition in which the body attacks its own tissues. (ACOG)
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
Specify if the Rh negative mother is sensitized to the Rh D antigen. A sensitized mother produces IgG anti-D (antibody) that crosses the placenta and coats D-positive fetal red cells which are then destroyed in the fetal spleen.
Gestational Age weeks
Specify gestational age in weeks at delivery of patient's previous pregnancies.
Infertility
Specify history of infertility. Infertility primarily refers to the biological inability of a man or a woman to contribute to conception. Infertility may also refer to the state of a woman who is unable to carry a pregnancy to full term.
Kidney disease/Urinary Tract Infection (UTI)
List any kidney disease or urinary tract infections. Kidney disease is either a declining or a sudden loss in renal function. A urinary tract infection (UTI) is a bacterial infection that affects any part of the urinary tract.
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. (Hospital name, city and state if known)
Preterm labor
Yes/No. Specify if the patient had preterm labor with previous pregnancies
Pulmonary (TB, Asthma)
Specify if patient has a history of asthma, TB or other pulmonary problems.
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
– Specify if the patient has any uterine structural abnormalities or exposure to diethylstilbesterol.
Varicosities/Phlebitis
Specify if patient has a history of swelling or inflammation of her veins.


Antepartum History & Physical - Other elements:

Abdomen
Area of the body that lies between the 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
Body Mass Index. 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 arterioles and capillaries, the elasticity of the arterial walls, and by the viscosity and volume of the blood.
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 adipose tissue and connective tissues.
Cervix
The lower, narrow end of the uterus, which protrudes into the vagina. (ACOG)
Diagonal Conjugate
The distance from the promontory of the sacrum to the lower margin of the pubic symphysis
Extremities
A bodily limb or appendage.
Fundi
Concave, interior of the eye, consisting of the retina, the choroid, the sclera, the optic disk, and blood vessels, seen by means of the opthalmoscope.
Gynecoid pelvic type
The normal female pelvis.
Heart
The hollow, muscular organ that maintains the circulation of the blood.
HEENT
Head, Eyes, Ears, Nose and Throat
Height
Measurement of stature
Lungs
Either of the pair of organs occupying the cavity of 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
(Ischial Spines) Two parts of the maternal pelvis resulting from the bony processes projecting backward and medially from the posterior border of the ischium.
Subpubic arch
Arch formed by the conjoined rami of the ischia and pubic bones of the two sides of the body.
Teeth
one of the hard, calcified structures set in the alveloar processes of the jaws for the biting and mastication of food.
Thyroid
The thyroid gland. One of the largest endocrine glands in the body. This gland is found in the neck below the thyroid cartilage and at approximately the same level as the cricoid cartilage. The thyroid controls how quickly the body burns energy, makes proteins, and how sensitive the body should be to other hormones.
Uterus size
In pregnancy the uterine size is estimated in terms of weeks of gestation. e.g 12 weeks if the fundus reaches the top of the smphysis pubis or 20 weeks' gestation when the fundus reaches the umbilicus.
Vagina
The genital canal in the female, leading from the opening of the vulva to the cervix of the uterus.
Vulva
The external genital organs of the female, including the labia majora, labia minora, clitoris, and vestibule of the vagina.
Patient Weight
A measurement of mass.

The following terms are found in the Antepartum Laboratory document of the Antepartum Record:

