Difference between revisions of "Talk:Antepartum Summary Form C"
Tsoutherland (talk | contribs) |
Tsoutherland (talk | contribs) |
||
(32 intermediate revisions by 3 users not shown) | |||
Line 15: | Line 15: | ||
=== Progress === | === Progress === | ||
TS: Has started an excel spreadsheet covering Form A, pulling out data elements, and identifying data types and LOINC codes. | TS: Has started an excel spreadsheet covering Form A, pulling out data elements, and identifying data types and LOINC codes. | ||
+ | |||
+ | See [[Media:APS_ACOG_Field_Mapping_Forms_A&B.xls|APS ACOG Field Mapping - Forms A & B.xls]] | ||
+ | |||
+ | See [[Media:APS_ACOG_Field_Mapping_Forms_C&F&G.xls|APS ACOG Field Mapping - Forms C, F & G.xls]] | ||
=== IP Issues === | === IP Issues === | ||
Line 70: | Line 74: | ||
Claims Attachment ballot has listed in it a number of very usefull LOINC codes here: [http://www.hl7.org/documentcenter/ballots/2007MAY/downloads/ASIG_INFOSPECS_CDAR2_I2_2007MAY.zip See Clinical Reports] | Claims Attachment ballot has listed in it a number of very usefull LOINC codes here: [http://www.hl7.org/documentcenter/ballots/2007MAY/downloads/ASIG_INFOSPECS_CDAR2_I2_2007MAY.zip See Clinical Reports] | ||
+ | |||
+ | ==Apr 4, Telcon== | ||
+ | ===Attendance=== | ||
+ | Tone, Ann, Larry | ||
+ | |||
+ | ===Status report=== | ||
+ | *Tone is working on loinc spreadsheet posted in discussion. | ||
+ | *Ann has text, but to work with Tone on getting it into the wiki. | ||
+ | *Larry still needs to fill in volume 2 templates that will later get expanded by Tone. | ||
+ | |||
+ | ===Action Items:=== | ||
+ | *Larry to send LOINC spreadsheet to Clem after Tone finishes his review. | ||
+ | |||
+ | ==Apr 13, Telcon== | ||
+ | ===Attendance=== | ||
+ | Tone, Keith, Larry, James | ||
+ | |||
+ | ===Status Report=== | ||
+ | *Tone has finished LOINC spreadsheet. | ||
+ | *Ann posted glossary. | ||
+ | *Keith to review LOINC spreadsheet. | ||
+ | *Larry has done nothing past week -- also busy this week, but will take action item to send LOINC to Clem. | ||
+ | *James will get legal/copywright wording posted (~2weeks) | ||
+ | * Link for VA/KP List ftp://ftp1.nci.nih.gov/pub/cacore/EVS/FDA/ProblemList/Browser/ | ||
+ | |||
+ | ==4/20/07 t-conn== | ||
+ | |||
+ | === | ||
+ | ===Issues=== | ||
+ | *EDD is 2 sections or 2 panels? | ||
+ | *How do you do panels? | ||
+ | *EDD is an assessment scale? -> calculated EDD similar to APGAR | ||
+ | *how to do entry constraints? Eg. Allergy requires Latex. | ||
+ | *in CCD Allergen = obs value, not material?? I thought we were not going to do that? | ||
+ | |||
+ | *upcoming meeting -- | ||
+ | Ann making progress on edits to volume 1. | ||
+ | Tone no significant changes this week. | ||
+ | Larry | ||
+ | |||
+ | ==5/21/07 Form C Misc Notes (TS)== | ||
+ | |||
+ | ====Form C - Flowsheet==== | ||
+ | * Larry referred to part of Form C as the Visit Summary section. A better term may be Flowsheet as this is how this particular section is generally referred to among most (if not all) ob/gyn practices. | ||
+ | |||
+ | |||
+ | * '''Example data values for flowsheet items:''' | ||
+ | ** '''Weeks Gestation''' | ||
+ | *** 0-46 weeks | ||
+ | *** Consider that different vendors report this different ways. | ||
+ | **** Ex1: 20.5 means 20 weeks, 5 days | ||
+ | **** Ex2: 20w5d means 20 weeks, 5 days | ||
+ | ** '''Fundal Height''' | ||
+ | *** < 100 cm | ||
+ | ** '''Presentation''' | ||
+ | *** breach, undetermined, vertex, etc. | ||
+ | ** '''FHR''' | ||
+ | *** < 300 | ||
+ | *** Could be a range or a specific number | ||
+ | ** '''Fetal Movement''' | ||
+ | *** present/absent/reduced | ||
+ | ** '''Preterm Labor Signs/Symptoms''' | ||
+ | *** present/absent | ||
+ | ** '''Cervix Exam Ultrasound Length''' | ||
