Mobile Antepartum Summary
1.0.0-comment - ballot International flag

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

Resource Profile: Antapartum Summary

Official URL: https://profiles.ihe.net/PCC/mAPS/StructureDefinition/IHE.PCC.APS.Composition Version: 1.0.0-comment
Active as of 2024-06-04 Computable Name: IHE_APS_Composition

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.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Composition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
... text S 0..1 Narrative Text summary of the resource, for human interpretation
... identifier S 0..1 Identifier Version-independent identifier for the Composition
... status S 1..1 code preliminary | final | amended | entered-in-error
... type S 1..1 CodeableConcept Kind of composition (LOINC if possible)
.... Slices for coding 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:asummary 1..1 Coding Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 57055-6
... Slices for category S 1..* CodeableConcept Categorization of Composition
Slice: Unordered, Open by pattern:$this
.... category:pstat 1..1 CodeableConcept Categorization of Composition
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 90767-5
... subject S 1..1 Reference(PDQm Patient Profile) Who and/or what the composition is about
... encounter S 0..1 Reference(Encounter) Context of the Composition
... date S 1..1 dateTime Composition editing time
... author S 1..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the composition
... title S 1..1 string Human Readable name/title
Required Pattern: Antepartum Summary
... attester S 0..* BackboneElement Attests to accuracy of composition
.... mode S 1..1 code personal | professional | legal | official
.... time S 0..1 dateTime When the composition was attested
.... party S 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
... custodian S 0..1 Reference(Organization) Organization which maintains the composition
... event S 0..* BackboneElement The clinical service(s) being documented
.... Slices for code 1..* CodeableConcept Code(s) that apply to the event being documented
Slice: Unordered, Open by pattern:$this
..... code:obs 1..1 CodeableConcept Code(s) that apply to the event being documented
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: OBS
... Slices for section 7..* BackboneElement Composition is broken into sections
Slice: Unordered, Open by pattern:code
.... section:All Slices Content/Rules for all slices
..... title S 1..1 string Label for section (e.g. for ToC)
..... code S 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
..... text S 1..1 Narrative Text summary of the section, for human interpretation
.... section:sectionMedications 1..1 BackboneElement Medication Summary Section
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10160-0
..... entry S 0..* Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference | Medication Statement (IPS) | Medication Request (IPS)) Medications relevant for the scope of the patient summary
..... emptyReason S 0..1 CodeableConcept Why the section is empty
.... section:sectionAllergies 1..1 BackboneElement Allergies and Intolerances Section
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48765-2
..... entry S 0..* Reference(AllergyIntolerance | DocumentReference | Allergy Intolerance (IPS)) Relevant allergies or intolerances (conditions) for that patient.
..... emptyReason S 0..1 CodeableConcept Why the section is empty
.... section:sectionProblems 1..1 BackboneElement Problems Section
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11450-4
..... entry S 0..* Reference(Condition | DocumentReference | Condition (IPS)) Clinical problems or conditions currently being monitored for the patient.
..... emptyReason S 0..1 CodeableConcept Why the section is empty
.... section:sectionPastIllnessHx 1..1 BackboneElement History of Past Illness Section
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11348-0
..... entry S 0..* Reference(Condition | DocumentReference | Condition (IPS)) Conditions the patient suffered in the past.
..... emptyReason S 0..1 CodeableConcept Why the section is empty
.... section:sectionSocialHistory 0..1 BackboneElement Social History Section
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29762-2
..... entry S 0..* Reference(Observation | DocumentReference | Observation - SH: tobacco use | Observation - SH: alcohol use | Drug Use | Smoking and Tobacco Use Frequency | alcohol Use | Exercise | Diet | Toxic Exposure | Homelessness | At risk of domestic violence | Combat Zone Period | Employment Status | Past Or Present Job | Retirement Date | Usual Work) Health related 'lifestyle factors' or 'lifestyle observations' (e.g. smoke habits; alcohol consumption; diets, risky habits.)
..... emptyReason S 0..1 CodeableConcept Why the section is empty
.... section:sectionProceduresHx 1..1 BackboneElement History of Procedures Section
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47519-4
..... entry S 0..* Reference(Procedure | DocumentReference | Procedure (IPS)) Patient past procedures pertinent to the scope of this document.
..... emptyReason S 0..1 CodeableConcept Why the section is empty
.... section:sectionPregnancyHx 1..1 BackboneElement History of Pregnancy Section
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10162-6
..... entry S 0..* Reference(Observation | DocumentReference | Observation - Pregnancy: status | Observation - Pregnancy: outcome | Multiple Pregnancy | Gestational Age | Date Of Last Menstral Period | Pregnancy History Observations) Current pregnancy status and, optionally, information about the outcome of earlier pregnancies.
..... emptyReason S 0..1 CodeableConcept Why the section is empty
.... section:sectionPlanOfCare 0..1 BackboneElement Plan of Care Section
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18776-5
..... entry S 0..* Reference(CarePlan | DocumentReference) entry used to represent structured care plans
..... emptyReason S 0..1 CodeableConcept Why the section is empty
.... section:sectionImmunizations 1..1 BackboneElement Immunization Section
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11369-6
..... entry S 0..* Reference(Immunization | DocumentReference | Immunization (IPS)) Patient's immunization status and pertinent history.
..... emptyReason S 0..1 CodeableConcept Why the section is empty
.... section:sectionResults 0..1 BackboneElement Results Section
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 30954-2
..... entry S 0..* Reference(Observation | Observation Results (IPS) | DiagnosticReport | DocumentReference | Antepartum Labs | Antepartum Genetic Screenings) Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient.
..... emptyReason S 0..1 CodeableConcept Why the section is empty
.... section:sectionAdvanceDirectives 0..1 BackboneElement Advance Directives Section
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 42348-3
..... entry 0..* Reference(Consent | DocumentReference) the patient's advance directive.
..... emptyReason S 0..1 CodeableConcept Why the section is empty
.... section:sectionVitalSigns 0..1 BackboneElement Vital Signs Section
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 8716-3
..... entry 0..* Reference(Observation | DocumentReference | Vital Signs Profile) Notable vital signs or physical findings.
..... emptyReason S 0..1 CodeableConcept Why the section is empty
.... section:ChiefComplaint 0..1 BackboneElement Cheif Complaint Section
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10154-3
.... section:FamilyMedicalHistory 0..1 BackboneElement Family Medical History
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10157-6
..... entry 0..* Reference(Observation) A reference to data that supports this section
.... section:ReviewOfSystems 0..1 BackboneElement Review of Systems
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10187-3
..... entry 0..* Reference(Observation | Menstrual Status) A reference to data that supports this section
.... section:HistoryOfInfection 0..1 BackboneElement History of Infection
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 56838-6
..... entry 0..* Reference(Condition) A reference to data that supports this section
.... section:PhysicalExams 0..1 BackboneElement Physical Exams
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29545-1
..... entry 0..* Reference(Observation) A reference to data that supports this section
.... section:AntepartumEducation 0..1 BackboneElement AntepartumEducation
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 34895-3
..... entry 0..* Reference(Procedure | Pregnancy Education Observation | Observation | DocumentReference) A reference to data that supports this section
.... section:Payors 0..1 BackboneElement Payors
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48768-6
..... entry 0..* Reference(Coverage) A reference to data that supports this section
.... section:AntepartumVisitSummaryFlowsheet 0..1 BackboneElement Antepartum Visit Summary Flowsheet
..... code 0..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 57059-8
..... entry 0..* Reference(Observation | Antepartum Visit Summary Flowsheet Battery) A reference to data that supports this section

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron