Pregnancy with Week Gestation

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Approval Status

Approval Status: Pending

Example Task Force: 9/17/2020

SDWG:

Templates

C-CDA 2.1 Example: 2.16.840.1.113883.10.20.22.2.6.1:2015-08-01

Problem Section: 2.16.840.1.113883.10.20.22.2.5.1:2015-08-01

Problem Act: 2.16.840.1.113883.10.20.22.4.3:2015-08-01

Problem Observation: 2.16.840.1.113883.10.20.22.4.4:2015-08-01

Estimated Date of Delivery: 2.16.840.1.113883.10.20.15.3.1

Validation location:

https://site.healthit.gov/sandbox-ccda/ccda-validator

Reference to full CDA sample: https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/C-CDAR2.1/PregnancyinfullC-CDA2.1.xml

Comments

This is an example of a patient pregnancy in problem list with information about estimateed delivery date. This is an alternative place to document and share pregancy informatoin in addition to social history and detailed pregnancy sections (see HL7 IG for more on pregancy status here: http://www.hl7.org/implement/standards/productbrief.cfm?productid=494)

Custodian

John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)

Keywords

problem, pregancy, estimated delivery date

 

Example: download example view on GitHub

<section>
	<!-- This is an example of patient pregancy documented in problem list -->
	<!-- This information may also be recorded in other sections (e.g. Social History or Pregancy Section) -->
  <!-- This is meant to represent high level information related to a pregnancy, not detailed OB/GYN information -->
	<!-- Other sections may include much more detail, such as dates of prior births, fetal plurality, etc. -->
	<!-- For pregnancy section, refer to IG related to Pregancy Status http://www.hl7.org/implement/standards/product_brief.cfm?product_id=494 -->
	<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
	<templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/>
	<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" displayName="Problem List"/>
	<title>Problem List</title>
	<text>
		<table>
			<thead>
				<tr>
					<th>Description</th>
					<th>Dates</th>
					<th>Status</th>
					<th>Additional Detail</th>
				</tr>
			</thead>
			<tbody>
				<tr ID="Problem1">
					<td ID="ProblemDescription1">Pregnancy</td>
					<td>
						<content>Estimated Conception: Jan 3 2020</content>
					</td>
					<td>Active</td>
					<td>Estimated Due Date: Sep 19 2020</td>
				</tr>
			</tbody>
		</table>
	</text>
	<entry>
		<act classCode="ACT" moodCode="EVN">
			<templateId root="2.16.840.1.113883.10.20.22.4.3"/>
			<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01"/>
			<id root="102ca2e9-884c-4523-a2b4-1b6c3469c397"/>
			<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
			<statusCode code="active"/>
			<effectiveTime>
				<!-- This equates to the date of when first documented (not date of conception) -->
				<low value="20200310"/>
			</effectiveTime>
			<entryRelationship typeCode="SUBJ">
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
					<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
					<id extension="10241104348" root="1.3.6.1.4.1.22812.4.111.0.4.1.2.1"/>
					<!-- Note a problem cannot be compliant to pregnancy observation template since code@code different SHALL -->
					<code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
						<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem"/>
					</code>
					<text>
						<reference value="#Problem1"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime>
						<!-- This represents the date of biological onset, which for pregnancy would be estimated conception date -->
						<low value="20200103"/>
					</effectiveTime>
					<!-- This is a SNOMED code as the primary vocabulary for problem lists-->
					<!-- This SNOMED aligns with pregancy observation value set: 2.16.840.1.113762.1.4.1099.24 -->
					<value xsi:type="CD" code="77386006" displayName="pregnant" codeSystem="2.16.840.1.113883.6.96">
						<originalText>
							<reference value="#problem00001"/>
						</originalText>
						<!-- These translation codes provide additional specificity, may be useful in tracking time and billing -->
						<translation code="38039008" displayName="Gestation period, 10 weeks" codeSystem="2.16.840.1.113883.6.96"/>
						<translation code="Z3A.10" displayName="10 weeks gestation of pregnancy" codeSystem="2.16.840.1.113883.6.90"/>
					</value>
					<author>
						<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
						<!-- This equates to the date when last updated by the author-->
						<time value="201903101256-0500"/>
						<assignedAuthor>
							<id extension="66666" root="2.16.840.1.113883.4.6"/>
							<code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Cardiovascular Disease"/>
							<addr>
								<streetAddressLine>6666 StreetName St.</streetAddressLine>
								<city>Silver Spring</city>
								<state>MD</state>
								<postalCode>20901</postalCode>
								<country>US</country>
							</addr>
							<telecom value="tel:+1(301)666-6666" use="WP"/>
							<assignedPerson>
								<name>
									<given>Heartly</given>
									<family>Sixer</family>
									<suffix>MD</suffix>
								</name>
							</assignedPerson>
						</assignedAuthor>
					</author>
					<!-- This is not required but the estimated time of delivery can be shared through structured entryRelationship-->
					<entryRelationship typeCode="REFR">
						<observation classCode="OBS" moodCode="EVN">
							<!-- Template for Estimated Date of Delivery -->
							<templateId root="2.16.840.1.113883.10.20.15.3.1"/>
							<code code="11778-8" codeSystem="2.16.840.1.113883.6.1" displayName="Estimated date of delivery"/>
							<text>
								<reference value="#Problem1Detail"/>
							</text>
							<statusCode code="completed"/>
							<value xsi:type="TS" value="20200919"/>
						</observation>
					</entryRelationship>
				</observation>
			</entryRelationship>
		</act>
	</entry>
</section>
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