Section Code |
LOINC: 57059-8 (Pregnancy Visit Summary) |
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Description |
The Antepartum Visit Summary flow sheet section is used to track information related to the most important information noted for the pregnant woman. |
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CDA Level |
Level 3 Only |
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Template IDs |
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Level / Spec |
Template ID |
Standards Reference |
3 / IHE |
1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2 |
IHE PCC CDA Suppl: 6.3.3.9.3 |
Expected Entries / Sub-Sections |
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Entry |
Template ID |
Reference |
Simple Observation |
1.3.6.1.4.1.19376.1.5.3.1.4.13 |
3.4.2.20 |
Antepartum Flow sheet Battery |
1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2 |
3.4.2.6 |
OpenSHR Implementation Notes |
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Data Model |
Obs |
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Code File |
AntepartumVisitSummaryFlowsheetSectionProcessor.java |
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Additional Constraints |
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Notes |
The simple observation contained within the flow sheet panel section shall be a single observation representing the pregnant woman's pre-pregnancy weight and shall have a code of 8348-5, BODY WEIGHT^PRE PREGNANCY-MASS-PT-QN-MEASURED. The value must be of type PQ. The units SHALL be "kg". |
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Specification |
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<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<!-- IHE PCC Antepartum Visit Flow sheet -->
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2"/>
<!-- Section Code -->
<code code="57059-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Pregnancy Visit Summary"/>
<title language="en-US">Antepartum Visit Flow sheet</title>
<!-- 1..1 Text as described in the general implementation notes -->
<text mediaType="text/x-hl7-text+xml">
...
</text>
<!-- 1..1 Observation representing the pre-pregnancy weight -->
<entry typeCode="COMP" contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
...
</observation>
</entry>
<!-- 1..n Organizer entries representing important pregnancy history information -->
<entry typeCode="COMP" contextConductionInd="true">
<organizer classCode="BATTERY" moodCode="EVN">
...
</organizer>
</entry>
</section>
</component> |
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Examples |
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This example illustrates an antenatal flow sheet panel section containing pre-pregnancy weight, blood pressure and fetal presentation information. |
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<section classCode="DOCSECT" moodCode="EVN">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2"/>
<code code="57059-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Pregnancy Visit Summary"/>
<title language="en-US">Antepartum flow sheet panel</title>
<text mediaType="text/x-hl7-text+xml">
...
</text>
<entry 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="b5e3b204-80f2-4866-b94b-5218c8bc6787"/>
<code code="8348-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prepregnancy Weight"/>
<statusCode code="completed"/>
<effectiveTime value="20150103210300.791-0500"/>
<value xsi:type="PQ" unit="kg" value="86"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" codeSystemName="ObservationInterpretation"/>
</observation>
</entry>
<entry typeCode="COMP" contextConductionInd="true">
<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="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="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>
</organizer>
</entry>
</section> |
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