Antepartum Record

Introduction

This is a draft of the Antepartum Record Profile (APR) 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 (APR) 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

Birth Control Pills (BCP)

Oral contraceptives.

Frequency

Duration of the monthly menstrual 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 last menstrual period.
• Unknown - Patient does not know the date of her last menstrual period.

Menarche

Age at onset of initial menstrual period.

Menses Monthly

Menses is the monthly flow of blood and cellular debris from the uterus that begins at puberty and ceases at menopause.

Normal Amount/duration

Last menstrual was typical in amount and duration.

Prior Menses

Date of most recent menstrual period.

Antepartum History & Physical - Past Pregnancies

Anesthesia

The loss of the ability to feel pain caused by administration of a drug or other intervention.

Artificial Reproductive Technology (ART) Treatment

Fertility procedures in which both eggs and sperm are handled in the laboratory (in vitro) to establish a pregnancy.

Autoimmune disorder

An autoimmune disorder is a condition in which the body attacks its own tissues. (ACOG)

Birth weight

Weight of infant at birth.

Date

Month/Year of birth of patient's previous babies.

DES

Diethylstilbesterol

D (Rh) sensitized

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

The number of weeks elapsed between the first day of the last normal menstrual period and the date of delivery.

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

Kidney disease is either a declining or a sudden loss in renal function.

Length of labor

The interval between onset of contractions and childbirth.

Place of Delivery

Hospital name, city and state if known.

Preterm labor

Labor that begins before 37 weeks gestation.

Pulmonary (TB, Asthma)

Diseases or disorders of the lungs, i.e. asthma, tuberculosis or other pulmonary problems.

Sex Male/Female

Sex of patient's previously delivered babies.

Type Delivery

Type of delivery in pregnancy: Vaginal (spontaneous, forceps, vacuum), Cesarean section (low-transverse, classical, low-vertical).

Urinary Tract Infection (UTI)

A urinary tract infection (UTI) is a bacterial infection that affects any part of the urinary tract.

Uterine Anomaly

– Any uterine structural abnormalities.

Varicosities/Phlebitis

Swelling or inflammation of 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 - Blood Pressure

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.

Amniocentesis (Amnio)

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 - Maternal Serum Alpha-Fetoprotein

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

Discussion with patient about any forms the patient will need completed for employment or insurance purposes.

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 (Vaginal Birth After Cesarean) 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.

Open Issues

1. How does the XDS Folder structure need to be handled?
2. Several LOINC and SNOMED codes are in the process of being created. These codes are denoted by a preceeding "xx-" or "XX-" with an abbreviated description of the code following.

Closed Issues

1. For Antepartum Laboratory there is a LOINC code for Laboratory Studies (26436-6) - is this too general? Should a new code be requested specific to Antepartum labs? The concern is that this could cause mapping issues in an EMR that has other lab results that are considered to be specific to antepartum that would live under that same loinc section code. the IHE formatCode supplied in the XDS Metadata will identify this as an Antepartum Laboratory document so a LOINC code is not needed.

Volume I

Add the following bullet to the list of profiles

• Antepartum Record - A folder of content profiles that contains the record of antepartum care including initial patient history and physical, recurring evaluations of mother and fetus(es), laboratory studies, patient education, and on-going plans of care.

Dependencies

Add the following row(s) to the list of dependencies

Integration Profile	Dependency	Dependency Type	Purpose
Antepartum Record	Sharing of Laboratory Reports (XD-LAB)	child	share laboratory results

Antepartum Record (APR)

The Antepartum Record Profile (APR) 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.

Obstetric patients in labor and admitted to the hospital or birthing facility 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 the birthing facility or hospital for any other problems or special care needs of the patient. The antepartum record must be available in its entirety for appropriate continuity of care and legal concerns.

The aggregated record provides important information for all health care professionals who are part of the patient's obstetric care team. Patients may incorporate the data from this aggregated record into their personal health record. Administration staff may use data for billing and payment purposes.

A typical pregnancy duration is approximately 40 weeks. Patient care during that time includes an initial history and physical examination, followed by repetitive office visits with multiple laboratory studies, imaging/ ultrasound studies, and serial physical examinations. As the patient is seen over a finite period for care, aggregation of data relevant to the evaluation of the obstetric patient upon presentation to the birthing facility or hospital is commonly collected on paper forms. This antepartum record contains the most critical information needed to provide care for the patient during pregnancy, delivery and the post-partum period. This data must all be presented and evaluated upon entry to the birthing facility or hospital to ensure optimal continuity of care for the patient and the fetus.

Although the patient and her care provider may plan for a vaginal 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 at the birthing facility or hospital prior to the chart copy arriving, or if the chart (or information within the chart) is missing on presentation of the patient (a frequent occurrence), the care team must 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 which may ultimately result in an injury, inadequate aftercare, or other undesirable outcomes.

