Shown below is the sample Antepartum History and Physical (APHP) document used for the testing of the SHR CDA handler. Note that for current purposes, this document expands only on the 'HISTORY OF PREGNANCIES' section.  This document was prepared largely thanks to assistance provided by Jeremy Keiper.

As discussed previously, this document, when translated into the OpenMRS data model, will be represented as a single encounter. Therefore, the 'HISTORY OF PREGNANCIES' section will be represented using an Obs Group, while the observations listed under this component will be represented via Obs.

The observations recorded under the HISTORY OF PREGNANCIES section represent numerical, date, string and concept data types.

This document will be revised as further amendments/improvements are made. At this time, it validates successfully with no errors and several warnings.

 

<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:mif="urn:hl7-org:v3/mif"
	xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
	xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
	<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3" />
	<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4' />
	<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1' />
	<id root='1' extension='1' />
	<code code='34117-2' displayName='HISTORY AND PHYSICAL'
		codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />
	<title>Antepartum History and Physical</title>
	<effectiveTime value='20140409012005' />
	<confidentialityCode code='N' displayName='Normal'
		codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
	<languageCode code='en-US' />
	<recordTarget>
		<patientRole>
			<id extension="12345" root="2.16.840.1.113883.19.5" />
			<patient>
				<name>
					<given>Henry</given>
					<family>Levin</family>
					<suffix>the 7th</suffix>
				</name>
				<administrativeGenderCode code="M"
					codeSystem="2.16.840.1.113883.5.1" />
				<birthTime value="19320924" />
			</patient>
			<providerOrganization>
				<id root="2.16.840.1.113883.19.5" />
				<name>Organization Name</name>
			</providerOrganization>
		</patientRole>
	</recordTarget>
	<author>
		<time value="20000407121000" />
		<assignedAuthor>
			<id extension="123456789" root="2.16.840.1.113883.19.5.1" />
			<assignedPerson>
				<name>
					<given>Robert</given>
					<family>Dolin</family>
					<suffix>MD</suffix>
				</name>
			</assignedPerson>
			<representedOrganization>
				<id root="2.16.840.1.113883.19.5" />
				<name>Organization Name</name>
			</representedOrganization>
		</assignedAuthor>
	</author>
	<custodian>
		<assignedCustodian>
			<representedCustodianOrganization>
				<id root="2.16.840.1.113883.19.5" />
				<name>Organization Name</name>
			</representedCustodianOrganization>
		</assignedCustodian>
	</custodian>
	<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 -->
					<id root='1' extension='2' />
					<code code='10154-3' displayName='CHIEF COMPLAINT' codeSystem='2.16.840.1.113883.6.1'
						codeSystemName='LOINC' />
					<text>
						Text as described above
					</text>
				</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 -->
					<id root='1' extension='2' />
					<code code='10164-2' displayName='HISTORY OF PRESENT ILLNESS'
						codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />
					<text>
						Text as described above
					</text>
				</section>
			</component>
			<component>
				<section>
					<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8' />
					<!-- Required History of Past Illness Section content -->
					<id root='1' extension='2' />
					<code code='11348-0' displayName='HISTORY OF PAST ILLNESS'
						codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />
					<text>
						Text as described above
					</text>
				</section>
			</component>
			<component>
				<section>
					<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1' />
					<id root='1' extension='2' />
					<code code='XX-HistoryOfInfection' displayName='HISTORY OF INFECTION'
						codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />
					<text>
						Text as described above
					</text>
				</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 -->
					<id root='1' extension='2' />
					<code code='10162-6' displayName='HISTORY OF PREGNANCIES'
						codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />
					<text>
						Text as described above
					</text>
					<entry>
						<!-- Required Pregnancy Observation element -->
						<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5' />
						<observation classCode="OBS" moodCode="EVN">
							<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13' />
							<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.5" />
							<id root='1' extension='2' />
							<code code='11636-8' displayName='BIRTHS LIVE (REPORTED)'
								codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />
							<statusCode code='completed' />
							<effectiveTime value="2011" />
							<repeatNumber />
							<value code="1325" codeSystem="1.3.6.1.4.1.12009.2"