1st Trimester Aneuploidy risk assessment (Free or Total)
Non-invasive screening for chromosomal abnormalities, such as Down syndrome, performed in the first trimester. Screening tests that uses a combination of fetal measurements (crown rump length and nuchal translucency) and maternal blood tests for beta-human chorionic gonadotropin (hCG) and pregnancy associated plasma protein (PAPP-A) to determine risk for trisomy 21, trisomy 13 and trisomy 18.
2nd Trimester serum screening
Non-invasive screening test for chromosomal abnormalities, such as Down yndrome, trisomy 18, or open neural defects. Blood test to measure alpha-fetoprotein (AFP), estriol, human chorionic gonadotropin (hCG) [free or total], and inhibin-A.
Amnio
Amniocentesis: Percutaneous transabdominal puncture of the uterus during pregnancy to obtain amniotic fluid.
Amniotic Fluid (AFP) Test
A test to detect the presence of Alpha-fetoprotein in amniotic fluid.
Antibody screen
A blood test to detect antibodies against red blood cell antigens.
Anti-D Immune Globulin (RHIG)
Anti-D antibodies given to prevent sensitization to the RhD antigen on red blood cells.
Blood type
Test to determine blood group, i.e. A, B, AB or O
Chlamydia Test
Test done to detect the bacterium, Chlamydia trachomatis.
Cystic Fibrosis Screening Test
Test to detect gene mutations that cause cystic fibrosis.
Chorionic Villi Sampling (CVS)
A method of sampling the cells of the placental chorionic villi, done either transabdominally or transcervically.
D (Rh) Antibody screen
A blood screening test for presence of IgG antibodies to the Rh D antigen on red blood cells.
D (Rh) type
A blood test to detect the presence of the Rh D red blood surface antigen.
Diabetes screen
Laboratory test to screen for gestational diabetes.
Familial Dysautonomia
Autosomal disorder of the peripheral and autonomic nervous systems limited to individuals of Ashkenazic Jewish descent; clinical manifestations are present at birth and include diminished lacrimation, defective thermoregulation, orthostatic hypotension, fixed pupils, excessive sweating, loss of pain and temperature sensation, and absent reflexes; pathologic features include reduced numbers of small diameter peripheral nerve fibers and autonomic ganglion neurons.
Genetic Screening Test
Screening for genetic disorders, e.g. sickle cell, Thalassemia, Tay-Sachs, Canavan, cystic fibrosis, fragile X syndrome, or Duchenne’s muscular dystrophy.
Gonorrhea Test
Test to detect Neisseria gonorrhea
Group B Streptococcus Rectovaginal Culture (Group B Strep)
A test to determine the presence of group B streptococcus (streptococcus agalactiae) in the lower genital tract in pregnant women.
GTT (if screen abnormal)
Glucose Tolerance Test. Used to determine how quickly the body metabolizes blood sugar. Test to diagnose gestational diabetes mellitus.
HBsAg Test
Test for the detection of the surface antigen of the Hepatitis-B virus.
HCT/HGB/MCV
  • HCT- Hematocrit – A blood test measuring the percentage of red blood cells found in a given volume of whole blood.
  • HGB- Hemoglobin – A blood test measuring the level of the protein carrying oxygen in red blood cells.
  • MCV - Mean corpuscular volume - The average volume of red blood cells calculated from the hematocrit red blood cell count
Hemoglobin Electrophoresis
A blood test done to measure the different types of hemoglobin. The test can detect abnormal levels of hemoglobin such as that found in sickle cell anemia.
HIV Test
A test to detect for the presence of antibodies to the human immunodeficiency virus.
HIV Counseling
Discussion with pregnant patient regarding Human Immunodeficiency Virus/ HIV status, risks and prevention strategies.
Karotype
Test done on cells/tissue to identify and evaluate the number, shape, and size of chromosomes.
MSAFP
A screening blood serum test on the mother for to determine the level of alpha-fetoprotein.
Multiple marker screening test
A maternal blood serum screening test for the detection of Down syndrome, trisomy 18, and neural tube defects in the fetus. The following analytes are measured: alpha-fetoprotein, human chorionic gonadotriopin, estriol, and inhibin-A. When the first three analytes are used, this is also called a maternal serum triple screen or a maternal serum quad screen when all four analytes are used.
Pap test
Cervical cytology test to determine abnormal cells of the cervix.
PPD Skin Test
- Mantoux test with purified protein derivative to screen for exposure to tuberculosis.
Rubella Test
A blood test to detect the presence of antibodies against the rubella virus (German measles).
Tay-Sachs Screening Test
A blood test done to measure the amount of beta-hexosaminidase A or B activity in serum or white blood cells, or for the most common DNA mutations causing Tay Sachs disease.
Ultrasound
A radiologic study using sound waves used in the assessment of gestational age, size, growth, anatomy, and blood flow of a fetus or in the assessment of maternal anatomy and blood flow.
Urine Culture
A Test that it used to detect the presenct of bacteria in the urine. , sugar and/or protein in urine.
Urine Screen
A physical, chemical, and / or microscopic examination of the urine. It may be used to screen for / or to detect abnormal kidney function, kidney stones, urinary tract infections, or substance abuse.
Varicella
A blood test to detect the presence of anti-varicella antibodies.
VDRL (Venereal Disease Research Laboratories)
A blood test to screen for the presence of antibodies against Treponema pallidum, the bacteria that causes syphilis.


