| ARCHETYPE ID | openEHR-EHR-OBSERVATION.pregnancy_finding.v0 |
| Concept | Pregnancy assertion |
| Description | A statement or declaration by a clinician about the known pregnancy state of the individual at a specific point-in-time, to be used as the basis for clinical decision-making. |
| Use | Use to record a statement or declaration about the pregnancy status of the individual at a specific point in time. This data group is very deliberately defined as the recording of an assertion, a careful clinical statement made by a clinician about whether they believe, based on their best knowledge, that an individual is pregnant or not pregnant. ‘May be pregnant’ is not usually offered as a value, much less recorded in the health record, as this is every clincian’s default assumption for any woman of child-bearing age, until proven otherwise. Asserting that an individual is pregnant is relatively straightforward and safe to do on the basis of evidence such as a positive urine or blood test or physical examination findings. Typically, the consequences of an error in this scenario lead to overly cautious treatment choices, which are unlikely to cause clinical harm. However, the opposite situation where a clinician needs to assert that an individual who has been assigned as female at birth is not pregnant is often not a straightforward or safe determination. Incorrectly asserting that the individual is not pregnant can have significant clinical consequences if it results in clinical management choices that can cause harm to a pregnant woman or to the fetus in an unrecognised pregnancy. Absolute exclusion of pregnancy is possible only in limited cases, such as after the confirmed absence or removal of both ovaries and the uterus. In most other situations, clinicians can only make a determination of ‘not pregnant’ based on a combination of history taking, physical examination, diagnostic testing and clinical judgment. Any statement of pregnancy exclusion should include the clinician’s rationale or justification, which may reference contemporaneous test results, an organ inventory or a past history of diagnoses and procedures. An assertion should be considered accurate only at the time of assertion. For example, an assertion that an individual is pregnant is needed to diagnose an ectopic pregnancy, however they should no longer be pregnant following surgery. Similarly, an assertion that an individual is not pregnant, based on history taking and a urine pregnancy test result, may need to be revised shortly after if a blood test for pregnancy returns positive. |
| Misuse | Not to be used to record summary information about a single pregnancy. Use the EVALUATION.pregnancy_summary archetype for this purpose. Not to be used to record the phase of an active pregnancy, such as preconception, pregnant, or postpartum. Use the EVALUATION.pregnancy_phase archetype 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 or other relevant archetypes for this purpose. Not to be used in the context of questionnaire-style representations, such as self-reported data with questions like 'Are you pregnant?'. Use the openEHR-EHR-OBSERVATION.problem_screening.v1 or other relevant archetypes for this purpose. |
| Purpose | To record a statement or declaration about the pregnancy status of the individual, which is to be considered accurate only at the date and time of assertion. |
| References | Note the similar approach in FHIR Pregnancy status Observation, but without the same semantics in terms of a clinician making an assertion: - AU Core Pregnancy Status, HL7 AU Core FHIR Profile [Internet]. Health Level Seven Australia; [cited: 2024 Oct 18]. Available from: https://hl7.org.au/fhir/core/0.1.0-draft/StructureDefinition-au-core-pregnancystatus.html. - Observation Pregnancy - Status (IPS) profile, International Patient Summary Implementation Guide, [Internet]. Patient Care Working Group, Health Level Seven International; [cited: 2024 Oct 18]. Available from: https://build.fhir.org/ig/HL7/fhir-ips/StructureDefinition-Observation-pregnancy-status-uv-ips.html |
| Copyright | © openEHR Foundation |
| Authors | Author name: Marit Alice Venheim Organisation: Helse Vest IKT AS Email: marit.alice.venheim@helse-vest-ikt-no Date originally authored: 2020-05-05 |
| Other Details Language | Author name: Marit Alice Venheim Organisation: Helse Vest IKT AS Email: marit.alice.venheim@helse-vest-ikt-no Date originally authored: 2020-05-05 |
| 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=Note the similar approach in FHIR Pregnancy status Observation, but without the same semantics in terms of a clinician making an assertion: - AU Core Pregnancy Status, HL7 AU Core FHIR Profile [Internet]. Health Level Seven Australia; [cited: 2024 Oct 18]. Available from: https://hl7.org.au/fhir/core/0.1.0-draft/StructureDefinition-au-core-pregnancystatus.html. - Observation Pregnancy - Status (IPS) profile, International Patient Summary Implementation Guide, [Internet]. Patient Care Working Group, Health Level Seven International; [cited: 2024 Oct 18]. Available from: https://build.fhir.org/ig/HL7/fhir-ips/StructureDefinition-Observation-pregnancy-status-uv-ips.html, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=04DB3ACCF005E496B0B9FD86C73867DA, build_uid=796371b7-f919-4609-ba43-39ba6f628ffc, ip_acknowledgements=This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org., revision=0.0.1-alpha} |
| Keywords | pregnancy, pregnant, exclusion, |
| Lifecycle | in_development |
| UID | 20f5182a-b3e4-4da1-bdaa-6951241c558d |
| Language used | en |
| Citeable Identifier | 1013.1.4720 |
| Revision Number | 0.0.1-alpha |
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