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

Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

Structures: Resource Profiles

These define constraints on FHIR resources for systems conforming to this implementation guide.

Advance Directives

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

Albumin Presence In Urine observation

Albumin Presence In Urine

Glucose Presence in Urine observation

Albumin Presence In Urine test by strip

Glucose Presence in Urine observation

Annotation Comment observation

Annotation Comment observation

Antapartum Summary

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 Screenings

Antepartum Genetic Screening lab results

Antepartum Labs

The Lab report results for the antepartum Labs.

Antepartum Visit Summary Flowsheet Battery

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 risk of domestic violence

At increased risk of domestic partner abuse.

Births Still Living

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

Births to Term

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 Pre Pregnancy

Body Weight Measured before the current pregnancy

Cervical Canal External os Diameter by ultrasound

Cervical Canal External os Diameter by ultrasound

Cervix Length by ultrasound

Cervix Length measured by ultrasound

Date Of First Prenatal Visit

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.

Date Of Last Live Birth

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

Date Of Last Menstral Period

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

Date Of Last Other Pregnancy Outcome

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

Date of Next Clinic Visit observation

Delivery Date Clinical Estimate

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

Delivery Date Clinical Estimated From Last Menstral Period

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.

Delivery Date Clinical Estimated From Ovulation Date

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

Delivery Risk

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

Diet

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

Drug Use

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

Duration of Menstrual Flow

Number of days typical for the patient’s menstrual flow

Edema observation

Edema observation

Effacement Cervix by Palpitation

Effacement observation of Cervix by Palpitation

Exercise

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

Fetal Body Weight palpation

The estimated weight of the fetus observation performed using palpation

Fetal Body Weight ultrasoud

The estimated weight of the fetus observation performed using an ultrasound

Fetal Heart Rate Auscultation

Fetal Heart rate determined by Auscultation

Fetal Heart Rate Ultrasound

Fetal Heart rate determined by ultrasound

Fetal Movement Reported

Fetal Movement Reported

Fetal Presentation Ultrasound

Fetal Presentation determined by ultrasound

Fetal Presentation palpation

Fetal Presentation determined by palpation

Fetus Gestational Age

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.

Fetus Gestational Age Clinical Estimate

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

Fetus Gestational Age Estimated From LMP

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

Fetus Gestational Age Estimated From Ovulation Date

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

Frequency of Menstrual Cycles

Number of days between menstrual cycle periods.

Gestational Age

Gestational age in weeks.

Homelessness

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

Labor Risk

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

Menarche

The patient age at the first occurrence of menstruation.

Menses Monthly

Regularity of menstrual cycle

Menstrual Status

MenstrualStatus Reported.

Multiple Pregnancy

To document multiple pregnancy.

Number Of Other Pregnancy Outcomes

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.

Number Of Prenatal Visits For This Pregnancy

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.

Number Of Previous Cesarean Deliveries

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

Number Of Previous Live Births Now Dead

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

Number of Abortions

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 Abortions Induced

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

Number of Abortions Spontanious

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

Number of Ectopic Pregnancy

Number of Ectopic Pregnancies

Number of Live Births

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.

Number of Pregnancies

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

Number of Preterm Births

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

Number of Stillborn Births

Number of Total 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

Pain Severity Reported observation

Pregnancy Education Observation

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

Pregnancy History Observations

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

Preterm labor symptoms

Prior Menses Date

The date of the last menstral period

Smoking and Tobacco Use Frequency

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

Toxic Exposure

Whether the patient has been exposed to a toxic substance.

Uterus Fundal Height

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

alcohol Use

Alcoholic drinks per day

hCG+

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

Terminology: Value Sets

These define sets of codes used by systems conforming to this implementation guide.

Advance Directives

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

Alcohol USe Frequency

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

Antepartum Education

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

Antepartum Family History and Genetic Screening

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

Antepartum History of Infection

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

Antepartum History of Past Illness

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

Antepartum Laboratory

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

Antepartum Review of Systems Menstrual History

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

Edema observation

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

Fetal Movement

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

Fetal Presentation

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

Presence In Urine

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

Smoking Status

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

Smoking Tabbacco Use Frequency

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

Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like.

