Example of the consent resource in the deffined method that IHE uses to deffine advance directives. modified from IHE advance directives Observation.

Albumin Presence In Urine observation

Glucose Presence in Urine observation

Glucose Presence in Urine observation

Annotation Comment observation

Antepartum Summary is a content profile that defines the structure for the aggregation of significant events, diagnoses, and plans of care derived from the visits over the course of an antepartum episode. It is represented in part by Estimated Due Dates and a Visit Summary Flowsheet, in which the aggregated data from the ambulatory office visits is recorded, as well as allergies, advance directives, care plans, and selected histories are provided. The Antepartum Summary represents a summary of the most critical information to an antepartum care provider regarding the status of a patient’s pregnancy.

Antepartum Genetic Screening lab results

The Lab report results for the antepartum Labs.

The battery is made of several component simple observations. The following table lists the allowable LOINC codes, displayNames, and observation types, and unit of measures for these observations.

At increased risk of domestic partner abuse.

Total number of children still living at time this record is generated.

Total number of children whose birth occurred after the beginning of the first day (259th day) of the 38th week following onset of the last menstrual period.

Body Weight Measured before the current pregnancy

Cervical Canal External os Diameter by ultrasound

Cervix Length measured by ultrasound

Date Of First Prenatal Visit The date a physician or other health care professional first examined and/or counseled the pregnant woman for the pregnancy.

The date of birth of the last live-born infant.

The date the mother’s last normal menstrual period began.

The date (year) that the last pregnancy that did not result in a live birth ended. Includes pregnancy losses at any gestation age. Examples: spontaneous or induced losses or ectopic pregnancy.

Date of Next Clinic Visit observation

The final number of weeks should be available in the OB admission H&P as the first source. The final number of weeks may also be obtained from the PNC records as a secondary source if the information is not available in the OB admissions H&P

The estimated delivery date as determined based on the reported first day of the last menstrual period (LMP), typically estimated as 280 days after the first day of the LMP.

The estimated delivery date as determined based on the reported ovulation date.

Increased chance of harm during the period supporting the expulsion of an offspring/child.

The customary amount and kind of food and drink taken by a person from day to day.

Use of illegal drugs or prescription medications for non-medical purposes.

Number of days typical for the patient’s menstrual flow

Edema observation

Effacement observation of Cervix by Palpitation

Frequency of Physical Activity (days per week) and duration of physical activity (in minutes per day).

The estimated weight of the fetus observation performed using palpation

The estimated weight of the fetus observation performed using an ultrasound

Fetal Heart rate determined by Auscultation

Fetal Heart rate determined by ultrasound

Fetal Movement Reported

Fetal Presentation determined by ultrasound

Fetal Presentation determined by palpation

The age of the conceptus, beginning from the time of fertilization. In clinical obstetrics, the gestational age is often estimated as the time from the last day of the last menstruation which is about 2 weeks before ovulation and fertilization.

The final number of weeks should be available in the OB admission H&P as the first source. The final number of weeks may also be obtained from the PNC records as a secondary source if the information is not available in the OB admissions H&P

The final number of weeks should be available in the OB admission H&P as the first source. The final number of weeks may also be obtained from the PNC records as a secondary source if the information is not available in the OB admissions H&P

The estimated delivery date as determined based on the reported ovulation date.

Number of days between menstrual cycle periods.

Gestational age in weeks.

The state of having no home or permanent place of residence.

Increased chance of harm during the period supporting the bringing forth of an offspring/child.

The patient age at the first occurrence of menstruation.

Regularity of menstrual cycle

MenstrualStatus Reported.

To document multiple pregnancy.

Other pregnancy outcomes # Includes perinatal death, small for gestational age/intrauterine growth restricted birth. History of pregnancies continuing into the 20th week of gestation and resulting in any of the listed outcomes. Perinatal death includes fetal and neonatal deaths.

Do not include visits for laboratory and other testing in which a physician or health care professional did not examine or counsel the pregnant woman Access the most recent prenatal records available. If up-to-date records are not available, contact the prenatal care provider for the most current information. Count the prenatal visits recorded in the record. Exclude visits for laboratory and other tests or classes in which the mother was not seen by a physician or other health care professional for pregnancy-related care. If it is not clear whether the mother was seen by a physician or other health care professional, include the visit(s) in the total number.

Previous delivery by extracting the fetus, placenta, and membranes through an incision in the mother’s abdominal and uterine walls.

Previous delivery by extracting the fetus, placenta, and membranes through an incision in the mother’s abdominal and uterine walls.