A large portion of patients arrive at the birthing facility or hospital without complete documentation. In one recent U.S. study, approximately 70 % of patients (with paper charts) arrived at the birthing facility 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 birthing facilities; availability of key information electronically will significantly enhance patient safety.

Use Cases

Use Case 1: Basic Antepartum Record Use Case

This use case reflects the course of care during an uncomplicated pregnancy.

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
• Documentation of patient education and counseling
• Plans for care

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 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.

Scenario 2 - At a specified time the initial and/or subsequent patient Antepartum Record 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(s). A request is made for the patient’s Antepartum Record. The applicable system which contains the patient’s Antepartum Record then makes available the patients Antepartum Record information to the requesting facility of delivery.

Post-condition
The received patient Antepartum Record 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 Consultative Care

This use case reflects an example of consultative prenatal care.

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. Preauthorization information is transmitted to both the consultant and to the hospital.

Events
The patient is seen in the obstetrician’s office where a complete medical and relevant psycho-social history are obtained and recorded in the office EHR. Data from the perinatologist’s consultation report is incorporated 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 current recorded data. Physical exam reveals some abnormalities. The obstetrician orders additional laboratory studies, and sends the patient to the hospital or birthing facility.

When the laboratory results return, the physician completes the admission history and physical, allergies, medications, includes the data prepared or ordered by the perinatologist, and makes it available to the hospital or birthing facility. This data includes an assessment of the patient’s health status, and the requisite data summarized from the antepartum care given. The care team assures the complete collection of documents needed is available and that there is a suitable environment with appropriate support for post-delivery after-care.

Post-condition
The pre-delivery history and physical 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 hospital or birthing center personnel for incorporation into their respective EHRs. The history and physical is also available to the patient for viewing and incorporation into the patient’s PHR, and into the newborn baby’s PHR.

Use Case 3: Antepartum Collaborative Care

This use case reflects two-way transmission of data in an example of collaborative care.

Pre-condition
A pregnant diabetic patient is seen by her obstetrician in the office for 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/or hospital birthing facility.

Events
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 birthing facility. Obstetrician completes the admission history and physical, allergies, medications, and includes the data prepared or ordered by the perinatologist, and makes it available to the hospital birthing facility. This data includes an assessment of the patient’s health status, and the requisite data summarized from the antepartum care given. The care team documents that the complete collection of documents required is available.

Post-condition
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's postpartum record is sent to the perinatologist for incorporation into the patient's record. The patient can incorporate the history and physical into her own personal health record and the newborn’s records into the newborn's personal health record.

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

Antepartum Record Options

Actor	Option	Section
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:

• A registry/repository-based infrastructure is defined by the IHE Cross Enterprise Document Sharing (XDS) and other IHE Integration Profiles such as patient identification (PIX & PDQ), and notification of availability of documents (NAV).
• A media-based infrastructure is defined by the IHE Cross Enterprise Document Media Interchange (XDM) profile.
• A reliable messaging-based infrastructure is defined by the IHE Cross Enterprise Document Reliable Interchange (XDR) profile.
• All of these infrastructures support Security and privacy through the use of the Consistent Time (CT) and Audit Trail and Node Authentication (ATNA) 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.

Process Flow

Antepartum Record Process Flow

This process flow diagram shows the movement of the antepartum record over the course of care for a pregnancy involving an ambulatory facility (obstetric provider), perinatologist (specialist) and hopsital (birthing facility). This diagram specifically excludes other infrastructure interactions for simplicity and readability. These infrastructure interactions may be found elsewhere in the framework.

Data from the patient's prenatal care aggregates into her electronic antepartum record by the obstetric provider. The antepartum record is then sent to a specialist for consultation (if any). The specialist provides the consultation, updates the antepartum record, and returns it to the obstetric provider. The electronic antepartum record is then sent to the birthing facility at the appropriate time(s).

Volume II

Antepartum Record Folder

Consists of the following documents:

• Antepartum History and Physical
• Antepartum Summary
• Antepartum Laboratory
• Antepartum Education

Note:

Add content here with details of XDS Folder management for an Antepartum Record

Development Only

The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC

Antepartum Record History and Physical Specification OID

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

Format Code

The XDSDocumentEntry format code for this content is formatCode

Parent Template

This document is an instance of the History and Physical template.

