ARCHETYPE Pregnancy summary (openEHR-EHR-EVALUATION.pregnancy_summary.v0)

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

ARCHETYPE ID	openEHR-EHR-EVALUATION.pregnancy_summary.v0
Concept	Pregnancy summary
Description	Overview or summary record of a pregnancy and outcome, including the antenatal period, labour, birth and the immediate postnatal period.
Use	Use to record an overview or summary record of an identified pregnancy and outcome, including the antenatal period, labor, birth and the immediate postnatal period. During an active pregnancy, this archetype supports the evolution of a persistent pregnancy-related health summary record, with information gradually accumulated or updated, throughout the duration of the pregnancy, labour, birth and the immediate postnatal period. As the data is committed to the persistent health record, the date of the update is also recorded in the 'Last Updated' data element in Protocol, to ensure that if this pregnancy summary is taken out of context of the health record for other purposes, such as data exchange, the date of the latest update is kept with the clinical data. After birth, this summary record can be used to share essential information with other healthcare providers about the pregnancy, labour, birth and immediate postnatal period. Each completed pregnancy summary saved to the health record can be re-used to populate the Past Pregnancy History details in subsequent pregnancy records. In situations where completed pregnancy summaries are not available for each previous pregnancy, this archetype can also be used to record a relevant subset of information that can be used to populate the Past Pregnancy History details with new or active pregnancy records.
Misuse	Not to be used to record event-based information during the pregnancy, labor, birth and immediate postnatal period. These will be recorded using OBSERVATION archetypes - for example, the information related to history & examination during antenatal visits or during labour. Not to be used to record summary information about a woman's Obstetric history - use EVALUATION.obstetric_summary. Not to be used to record detailed information about a woman's Menstrual Cycle - use OBSERVATION.menstrual_cycle. Not to be used to record detailed information about infant feeding - a separate archetype will be used. Not to be used to record a general menstrual history summary or diary - separate archetypes will be used.
Purpose	To support the recording of an overview or summary record of an identified pregnancy and outcome, including the antenatal period, labor, birth and the immediate postnatal period.
References	Pregnancy Summary, Draft Archetype [Internet]. nehta, Australia, nehta Clinical Knowledge Manager [cited: 2016-02-21]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1013 AIHW 2003. Perinatal National Minimum Data Set: National Health Data Dictionary, Version 12. National Health Data Dictionary. Cat. no. HWI 59. Canberra: AIHW. Northern Territory Government, Department of Health. Pregnancy Health Record. HM424-12/06. Queensland Government, Department of Health. Pregnancy Health Record. SW071 - v1.00 - 06/2010.
Copyright	© openEHR Foundation
Authors	Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2007-02-28
Other Details Language	Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2007-02-28
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=Pregnancy Summary, Draft Archetype [Internet]. nehta, Australia, nehta Clinical Knowledge Manager [cited: 2016-02-21]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1013 AIHW 2003. Perinatal National Minimum Data Set: National Health Data Dictionary, Version 12. National Health Data Dictionary. Cat. no. HWI 59. Canberra: AIHW. Northern Territory Government, Department of Health. Pregnancy Health Record. HM424-12/06. Queensland Government, Department of Health. Pregnancy Health Record. SW071 - v1.00 - 06/2010., current_contact=Heather Leslie, Atomica Informatics, original_namespace=openEHR Foundation, original_publisher=org.openehr, custodian_namespace=org.openehr, MD5-CAM-1.0.1=768700943707E9FAAA043B59F904850A, build_uid=4845f1f1-614b-4ed4-b692-a454c7b33cb9, revision=0.0.1-alpha}
Keywords	pregnancy, fetus, foetus, infant, neonate, delivery, conception, due, date, expected, labor, labour, birth, baby, babies, EDD, EDB
Lifecycle	in_development
UID	9122c39a-3817-426e-9ae4-d1f438b1d26b
Language used	en
Citeable Identifier	1013.1.177
Revision Number	0.0.1-alpha
All	Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Overview or summary record of a pregnancy and outcome, including the antenatal period, labour, birth and the immediate postnatal period., archetypeConceptComment=null, otherContributors=Sheryl Alexander, NT Department of Health, Australia Rita Apelt, Department of Health,NT, Australia Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor) Stephen Chu, NEHTA, Australia Margaret Cotter, AMSANT, Australia Michelle Dowden, Miwatj Health Ngalkanbuy Health, Australia Tim Garden, NTG Department of Health, Australia Tanya Gardner, CAAC, Australia Sam Heard, Ocean Informatics, Australia (Editor) Bernadette Lack, Department of Health, Australia Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Hugh Leslie, Ocean Informatics, Australia Chunlan Ma, Ocean Informatics, Australia Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor) Jeremy Oats, NT Health, Australia Steven Schatz, Department of Health (Northern Territory), Australia Rosalie Schultz, Anyinginyi Health Aboriginal Corporation, Australia Gary Sinclair, NT DoH, Australia Cherie Whitbread, Royal Darwin Hospital, Australia Jo Wright, NT Dept of Health, Australia (Editor), originalLanguage=en, translators= Norwegian Bokmål: Marit Alice Venheim, Helse Vest IKT AS, marit.alice.venheim@helse-vest-ikt.no Portuguese (Brazil): Adriana Kitajima, Gabriela Alves, Maria Angela Scatena, Marivan Abrahäo, Core Consulting, contato@coreconsulting.com.br, Hospital Alemão Oswaldo Cruz Spanish (Colombia): Francisco Ramirez ante, SITIS SAS, framirez74@gmail.com, Ingeniero de Sistemas , subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={identities=[], other_participations=[], events=[], details=[], provider=[], items=[], description=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0081]/items[at0082], code=at0082, itemType=ELEMENT, level=2, text=Last updated, description=The date/time the pregnancy 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[at0081]/items[at0164], code=at0164, 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. , 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]], ism_transition=[], context=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0146], code=at0146, itemType=ELEMENT, level=2, text=Pregnancy label, description=, 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], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0158], code=at0158, itemType=ELEMENT, level=2, text=Pregnancy confirmed, description=Confirmation of the pregnancy., comment=Confirmation may be documented either by date, boolean selection or a link to a confirmatory test result within the health record. This data element may be used to trigger a 'Current' 'Pregnancy status' within the EVALUATION.pregnancy_status archetype., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of: Date/Time URI Boolean , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0083], code=at0083, itemType=ELEMENT, level=2, text=Pregnancy synopsis, description=Narrative description about the entire pregnancy, labour and delivery, including complications., comment=This data element may be used to populate the 'Pregnancy/birth synopsis' data element within the EVALUATION.birth_details archetype in an infant health record., 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[at0104], code=at0104, itemType=ELEMENT, level=2, text=Assisted reproduction?, description=Was the pregnancy a result of assisted reproductive technology?, comment=True, if assisted reproduction was required to achieve the pregnancy., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0105], code=at0105, itemType=ELEMENT, level=2, text=Assisted reproduction type, description=Type of assisted reproductive technology used to achieve pregnancy., comment=Coding with a terminology is preferred, where possible., 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[at0094], code=at0094, itemType=ELEMENT, level=2, text=Early pregnancy outcome, description=Outcome of the pregnancy as a whole., comment=This data element is only used to record the outcome of a pregnancy, before it is useful to record an outcome on a per foetus basis. For example: a 'miscarriage' or a 'missed abortion'. Coding of the 'Early pregnancy outcome' with an external terminology is recommended. If it is necessary to record outcome information per infant or foetus use the 'Infant outcome' data element instead. This data element is redundant if 'Infant outcome' has been recorded. , 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[at0159], code=at0159, itemType=ELEMENT, level=2, text=Pregnancy duration, description=The gestation when the pregnancy has ended., comment=Also known as 'Gestation at birth' for pregnancies resulting in viable outcomes., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Allowed values: weeks, days 0 days..52 weeks , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0174], code=at0174, itemType=ELEMENT, level=2, text=Pregnancy end date, description=The date and/or time marking the end of the pregnancy., comment=This data element may be renamed in a template, depending on the pregnancy outcome. For example: date of delivery for a live birth or stillbirth; date of miscarriage; or date of termination., 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=/data[at0001]/items[at0178], code=at0178, itemType=ELEMENT, level=2, text=Multiple pregnancy?, description=Assertion about whether the pregnancy is cateogrised as 'multiple pregnancy'., comment=This categorial data element is commonly required within registries or used in risk assessment, rather than recording the actual 'Number of foetuses'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of: Coded Text at0179::Present [The pregnancy has more than one foetus.] at0180::Absent [The pregnancy has only one foetus.] Text Boolean , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0007], code=at0007, itemType=ELEMENT, level=2, text=Number of foetuses, description=Number of foetuses identified in utero., 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 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0008], code=at0008, itemType=ELEMENT, level=2, text=Onset of labour, description=Manner in which labour started., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0112::No labour [No onset of labour.] at0009::Spontaneous [Onset without intervention.] at0010::Induced [Onset through intervention.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0096], code=at0096, itemType=ELEMENT, level=2, text=Induction method, description=Method of labour induction., comment=Coding of the 'Induction Method' with a terminology is desirable, where possible., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0097], code=at0097, itemType=ELEMENT, level=2, text=Reason for induction, description=Reason for induction of labour., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0022], code=at0022, itemType=ELEMENT, level=2, text=Augmentation method, description=Method of labour augmentation., comment=Coding of the 'Augmentation Method' with a terminology is desirable, where possible., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0016], code=at0016, itemType=ELEMENT, level=2, text=Total duration of labor, description=Total duration of all three stages of labour., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Allowed values:* days, hours, minutes >=0 hours , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0118], code=at0118, itemType=ELEMENT, level=2, text=Perineum, description=Coded or narrative description about the condition of the perineum after birth, including injuries and repairs., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of: Text Coded Text at0153::First degree vaginal tear [Involve just the skin of the vaginal opening and perineum.] at0154::Second degree vaginal tear [Involve the skin and muscle of the perineum and might extend deep into the vagina.] at0155::Third degree vaginal tear [Tear in the vaginal tissue, perineal skin, and perineal muscles that extends into the anal sphincter.] at0156::Fourth degree vaginal tear [Extend through the anal sphincter and into the mucous membrane that lines the rectum.