Number of pregnancies terminated before 20 weeks of gestation calculated from the date of onset of last menses [or equivalent date estimated from ultrasound or other measurement or from data derived from assisted fertilization procedure].

Number of intentional medical or surgical terminations of pregnancies before 20 weeks of gestation. [Includes elective and therapeutic terminations.

Number of unintentional terminations of pregnancies before 20 weeks of gestation. [Excludes induced terminations].

Number of Ectopic Pregnancies

Total number of live births. [Complete expulsion or extraction from the mother if a product of human conception, irrespective of duration of pregnancy, which, after expulsion or extraction, breathes or shows any other evidence of life such as heart beat.

Total number of times the patient has been pregnant including the present pregnancy.

Total number of children whose birth occurred through the end of the last day of the 37th week (259th day) following onset of the last menstrual period.

Number of Stillborn Births

Total number of births including abortions, stillbirths and live births. [Note: Because of multiple gestation this number may be greater than the number of abortions plus parity, the number of times the uterus is emptied of a viable pregnancy.

Pain Severity Reported observation

Any education provided to a patient relating to their pregnancy or birth plan (e.g. pregnancy risks from tobacco use, breastfeeding)

The pregnancy history collects observations relevant to a single pregnancy within the patient’s history. The organizer for a pregnancy event shall either contain subordinate birth event organizers for each birth event associated with the pregnancy or shall conform to the birth event organizer template, but not both.

Preterm labor symptoms

The date of the last menstral period

The frequency of tobacco use. This may be measured in packs/day, packs/week, or packs/year.

Whether the patient has been exposed to a toxic substance.

Distance from the top of the symphysis pubis to the palpable superior border of the uterine fundus

Alcoholic drinks per day

Positive pregnancy test as determined by the presence of Human Chorionic Gonadotropin (hCG)

This value set lists the interventions that the patient may choose to accept or decline in their advance directives.

This value set lists the frequency metrics to express the frequency of alcohol use (e.g. drinks per day, drinks per week).

This value set identifies the types of pregnancy-related education that may be delivered to the patient.

This value set includes the type of genetic-related risks identified through screening of the patient’s and biological father’s family history.

This value set identifies the infections that may result in risk to the pregnancy or otherwise inform the birth plan.

This value set identifies conditions that may impact the pregnancy care and monitoring decisions.

This value set identifies the laboratory tests that may be ordered and monitored during pregnancy.

Antepartum Review of Systems Menstrual History This value set identifies the menstrual-history related observations that may inform the pregnancy care.

This value set lists the expected values for the Edema observation.

This value set lists the expected values for the Fetal Movement observation.

This value set lists the expected values for the Fetal Presentation observation.

This value set lists the expected values for the Presence In Urine observation.

This value set identifies whether the patient is a smoker (everyday smoker or some day smoker) or whether the patient was a previous smoker.

This value set identifies the frequency of tobacco use in packs/day, packs/week, or packs/year.

Amanda Alvarez patient father example for antepartum summary

Amanda Alvarez patient example for antepartum summary

The Example instance for the Antepartum Summary composition for example patient Amanda Alvarez

Diagnostic Report Example for Gestational Diabetes

Diagnostic Report Example for Sepsis

Example for Employment status

Encounter Example for Antepartum Summary

Estimated Delivery Date

Example Amanda Alvarez documents what an example compositoin for an Antepartum Summary should look like as well as what observations should be included within the composition.

Example Family history condition - colon cancer

History Of Infection example

Menstrual Status example for a pregnant patient

Physical Exam Abdominal tenderness example

Pregnancy Estimated Due date example

The Example instance for the PregnancyHistory observation

Example for Pregnency Status where patient is pregnant

Social History alcohol Use example

Example for Social History - smoking Tobacco Use

Example for Social History - smoking Tobacco Use

Example for vital signs - body weight

Example for vital signs - body weight

Example appointment 1 for the ex-birthpan element.

Example appointment 2 for the ex-birthpan element.

Example appointment 3 for the ex-birthpan element.

The Example instance for the IHE Advance Directives resource for blood transfuaion

The Example instance for the Albumin Presence In Urine observation

The Example instance for the AlcoholUseFrequency observation

The Example instance for the Allergy Intolerance - fish

The Example instance for the Allergy Intolerance - Latex

The Example instance for the Annotation Comment observation

The Example instance for Antepartum Genetic Screening lab results

The Example instance for Antepartum Lab results

The Example instance for the AntepartumVisitSummaryFlowsheetBattery

The Example instance for the BodyWeightMeasuredPrePregnancy observation

Example birth plan for ex composition.

The Example instance for the Cervical Canal External os Diameter Ultrasound observation

The Example instance for the Cervical Canal External os Diameter Ultrasound observation

Example coverage for ex composition.

Example organization for ex composition.

The Example instance for the Date of Next Clinic Visit observation

The Example instance for the DateOfFirstPrenatalVisit observation

The Example instance for the DateOfFirstPrenatalVisit observation

The Example instance for the DateOfLastLiveBirth observation

The Example instance for the DateOfLastLiveBirth observation

The Example instance for the DateOfLastMenstralPeriod observation

The Example instance for the DateOfLastOtherPregnancyOutcome observation

The Example instance for the DeliveryDateClinicalEstimate observation

The Example instance for the DeliveryDateEstimatedFromLMP observation

The Example instance for the DeliveryDateEstimatedFromOvulationDate observation

The Example instance for the DeliveryRisk observation

The Example instance for the Diet observation

The Example instance for the DomesticViolenceRisk observation

The Example instance for the DrugUse observation

The Example instance for the DurationOfMenstrualFlow observation

The Example instance for the Edema observation

The Example instance for the Cervical Canal External os Diameter Ultrasound observation

The Example instance for the Exercise observation

The Example instance for the Fetal Body Weight Palpation observation

The Example instance for the Fetal Body Weight ultrasound observation

The Example instance for the Fetal Heart Rate by Ultrasound observation

The Example instance for the Fetal Heart Rate by Ultrasound observation

The Example instance for the Fetal Movement Reported observation

The Example instance for the Fetal Presentation Palpitation observation

The Example instance for the Fetal Presentation Palpitation observation

The Example instance for the FetusGestationalAge observation

The Example instance for the FetusGestationalAgeClinicalEstimate observation

The Example instance for the FetusGestationalAgeEstimatedFromLMP observation

The Example instance for the FetusGestationalAgeEstimatedFromOvulationDate observation

The Example instance for the FrequencyOfMenstrualCycles observation

The Example instance for the GestationalAge observation

The Example instance for the glucose Presence In Urine observation

The Example instance for the glucose Presence In Urine observation

The Example instance for the HCGPlus observation

The Example instance for the HCGPlus observation

The Example instance for the Homelessness observation

The Example instance for an immunizaiton - Vericella

The Example instance for the LaborRisk observation

The Example instance for the Menarche observation

The Example instance for the MensesMonthly observation

The Example instance for the MenstrualStatus observation

The Example instance for the MultiplePregnancy observation

The Example instance for the NumberOfAbortions observation

The Example instance for the NumberOfAbortionsInduced observation

The Example instance for the NumberOfAbortionsSpontanious observation

The Example instance for the NumberOfBirthsStillLiving observation

The Example instance for the NumberOfBirthsToTerm observation

The Example instance for the NumberOfEctopicPregnancies observation

The Example instance for the NumberOfLiveBirths observation

The Example instance for the NumberOfOtherPregnancyOutcomes observation

The Example instance for the NumberOfPregnancies observation

The Example instance for the NumberOfPrenatalVisitsForThisPregnancy observation

The Example instance for the NumberOfPretermBirths observation

The Example instance for the NumberOfPreviousCesareanDeliveries observation

The Example instance for the NumberOfPreviousLiveBirthsNowDead observation

The Example instance for the NumberOfStillbornBirths observation

The Example instance for the NumberOfTotalBirths observation

The Example instance for the Pain Severity Reported observation

The Example instance for the PregnancyEducationObservation

The Example instance for the PregnancyHistory observation

The Example instance for the Fetal Movement Reported observation

The Example instance for the PriorMensesDate observation

The Example instance for the Problems - Gestational diabetes

The Example instance for the Problems - bacterial sepsis

The Example instance for the procedure - Cephalic Version

The Example instance for the procedure - Education Smoking

The Example instance for the Service Request for the Education Smoking procedure

The Example instance for the SmokingTobaccoUseFrequency observation

The Example instance for the ToxicExposure observation

The Example instance for the Uterus Fundal Height observation

The Example instance for the bloodpressure observation amanda alvarez

Example care team for the ex-birthpan element.

Example goal for the ex-birthpan element.

The Example instance for the Medication Statement

OBGYN Organization example for antepartum summary

Practitioner example for antepartum summary

Example condition for the ex-birthpan element.

Example practitioner 2 for the ex-birthpan care team

Example practitioner 2 for the ex-birthpan care team.