ARCHETYPE Obstetric summary (openEHR-EHR-EVALUATION.obstetric_summary.v1)

Name: Obstetric summary
License: http://creativecommons.org/licenses/by-sa/4.0/

ARCHETYPE ID	openEHR-EHR-EVALUATION.obstetric_summary.v1
Concept	Obstetric summary
Description	Summary or persistent information about the numbers of key obstetric events.
Use	Use to record summary or persistent information about the numbers of key obstetric events that may impact risk assessment or decision support. Data recorded using this archetype is intended to be revised and updated after each pregnancy, either manually by a clinician or automatically calculated within a clinical system. It is anticipated that this archetype represents only one component of an obstetric history. A complete obstetric history should be represented using multiple archetypes within a template. In order to record a TPAL overview, Term Births (T), Preterm Births (P) and Abortions (A) can be recorded using this archetype. Living Children (L) can be recorded using the EVALUATION.social_network archetype, so that it can be used more broadly. Some variants may also use Gravidity (G) and the number of Multiple Births (M). In many jurisdictions, the definition of some of these data elements may vary. For this reason, definitions may be included in the Protocol to ensure clarity of intent especially if the data is being exchanged between jurisdictions.
Misuse	Not for recording summary information about a single pregnancy. Use specific archetypes for this purpose. Not to be used to record details about procedures performed during a pregnancy, for example terminations or deliveries. Use the ACTION.procedure archetype for this purpose. Not to be used to record the details about findings in each antenatal visits or during labour. Detailed data should be recorded using appropriate archetypes for this purpose such as OBSERVATION.story together with CLUSTER.symptom_sign; OBSERVATION.blood pressure; OBSERVATION.urinalysis; or EVALUATION.problem_diagnosis.
Purpose	To record summary or persistent information about the numbers of key obstetric events that may impact risk assessment or decision support.
References	Born Too Soon: The Global Action Report on Preterm Birth [Internet]. Geneva: World Health Organization; 2012. Available from: https://www.who.int/maternal_child_adolescent/documents/born_too_soon/en/. Derived from: Obstetric summary, draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. No longer available. Fact sheet: Preterm birth [Internet]. Geneva: World Health Organisation. Preterm birth; 2018 Feb 19 [cited 2020 May 07]. Available from: https://www.who.int/news-room/fact-sheets/detail/preterm-birth. Opara EI, Zaidi J. The interpretation and clinical application of the word 'parity': a survey [Internet]. BJOG. 2007 Oct;114(10):1295-7. doi: 10.1111/j.1471-0528.2007.01435.x. PMID: 17877683. Available from: https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/j.1471-0528.2007.01435.x. reVITALize: Obstetrics Data Definitions V1.0 [Internet]. Washington, American College of Obstetricians and Gynecologists; 2014 [cited 2020 May 07]. Available from: https://www.acog.org/practice-management/health-it-and-clinical-informatics/revitalize-obstetrics-data-definitions. Tidy C, Payne J. Gravidity and Parity Definitions: Implications in Risk Assessment [Internet]. Leeds: Patient Platform Limited; 2019 Jan 21 [cited 2020 May 07]. Available from: https://patient.info/doctor/gravidity-and-parity-definitions-and-their-implications-in-risk-assessment#.
Copyright	© openEHR Foundation
Authors	Author name: Sam Heard Organisation: Ocean Informatics Email: sam.heard@oceaninformatics.com Date originally authored: 2011-02-24
Other Details Language	Author name: Sam Heard Organisation: Ocean Informatics Email: sam.heard@oceaninformatics.com Date originally authored: 2011-02-24
OtherDetails Language Independent	{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=openEHR Foundation, references=Born Too Soon: The Global Action Report on Preterm Birth [Internet]. Geneva: World Health Organization; 2012. Available from: https://www.who.int/maternal_child_adolescent/documents/born_too_soon/en/. Derived from: Obstetric summary, draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. No longer available. Fact sheet: Preterm birth [Internet]. Geneva: World Health Organisation. Preterm birth; 2018 Feb 19 [cited 2020 May 07]. Available from: https://www.who.int/news-room/fact-sheets/detail/preterm-birth. Opara EI, Zaidi J. The interpretation and clinical application of the word 'parity': a survey [Internet]. BJOG. 2007 Oct;114(10):1295-7. doi: 10.1111/j.1471-0528.2007.01435.x. PMID: 17877683. Available from: https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/j.1471-0528.2007.01435.x. reVITALize: Obstetrics Data Definitions V1.0 [Internet]. Washington, American College of Obstetricians and Gynecologists; 2014 [cited 2020 May 07]. Available from: https://www.acog.org/practice-management/health-it-and-clinical-informatics/revitalize-obstetrics-data-definitions. Tidy C, Payne J. Gravidity and Parity Definitions: Implications in Risk Assessment [Internet]. Leeds: Patient Platform Limited; 2019 Jan 21 [cited 2020 May 07]. Available from: https://patient.info/doctor/gravidity-and-parity-definitions-and-their-implications-in-risk-assessment#., original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=90184A07972E5ED5D44D07D8A5791BBE, build_uid=44aaf0f6-4aca-404a-82b9-734bcffaad3c, revision=1.0.1}
Keywords	obstetric, pregnancy, parity, para, gravidity, gravida, termination, miscarriage, abortions, birth, stillbirth, caesarean, cesarean, ectopic, tubal, TPAL, GTPAL