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0157], code=at0157, itemType=ELEMENT, level=2, text=Episiotomy, description=Was an episiotomy performed?, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0119], code=at0119, itemType=ELEMENT, level=2, text=Estimated blood loss, description=Estimation of total maternal blood loss during birth and immediately postpartum., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Volume Units: ml, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0173], code=at0173, itemType=ELEMENT, level=2, text=Place category, description=Category of the place where the individual died., comment=It is strongly recommended that 'Place category' be coded with an external terminology. For example: hospital; birthing clinic; or home., 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[at0175], code=at0175, itemType=ELEMENT, level=2, text=Place of outcome, description=Simple details about the location where the pregnancy was delivered or an alternative outcome of the pregnancy was treated or managed., comment=For example: the name of the hospital or clinic., 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[at0172], code=at0172, itemType=SLOT, level=2, text=Structured place of outcome, description=Structured details about the location where the pregnancy was delivered or an alternative outcome of the pregnancy was treated or managed., comment=For example: this data element will be renamed to 'Place of delivery' for a pregnancy that ends in the delivery of one or more newborns., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* openEHR-EHR-CLUSTER.address.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0161], code=at0161, itemType=SLOT, level=2, text=Additional details, description=Structured details about additional information related to the pregnancy summary., comment=For example: findings from examination of the placenta., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* openEHR-EHR-CLUSTER.exam-placenta.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0065], code=at0065, itemType=CLUSTER, level=2, text=Maternal complication, description=Details about pregnancy complications or birth complications affecting the mother., comment=Maternal complications recorded within this maternal 'Pregnancy summary' archetype may be used to populate EVALUATION.problem_diagnosis or ACTION.procedure archetypes as part of a maternal Problem list, or similar. Alternatively these complications may be derived from relevant entries previously documented in the maternal health record using EVALUATION.problem_diagnosis or ACTION.procedure archetypes., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=1.., cardinalityText= (Cardinality: 1.., unordered), subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0065]/items[at0066], code=at0066, itemType=ELEMENT, level=3, text=Complication, description=Identification of the complication., comment=Coding of the 'Complication' with a terminology is desirable, where possible. For example, post partum haemorrhage or pre-eclampsia., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0065]/items[at0068], code=at0068, itemType=ELEMENT, level=3, text=Description, description=Narrative description of the maternal complication., 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], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0065]/items[at0067], code=at0067, itemType=ELEMENT, level=3, text=Date/Time of onset, description=Date of onset of complication, as assessed by a clinician., comment=If only a partial date is available, this is acceptable., 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=/data[at0001]/items[at0028], code=at0028, itemType=CLUSTER, level=2, text=Per infant, description=Information about a single foetus or newborn infant., comment=These data elements may be used to record details about live births or stillborn infants., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=1.., cardinalityText= (Cardinality: 1.., unordered), subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0028]/items[at0036], code=at0036, itemType=ELEMENT, level=3, text=Label/name, description=Identification of the infant., comment=Identification might be by the name of the neonate or a label given to a non-viable foetus., 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[at0028]/items[at0163], code=at0163, itemType=ELEMENT, level=3, text=Infant outcome, description=Outcome of the pregnancy for the identified infant or foetus., comment=This data element is only used to record the outcome of a pregnancy for a single infant or foetus. For example: 'Live birth'; or 'Stillbirth'. Coding of the 'Infant outcome' with an external terminology is recommended. If it is necessary to record outcome information for the pregnancy as a whole use the 'Early pregnancy outcome' data element instead. This data element is redundant if 'Early pregnancy outcome' has been recorded., 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[at0028]/items[at0029], code=at0029, itemType=ELEMENT, level=3, text=Date/time of delivery, description=Date and time of delivery for the infant., comment=This data element may be used to populate the newborn's health record using the 'Date of birth' data element within the EVALUATION.birth_details archetype., 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=/data[at0001]/items[at0028]/items[at0037], code=at0037, itemType=ELEMENT, level=3, text=Assigned sex, description=Sex of the infant by direct observation of external genitalia., comment=Coding with a terminology is preferred, where possible. For example: Male; female; intersex; indeterminate. Indeterminate is to be used in the situation where the infant has ambiguous external genitalia. This data element may be used to populate the newborn health record using the 'Sex assigned at birth' data element within the EVALUATION.gender archetype., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0113::Male [Baby appears physically male.] at0114::Female [Baby appears physically female.] at0115::Indeterminate [Sex of the baby has not yet been able to be determined from observation of physical characteristics.] at0176::Intersex at0177::Unknown , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0028]/items[at0160], code=at0160, itemType=SLOT, level=3, text=Birth detail, description=A subset of persistent or summary information about the pregnancy and birth of an infant, selected for utility of use within both the maternal and infant health records., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* openEHR-EHR-CLUSTER.birth_detail.