Mobile Antepartum Summary
1.0.0-comment - ballot
Mobile Antepartum Summary
1.0.0-comment - ballot
This page is part of the Mobile Antepartum Summary (v1.0.0-comment: Publication Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
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<text>
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<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: Composition </b><a name="ex-APS-Composition-AmandaAlvarez"> </a><a name="hcex-APS-Composition-AmandaAlvarez"> </a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">ResourceComposition "ex-APS-Composition-AmandaAlvarez" </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-IHE.PCC.APS.Composition.html">Antapartum Summary</a></p><p style="margin-bottom: 0px">Security Labels: <span title="{http://terminology.hl7.org/CodeSystem/v3-ActReason http://terminology.hl7.org/CodeSystem/v3-ActReason}">http://terminology.hl7.org/CodeSystem/v3-ActReason</span></p></div><p><b>status</b>: final</p><p><b>type</b>: Antepartum summary note <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://loinc.org/">LOINC</a>#57055-6)</span></p><p><b>category</b>: Pregnancy summary Document <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://loinc.org/">LOINC</a>#90767-5)</span></p><p><b>date</b>: 2023-01-08 14:30:00+0100</p><p><b>author</b>: <a href="Practitioner-ex-Practitioner.html">Practitioner/ex-Practitioner</a> " HEPS"</p><p><b>title</b>: Antepartum Summary</p><p><b>confidentiality</b>: N</p><blockquote><p><b>attester</b></p><p><b>mode</b>: legal</p><p><b>time</b>: 2023-01-08 14:30:00+0100</p><p><b>party</b>: <a href="Practitioner-ex-Practitioner.html">Practitioner/ex-Practitioner</a> " HEPS"</p></blockquote><blockquote><p><b>attester</b></p><p><b>mode</b>: legal</p><p><b>time</b>: 2023-01-08 14:30:00+0100</p><p><b>party</b>: <a href="Organization-ex-Organization-OB.html">Organization/ex-Organization-OB</a> "Acme Healthcare"</p></blockquote><p><b>custodian</b>: <a href="Organization-ex-Organization-OB.html">Organization/ex-Organization-OB</a> "Acme Healthcare"</p></div>
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<system value="http://loinc.org"/>
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<system value="http://loinc.org"/>
<code value="90767-5"/>
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<subject>🔗
<reference value="Patient/ex-Patient-AmandaAlvarez"/>
</subject>
<date value="2023-01-08T14:30:00+01:00"/>
<author>🔗
<reference value="Practitioner/ex-Practitioner"/>
</author>
<title value="Antepartum Summary"/>
<confidentiality value="N"/>
<attester>
<mode value="legal"/>
<time value="2023-01-08T14:30:00+01:00"/>
<party>🔗
<reference value="Practitioner/ex-Practitioner"/>
</party>
</attester>
<attester>
<mode value="legal"/>
<time value="2023-01-08T14:30:00+01:00"/>
<party>🔗
<reference value="Organization/ex-Organization-OB"/>
</party>
</attester>
<custodian>🔗
<reference value="Organization/ex-Organization-OB"/>
</custodian>
<section>
<title value="Medication Summary section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10160-0"/>
<display value="History of Medication use Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">Active Medications - Amoxicillin</div>
</text>
<entry>🔗
<reference value="MedicationStatement/ex-medicationStatement"/>
</entry>
</section>
<section>
<title value="Allergies and Intolerances"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="48765-2"/>
<display value="Allergies and adverse reactions Document"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">active allergies - latex and fish</div>
</text>
<entry>🔗
<reference value="AllergyIntolerance/ex-Allergy-Latex"/>
</entry>
<entry>🔗
<reference value="AllergyIntolerance/ex-Allergy-Fish"/>
</entry>
</section>
<section>
<title value="Problems"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11450-4"/>
<display value="Problem list - Reported"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">active problems - sepsis and gestational diabedies</div>
</text>
<entry>🔗
<reference value="Condition/ex-Problem-Sepsis"/>
</entry>
<entry>🔗
<reference value="Condition/ex-Problem-GestationalDiabetes"/>
</entry>
</section>
<section>
<title value="Past Illness History"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11348-0"/>
<display value="History of Past illness Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">none found</div>
</text>
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</section>
<section>
<title value="Procedures History"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="47519-4"/>
<display value="History of Procedures Document"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">past procedures - Education for smoking provided and Cephallic Version</div>
</text>
<entry>🔗
<reference value="Procedure/ex-Procedure-CephalicVersion"/>
</entry>
<entry>🔗
<reference value="Procedure/ex-Procedure-EducationSmoking"/>
</entry>
</section>
<section>
<title value="Pregnancy History"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10162-6"/>
<display value="Pregnancies Hx"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">observations for pregnancy history</div>
</text>
<entry>🔗
<reference value="Observation/ex-PregnencyStatus-pregnant"/>
</entry>
<entry>🔗
<reference value="Observation/ex-EstimatedDeliveryDate"/>
</entry>
<entry>🔗
<reference value="Observation/ex-GestationalAge"/>