LOINC Code

The LOINC code for this document is LOINC TBD TBD

Standards

CDAR2	HL7 CDA Release 2.0
CCD	ASTM/HL7 Continuity of Care Document
CDTHP	CDA for Common Document Types History and Physical Notes (DSTU)

Data Element Index

Data Element	CDA Section	Comments
Header	Need to include Language, Ethnicity, Husband/Domestic Partner, Father of Baby; needs further analysis
Chief Complaint	Chief Complaint
Pregnancy History	Pregnancy History	Summary (Gravida Para Abortus) and detailed history of pregnancies
Medical History	Past Medical History	Exclude social and family history (included in other sections)
Medical History - Tobacco, Alcohol, Drugs	Social History
Medical History - Relevant Family History	Family History
Medications	Medications
Allergies	Allergies and Other Adverse Reactions Section
Menstrual History/Symptoms Since LMP	Review of Systems
Genetic Screening/Teratology Counseling	Family History
Infection History	History of Infection
Initial Physical Examination	Physical Examination
Vital Signs	Vital Signs	subsection of Physical Examination
Diagnostic Findings	This section is required by CDA4CDT H&P - The intent in the APR specification is to have the antepartum specific laboratory results in the APR Laboratory document. However, this type of data may also be included here.

Specification

Data Element Name	Opt	Template ID
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.	R
Chief Complaint	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
History of Present Illness	R	1.3.6.1.4.1.19376.1.5.3.1.3.4
Past Medical History This section is the same as it is for History & Physical, and it SHALL contain entries and SHOULD use the codes specified in the appropriate APR Past Medical History tables. There is currently a CP to change this section name from Resolved Problems to Past Medical History.	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. 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	R	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
Pregnancy Summary History SHALL use the existing observation Pregnancy Observation and MAY use LOINC or SNOMED CT coded value sets	R
Pregnancy Detail History Will contain the details of each pregnancy as specified in the APR H&P Pregnancy History Observation Codes table.	O
Social History This section is the same as it is for History & Physical, however it SHALL contain coded entries and SHOULD use the codes specified in the APR H&P Social History Observation Codes table.	R	1.3.6.1.4.1.19376.1.5.3.1.3.16
Coded Family Medical History This section is the same as it is for History & Physical, however it SHALL contain Genetic Screening and Teratology Counseling information as specified in the APR H&P Family History and Genetic Screening Observation Codes tables. This section SHOULD also contain any additional relevant family history.	R	1.3.6.1.4.1.19376.1.5.3.1.3.15
Review of Systems This section is the same as it is for History & Physical, however it SHALL include organizers for Menstrual History and MAY include CDA entries for general review of systems data. The 'Menstrual History observations SHOULD use the codes specified in the APR H&P Review of Systems - Menstrual History Observation Codes table. The section code for the Menstrual History organizer SHALL be 49033-4 and the code system name is LOINC.	R	1.3.6.1.4.1.19376.1.5.3.1.3.18
History of Infection This section SHALL contain coded entries for infection history and SHOULD use the codes as specified in the APR H&P History of Infection Observation Codes table.	R	1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1
Physical Examination This section is the same as it is for History & Physical, and if Vital Signs data are present it SHALL include a Vital Signs subsection.	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.15
Vital Signs If Vital Signs data are present they SHALL be included as a subsection of Physical Examination.	C	1.3.6.1.4.1.19376.1.5.3.1.3.25

Conformance

CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown in the sample document below. A CDA Document may conform to more than one template. This content module inherits from the History and Physical content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Antepartum Record History and Physical Document

<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root='ParentOID'/>  <templateId root='OID'/> <id root=' ' extension=' '/> <code code='LOINC TBD' displayName='TBD' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Antepartum Record History and Physical</title> <effectiveTime value='20240418012005'/> <confidentialityCode code='N' displayName='Normal' codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' /> <languageCode code='en-US'/> : <component><structuredBody>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'/> <!-- Required Chief Complaint Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/> <!-- Required History of Present Illness Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/> <!-- Required Past Medical History Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/> <!-- Required Pregnancy History Section content --> </section> </component>  <component> <section> <templateId root=' '/> <!-- Required Pregnancy Summary History Section content --> </section> </component>  <component> <section> <templateId root=' '/> <!-- Optional Pregnancy Detail History Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16'/> <!-- Required Social History Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.15'/> <!-- Required Coded Family Medical History Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/> <!-- Required Review of Systems Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1'/> <!-- Required History of Infection Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.15'/> <!-- Required Physical Examination Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/> <!-- Conditional Vital Signs Section content --> </section> </component>     </structuredBody></component> </ClinicalDocument>