+ | *** Dilation: 0-10cm | ||
+ | *** Effacement: 0-100% | ||
+ | *** Station: | ||
+ | **** -2 -1 0 +1 +2 +3 | ||
+ | **** Floating (-2 -1) | ||
+ | **** Engaged (+1 +2 +3) | ||
+ | ** '''Blood Pressure''' | ||
+ | *** Systolic: 0-300 | ||
+ | *** Diastolic: 0-200 | ||
+ | ** '''Weight''' | ||
+ | *** 0-1000 lbs | ||
+ | *** kg? | ||
+ | ** '''Urine''' | ||
+ | *** Albumin/Glucose: 0 Trace +1 +2 +3 +4 | ||
+ | ** '''Edema''' | ||
+ | *** 0/none Trace +1 +2 +3 | ||
+ | ** '''Pain Scale (0-10)''' | ||
+ | *** 0-10 | ||
+ | ** '''Next Appointment''' | ||
+ | *** Days, weeks | ||
+ | *** How far out is next appointment? | ||
+ | |||
+ | ====Form C - Problems and Medications Section==== | ||
+ | Looking on Form C at the problems/plans section (above visit summary/flowsheet) consider the following: | ||
+ | * There can be a medication listed that does not correlate with a problem | ||
+ | ** ex: prenatal vitamins - the problem is pregnancy, but it may not be listed | ||
+ | * There can be a problem listed that does not correlate with a medication | ||
+ | ** ex: patient chose not to take medication | ||
+ | ** ex: no medications available for a particular problem | ||
+ | * Both problems and medications will often be prefixed with an abbreviation to determine the type of problem/medication | ||
+ | ** ex: Hx, Rx, current, patient reported | ||
+ | * '''The intent of this section is to collect all problems that are significant, to either the pregnancy or the patient''' | ||
+ | ** ex: tonsillectomy at age 10 IS NOT significant to either patient or pregnancy (and thus would not be collected) | ||
+ | ** ex: exposure to Rubella in a non-immune patient IS significant to the pregnancy, but not to the patient | ||
+ | ** ex: previous ectopic pregnancies IS significant to both pregnancy and patient | ||
+ | ** ex: blindness IS significant to the patient, but not to the pregnancy | ||
+ | * The data collected here is usually done so by the ob-gyn practice and not from any outside sources - such as the patient's PCP |
Latest revision as of 06:58, 5 June 2007
- Forms (A, B, C) can be covered by extending Medical Summary
- Form D can be covered by XD*-LAB
- Form E can be covered by an Education Plan
- Form F & G are simply extensions of C.
- Discharge Summary back to Ob.
- Post Partum Form
The following terminologies were found by GE in their review of this data Media:GECodes.xls
March 23 Telcon
- Attending
- Anne Diamond - ACOG, Dr. Al Strunk, Tone Southerland - Digichart, James Scroggs - ACOG, Larry McKnight - Siemens, Keith W. Boone - GE Healthcare
Progress
TS: Has started an excel spreadsheet covering Form A, pulling out data elements, and identifying data types and LOINC codes.
See APS ACOG Field Mapping - Forms A & B.xls
See APS ACOG Field Mapping - Forms C, F & G.xls
IP Issues
LM: Does AGOC License the form? AS: ACOG does license the form itself. It is a non-exclusive license and has no cost associated with it.
KB: We should incorporate a statement about this in the profile. Would ACOG draft some text that we could include in the profile?
JS/AS: Yes.
Status
LM: Wiki updates were made recently.
LM: I've divided volume 2 into four parts: A and B; C, F and G; D; and E, is that OK?
Yes
LM: Do we have a volunteer to make sure the mood of the profile is rewrittent to be declaritive?
AD: Yes, we can do that.
LM: We need an Open Issues Log...
KB: Put that on the discussion page.
LM: So delete it ...
KB: Yes
LM: On the Actors and Transactions section, do we need this?
KB: I would ignore that for now. In the supplements, this is probably needed, but in the overall document it isn't.
LM: Does Radiology have a mechanism to deal with this?
KB: Probably not, since this seems to be a content profile issue.