Lifecycle	published
UID	1ce3e0c7-8b5c-4672-b5e4-b02cfc9c4e0c
Language used	en
Citeable Identifier	1013.1.1093
Revision Number	1.0.1
All	Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Summary or persistent information about the numbers of key obstetric events., archetypeConceptComment=null, otherContributors=Sheryl Alexander, NT Department of Health, Australia Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor) Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor) SB Bhattacharyya, Sudisa Consultancy Services, India Margaret Cotter, AMSANT, Australia Michelle Dowden, Miwatj Health Ngalkanbuy Health, Australia Peter Fedorcsak, Oslo universitetssykehus, Norway Shahla Foozonkhah, Iran ministry of health and education, Iran Tim Garden, NTG Department of Health, Australia Heather Grain, Llewelyn Grain Informatics, Australia Kristin Grødem, Helse Vest IKT, Norway Mikkel Gaup Grønmo, Helse-Nord, FSE, Norway (openEHR Editor) Sam Heard, Ocean Informatics, Australia (Editor) Anne Hedvig Mellbye Pfeffer, OUS, Norway Anca Heyd, DIPS ASA, Norway Evelyn Hovenga, EJSH Consulting, Australia Michelle Kealy, Australia Nils Kolstrup, Skansen Legekontor og Nasjonalt Senter for samhandling og telemedisin, Norway Bernadette Lack, Deptartment of Health, NT, Australia Liv Laugen, Oslo universitetssykehus, Norway Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Anne M Gromsrud, DIPS AS, Norway Priscila Maranhão, MEDCIDS-FMUP, Portugal Ian McNicoll, freshEHR Clinical Informatics, United Kingdom Paul Miller, SCIMP NHS Scotland, United Kingdom Lars Morgan Karlsen, Nordlandssykehuset Bodø, Norway Svenne Naumann, Finnmarkssykehuset, Norway Rogerio Neri, Soft & Solutions, Brazil Jeremy Oats, NT Health, Australia Andrej Orel, Marand d.o.o., Slovenia Jayashree Panickar, Karolinska Institute, Sweden Danielle Santos Alves, Federal University of Pernambuco, Brazil Gro-Hilde Severinsen, Norwegian center for ehealthresearch, Norway Line Silsand, Universitetssykehuset i Nord-Norge, Norway Gary Sinclair, NT DoH, Australia trine stavseth, Oslo universitetsykehus, Norway Tove Stenquist, Helseforetak, Norway Norwegian Review Summary, Nasjonal IKT HF, Norway Chen Sun, Haukeland universitetssykehus, Norway June Susanne Berge, DIPS AS, Norway Nyree Taylor, Ocean Informatics, Australia John Tore Valand, Helse Bergen, Norway (openEHR Editor) Marit Alice Venheim, Helse Vest IKT, Norway (openEHR Editor) Ørjan Vermeer, Haukeland Universitetssjukehus, Kvinneklinikken, Norway Cherie Whitbread, Royal Darwin Hospital, Australia Jo Wright, NT Dept of Health, Australia Krister Åkesson, Region Örebro län, Sweden, originalLanguage=en, translators= Norwegian Bokmål: Marit Alice Venheim, Helse Vest IKT AS, marit.alice.venheim@helse-vest-ikt.no Portuguese: Danielle Santos Alves, Federal University of Pernambuco, danielle.salves@ufpe.br Portuguese (Brazil): Marivan Abrahão, Gabriela Alves, Adriana Kitajima e Maria Ângela Scatena / Danielle Santos Alves, Core Consulting / Federal University of Pernambuco, contato@coreconsulting.com.br / danielle.salves@ufpe.com, Hospital Alemão Oswaldo Cruz (HAOC) Spanish (Colombia): Francisco Ramirez ante, SITIS SAS, framirez74@gmail.com, Ingeniero de Sistemas , subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={state=[], contacts=[], details=[], description=[], content=[], provider=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0025], code=at0025, itemType=ELEMENT, level=2, text=Description, description=Narrative description about the overall obstetric history., comment=The content of this description is intended to provide a narrative context that will complement the numbers of key obstetric events captured using this archetype., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Gravidity, description=Number of times a woman has been pregnant, current and past, regardless of the pregnancy outcome., comment=Clinical systems might represent this data element by the term 'Gravida' on a clinical form., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0; max: <100 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=2, text=Parity, description=Number of times a woman has given birth to a viable baby, regardless of the pregnancy outcome., comment=Parity includes all pregnancies that are carried after the fetus is considered viable, as defined in the 'Definition of viability data' element. Stillbirths, late abortions, and all live births are included in the assessment of Parity. In cases of multiple pregnancies, parity is only increased with birth of the last fetus., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0; max: <100 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0015], code=at0015, itemType=ELEMENT, level=2, text=Term births, description=Number of births at or after term., comment=The definition of a term birth is a viable birth at or after 37 weeks and 0 days of gestation. , uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0; max: <100 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0016], code=at0016, itemType=ELEMENT, level=2, text=Preterm births, description=Number of births before term., comment=The definition of a preterm birth is a viable birth before 37 weeks of gestation., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0; max: <100 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0017], code=at0017, itemType=ELEMENT, level=2, text=Abortions, description=Number of pregnancies that do not reach viability from all causes, including spontaneous miscarriages, induced terminations