Schematron

<pattern name='Template_OID'>
 <rule context='*[cda:templateId/@root="OID"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Antepartum Record History and Physical can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="ParentOID"]'>
     Error: The parent template identifier for Antepartum Record History and Physical is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "LOINC TBD"]'>
     Error: The document type code of a Antepartum Record History and Physical must be LOINC TBD
   </assert>
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'>
     Error: The document type code must come from the LOINC code 
     system (2.16.840.1.113883.6.1).
   </assert> 
   <assert test='.//cda:templateId[@root = " "]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Record History and Physical Document must contain a(n) Header Entry.
     See http://wiki.ihe.net/index.php?title=OID 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Record History and Physical Document must contain a(n) Chief Complaint Section.
     See http://wiki.ihe.net/index.php?title=OID
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Record History and Physical Document must contain a(n) History of Present Illness Section.
     See http://wiki.ihe.net/index.php?title=OID
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Record History and Physical Document must contain a(n) Past Medical History Section.
     See http://wiki.ihe.net/index.php?title=OID 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Record History and Physical Document must contain a(n) Pregnancy History Section.
     See http://wiki.ihe.net/index.php?title=OID 
   </assert> 
   <assert test='.//cda:templateId[@root = " "]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Record History and Physical Document must contain a(n) Pregnancy Summary History Section.
     See http://wiki.ihe.net/index.php?title=OID 
   </assert> 
   <assert test='.//cda:templateId[@root = " "]'> 
     <!-- Note any missing optional elements -->
     Note: This Antepartum Record History and Physical Document does not contain a(n) Pregnancy Detail History Section.
     See http://wiki.ihe.net/index.php?title=OID 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Record History and Physical Document must contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=OID 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.15"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Record History and Physical Document must contain a(n) Coded Family Medical History Section.
     See http://wiki.ihe.net/index.php?title=OID 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Record History and Physical Document must contain a(n) Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=OID 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Record History and Physical Document must contain a(n) History of Infection Section.
     See http://wiki.ihe.net/index.php?title=OID 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Record History and Physical Document must contain a(n) Physical Examination Section.
     See http://wiki.ihe.net/index.php?title=OID 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Antepartum Record History and Physical Document does not contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=OID 
   </assert> 
 </rule>
</pattern>

Data Element Index

Antepartum Record History and Physical Data Elements

Data Element	CDA Section	Comments
Header		Need to include Language, Ethnicity, Husband/Domestic Partner, Father of Baby; needs further analysis
Chief Complaint	Chief Complaint
Pregnancy History	Pregnancy History	Summary (Gravida Para Abortus) and detailed history of pregnancies
Medical History	Past Medical History	Exclude social and family history (included in other sections)
Medical History - Tobacco, Alcohol, Drugs	Social History
Medical History - Relevant Family History	Family History
Medications	Medications
Allergies	Allergies and Other Adverse Reactions Section
Menstrual History/Symptoms Since LMP	Review of Systems
Genetic Screening/Teratology Counseling	Family History
Infection History	History of Infection
Initial Physical Examination	Physical Examination
Vital Signs	Vital Signs	subsection of Physical Examination
Diagnostic Findings		This section is required by CDA4CDT H&P - The intent in the APR specification is to have the antepartum specific laboratory results in the APR Laboratory document. However, this type of data may also be included here.
Assessment and Plans		This section is required by CDA4CDT H&P - The intent in the APR specification is to have the antepartum specific education in the APR Education document. However, this type of data may also be included here.

Document Specification

APR History and Physical Constraints

Data Element	Opt	Template ID	Comments
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.	R
Chief Complaint	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
History of Present Illness	R	1.3.6.1.4.1.19376.1.5.3.1.3.4
Past Medical History This section is the same as it is for History & Physical, and it SHALL contain entries and SHOULD use the codes specified in the appropriate APR Past Medical History tables.	R	1.3.6.1.4.1.19376.1.5.3.1.3.8	There is currently a CP to change this section name from Resolved Problems to Past Medical History.
Pregnancy History This section will consist of two entries, both of which will live under the existing Pregnancy History section. Pregnancy Summary History: Required; SHALL use the existing observation Pregnancy Observation and MAY use LOINC or SNOMED CT coded value sets Note: LOINC or SNOMED depends on outcome of CP . Pregnancy Detail History: Optional; will contain the details of each pregnancy as specified in the APR H&P Pregnancy History Observation Codes table.	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 and SHOULD use the codes specified in the APR H&P Social History Observation Codes table.	R	1.3.6.1.4.1.19376.1.5.3.1.3.16
Coded Family Medical History This section is the same as it is for History & Physical, however it SHALL contain Genetic Screening and Teratology Counseling information as specified in the APR H&P Family History and Genetic Screening Observation Codes tables. This section SHOULD also contain any additional relevant family history.	R	1.3.6.1.4.1.19376.1.5.3.1.3.15
Review of Systems This section is the same as it is for History & Physical, however it SHALL include organizers for Menstrual History and MAY include CDA entries for general review of systems data. The 'Menstrual History observations SHOULD use the codes specified in the APR H&P Review of Systems - Menstrual History Observation Codes table. The section code for the Menstrual History organizer SHALL be 49033-4 and the code system name is LOINC.	R	1.3.6.1.4.1.19376.1.5.3.1.3.18
History of Infection This section SHALL contain coded entries for infection history and SHOULD use the codes as specified in the APR H&P History of Infection Observation Codes table.	R	1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1
Physical Examination This section is the same as it is for History & Physical, and if Vital Signs data are present it SHALL include a Vital Signs subsection.	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.15
Vital Signs If Vital Signs data are present they SHALL be included as a subsection of Physical Examination.	C	1.3.6.1.4.1.19376.1.5.3.1.3.25