The following terms are found in the Antepartum Education document of the Antepartum Record:

First Trimester

Alcohol
Discussion with patient about past and present use of alcohol and the perinatal implications of continued use during pregnancy; referral to treatment program if appropriate.
Anticipated Course of prenatal care
Discussion with the patient on the scope of care that will be performed in the office, lab work that may be performed, signs and symptoms that should be reported, anticipated schedule of visits, physician coverage of labor and delivery.
Childbirth classes/hospital facilities
Discussion with the patient on educational programs available for childbirth and hospital choice.
Domestic violence
Screening/Discussion with patient regarding physical threats/abuse/safety concerns; referral to appropriate counseling, legal and/or social advocacy program if appropriate.
Environmental/Work hazards
Discussion with patient about potential exposures to environmental agents at work, home, or locations that may affect pregnancy.
Exercise
Discussion with patient on appropriate level of exercise activities during the pregnancy.
Illicit/Recreational drugs
Discussion with patient about past and present use of illicit or recreational drugs and the perinatal implications of continued use during pregnancy; referral to treatment program if appropriate.
Indications for ultrasounds
Discussion with patient regarding reasons ultrasound test will be performed during pregnancy.
Influenza vaccine
Discussion with patient of risks/benefits of influenza and influenza vaccine.
Nutrition and weight gain counseling, special diet
Information about balanced nutrition, ideal caloric intake and weight gain.
Risk factors identified by prenatal history
Seatbelt use
Discussion with patient on use of seatbelts.
Sexual activity
Discussion with the patient of sexual activity: concerns, restrictions, warning signs and/or safe sex practices.
Smoking counseling
Discussion with patient regarding smoking cessation and smoke exposure.
Tobacco (Ask,advise,assess,assist,and arrange)
status; Advise patient to stop smoking; Assess patient's willingness to attempt to quit smoking; Assist patients who are interested in quitting by providing pregnancy specific cessation materials; Arrange follow up visits to track progress.
Toxoplasmosis precautions
Discussion with patient of risk factors for toxoplasmosis and precautions for avoiding/preventing infection.
Travel
Discussion with patient on travel precautions, if any.
Use of any medications (including supplements, vitamins, herbs or OTC drugs)
Discussion with patient of risks/benefits/safety of any medications currently used by patient.

Second Trimester

Abnormal lab values
Discussion with patient of lab results that fall outside normal range and that may require further testing.
Domestic violence
Screening/Discussion with patient regarding physical threats/abuse/safety concerns; referral to appropriate counseling, legal and/or social advocacy program if appropriate.
Influenza vaccine
Discussion with patient of risks/benefits of influenza and influenza vaccine.
Postpartum family planning/tubal sterilization
Discussion with patient of intended postpartum contraception options, including tubal sterilization.
Selecting a newborn care provider
Discussion with patient to identify newborn care provider; referral to resources to help patient choose provider if none previously identified.
Signs and symptoms of preterm labor
Discussion with patient on risks, signs and symptoms of preterm labor.
Smoking counseling
Discussion with patient regarding smoking cessation and smoke exposure.

Third Trimester

Anesthesia/Analgesia plans
Discussion with patient to determine intended method of pain management/discomfort during labor and delivery.
Breast or bottle feeding
Discussion with patient of nutritional advantages/disadvantages of human breast milk, bottled formula; advise on available lactation consultation services.
Circumcision
Discussion with patient on circumcision of male newborn.
Domestic violence
Screening/Discussion with patient regarding physical threats/abuse/safety concerns; referral to appropriate counseling, legal and/or social advocacy program if appropriate.
Family medical leave or disability forms
Fetal Movement monitoring
Discussion with patient regarding her perception and assessment of fetal movement.
Influenza vaccine
Discussion with patient of risks/benefits of influenza and influenza vaccine.
Labor signs
Discussion with patient on signs of labor, i.e. contractions, membrane rupture, bleeding, etc.
Newborn education (Newborn screening, jaundice, SIDS, car seat)
Prenatal discussion with patient of preventive public health screening procedures available to newborns; testing that will occur on baby after birth to screen for up to 30 disorders.
Postpartum depression
Discussion with patient of signs of postpartum depression.
Postterm counseling
Discussion with patient of risks of pregnancy extending beyond 42 weeks.
Signs & Symptoms of Pregnancy-induced hypertension
Discussion with patient of signs and symptoms of hypertension.
Smoking counseling
Discussion with patient regarding smoking cessation and smoke exposure.
VBAC counseling
Discussion with patient of risks/benefits of vaginal birth after previous cesarean surgery.
History and physical have been sent to hospital
Notation of date and initials of person transmitting history and physical to hospital prior to delivery.
Tubal sterilization consent signed
Notation of date the consent form for tubal sterilization signed and the initials of person witnessing.