								codeSystemName="LOINC" displayName="CODED ANSWER" xsi:type="CD" />
							<!-- <value xsi:type='INT' value='1'/> -->
							<interpretationCode code="Value" />
							<methodCode code="Value" />
							<targetSiteCode code="1506555919" />
						</observation>
					</entry>
					<entry>
						<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5' />
						<observation classCode="OBS" moodCode="EVN">
							<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13' />
							<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.5" />
							<id root='1' extension='2' />
							<code code='11636-8-A' displayName='A' codeSystem='2.16.840.1.113883.6.1'
								codeSystemName='LOINC' />
							<statusCode code='completed' />
							<effectiveTime value="2011" />
							<repeatNumber />
							<value xsi:type='INT' value='1' />
							<interpretationCode code="Value" />
							<methodCode code="Value" />
							<targetSiteCode code="1506555919" />
						</observation>
					</entry>
					<entry>
						<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5' />
						<observation classCode="OBS" moodCode="EVN">
							<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13' />
							<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.5" />
							<id root='1' extension='2' />
							<code code='11636-8-B' displayName='B' codeSystem='2.16.840.1.113883.6.1'
								codeSystemName='LOINC' />
							<statusCode code='completed' />
							<effectiveTime value="2011" />
							<repeatNumber />
							<value xsi:type='ST'>TEST</value>
							<interpretationCode code="Value" />
							<methodCode code="Value" />
							<targetSiteCode code="1506555919" />
						</observation>
					</entry>
					<entry>
						<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5' />
						<observation classCode="OBS" moodCode="EVN">
							<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13' />
							<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.5" />
							<id root='1' extension='2' />
							<code code='11636-8-C' displayName='C' codeSystem='2.16.840.1.113883.6.1'
								codeSystemName='LOINC' />
							<statusCode code='completed' />
							<effectiveTime value="2011" />
							<repeatNumber />
							<value xsi:type='TS' value='20110101' />
							<interpretationCode code="Value" />
							<methodCode code="Value" />
							<targetSiteCode code="1506555919" />
						</observation>
					</entry>
				</section>
			</component>
			<component>
				<section>
					<templateId root='2.16.840.1.113883.10.20.1.15' />
					<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16' />
					<!-- Required Social History Section content -->
					<id root='1' extension='2' />
					<code code='29762-2' displayName='SOCIAL HISTORY' codeSystem='2.16.840.1.113883.6.1'
						codeSystemName='LOINC' />
					<title>boink</title>
					<text>
						Text as described above
					</text>
				</section>
			</component>
			<component>
				<section>
					<templateId root='2.16.840.1.113883.10.20.1.4' />
					<!-- Required Coded Family Medical History Section content -->
					<id root='1' extension='2' />
					<code code='10157-6' displayName='HISTORY OF FAMILY MEMBER DISEASES'
						codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />
					<title>boink</title>
					<text>
						Text as described above
					</text>
				</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 -->
					<id root='1' extension='2' />
					<code code='10187-3' displayName='REVIEW OF SYSTEMS'
						codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />
					<text>
						Text as described above
					</text>
				</section>
			</component>
			<component>
				<section>
					<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24' />
					<!-- Required Physical Examination Section content -->
					<id root='1' extension='2' />
					<code code='29545-1' displayName='PHYSICAL EXAMINATION'
						codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />
					<text>
						Text as described above
					</text>
				</section>
			</component>
			<component>
				<section>
					<templateId root='2.16.840.1.113883.10.20.1.16' />
					<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25' />
					<!-- Conditional Vital Signs Section content -->
					<id root='1' extension='2' />
					<code code='8716-3' displayName='VITAL SIGNS' codeSystem='2.16.840.1.113883.6.1'
						codeSystemName='LOINC' />
					<title>boink</title>
					<text>
						Text as described above
					</text>
				</section>
			</component>
		</structuredBody>
	</component>
</ClinicalDocument>
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1 Comment

  1. Justin Fyfe

    Hello,

     

    I have an updated sample of this APHP document which contains Vital Signs, Allergies, and more detail in the history of pregnancies section. I can upload this if it would help, just didnt want to overwrite this copy in case others are using it for reference/testing.

    Cheers

    -Justin

This work is licensed under a Creative Commons Attribution 4.0 International License.