APR H&P Header - Details

APR H&P Header Details

Data Element	Code(s)	Code System	Opt	Comment
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. This element SHALL use xx-spouse (requested) to represent the patient's spouse or 184142008 to represent the patient's next of kin. The code system name is SNOMED CT.	xx-spouse 184142008	SNOMED CT	R
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. For father of baby the code SHALL be xx-fatherofbaby (requested). The code system name is SNOMED CT	xx-fatherofbaby	SNOMED CT	R
Ethnicity/Race This element SHOULD be included in recordTarget/patientRole/patient/ethnicGroupCode or in recordTarget/patientRole/patient/raceCode in the header of the CDA document if known. This information can be relevant to the course of care provided to the patient. For ethnicity the code SHALL be 364699009. For race the code SHALL be 103579009. The code system name is SNOMED CT.	364699009 103579009	SNOMED CT	R2

  <!-- Husband/Domestic Partner -->
  <participant typeCode="IND">
    <associatedEntity classCode="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 -->
  <participant typeCode="IND">
    <associatedEntity classCode="NOK"> 
      <code code="xx-fatherofbaby" displayName="Father of Baby" 
        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>

  <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>
        <raceCode code="103579009" displayName="race" 
          codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
        <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>

APR H&P Past Medical History Lookup Table(s)

APR H&P Past Medical History Observation Codes - Medical History

CDA Entry	Code(s)	Code System	Opt	Comments	xsi:Type
Diabetes	73211009	SNOMED CT	R		CD
Hypertension	38341003	SNOMED CT	R		CD
Heart Disease	56265001	SNOMED CT	R		CD
Autoimmune Disorder	85828009	SNOMED CT	R		CD
Kidney Disease	90708001	SNOMED CT	R		CD
UTI	68566005	SNOMED CT	R		CD
Neurologic	118940003	SNOMED CT	R		CD
Epilepsy	84757009	SNOMED CT	R		CD
Psychiatric	74732009	SNOMED CT	R		CD
Depression	41006004	SNOMED CT	R		CD
Postpartum Depression	58703003	SNOMED CT	R		CD
Hepatitis	128241005	SNOMED CT	R		CD
Liver Disease	235856003	SNOMED CT	R		CD
Varicosities	276504003	SNOMED CT	R		CD
Phlebitis	61599003	SNOMED CT	R		CD
Thyroid Dysfunction	14304000	SNOMED CT	R		CD
Trauma	417746004	SNOMED CT	R		CD
Violence	225818009	SNOMED CT	R		CD
History of Blood Transfusion	116859006	SNOMED CT	R		CD
D(Rh) Sensitized	3885002	SNOMED CT	R		CD
Pulmonary	19829001	SNOMED CT	R		CD
Seasonal Allergies	367498001	SNOMED CT	R		CD
Drug Allergy	416098002	SNOMED CT	R		CD
Latex Allergy	300916003	SNOMED CT	R		CD
Food Allergy	414285001	SNOMED CT	R		CD
Breast	79604008	SNOMED CT	R		CD
Gyn Surgery	12658000	SNOMED CT	R		CD
Operations	387713003	SNOMED CT	R		CD
Hospitalizations	32485007	SNOMED CT	R		CD
Anesthetic Complications	33211000	SNOMED CT	R		CD
History of Abnormal Pap	274688009	SNOMED CT	R		CD
Uterine Anomaly/DES	37849005	SNOMED CT	R		CD
DES Exposure	xx-desexposure	SNOMED CT	R		CD
Infertility	8619003	SNOMED CT	R		CD
Art Treatment	63487001	SNOMED CT	R		CD

APR H&P Pregnancy History Lookup Table(s)

Note:

This SNOMED code list may exist alongside the current LOINC code list for Pregnancy Observation depending on the outcome of an outstanding CP dealing with SHALL vs SHOULD for coded value sets