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 History & Physical IHE History and Physical Child Initial Intake and Assessment for antepartum care
Antepartum Summary Medical Summary Child Update and Progress Note
Antepartum Laboratory XD-Lab Child Laboratory Evaluation
Antepartum Education Education Record

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 1: 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 make up the components which are included in the patient’s Antepartum Record.

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 2: 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 3

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

Actors are information systems or components of information systems that produce, manage, or act on information associated with operational activities in the enterprise.

Content Creator
The Content Creator Actor is responsible for the creation of content and transmission to a Content Consumer.
Content Consumer
A Content Consumer Actor is responsible for viewing, import, or other processing of content created by a Content Creator Actor.

Transaction Definitions

Transactions are interactions between actors that transfer the required information through standards-based messages.

Transaction
Definition

Volume II

Open Issues/to do items for face-to-face 5/19-5/23

  • Review proposed document structures (APH&P, APL, APE)
  • Determine where to use SHALL, SHOULD and MAY
  • Review/discuss selection of SNOMED CT codes (Christine Spisla is available from 4-4:30pm on Monday and 12pm-till on Tuesday)


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) Pregnancy History Summary (Gravida Para Abortus) and detailed history of pregnancies
Menstrual/Gynecological History (Form A) Resolved Problems(PMH)
Medical History (Form A) Resolved Problems (PMH) 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 (Form B) Vital Signs
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 participant elements for husband/domestic partner and father of baby. Ethnicity for the patient SHOULD also be included. The coding system SHALL be SNOMED CT for all three entries. For husband the code SHALL be 127849001. For domestic partner the code SHALL be 414043009. For father of baby the code SHALL be 9947008. For ethnicity the code SHALL be 397731000. 		R See below this table for more details
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 about patient reported 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 and represents the patient's past medical history and gynecological history. These entries SHOULD use the codes specified in the appropriate Antepartum Resolved Problems Entries tables and SHALL be grouped into organizers with classCode='CLUSTER'		 R 1.3.6.1.4.1.19376.1.5.3.1.3.8
Pregnancy History
This section will consist of two entries, both of which will live under the existing Pregnancy History section.

Pregnancy Summary History: Required; will use the existing observation Pregnancy Observation and add SNOMED codes for additional fields.

Pregnancy Detail History: Optional; will contain the details of each pregnancy as list in the table below.

R 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Fields that don't exist in the current Pregnancy Observation list:
Summary - ectopics, multiple births
Details - length of labor, birth weight, sex, type of delivery, anesthestics, place of delivery, preterm labor
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 SHOULD use the codes specified in the appropriate Antepartum Review of Systems tables and SHALL be grouped into organizers with classCode='CLUSTER'. The code system for genetic screening SHALL be LOINC and the code SHALL be 19102-3. 		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)
- check LOINC code

