Template ID(s) |
1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2 (IHE PCC CDA Suppl: 6.3.4.28) |
Description |
The antenatal flow sheet battery entry represents one line in the antepartum flow sheet. |
RMIM Class |
Organizer |
Profiled Elements |
|
Element |
Notes |
@classCode 1..1
CS |
The class code attribute of the organizer must be present and must be valued with 'BATTERY' |
code [1..1]
CD |
The code element must be present and must be valued with code 57061-4 (Antepartum Flow sheet Panel) in code system LOINC. |
statusCode [1..1]CS |
The status code must be present and must carry code 'completed' |
author [1..1] |
The author and author/time elements are used to express the provider which observed/performed the tests described in the component observations. |
component [1..*] |
The organizer shall contain one or more component observations adhering to the simple observation (see 3.4.2.20). All observations shall have a code drawn from the following table having the specified value type. Note all codes listed in the table are drawn from the LOINC code system.
|
Code |
Description |
Value |
Units / Value Set |
11884-4 |
Gestational age Clinical.estimate |
PQ |
wk |
57067-1
or
11727-5 (by US) |
Fetal Body weight Estimated by palpation
or
Fetal weight estimated by US |
PQ |
g, kg |
11881-0 |
Uterus Fundal height Tape measure |
PQ |
cm |
11876-0 (by PE)or11877-8 (by US) |
Fetal presentation by palpitation
orFetal presentation US |
CD |
SNOMED CTVertex (70028003)Breech (6096002)Transverse (73161006)Oblique (63750008)Compound (124736009)Brow (8014007)Face (21882006) |
11948-7or57068-9 |
Fetal Heart rate USorFetal Heart rate Auscultation
|
PQ |
/min |
57088-7 |
Fetal Movement - Reported |
CO |
SNOMED CT
fetal movement activity (364755008)
baby kicks a lot (276368003)
baby not moving (276370007)
reduced fetal movement (276369006)
fetal movements present (289431008)
fetal movements felt (268470003)
fetal movements seen (169731002) |
57069-7 |
Preterm labor symptoms |
BL |
|
11709-7or 11785-3 |
DILATION-LEN-PT-CERVICAL CANAL.external os -QN-PALPATIONorDILATION-LEN-PT-CERVICAL CANAL.external os-QN-US |
PQ |
cm |
11867-9 |
Effacement Cervix by palpitation |
PQ |
percent |
11961-0 |
Cervix [Length] US |
PQ |
cm |
8480-6 |
Systolic blood pressure |
PQ |
mmHg |
8462-4 |
Diastolic blood pressure |
PQ |
mmHg |
3141-9 |
Body weight Measured |
PQ |
g, kg |
1753-3 |
Albumin [Presence] in Urine |
CO |
SNOMED CT
Negative (finding) CID 167273002
Trace (finding) CID 167274008
1+ (finding) CID 167275009
2+ (finding) CID 167276005
3+ (finding) CID 167277001
4+ (finding) CID 167278006 |
2349-9or25428-4(test strip) |
Glucose [Presence] in UrineorGlucose [Presence] in Urine by Test strip |
CO |
SNOMED CT
Negative (finding) CID 167261002
Trace (finding) CID 167262009
1+ (finding) CID 167264005
2+ (finding) CID 167265006
3+ (finding) CID 167266007
4+ (finding) CID 167267003 |
44966-0 |
Edema |
CO |
SNOMED CT
Trace 44996-0
1+ pitting edema 420829009
2+ pitting edema 421605005
3+ pitting edema 421346005
4+ pitting edema 421129002 |
38208-5 |
Pain severity - Reported |
CO |
0 (no pain):10 (worst possible pain) |
OpenSHR Implementation Notes |
|
Data Model |
Obs (group / member obs) |
Code File |
AntepartumFlowsheetBatteryEntryProcessor.java |
Permitted Moods |
EVN |
Additional Constraints |
- OpenSHR will accept either author/time or effectiveTime as the timestamp of the organizer.
