Template ID |
1.3.6.1.4.1.19376.1.5.3.1.1.11.2 |
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Reference(s) |
IHE PCC Antepartum Care Supplement 6.3.1.B.3 |
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Base Template (IS-A) |
Medical Summary Document |
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Document Code |
LOINC: 57055-6 (ANTEPARTUM SUMMARY NOTE) |
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XDS Format Code |
IHE Format Code: urn:ihe:pcc:aps:2007 |
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XDS Type Code |
LOINC: 57055-6 |
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Description |
The APS document template is used to summarize the care provided during the course of a pregnancy. This document is a summary and contains information related to the episode of pregnancy.
An APS typically represents a "living document" meaning that the content of an APS will change during the progression of pregnancy. |
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Expected Sections |
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Section |
Template ID |
Reference |
Estimated Delivery Dates |
1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1 |
3.3.2.8 |
Visit Summary Flow sheet |
1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2 |
3.3.2.5 |
History of Surgical Procedures |
1.3.6.1.4.1.19376.1.5.3.1.1.16.2.2 |
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Coded Antenatal Testing and Surveillance |
1.3.6.1.4.1.19376.1.5.3.1.1.21.2.5.1 |
3.3.2.4 |
Allergies and Other Adverse Reactions |
1.3.6.1.4.1.19376.1.5.3.1.3.13 |
3.3.2.3 |
Medications |
1.3.6.1.4.1.19376.1.5.3.1.3.19 |
3.3.2.12 |
Care Plan |
1.3.6.1.4.1.19376.1.5.3.1.3.31 |
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Advance Directives |
1.3.6.1.4.1.19376.1.5.3.1.3.34 or 1.3.6.1.4.1.19376.1.5.3.1.3.35 |
3.3.2.2 |
Problems |
1.3.6.1.4.1.19376.1.5.3.1.3.6 |
3.3.2.1 |
Vital Signs |
1.3.6.1.4.1.19376.1.5.3.1.3.25 or 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 |
3.3.2.17 |
OpenSHR Implementation Notes |
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Additional Constraints |
- SHOULD have <participant> representing natural father of fetus (see: 3.2.1.4)
- SHOULD have <participant> representing the domestic partner (see: 3.2.1.4)
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Notes |
All sections in this document are optional, however the document should, at minimum, contain the Vital Signs.
Additionally when this document is generated as an On-Demand Document, OpenSHR will make assertions about the following conditions and allergies indicating "unknown":
- An allergy entry describing the patient's allergy to Latex will be included in all ODD APS summaries generated by the SHR.
- An advance directive related to acceptance of blood transfusion will be included in all ODD APS summaries generated by the SHR.
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Specification |
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<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" classCode="DOCCLIN" moodCode="EVN">
<realmCode code="UV"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.11.2"/>
<id root="1.2.3.4.5.6.9.100.2" extension="2-20141027135823"/>
<code code="57055-6" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="ANTEPARTUM SUMMARY NOTE"/>
<title language="en-US">ANTEPARTUM SUMMARY NOTE</title>
<effectiveTime value=""/>
<confidentialityCode code="" codeSystem="2.16.840.1.113883.5.25" codeSystemName="x_BasicConfidentialityKind"/>
<languageCode code=""/>
<!-- 1..1 Record Target -->
<recordTarget typeCode="RCT" contextControlCode="OP">
...
</recordTarget>
<!-- 1..n Author Persons -->
<author typeCode="AUT" contextControlCode="OP">
<time value=""/>
...
</author>
<!-- 1..1 Custodial Organization -->
<custodian typeCode="CST">
...
</custodian>
<!-- 0..n Participants -->
<participant typeCode="IND">
<time value=""/>
<associatedEntity classCode="PRS">
...
</associatedEntity>
</participant>
<!-- 1..n Documentation Of -->
<documentationOf typeCode="DOC">
<serviceEvent classCode="PCPR" moodCode="EVN">
<effectiveTime>
<low value=""/>
<high value=""/>
</effectiveTime>
</serviceEvent>
</documentationOf>
<!-- 1..1 Component -->
<component typeCode="COMP" contextConductionInd="true">
<!-- Must be structured body -->
<structuredBody classCode="DOCBODY" moodCode="EVN">
<!-- 1..n Components -->
<component typeCode="COMP" contextConductionInd="true">
<!-- 1..1 Section -->
<section classCode="DOCSECT" moodCode="EVN">
...
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument> |
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