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. These required entries SHOULD use the codes from the Anterpartum Physical Examination table. 		R 1.3.6.1.4.1.19376.1.5.3.1.3.24
Vital Signs
This section is the same as it is for History & Physical, however it SHALL include coded entries for vital signs related to antepartum care. These required entries SHOULD use the codes from the Anterpartum Vital Signs table. 		R 1.3.6.1.4.1.19376.1.5.3.1.3.25
Antepartum Header - Details
Data Element Example
Antepartum Header Details
Husband/Domestic Partner This element SHALL be included as a participant in the header of the CDA document in the event of the pregnancy. If this does not apply to the patient this element SHALL use a null flavor. 
  <!-- Husband/Domestic Partner -->
  <participant typeCode="IND"> <!-- what is IND? -->
    <associatedEntity classCode="NOK"> <!-- what is NOK? -->
      <code code="184142008" displayName="patient's next of kin" 
        codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
      <addr>
        <streetAddressLine>45 Chunn Dr.</streetAddressLine>
        <city>Spring Hill</city>
        <state>TN</state>
        <postalCode>37174</postalCode>
        <country>USA</country>
      </addr>
      <telecom value="tel:(999)555-1212" use="WP"/>
      <associatedPerson>
        <name>
          <prefix>Mr.</prefix>
          <given>John</given>
          <family>Youngston</family>
        </name>
      </associatedPerson>
    </associatedEntity>
  </participant>
Father of Baby This element SHALL be included as a participant in the header of the CDA document in the event of the pregnancy. If the father of the baby is unknown this element SHALL use a null flavor. 
  <!-- Father of baby -->
  <participant typeCode="IND"> <!-- what is IND? -->
    <associatedEntity classCode="NOK"> <!-- what is NOK? -->
      <code code="9947008" displayName="natural father" 
        codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
      <addr>
        <streetAddressLine>18 Oak Valley Dr.</streetAddressLine>
        <city>Monteagle</city>
        <state>TN</state>
        <postalCode>37205</postalCode>
        <country>USA</country>
      </addr>
      <telecom value="tel:(999)555-1212" use="WP"/>
      <associatedPerson>
        <name>
          <prefix>Mr.</prefix>
          <given>Thomas</given>
          <family>Caster</family>
        </name>
      </associatedPerson>
    </associatedEntity>
  </participant>
Ethnicity This element SHOULD be included in recordTarget/patientRole/patient/ethnicGroupCode in the header of the CDA document. This information can be relevant to the course of care provided to the patient. 
  <recordTarget>
    <patientRole classCode="PAT">
      <id root="27143B24-E580-4F47-9405-3D0DC2BF1223" extension="1022"/>
      <addr>
        <streetAddressLine/>
        <city/>
        <state>FM</state>
        <postalCode/>
        <country>Canada</country>
      </addr>
      <telecom nullFlavor="UNK" use="HP"/>
      <patient classCode="PSN" determinerCode="INSTANCE">
        <name>
          <prefix/>
          <given>Christine</given>
          <family>Smith</family>
          <suffix/>
        </name>
        <ethnicGroupCode code="364699009" displayName="ethnic group" 
          codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
        <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>
        <birthTime value="20040725"/>
      </patient>
      <providerOrganization classCode="ORG" determinerCode="INSTANCE">
        <id root="2.16.840.1.113883.19.5"/>
      </providerOrganization>
    </patientRole>
  </recordTarget>
Antepartum H&P Resolved Problems Entries
CDA Entry Code(s) Code System Opt Comments xsi:Type units value set
Antepartum H&P Resolved Problems Entries - Gynecological History
Date of Last Menstrual Period 21840007 SNOMED CT R TS
Menses Monthly SNOMED CT R BL
Prior Menses Date 84292000 SNOMED CT R TS
Duration of Menstrual Flow 161720007 SNOMED CT R Frequency PQ days
Oral Contraceptive Preparation 59261009 SNOMED CT R on BCP at conception BL
Menarche 20016009 SNOMED CT R PQ
hCG+ SNOMED CT R several codes TS