|
Example |
|
The following example illustrates an antepartum flow sheet panel containing several observations such as blood pressure, fetal presentation, movement and weight, preterm labor symptoms and pain severity. It is intended to provide a sample of each type of observation that can be placed within an antepartum flow sheet panel.
|
|
<organizer classCode="BATTERY" moodCode="EVN">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2"/>
<code code="57061-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Antepartum flow sheet panel"/>
<statusCode code="completed"/>
<effectiveTime value="20150103210300.791-0500"/>
<component typeCode="COMP" contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
<id root="a577bb27-90aa-4bbf-a323-1d0616bae44b"/>
<code code="57067-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Fetal Body weight Estimated by palpation"/>
<statusCode code="completed"/>
<effectiveTime value="20150103210300.807-0500"/>
<value xsi:type="PQ" unit="g" value="900"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" codeSystemName="ObservationInterpretation"/>
</observation>
</component>
<component typeCode="COMP" contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
<id root="d7911c3b-6775-462f-8089-280031d0e7f6"/>
<code code="11876-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Fetal presentation by palpation"/>
<statusCode code="completed"/>
<effectiveTime value="20150103210300.807-0500"/>
<value xsi:type="CD" code="21882006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Face Presentation"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" codeSystemName="ObservationInterpretation"/>
</observation>
</component>
<component typeCode="COMP" contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
<id root="cc2ba39e-5545-4740-b068-240a58f2d9e7"/>
<code code="11948-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Fetal heart rate US"/>
<statusCode code="completed"/>
<effectiveTime value="20150103210300.807-0500"/>
<value xsi:type="PQ" unit="/min" value="80"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" codeSystemName="ObservationInterpretation"/>
</observation>
</component>
<component typeCode="COMP" contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
<id root="b052933c-a909-41e9-9aa1-34b8e62a7f14"/>
<code code="57088-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Fetal movement reported"/>
<statusCode code="completed"/>
<effectiveTime value="20150103210300.807-0500"/>
<value xsi:type="CO" code="364755008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="fetal movement activity"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" codeSystemName="ObservationInterpretation"/>
</observation>
</component>
<component typeCode="COMP" contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
<id root="d436e51b-7a27-432f-9646-4ea100b47a66"/>
<code code="57069-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Preterm labor symptoms"/>
<statusCode code="completed"/>
<effectiveTime value="20150103210300.807-0500"/>
<value xsi:type="BL" value="false"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" codeSystemName="ObservationInterpretation"/>
</observation>
</component>
<component typeCode="COMP" contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
<id root="6a9226d9-1b43-4ee3-a87d-07af4889b4aa"/>
<code code="8480-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Systolic blood pressure"/>
<statusCode code="completed"/>
<effectiveTime value="20150103210300.807-0500"/>
<value xsi:type="PQ" unit="mm[Hg]" value="120"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" codeSystemName="ObservationInterpretation"/>
</observation>
</component>
<component typeCode="COMP" contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
<id root="b88ed3c6-7285-4a73-a341-9ab26942b87e"/>
<code code="8462-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diastolic blood pressure"/>
<statusCode code="completed"/>
<effectiveTime value="20150103210300.807-0500"/>
<value xsi:type="PQ" unit="mm[Hg]" value="80"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" codeSystemName="ObservationInterpretation"/>
</observation>
</component>
<component typeCode="COMP" contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
<id root="31fb1660-a177-4393-9e2f-16959a7df169"/>
<code code="1753-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Albumin [Presence] in Urine"/>
<statusCode code="completed"/>
<effectiveTime value="20150103210300.807-0500"/>
<value xsi:type="CO" code="167275009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="2+ (Finding)"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" codeSystemName="ObservationInterpretation"/>
</observation>
</component>
<component typeCode="COMP" contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
<id root="a3c4152b-692e-470e-b09f-5dd23bc847a9"/>
<code code="38208-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Pain severity - reported"/>
<statusCode code="completed"/>
<effectiveTime value="20150103210300.807-0500"/>
<value xsi:type="CO" value="2"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" codeSystemName="ObservationInterpretation"/>
</observation>
</component>
</organizer> |
|