LM: When Radiology included PIR, how did they handle this? Did they repeat pre-existing information or refer to existing material?
KB: I don't know.
LM: Can you take that as a to-do? To figure out our approach to this.
KB: Yes.
LM: Do you have any opinions about how to write the folder strategy?
KB: One of the things I'd like to do is to define the vocabulary used to identify the folder. This should be an update to the Bindings Section,
LM: Would this be the same for XD*
KB: I believe they all have folders.
We probably want to ask LOINC code for a new code for a SET of records that covers Antepartum Care, since these documents are not explicitely "LABOR AND DELIVERY RECORDS".
Claims Attachment ballot has listed in it a number of very usefull LOINC codes here: See Clinical Reports
Apr 4, Telcon
Attendance
Tone, Ann, Larry
Status report
- Tone is working on loinc spreadsheet posted in discussion.
- Ann has text, but to work with Tone on getting it into the wiki.
- Larry still needs to fill in volume 2 templates that will later get expanded by Tone.
Action Items:
- Larry to send LOINC spreadsheet to Clem after Tone finishes his review.
Apr 13, Telcon
Attendance
Tone, Keith, Larry, James
Status Report
- Tone has finished LOINC spreadsheet.
- Ann posted glossary.
- Keith to review LOINC spreadsheet.
- Larry has done nothing past week -- also busy this week, but will take action item to send LOINC to Clem.
- James will get legal/copywright wording posted (~2weeks)
- Link for VA/KP List ftp://ftp1.nci.nih.gov/pub/cacore/EVS/FDA/ProblemList/Browser/
4/20/07 t-conn
=
Issues
- EDD is 2 sections or 2 panels?
- How do you do panels?
- EDD is an assessment scale? -> calculated EDD similar to APGAR
- how to do entry constraints? Eg. Allergy requires Latex.
- in CCD Allergen = obs value, not material?? I thought we were not going to do that?
- upcoming meeting --
Ann making progress on edits to volume 1. Tone no significant changes this week. Larry
5/21/07 Form C Misc Notes (TS)
Form C - Flowsheet
- Larry referred to part of Form C as the Visit Summary section. A better term may be Flowsheet as this is how this particular section is generally referred to among most (if not all) ob/gyn practices.
- Example data values for flowsheet items:
- Weeks Gestation
- 0-46 weeks
- Consider that different vendors report this different ways.
- Ex1: 20.5 means 20 weeks, 5 days
- Ex2: 20w5d means 20 weeks, 5 days
- Fundal Height
- < 100 cm
- Presentation
- breach, undetermined, vertex, etc.
- FHR
- < 300
- Could be a range or a specific number
- Fetal Movement
- present/absent/reduced
- Preterm Labor Signs/Symptoms
- present/absent
- Cervix Exam Ultrasound Length
- Dilation: 0-10cm
- Effacement: 0-100%
- Station:
- -2 -1 0 +1 +2 +3
- Floating (-2 -1)
- Engaged (+1 +2 +3)
- Blood Pressure
- Systolic: 0-300
- Diastolic: 0-200
- Weight
- 0-1000 lbs
- kg?
- Urine
- Albumin/Glucose: 0 Trace +1 +2 +3 +4
- Edema
- 0/none Trace +1 +2 +3
- Pain Scale (0-10)
- 0-10
- Next Appointment
- Days, weeks
- How far out is next appointment?
- Weeks Gestation
Form C - Problems and Medications Section
Looking on Form C at the problems/plans section (above visit summary/flowsheet) consider the following:
- There can be a medication listed that does not correlate with a problem
- ex: prenatal vitamins - the problem is pregnancy, but it may not be listed
- There can be a problem listed that does not correlate with a medication
- ex: patient chose not to take medication
- ex: no medications available for a particular problem
- Both problems and medications will often be prefixed with an abbreviation to determine the type of problem/medication
- ex: Hx, Rx, current, patient reported
- The intent of this section is to collect all problems that are significant, to either the pregnancy or the patient
- ex: tonsillectomy at age 10 IS NOT significant to either patient or pregnancy (and thus would not be collected)
- ex: exposure to Rubella in a non-immune patient IS significant to the pregnancy, but not to the patient
- ex: previous ectopic pregnancies IS significant to both pregnancy and patient
- ex: blindness IS significant to the patient, but not to the pregnancy
- The data collected here is usually done so by the ob-gyn practice and not from any outside sources - such as the patient's PCP