Amanda Alvarez Father example

Amanda Alvarez patient father example for antepartum summary

Amanda Alvarez example

Amanda Alvarez patient example for antepartum summary

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 Gestational Diabetes

Diagnostic Report Example for Sepsis

Diagnostic Report Example for Sepsis

Employment Status example

Example for Employment status

Encounter Example for APS

Encounter Example for Antepartum Summary

Estimated Delivery Date example

Estimated Delivery Date

Example Amanda Alvarez

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

Example Family history condition - colon cancer

History Of Infection example

History Of Infection example

Menstrual Status example

Menstrual Status example for a pregnant patient

Physical Exam Abdominal tenderness example

Physical Exam Abdominal tenderness example

Pregnancy Estimated Due date example

Pregnancy Estimated Due date example

Pregnancy History observation example

The Example instance for the PregnancyHistory observation

Pregnency Status - pregnant example

Example for Pregnency Status where patient is pregnant

Social History alcohol Use example

Social History alcohol Use example

Social History smoking Tobacco Use example

Example for Social History - smoking Tobacco Use

Social History smoking Tobacco Use example

Example for Social History - smoking Tobacco Use

Vital Signs Body Weight example

Example for vital signs - body weight

Vital Signs Body Weight example

Example for vital signs - body weight

activity-1

Example appointment 1 for the ex-birthpan element.

activity-2

Example appointment 2 for the ex-birthpan element.

activity-3

Example appointment 3 for the ex-birthpan element.

ex-AdvanceDirectives-BloodTransfusion

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

ex-AlbuminPresenceInUrine

The Example instance for the Albumin Presence In Urine observation

ex-AlcoholUseFrequency

The Example instance for the AlcoholUseFrequency observation

ex-Allergy-Fish

The Example instance for the Allergy Intolerance - fish

ex-Allergy-Latex

The Example instance for the Allergy Intolerance - Latex

ex-AnnotationComment

The Example instance for the Annotation Comment observation

ex-Antepartum-Genetic-Screening

The Example instance for Antepartum Genetic Screening lab results

ex-AntepartumLabs

The Example instance for Antepartum Lab results

ex-AntepartumVisitSummaryFlowsheetBattery

The Example instance for the AntepartumVisitSummaryFlowsheetBattery

ex-BodyWeightMeasuredPrePregnancy

The Example instance for the BodyWeightMeasuredPrePregnancy observation

ex-CarePlan-BirthPlan

Example birth plan for ex composition.

ex-CervicalCanalExternalosDiameterUltrasound

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

ex-CervixLengthUltrasound

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

ex-Coverage

Example coverage for ex composition.

ex-Coverage-Organization

Example organization for ex composition.

ex-DateNextClinicVisit

The Example instance for the Date of Next Clinic Visit observation

ex-DateOfFirstPrenatalVisit

The Example instance for the DateOfFirstPrenatalVisit observation

ex-DateOfFirstPrenatalVisit-AmandaAlvarez

The Example instance for the DateOfFirstPrenatalVisit observation

ex-DateOfLastLiveBirth

The Example instance for the DateOfLastLiveBirth observation

ex-DateOfLastLiveBirth-AmandaAlvarez

The Example instance for the DateOfLastLiveBirth observation

ex-DateOfLastMenstralPeriod

The Example instance for the DateOfLastMenstralPeriod observation

ex-DateOfLastOtherPregnancyOutcome

The Example instance for the DateOfLastOtherPregnancyOutcome observation

ex-DeliveryDateClinicalEstimate

The Example instance for the DeliveryDateClinicalEstimate observation

ex-DeliveryDateEstimatedFromLMP

The Example instance for the DeliveryDateEstimatedFromLMP observation

ex-DeliveryDateEstimatedFromOvulationDate

The Example instance for the DeliveryDateEstimatedFromOvulationDate observation

ex-DeliveryRisk

The Example instance for the DeliveryRisk observation

ex-Diet

The Example instance for the Diet observation

ex-DomesticViolenceRisk

The Example instance for the DomesticViolenceRisk observation

ex-DrugUse

The Example instance for the DrugUse observation

ex-DurationOfMenstrualFlow

The Example instance for the DurationOfMenstrualFlow observation

ex-Edema

The Example instance for the Edema observation

ex-EffacementCervixPalpitation

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

ex-Exercise

The Example instance for the Exercise observation

ex-FetalBodyWeightPalpation

The Example instance for the Fetal Body Weight Palpation observation

ex-FetalBodyWeightUltrasound

The Example instance for the Fetal Body Weight ultrasound observation

ex-FetalHeartRateAuscultation

The Example instance for the Fetal Heart Rate by Ultrasound observation

ex-FetalHeartRateUltrasound

The Example instance for the Fetal Heart Rate by Ultrasound observation

ex-FetalMovementReported

The Example instance for the Fetal Movement Reported observation

ex-FetalPresentationPalpitation

The Example instance for the Fetal Presentation Palpitation observation

ex-FetalPresentationUltrasound

The Example instance for the Fetal Presentation Palpitation observation

ex-FetusGestationalAge

The Example instance for the FetusGestationalAge observation

ex-FetusGestationalAgeClinicalEstimate

The Example instance for the FetusGestationalAgeClinicalEstimate observation

ex-FetusGestationalAgeEstimatedFromLMP

The Example instance for the FetusGestationalAgeEstimatedFromLMP observation

ex-FetusGestationalAgeEstimatedFromOvulationDate

The Example instance for the FetusGestationalAgeEstimatedFromOvulationDate observation

