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. For a full list of available versions, see the Directory of published versions
{
"resourceType" : "Composition",
"id" : "ex-APS-Composition-AmandaAlvarez",
"meta" : {
"profile" : [
🔗 "https://profiles.ihe.net/PCC/mAPS/StructureDefinition/IHE.PCC.APS.Composition"
],
"security" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-ActReason",
"code" : "HTEST"
}
]
},
"text" : {
"status" : "generated",
"div" : "<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>"
},
"status" : "final",
"type" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "57055-6"
}
]
},
"category" : [
{
"coding" : [
{
"system" : "http://loinc.org",
"code" : "90767-5"
}
]
}
],
"subject" : {
🔗 "reference" : "Patient/ex-Patient-AmandaAlvarez"
},
"date" : "2023-01-08T14:30:00+01:00",
"author" : [
{
🔗 "reference" : "Practitioner/ex-Practitioner"
}
],
"title" : "Antepartum Summary",
"confidentiality" : "N",
"attester" : [
{
"mode" : "legal",
"time" : "2023-01-08T14:30:00+01:00",
"party" : {
🔗 "reference" : "Practitioner/ex-Practitioner"
}
},
{
"mode" : "legal",
"time" : "2023-01-08T14:30:00+01:00",
"party" : {
🔗 "reference" : "Organization/ex-Organization-OB"
}
}
],
"custodian" : {
🔗 "reference" : "Organization/ex-Organization-OB"
},
"section" : [
{
"title" : "Medication Summary section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10160-0",
"display" : "History of Medication use Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Active Medications - Amoxicillin</div>"
},
"entry" : [
{
🔗 "reference" : "MedicationStatement/ex-medicationStatement"
}
]
},
{
"title" : "Allergies and Intolerances",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "48765-2",
"display" : "Allergies and adverse reactions Document"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">active allergies - latex and fish</div>"
},
"entry" : [
{
🔗 "reference" : "AllergyIntolerance/ex-Allergy-Latex"
},
{
🔗 "reference" : "AllergyIntolerance/ex-Allergy-Fish"
}
]
},
{
"title" : "Problems",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11450-4",
"display" : "Problem list - Reported"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">active problems - sepsis and gestational diabedies</div>"
},
"entry" : [
{
🔗 "reference" : "Condition/ex-Problem-Sepsis"
},
{
🔗 "reference" : "Condition/ex-Problem-GestationalDiabetes"
}
]
},
{
"title" : "Past Illness History",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11348-0",
"display" : "History of Past illness Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">none found</div>"
},
"emptyReason" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/list-empty-reason",
"code" : "unavailable"
}
]
}
},
{
"title" : "Procedures History",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "47519-4",
"display" : "History of Procedures Document"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">past procedures - Education for smoking provided and Cephallic Version</div>"
},
"entry" : [
{
🔗 "reference" : "Procedure/ex-Procedure-CephalicVersion"
},
{
🔗 "reference" : "Procedure/ex-Procedure-EducationSmoking"
}
]
},
{
"title" : "Pregnancy History",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10162-6",
"display" : "Pregnancies Hx"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">observations for pregnancy history</div>"
},
"entry" : [
{
🔗 "reference" : "Observation/ex-PregnencyStatus-pregnant"
},
{
🔗 "reference" : "Observation/ex-EstimatedDeliveryDate"
},
{
🔗 "reference" : "Observation/ex-GestationalAge"
},
{
🔗 "reference" : "Observation/ex-DateOfLastMenstralPeriod"
},
{
🔗 "reference" : "Observation/ex-DateOfFirstPrenatalVisit"
},
{
🔗 "reference" : "Observation/ex-PregnancyHistory-AmandaAlvarez"
}
]
},
{
"title" : "Immunizations",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11369-6",
"display" : "History of Immunization Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Immunizations - Varicella</div>"
},
"entry" : [
{
🔗 "reference" : "Immunization/ex-Immunization-Vericella"
}
]
},
{
"title" : "Chief Complaint",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10154-3",
"display" : "Chief complaint Narrative - Reported"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Complains of fever and having lack of energy</div>"
}
},
{
"title" : "Results",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "30954-2",
"display" : "Relevant diagnostic tests/laboratory data Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">no abnormal results for labs</div>"
},
"entry" : [
{
🔗 "reference" : "Observation/ex-AntepartumLabs"
},
{
🔗 "reference" : "Observation/ex-Antepartum-Genetic-Screening"
}
]
},
{
"title" : "Vital Signs",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8716-3",
"display" : "Vital signs"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">body weight - 185 lbs , prepregnancy weight - 148 lbs</div>"
},
"entry" : [
{
🔗 "reference" : "Observation/ex-VitalSigns-BodyWeight"
}
]
},
{
"title" : "Review Of Systems",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10187-3",
"display" : "Review of systems Narrative - Reported"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">last menstral period</div>"
},
"entry" : [
{
🔗 "reference" : "Observation/ex-MenstralStatus-Pregnancy"
}
]
},
{
"title" : "Physical Exams",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29545-1",
"display" : "Physical findings Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">abdominal tenderness</div>"
},
"entry" : [
{
🔗 "reference" : "Observation/ex-PhysicalExam-AbdominalTenderness"
}
]
},
{
"title" : "History Of Infection",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "56838-6",
"display" : "History of Infectious disease Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">history of clamidia infection</div>"
},
"entry" : [
{
🔗 "reference" : "Condition/ex-HistoryOfInfection"
}
]
},
{
"title" : "Plan Of Care",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "18776-5",
"display" : "Plan of care note"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Birth Plan</div>"
},
"entry" : [
{
🔗 "reference" : "CarePlan/ex-CarePlan-BirthPlan"
}
]
},
{
"title" : "Social History",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29762-2"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">active smoker, drinks occasionally, no domestic violence risk, no homlessness, currently working</div>"
},
"entry" : [
{
🔗 "reference" : "Observation/ex-SocialHistory-smokingTobaccoUse"
},
{
🔗 "reference" : "Observation/ex-SocialHistory-alcoholUse"
},
{
🔗 "reference" : "Observation/ex-DomesticViolenceRisk"
},
{
🔗 "reference" : "Observation/ex-Homelessness"
},
{
🔗 "reference" : "Observation/ex-SocialHistory-EmploymentStatus"
}
]
},
{
"title" : "Advance Directives",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "42348-3",
"display" : "Advance Directives"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">advance directve present</div>"
},
"entry" : [
{
🔗 "reference" : "Consent/ex-AdvanceDirectives-BloodTransfusion"
}
]
},
{
"title" : "Payors",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "48768-6",
"display" : "Payment sources Document"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">payors for coverage</div>"
},
"entry" : [
{
🔗 "reference" : "Coverage/ex-Coverage"
}
]
},
{
"title" : "Antepartum Education",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "34895-3",
"display" : "Education Note"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">education on smoking provided to patient in first and second trimesters</div>"
},
"entry" : [
{
🔗 "reference" : "Observation/ex-PregnancyEducationObservation"
},
{
🔗 "reference" : "Observation/ex-PregnancyEducationObservation"
}
]
},
{
"title" : "Antepartum Visit Summary Flowsheet",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "57059-8",
"display" : "Pregnancy visit summary note Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Antepartum visit summary flowsheet documented</div>"
},
"entry" : [
{
🔗 "reference" : "Observation/ex-VitalSigns-BodyWeight-PrePregnancy"
},
{
🔗 "reference" : "Observation/ex-AntepartumVisitSummaryFlowsheetBattery"
}
]
}
]
}
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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