CDA Entry Code(s) Code System Opt Comments xsi:Type units value set
Antepartum H&P Resolved Problems Entries - Medical History
These elements SHALL be boolean in nature, and SHOULD also include a text narrative field if applicable.
Diabetes 161445009 / 266991009 SNOMED CT R diabetes mellitus / metabolic disorder? BL
Hypertension 161501007 SNOMED CT R BL
Heart Disease 275544003 SNOMED CT R BL
Autoimmune Disorder SNOMED CT R BL
Kidney Disease 275552000 SNOMED CT R BL
UTI 267002001 SNOMED CT R BL
Neurologic/Epilepsy 161480008 SNOMED CT R BL
Psychiatric 161464003 SNOMED CT R BL
Depression/Postpartum Depression 161469008 SNOMED CT R BL
Hepatitis/Liver Disease 161535005 SNOMED CT R BL
Varicosities/Phlebitis 413154005 SNOMED CT R BL
Thyroid Dysfunction 275536003 SNOMED CT R BL
Trauma/Violence 161472001 SNOMED CT R BL
History of Blood Transfusion 161664006 SNOMED CT R BL
D(Rh) Sensitized SNOMED CT R BL
Pulmonary 161523006 SNOMED CT R BL
Seasonal Allergies 161524000 SNOMED CT R BL
Drug/Latex Allergy/Reactions 161611007 SNOMED CT R BL
Breast 429087003 SNOMED CT R H/O malignant neoplasm of breast? BL
Gyn Surgery SNOMED CT R Complex Type
Operations/Hospitalizations 161615003 SNOMED CT R Complex Type
Anesthetic Complications 161593001 SNOMED CT R BL
History of Abnormal Pap 271902005 SNOMED CT R H/O gynecological disorder? BL
Uterine Anomaly/DES 267016006 SNOMED CT R H/O abnormal uterine bleeding? BL
Infertility 169589005 SNOMED CT R BL
Art Treatment SNOMED CT R BL
Antepartum H&P Pregnancy History Entries
Description Code(s) Code System Opt Comments xsi:Type units value set
Antepartum H&P Pregnancy History Entries - these will be added to existing codes in Pregnancy Observation
Summary over All Pregnancies
Gravida (Number of Total Pregnancies) 161732006 SNOMED CT R PQ
Number of Full Term Deliveries 267015005 SNOMED CT R PQ
Number of Premature Deliveries 161765003 SNOMED CT R PQ
Number of Abortion, Induced 252114001 SNOMED CT R PQ
Number of Abortion, Spontaneous (Miscarriages) 248989003 SNOMED CT R PQ
Number of Ectopic Pregnancies 29717002 SNOMED CT R PQ
Number of Multiple Births 364323006 SNOMED CT R PQ
Number of Living Children 364325004 SNOMED CT R PQ
Number of Live Births SNOMED CT R PQ
Detailed Pregnancy Data
Date Month/Year SNOMED CT R TS
Weeks Gestation at Delivery 268477000 SNOMED CT R PQ
Length of Labor 271562002 SNOMED CT R PQ
Birth Weight 364589006 SNOMED CT R PQ
Sex 365873007 SNOMED CT R CD Male
Female
Type of Delivery (Past Pregnancy Outcome) 267013003 SNOMED CT R CD Vaginal
Caesarian
Type of Anesthetic 399084002 SNOMED CT R ST
Place of Delivery SNOMED CT R narrative text ST
Preterm Labor 6383007 SNOMED CT R BL
Antepartum H&P Social History Entries
CDA Entry Code(s) Code System Opt Comments xsi:Type units value set
Antepartum H&P Social History Entries
Tobacco Use - Amount per day pre-pregnancy 365981007 SNOMED CT R PQ /day
Tobacco Use - Amount per day post-pregnancy SNOMED CT R PQ /day
Tobacco Use - # years use SNOMED CT R PQ
Alcohol Use - Amount per day pre-pregnancy 228273003 / 427013000 SNOMED CT R PQ /day
Alcohol Use - Amount per day post-pregnancy SNOMED CT R PQ /day
Alcohol Use - # years use SNOMED CT R PQ
Illicit/Recreational Drugs - Amount per day pre-pregnancy 361055000 / 199254001 SNOMED CT R PQ /day
Illicit/Recreational Drugs - Amount per day post-pregnancy SNOMED CT R PQ /day
Illicit/Recreational Drugs - # years use SNOMED CT R PQ
Antepartum H&P Family History Entries
CDA Entry Code(s) Code System Opt Comments xsi:Type units value set
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 xsi:Type units value set
Antepartum H&P Review of Systems - Genetic Screening Entries
Thalassemia 40108008 SNOMED CT R BL
Neural Tube Defect 253098009 SNOMED CT R BL
Congenital Heart Defect 59494005 SNOMED CT R BL