ex-FrequencyOfMenstrualCycles

The Example instance for the FrequencyOfMenstrualCycles observation

ex-GestationalAge

The Example instance for the GestationalAge observation

ex-GlucosePresenceinUrine

The Example instance for the glucose Presence In Urine observation

ex-GlucosePresenceinUrineTestStrip

The Example instance for the glucose Presence In Urine observation

ex-HCGPositive

The Example instance for the HCGPlus observation

ex-HCGPositive-Positive

The Example instance for the HCGPlus observation

ex-Homelessness

The Example instance for the Homelessness observation

ex-Immunization-Vericella

The Example instance for an immunizaiton - Vericella

ex-LaborRisk

The Example instance for the LaborRisk observation

ex-Menarche

The Example instance for the Menarche observation

ex-MensesMonthly

The Example instance for the MensesMonthly observation

ex-MenstrualStatus

The Example instance for the MenstrualStatus observation

ex-MultiplePregnancy

The Example instance for the MultiplePregnancy observation

ex-NumberOfAbortions

The Example instance for the NumberOfAbortions observation

ex-NumberOfAbortionsInduced

The Example instance for the NumberOfAbortionsInduced observation

ex-NumberOfAbortionsSpontanious

The Example instance for the NumberOfAbortionsSpontanious observation

ex-NumberOfBirthsStillLiving

The Example instance for the NumberOfBirthsStillLiving observation

ex-NumberOfBirthsToTerm

The Example instance for the NumberOfBirthsToTerm observation

ex-NumberOfEctopicPregnancies

The Example instance for the NumberOfEctopicPregnancies observation

ex-NumberOfLiveBirths

The Example instance for the NumberOfLiveBirths observation

ex-NumberOfOtherPregnancyOutcomes

The Example instance for the NumberOfOtherPregnancyOutcomes observation

ex-NumberOfPregnancies

The Example instance for the NumberOfPregnancies observation

ex-NumberOfPrenatalVisitsForThisPregnancy

The Example instance for the NumberOfPrenatalVisitsForThisPregnancy observation

ex-NumberOfPretermBirths

The Example instance for the NumberOfPretermBirths observation

ex-NumberOfPreviousCesareanDeliveries

The Example instance for the NumberOfPreviousCesareanDeliveries observation

ex-NumberOfPreviousLiveBirthsNowDead

The Example instance for the NumberOfPreviousLiveBirthsNowDead observation

ex-NumberOfStillbornBirths

The Example instance for the NumberOfStillbornBirths observation

ex-NumberOfTotalBirths

The Example instance for the NumberOfTotalBirths observation

ex-PainSeverityReported

The Example instance for the Pain Severity Reported observation

ex-PregnancyEducationObservation

The Example instance for the PregnancyEducationObservation

ex-PregnancyHistory

The Example instance for the PregnancyHistory observation

ex-PretermLaborSymptoms

The Example instance for the Fetal Movement Reported observation

ex-PriorMensesDate

The Example instance for the PriorMensesDate observation

ex-Problem-GestationalDiabetes

The Example instance for the Problems - Gestational diabetes

ex-Problem-Sepsis

The Example instance for the Problems - bacterial sepsis

ex-Procedure-CephalicVersion

The Example instance for the procedure - Cephalic Version

ex-Procedure-EducationSmoking

The Example instance for the procedure - Education Smoking

ex-ServiceRequest-EducationSmoking

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

ex-SmokingTobaccoUseFrequency

The Example instance for the SmokingTobaccoUseFrequency observation

ex-ToxicExposure

The Example instance for the ToxicExposure observation

ex-UterusFundalHeight

The Example instance for the Uterus Fundal Height observation

ex-bloodpressure-amanda-alvarez

The Example instance for the bloodpressure observation amanda alvarez

ex-careteam

Example care team for the ex-birthpan element.

ex-goal

Example goal for the ex-birthpan element.

ex-medicationStatement

The Example instance for the Medication Statement

mAPS Organization example

OBGYN Organization example for antepartum summary

mAPS Practitioner example

Practitioner example for antepartum summary

p1

Example condition for the ex-birthpan element.

pr1

Example practitioner 2 for the ex-birthpan care team

pr2

Example practitioner 2 for the ex-birthpan care team.