and ectopic pregnancies., comment=The value recorded for 'Abortions' should be equal to the sum of 'Miscarriages', 'Terminations' and 'Ectopic pregnancies', if these additional fields are recorded., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0; max: <100 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Miscarriages, description=Number of times a woman has had a miscarriage., comment=The definition of viability can be recorded in the Protocol., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0; max: <100 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Terminations, description=Number of times a woman has had an induced pregnancy termination, regardless of gestation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0; max: <100 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0011], code=at0011, itemType=ELEMENT, level=2, text=Ectopic pregnancies, description=Number of ectopic pregnancies., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0; max: <100 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0006], code=at0006, itemType=ELEMENT, level=2, text=Live births, description=Number of infants born alive., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0; max: <100 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018], code=at0018, itemType=ELEMENT, level=2, text=Multiple births, description=Number of birth events in which more than one fetus has been born., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0; max: <100 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=2, text=Stillbirths, description=Number of stillbirths., comment=The definition of viability can be recorded in the Protocol., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0; max: <100 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0028], code=at0028, itemType=ELEMENT, level=2, text=Neonatal deaths, description=The number of neonatal deaths., comment=The neonatal period begins at birth and ends at 28 completed days of life , uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0027], code=at0027, itemType=ELEMENT, level=2, text=Caesarean sections, description=Number of caesarean sections., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0026], code=at0026, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the obstetric summary, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], identities=[], other_participations=[], activities=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0009], code=at0009, itemType=ELEMENT, level=2, text=Last updated, description=The date this summary was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0021], code=at0021, itemType=ELEMENT, level=2, text=Definition of viability, description=The number of weeks of gestation that differentiates between a miscarriage and a viable birth, that is used in the data collection., comment=If the baby is born before the defined gestation or less than the defined weight, it is recorded using the 'Miscarriage' data element. If the baby is born after the defined gestation or greater than the defined weight it is recorded using the 'Parity' data element. If the baby is born dead after the defined gestation or greater than the defined weight it may also recorded using the 'Stillbirth' data element. Depending on local definitions, missed abortions may be captured in this data element. Maybe useful to record when comparing data from different regions as definitions of a miscarriage may vary., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of: Duration Allowed values: weeks Quantity Property: Mass Units: g , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0024], code=at0024, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* All not explicitly excluded archetypes, extendedValues=null]], credentials=[], events=[], context=[], relationships=[], target=[], capabilities=[], items=[], source=[], ism_transition=[]}, topLevelItems={data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001], code=at0001, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0.., subCardinalityText=Minimum of 0 items (Cardinality: 0.., unordered), dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0008], code=at0008, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0.., subCardinalityText=Minimum of 0 items (Cardinality: 0.., unordered), dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0009], code=at0009, itemType=ELEMENT, level=2, text=Last updated, description=The date this summary was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0021], code=at0021, itemType=ELEMENT, level=2, text=Definition of viability, description=The number of weeks of gestation that differentiates between a miscarriage and a viable birth, that is used in the data collection., comment=If the baby is born before the defined gestation or less than the defined weight, it is recorded using the 'Miscarriage' data element. If the baby is born after the defined gestation or greater than the defined weight it is recorded using the 'Parity' data element. If the baby is born dead after the defined gestation or greater than the defined weight it may also recorded using the 'Stillbirth' data element. Depending on local definitions, missed abortions may be captured in this data element. Maybe useful to record when comparing data from different regions as definitions of a miscarriage may vary., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of: Duration Allowed values: weeks Quantity Property: Mass Units: g , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0024], code=at0024, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]