APR H&P Pregnancy History Observation Codes

Description	Code(s)	Code System	Opt	Comments	xsi:Type
Summary over All Pregnancies
Total Pregnancies (Gravida)	161732006	SNOMED CT	R		PQ
Full Term Deliveries	xx-fullterm	SNOMED CT	R		PQ
Premature Deliveries	xx-premature	SNOMED CT	R		PQ
Abortion, Induced	252114001	SNOMED CT	R		PQ
Abortion, Spontaneous (Miscarriages)	248989003	SNOMED CT	R		PQ
Ectopic Pregnancies	xx-ectopics	SNOMED CT	R		PQ
Multiple Births	364323006	SNOMED CT	R		PQ
Live Births	248991006	SNOMED CT	R		PQ
Detailed Pregnancy Data
Date Month/Year	184099003	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		ST
Type of Delivery (Past Pregnancy Outcome)	267013003	SNOMED CT	R		ST
Type of Anesthetic	399084002	SNOMED CT	R		ST
Place of Delivery	169812000	SNOMED CT	R		ST
Preterm Labor	6383007	SNOMED CT	R		BL

APR H&P Social History Lookup Table(s)

APR H&P Social History Observation Codes

CDA Entry	Code(s)	Code System	Opt	Comments	xsi:Type
Tobacco Use	266918002	SNOMED CT	R		ED
Alcohol Use	160573003	SNOMED CT	R		ED
Illicit/Recreational Drugs	xx-illicitdrugs	SNOMED CT	R		ED

APR H&P Family History Lookup Table(s)

APR H&P Family History and Genetic Screening Observation Codes

CDA Entry	Code(s)	Code System	Opt	Comments	xsi:Type
Thalassemia	40108008	SNOMED CT	R		CD
Neural Tube Defect	253098009	SNOMED CT	R		CD
Congenital Heart Defect	13213009	SNOMED CT	R		CD
Down Syndrome	41040004	SNOMED CT	R		CD
Tay-Sachs	111385000	SNOMED CT	R		CD
Canavan Disease	80544005	SNOMED CT	R		CD
Familial Dysautonomia	29159009	SNOMED CT	R		CD
Sick Cell Disease	417357006	SNOMED CT	R		CD
Sick Cell Trait	16402000	SNOMED CT	R		CD
Hemophilia	90935002	SNOMED CT	R		CD
Blood Disorders	414022008	SNOMED CT	R		CD
Muscular Dystrophy	73297009	SNOMED CT	R		CD
Cystic Fibrosis	190905008	SNOMED CT	R		CD
Huntington's Chorea	58756001	SNOMED CT	R		CD
Mental Retardation	91138005	SNOMED CT	R		CD
Autism	408856003	SNOMED CT	R		CD
Chrosomosal Disorder	409709004	SNOMED CT	R	Includes any inherited genetic or chromosomal disorders	CD
Maternal Metabolic Disorder	75934005	SNOMED CT	R		CD
Dysmorphism (Birth Defect)	276720006	SNOMED CT	R	Patient or baby's father has a child with birth defects	CD
Recurrent pregnancy loss/stillbirth	102878001	SNOMED CT	R		CD

APR H&P Review of Systems Lookup Table(s)

APR H&P Review of Systems - Menstrual History Observation Codes

CDA Entry	Code(s)	Code System	Opt	Comments	xsi:Type	units
Date of Last Menstrual Period	21840007	SNOMED CT	R		TS
Menses Monthly	364307006	SNOMED CT	R		BL
Prior Menses Date	21840007	SNOMED CT	R		TS
Duration of Menstrual Flow	364306002	SNOMED CT	R	Frequency	PQ	days
on Birth Control Pills at conception	xx-onbcp	SNOMED CT	R		BL
Menarche	398700009	SNOMED CT	R		PQ
hCG+	xx-dateofhcg	SNOMED CT	R		TS

APR H&P History of Infection Lookup Table(s)

APR H&P History of Infection Observation Codes

CDA Entry	Code(s)	Code System	Opt	Comments	xsi:Type
Live with someone with TB or exposed to TB	170464005	SNOMED CT	R		CD
History of Genital Herpes	402888002	SNOMED CT	R		CD
Exposed to Genital Herpes	240480009	SNOMED CT	R		CD
Rash since LMP	49882001	SNOMED CT	R		CD
Viral illness since LMP	34014006	SNOMED CT	R		CD
Rash or viral illness since LMP	49882001	SNOMED CT	R		CD
Hepatitis B	235871004	SNOMED CT	R		CD
Hepatitis C	235872006	SNOMED CT	R		CD
History of STD	8098009	SNOMED CT	R		CD
History of Gonorrhea	15628003	SNOMED CT	R		CD
History of Chlamydia	312099009	SNOMED CT	R		CD
History of HPV	302812006	SNOMED CT	R		CD
History of HIV	165816005	SNOMED CT	R		CD
History of Syphilis	76272004	SNOMED CT	R		CD

APR History & Physical Example

Note:

APR History & Physical example to go here

Antepartum Laboratory Document

Data Element Index

Antepartum Laboratory Data Elements

Data Element	Reference	Comments
Header	Medical Summary Header	The header of the Laboratory Results document follows all header constraints as outlined in Medical Summaries.
Antepartum Laboratory Results	XDSLAB	The Antepartum Laboratory document SHALL follow all constraints as defined in the XDSLAB Harmonization profile. The code to identify the document SHALL be 26436-6. The display name is Laboratory studies. The code system is 2.16.840.1.113883.6.1. The code system name is LOINC.