</entry>
<entry>🔗
<reference value="Observation/ex-DateOfLastMenstralPeriod"/>
</entry>
<entry>🔗
<reference value="Observation/ex-DateOfFirstPrenatalVisit"/>
</entry>
<entry>🔗
<reference value="Observation/ex-PregnancyHistory-AmandaAlvarez"/>
</entry>
</section>
<section>
<title value="Immunizations"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11369-6"/>
<display value="History of Immunization Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">Immunizations - Varicella</div>
</text>
<entry>🔗
<reference value="Immunization/ex-Immunization-Vericella"/>
</entry>
</section>
<section>
<title value="Chief Complaint"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10154-3"/>
<display value="Chief complaint Narrative - Reported"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">Complains of fever and having lack of energy</div>
</text>
</section>
<section>
<title value="Results"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="30954-2"/>
<display value="Relevant diagnostic tests/laboratory data Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">no abnormal results for labs</div>
</text>
<entry>🔗
<reference value="Observation/ex-AntepartumLabs"/>
</entry>
<entry>🔗
<reference value="Observation/ex-Antepartum-Genetic-Screening"/>
</entry>
</section>
<section>
<title value="Vital Signs"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="8716-3"/>
<display value="Vital signs"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">body weight - 185 lbs , prepregnancy weight - 148 lbs</div>
</text>
<entry>🔗
<reference value="Observation/ex-VitalSigns-BodyWeight"/>
</entry>
</section>
<section>
<title value="Review Of Systems"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10187-3"/>
<display value="Review of systems Narrative - Reported"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">last menstral period</div>
</text>
<entry>🔗
<reference value="Observation/ex-MenstralStatus-Pregnancy"/>
</entry>
</section>
<section>
<title value="Physical Exams"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="29545-1"/>
<display value="Physical findings Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">abdominal tenderness</div>
</text>
<entry>🔗
<reference value="Observation/ex-PhysicalExam-AbdominalTenderness"/>
</entry>
</section>
<section>
<title value="History Of Infection"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="56838-6"/>
<display value="History of Infectious disease Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">history of clamidia infection</div>
</text>
<entry>🔗
<reference value="Condition/ex-HistoryOfInfection"/>
</entry>
</section>
<section>
<title value="Plan Of Care"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="18776-5"/>
<display value="Plan of care note"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">Birth Plan</div>
</text>
<entry>🔗
<reference value="CarePlan/ex-CarePlan-BirthPlan"/>
</entry>
</section>
<section>
<title value="Social History"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="29762-2"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">active smoker, drinks occasionally, no domestic violence risk, no homlessness, currently working</div>
</text>
<entry>🔗
<reference value="Observation/ex-SocialHistory-smokingTobaccoUse"/>
</entry>
<entry>🔗
<reference value="Observation/ex-SocialHistory-alcoholUse"/>
</entry>
<entry>🔗
<reference value="Observation/ex-DomesticViolenceRisk"/>
</entry>
<entry>🔗
<reference value="Observation/ex-Homelessness"/>
</entry>
<entry>🔗
<reference value="Observation/ex-SocialHistory-EmploymentStatus"/>
</entry>
</section>
<section>
<title value="Advance Directives"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="42348-3"/>
<display value="Advance Directives"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">advance directve present</div>
</text>
<entry>🔗
<reference value="Consent/ex-AdvanceDirectives-BloodTransfusion"/>
</entry>
</section>
<section>
<title value="Payors"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="48768-6"/>
<display value="Payment sources Document"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">payors for coverage</div>
</text>
<entry>🔗
<reference value="Coverage/ex-Coverage"/>
</entry>
</section>
<section>
<title value="Antepartum Education"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="34895-3"/>
<display value="Education Note"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">education on smoking provided to patient in first and second trimesters</div>
</text>
<entry>🔗
<reference value="Observation/ex-PregnancyEducationObservation"/>
</entry>
<entry>🔗
<reference value="Observation/ex-PregnancyEducationObservation"/>
</entry>
</section>
<section>
<title value="Antepartum Visit Summary Flowsheet"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="57059-8"/>
<display value="Pregnancy visit summary note Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">Antepartum visit summary flowsheet documented</div>
</text>
<entry>🔗
<reference value="Observation/ex-VitalSigns-BodyWeight-PrePregnancy"/>
</entry>
<entry>🔗
<reference
value="Observation/ex-AntepartumVisitSummaryFlowsheetBattery"/>
</entry>
</section>
</Composition>
IG © 2021+ IHE Patient Care Coordination Committee. Package ihe.pcc.maps#1.0.0-comment based on FHIR 4.0.1. Generated 2024-06-04
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