Template ID |
1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 |
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Reference(s) |
IHE PCC Antepartum Care Supplement 6.3.1.A.3 |
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Base Template (IS-A) |
History and Physical Document |
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Document Code |
LOINC: 34117-2 (HISTORY AND PHYSICAL) |
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XDS Format Code |
IHE Format Code: urn:ihe:pcc:aphp:2007 |
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XDS Type Code |
LOINC: 34117-2 |
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Description |
The APHP Document template is used to summarize the results of a particular antenatal care visit. |
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Expected Sections |
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|
Section |
Template ID |
Reference |
Pregnancy History |
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 |
3.3.2.14 |
Detailed Physical Examination |
1.3.6.1.4.1.19376.1.5.3.1.1.9.15 or 1.3.6.1.4.1.19376.1.5.3.1.1.9.15.1 |
3.3.2.13 |
Allergies and Other Adverse Reactions |
1.3.6.1.4.1.19376.1.5.3.1.3.13 |
3.3.2.3 |
Family History |
1.3.6.1.4.1.19376.1.5.3.1.3.14 or 1.3.6.1.4.1.19376.1.5.3.1.3.15 |
3.3.2.9 |
Social History |
1.3.6.1.4.1.19376.1.5.3.1.3.16 or 1.3.6.1.4.1.19376.1.5.3.1.3.16.1 |
3.3.2.15 |
Review of Systems |
1.3.6.1.4.1.19376.1.5.3.1.3.18 |
|
Medications |
1.3.6.1.4.1.19376.1.5.3.1.3.19 |
3.3.2.12 |
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 |
Results |
1.3.6.1.4.1.19376.1.5.3.1.3.27 or 1.3.6.1.4.1.19376.1.5.3.1.3.28 |
3.3.2.7 |
History of Present Illness |
1.3.6.1.4.1.19376.1.5.3.1.3.4 |
|
History of Past Illness |
1.3.6.1.4.1.19376.1.5.3.1.3.8 |
3.3.2.10 |
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
- This document type is only supported for import
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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="1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1"/>
<id root="1.2.3.4.5.6.9.100.2" extension="2-20141027135823"/>
<code code="34117-2" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="HISTORY AND PHYSICAL"/>
<title language="en-US">ANTEPARTUM HISTORY AND PHYSICAL</title>
<effectiveTime value=""/>
<confidentialityCode code="" codeSystem="2.16.840.1.113883.5.25" codeSystemName="x_BasicConfidentialityKind"/>
<languageCode code=""/>
<!-- 1..1 Authors -->
<recordTarget typeCode="RCT" contextControlCode="OP">
<patientRole classCode="PAT">
...
</patientRole>
</recordTarget>
<!-- 1..n Authors -->
<author typeCode="AUT" contextControlCode="OP">
<time value=""/>
<assignedAuthor classCode="ASSIGNED">
...
</assignedAuthor>
</author>
<!-- 1..1 Custodial Organization -->
<custodian typeCode="CST">
<assignedCustodian classCode="ASSIGNED">
<representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
...
</representedCustodianOrganization>
</assignedCustodian>
</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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