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0028]/items[at0045], code=at0045, itemType=ELEMENT, level=3, text=Presenting part, description=Presenting part of the infant at delivery., comment=The clinical context for recording this data element is only presentation at delivery, not at any other phase of labour., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of: Coded Text at0046::Vertex [The vertex was the presenting part.] at0047::Breech [The breech was the presenting part.] at0048::Face [The face was the presenting part.] at0049::Brow [The brow was the presenting part.] at0106::Foot [A foot was the presenting part.] at0107::Arm [An arm was the presenting part.] at0133::Shoulder [A shoulder was the presenting part.] Text , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0028]/items[at0149], code=at0149, itemType=ELEMENT, level=3, text=Position, description=Position of the infant at delivery., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0150::Left occiput anterior/transverse [The baby's back was toward the left side of the uterus at onset of labour.] at0151::Right occiput anterior/transverse [The baby's back was toward the right side of the uterus at onset of labour.] at0152::Unknown [It is not known which side the baby's back was positioned by onset of labour.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0028]/items[at0038], code=at0038, itemType=ELEMENT, level=3, text=Birthweight, description=Weight of the infant at delivery., comment=This data element may be used to populate the newborn health record using both the 'Weight' data element and 'Birth' EVENT within the OBSERVATION.body_weight archetype., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Mass Units: 0.0..10000.0 g Limit decimal places: 0 0.0..10.0 kg Limit decimal places: 2 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0028]/items[at0109], code=at0109, itemType=ELEMENT, level=3, text=Feeding, description=Narrative description about feeding of the infant., 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], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0028]/items[at0165], code=at0165, itemType=ELEMENT, level=3, text=Neonatal outcome, description=Description of the outcome at the end of the neonatal period per newborn infant., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of: Text Coded Text at0168::Live [The infant survived the neonatal period.] at0169::Deceased [The infant did not survive the neonatal period.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0028]/items[at0170], code=at0170, itemType=ELEMENT, level=3, text=Neonatal summary, description=Narrative description about issues, concerns about the infant or events occurring during the neonatal period., 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], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0028]/items[at0167], code=at0167, itemType=ELEMENT, level=3, text=Date/time of neonatal death, description=, 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=/data[at0001]/items[at0028]/items[at0166], code=at0166, itemType=ELEMENT, level=3, text=Age at neonatal death, description=The age of the infant if they died during the neonatal period., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0028]/items[at0061], code=at0061, itemType=CLUSTER, level=3, text=Newborn complication, description=Details about any complications affecting the newborn., comment=Newborn complications recorded within this maternal 'Pregnancy summary' archetype may be used to populate EVALUATION.problem_diagnosis or ACTION.procedure archetypes to initiate a Problem list, or similar, within a newborn health record., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=1.., cardinalityText= (Cardinality: 1.., unordered), subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0028]/items[at0061]/items[at0062], code=at0062, itemType=ELEMENT, level=4, text=Complication, description=Identification of the complication after birth., comment=Coding of the 'Complication' with a terminology is desirable, where possible. For example, neonatal hypoglycaemia or hypothermia., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0028]/items[at0061]/items[at0064], code=at0064, itemType=ELEMENT, level=4, text=Description, description=Narrative description of complication., 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], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0028]/items[at0061]/items[at0063], code=at0063, itemType=ELEMENT, level=4, text=Date/time of onset, description=Date and/or time of onset of the complication., 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]], activities=[], relationships=[], credentials=[], target=[], source=[], state=[], content=[], contacts=[], capabilities=[]}, topLevelItems={protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0081], code=at0081, 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], 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]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0081]/items[at0082], code=at0082, itemType=ELEMENT, level=2, text=Last updated, description=The date/time the pregnancy 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[at0081]/items[at0164], code=at0164, 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. , 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]