Down Syndrome 41040004 SNOMED CT R BL
Tay-Sachs 111385000 SNOMED CT R BL
Canavan Disease 80544005 SNOMED CT R BL
Familial Dysautonomia 29159009 SNOMED CT R BL
Sick Cell Disease 417357006 SNOMED CT R BL
Sick Cell Trait 16402000 SNOMED CT R BL
Hemophilia 90935002 SNOMED CT R BL
Blood Disorders 266992002 SNOMED CT R BL
Muscular Dystrophy 58795000 SNOMED CT R BL
Cystic Fibrosis 190905008 SNOMED CT R BL
Huntington's Chorea 58756001 SNOMED CT R BL
Mental Retardation 91138005 SNOMED CT R BL
Autism 408856003 SNOMED CT R BL
Chrosomosal Disorder 409709004 SNOMED CT R Other inherited genetic or chromosomal disorder BL
Maternal Metabolic Disorder SNOMED CT R metabolic disorder following molar and/or ectopic pregnancies BL
Dysmorphism (Birth Defect) 276720006 SNOMED CT R Patient or baby's father has a child with birth defects BL
Stillbirth 161743003 SNOMED CT R Recurrent pregnancy loss/stillbirth BL
Counseling 409063005 SNOMED CT R BL
Hydrocephaly SNOMED CT R BL
History of cleft Lip or palate SNOMED CT R BL
Polycystic kidney disease SNOMED CT R BL
Antepartum H&P Review of Systems - Infection History Entries
CDA Entry Code(s) Code System Opt Comments xsi:Type units value set
Antepartum H&P Review of Systems - Infection History Entries
Tuberculosis 161414005 SNOMED CT R BL
Genital Herpes 402888002 SNOMED CT R BL
Viral Exanthem (Viral Rash) 49882001 SNOMED CT R Rash or viral illness since LMP BL
Hepatitis B SNOMED CT R BL
Viral Hepatitis C 50711007 SNOMED CT R BL
History of STD 275881005 SNOMED CT R BL
History of Gonorrhea 274118001 SNOMED CT R Venereal Disease in Pregnancy BL
History of Chlamydia SNOMED CT R BL
History of HPV SNOMED CT R BL
History of HIV SNOMED CT R BL
History of Syphilis SNOMED CT R BL
Antepartum H&P Physical Examination Entries
CDA Entry Code(s) Code System Opt Comments xsi:Type units value set
Antepartum H&P Physical Examination Entries
All values SHALL have a normal/abnormal (BL) value and a text narrative with related comments. The elements with value sets other than normal/abnormal (e.g. vulva, vagina) have value sets that may change and therefore should not be coded to a specific value set.
Head 162824006 SNOMED CT R BL normal
abnormal
Eyes 271894002 SNOMED CT R BL normal
abnormal
Ears, Nose, Throat 271896000 SNOMED CT R BL normal
abnormal
FUNDI SNOMED CT O BL normal
abnormal
Teeth 270479002 SNOMED CT R BL normal
abnormal
Thyroid 162836000 SNOMED CT R BL normal
abnormal
Breasts 163433006 SNOMED CT R BL normal
abnormal
Lungs 423649001 SNOMED CT R BL normal
abnormal
Heart 309652009 SNOMED CT R BL normal
abnormal
Abdomen 271911005 SNOMED CT R BL normal
abnormal
Extremeties 164443003 SNOMED CT R BL normal
abnormal
Skin 271303006 SNOMED CT R BL normal
abnormal
Lymph Nodes 284427004 SNOMED CT R BL normal
abnormal
Vulva 275961008 SNOMED CT R BL normal
abnormal
Vagina 274297000 SNOMED CT R BL normal
abnormal
Cervix 309668003 SNOMED CT R BL normal
abnormal
Uterus Size 163509002(fundus = term size)
163498004(gravid uterus size)		 SNOMED CT R weeks gestation, fibroids determined from ultrasound BL
Adnexa SNOMED CT R BL normal
abnormal
Rectum SNOMED CT R BL normal
abnormal
Diagonal Conjugate SNOMED CT O CD reached
not reached
length
Spines 163576005 SNOMED CT O CD average
prominent
blunt
Sacrum 164565001 SNOMED CT O CD concave
straight
anterior
Subpubic Arch SNOMED CT O CD normal
wide
narrow
Gynecoid Pelvic Type 163555000 SNOMED CT O BL yes
no
Antepartum H&P Vital Signs Entries
CDA Entry Code(s) Code System Opt Comments xsi:Type units value set
Antepartum H&P Vital Signs Entries
Weight 424927000(w/shoes)
425024002(w/o shoes)		 SNOMED CT R PQ lb_av or kg
Height 24833004 SNOMED CT R PQ in or cm
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>
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