APR Laboratory LOINC Code List

Antepartum Record Laboratory LOINC Codes

Lab	LOINC Code	Comments
Antibody Screen (AB)	890-4 Ab Screen
Blood Type	XX-AR ABO RH (profile test)	XX-AR: A LOINC profile code will be requested
Hepatitis B virus (HBV) surface Antigen (Ag)	5196-1 HBV surface Ag (EIA) 5195-3 HBV surface Ag 5197-9 HBV surface Ag (RIA) 7905-3 HBV surface Ag (Neut)
Hemoglobin (Hgb)/Hematocrit (Hct)	718-7 Hgb 4544-3 Hct (Automated count) 30350-3 Hgb
Pap Test/Human papilloma virus (HPV)	21440-3 HPV I/H Risk DNA Cervix (Probe) 21441-1 HPV Low Risk DNA Cervix (Probe) 10524-7 Cytology Cervix 18500-9 Thin Prep Cervix 19765-7 Cytology Cervix/Vaginal (Nominal) 19766-5 Cytology Cervix/Vaginal (Narrative)
Rubella Virus (RUBV) Antibody (Ab)	5334-8 RUBV Ab IgG (EIA) 25514-1 RUBV Ab IgG 40667-8 RUBV Ab IgG (EIA) 8014-3 RUBV Ab IgG
Urine Culture Screen	630-4 Bacteria Urine Culture
Hemoglobin (Hgb) Electrophoresis	XX-HTPR Hemoglobinopathy/Thalassemia Panel (Reflexive) (Profile)	XX-HTPR: A LOINC profile code will be requested
Purified protein derivative (PPD)	1647-7 Purified protein derivative skin test
Chlamydia	6347-9 Chlamydia Ag XX-CTD Chlamydia Trachomatis (DFA) (Profile) XX-CTA Chlamydia Trachomatis (Aptima) (Profile) 6349-5 Neisseria Gonorrhoeae XX-CTNGA Chlamydia Trachomatis Neisseria Gonorrhoeae (Aptima) (Profile)	XX-CTD, XX-CTA and XX-CTNGA: A LOINC profile code will be requested
Gonorrhea	XX-CTNGA Chlamydia Trachomatis Neisseria Gonorrhoeae (Aptima) (Profile) 691-6 Neisseria Gonorrhoeaea 9568-7 Neisseria Gonorrhoeaea Ab XX-CNGA Chlamydia Neisseria Gonorrhoeae (Aptima) (Profile)	XX-CTNGA and XX-CNGA: A LOINC profile code will be requested
Ultrasound	35096-7 OB Ultrasound Panel
MSAFP Multiple Markers	XX-AFPM Alpha-Feto Protein (Maternal) (Profile) 1834-1 Alpha-1 Fetoprotein 8270-1 Prenatal Risk Quad Screen XX-AFP Alpha-Feto Protein (Profile)	XX-AFPM and XX-AFP: A LOINC profile code will be requested
Amnio Chorionic Villus Sampling (CVS)	XX-CVS CVS	XX-CVS: A LOINC profile code will be requested
Karotype	33373-2 Karyotype (Amino Fluid) 33774-0 Karyotype (CVS)
Amniotic Fluid (AFP)	XX-AFPAFR Alpha-Feto Protein, Amniotic Fluid (Reflexive) (Profile)	XX-AFPAFR: A LOINC profile code will be requested
Diabetes Screen	12646-6 Glucose Challenge, Pregnant (1hr)
Glucose Tolerance Test (GTT)	12646-6 Glucose Challenge, Pregnant (1hr) XX-GTP2 Glucose Tolerance, Pregnant (2hr) XX-GTP3 Glucose Tolerance, Pregnant (3hr)	XX-GTP2 and XX-GTP3: A LOINC profile code will be requested
Anti-D Immune Globulin (RhIG)	XX-RHIG Anti-D Immune Globulin (RhIG)	XX-RHIG: A LOINC profile code will be requested
Venereal Disease Research Laboratory (VDRL)	20507-0 Rapid Plasma Reagin (RPR) XX-RWRTT RPR with Reflex to Titer (Reflexive) (Profile) XX-RR Rubella and RPR (Profile)	XX-RWRTT and XX-RR: A LOINC profile code will be requested
Group B Strep	XX-BSGB Beta Strep Group B (PCR) 11267-2 Strep Group B	XX-BSGB: A LOINC profile code will be requested
Beta Human Chorionic Gonadotropin (HCG)	21198-7 Beta HCG
Urinalysis (Urine Screen)	XX-U Urinalysis (Profile) XX-UM Urinalysis with Microscopic (Profile) XX-UMA Urinalysis with Microscopic Analysis (Profile) XX-UD Urinalysis Dipstick (Profile) XX-UDO Urinalysis Dipstick Only (Profile) XX-UMO Urinalysis Microscopic Only (Profile) XX-UMON Urinalysis Microscopic Only (New)(Profile)	XX-U, XX-UM, XX-UMA, XX-UD, XX-UDO, XX-UMO and XX-UMON: A LOINC profile code will be requested
Aneuploidy Screening (Ultrasound)	XX-ASU Aneuploidy Screening (Ultrasound)	XX-ASU: A LOINC profile code will be requested
First Trimester Screening with Nuchal Translucency and maternal serum	XX-NTMS Nuchal Translucency and Maternal Serum	XX-NTMS: A LOINC profile code will be requested
Maternal Serum Triple Screen	XX-MSTS Maternal Serum Triple Screen (Profile	XX-MSTS: A LOINC profile code will be requested
Thyroid Stimulating Hormone (TSH)	11580-8 Thyrotropin (3rd generation) 3016-3 TSH 5385-0 Thyrotropin Receptor Ab
Triiodothyronine (T3)	3051-0 T3 Free 3052-8 T3 Reverse 3054-4 T3 True 3050-2 T3 Resin Uptake XX-T3FT T3 Free and Total (Profile)	XX-T3FT: A LOINC profile code will be requested
Varicella Zoster Virus (VZV) Ab	22600-1 Varicella Zoster Virus Ab XX-VZVP Varicella Zoster Virus (PCR) (Profile) 10860-5 Varicella Zoster Virus 6584-7 Virus Identified	XX-VZVP: A LOINC profile code will be requested

APR Laboratory Example

Note:

APR Laboratory example to go here

Antepartum Education Document

Data Element Index

APR Education Data Elements

Data Elements	CDA Section	Comments
Header	Medical Summary Header	The header of the Antepartum Record Education document follows all header constraints as outlined in Medical Summaries.
Antepartum Education and Consents	Coded Patient Education and Consents

Document Specification

Antepartum Education Constraints

Data Element	Opt	Section	Template ID
Coded Patient Education and Consents This section SHALL be the same as it is for History & Physical, and SHOULD use the codes available in the Antepartum Education Code table.	R		1.3.6.1.4.1.19376.1.5.3.1.1.9.39

APR Education SNOMED CT Code List

Antepartum Education SNOMED CT Codes

Education Element	Code	SNOMED Display Name
First Trimester
Risk factors identified by prenatal history	xx-edu-prenatalriskfactors
Anticipated course of prenatal care	17629007
Special Diet	171054004
Nutrition and weight gain counseling	429095004
Toxoplasmosis precautions (cats/raw meat)	xx-edu-toxoplasmosis
Sexual activity	162169002
Exercise	171056002
Influenza vaccine	xx-edu-influenza
Smoking/tobacco counseling	171055003
Environmental/work hazards	370995009
Travel	xx-edu-travel
Alcohol	171057006
Illicit/recreational drugs	171058001
Use of any medications	xx-edu-useofmeds	Including supplements, vitamins, herbs, or OTC drugs
Indications for ultrasound	xx-edu-indicationsforultrasound	Note: can SNOMED code be requested?
Domestic violence	413457006
Seatbelt use	xx-edu-seatbeltuse
Childbirth classes/hospital facilities
Second Trimester
Childbirth classes/hospital facilities	61324002
Signs and symptoms of preterm labor	xx-edu-pretermlaborsignssymptoms	Note: can SNOMED code be requested?
Abnormal Lab Values	410299006
Influenza vaccine	xx-edu-fluvaccine
Selecting a newborn care provider	xx-edu-newborncareprovider
Postpartum family planning	54070000
Tubal sterilization	243064009
Third Trimester
Anesthesia/analgesia plans	243062008
Fetal movement monitoring	xx-edu-fetalmovement
Labor signs	xx-edu-sslabor
VBAC counseling	xx-edu-vbac
Signs & Symptoms of Pregnancy-induced hypertension	xx-edu-sspreclampsia
Postterm counseling	xx-edu-postterm
Circumcision	184002001
Bottle feeding	169644004
Breast feeding	169643005
Postpartum depression	xx-edu-ssppd
Newborn education (Newborn screening, jaundice, SIDS, car seat)	75461000
Family medical leave or disability forms	40791000
Tubal sterilazation consent signed	408835000

APR Education Example

Note:

APR Education example to go here