TEMPLATE Pregnancy ecosystem testing (Pregnancy ecosystem testing)

TEMPLATE ID	Pregnancy ecosystem testing
Concept	Pregnancy ecosystem testing
Description	Not Specified
Purpose	Not Specified
References
Authors	name: Heather Leslie; organisation: Atomica Informatics; email: heather.leslie@atomicainformatics.com; date: 2022-04-14
Other Details Language	name: Heather Leslie; organisation: Atomica Informatics; email: heather.leslie@atomicainformatics.com; date: 2022-04-14
Other Details (Language Independent)	Sem Ver: 1.0.0 PARENT:MD5-CAM-1.0.1: 545BE872FFC24978414237B682F6C597 Original Language: ISO_639-1::en
Language used	en
Citeable Identifier	1013.26.430
Root archetype id	openEHR-EHR-COMPOSITION.pregnancy_summary.v0
Pregnancy ecosystem testing	Pregnancy ecosystem testing: Summary or persistent details about a single pregnancy.
Pregnancy summary	Pregnancy summary: Overview or summary record of a pregnancy and outcome, including the antenatal period, labour, birth and the immediate postnatal period.
Data
Pregnancy label	Pregnancy label: *
Pregnancy confirmed	Pregnancy confirmed: Confirmation of the pregnancy. 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. Date/Time URI Boolean
Pregnancy outcome	Pregnancy outcome: Outcome of the pregnancy as a whole. Coding of the 'Pregnancy outcome' with an external terminology is recommended. This data element is redundant if 'Delivery outcome' has been recorded. If it is necessary to record outcome information per fetus post delivery use the 'Delivery outcome' data element. Please note - in some existing situations the possible value sets for 'Pregnancy outcome' and 'Delivery outcome' may overlap, and it may be necessary for the user interface in an application to present a merged value set.
Pregnancy synopsis	Pregnancy synopsis: Narrative description about the entire pregnancy, labour and delivery, including complications. 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.
Assisted reproduction?	Assisted reproduction?: Was the pregnancy a result of assisted reproductive technology? True, if assisted reproduction was required to achieve the pregnancy.
Assisted reproduction type	Assisted reproduction type: Type of assisted reproductive technology used to achieve pregnancy. Coding with a terminology is preferred, where possible.
Number of fetuses	Number of fetuses: Number of fetuses identified in utero. >=0
Pregnancy duration	Pregnancy duration: The length of the pregnancy until the pregnancy has ended. Also known as 'Gestation at birth' for pregnancies resulting in viable outcomes. P0D..P52W Units: Week Day
Onset of labour	Onset of labour: Manner in which labour started. No labour Spontaneous Induced
Induction method	Induction method: Method of labour induction. Coding of the 'Induction Method' with a terminology is desirable, where possible.
Reason for induction	Reason for induction: Reason for induction of labour.
Augmentation method	Augmentation method: Method of labour augmentation. Coding of the 'Augmentation Method' with a terminology is desirable, where possible.
Total duration of labor	Total duration of labor: Total duration of all three stages of labour. >=PT0H Units: Day Hour Minute
Perineum	Perineum: Coded or narrative description about the condition of the perineum after birth, including injuries and repairs. Text Coded Text First degree vaginal tear Second degree vaginal tear Third degree vaginal tear Fourth degree vaginal tear
Episiotomy	Episiotomy: Was an episiotomy performed?
Estimated blood loss	Estimated blood loss: Estimation of total maternal blood loss during birth and immediately postpartum. Units: ml
Examination of a placenta	Examination of a placenta: Findings observed during the physical examination of a placenta.
System or structure examined	System or structure examined: Identification of the examined body system or anatomical structure. Coding of the system or structure examined with a terminology is preferred, where possible. Placenta
Body site	Body site: Identification of the area of the body under examination. If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant.
Clinical description	Clinical description: Narrative description of the overall findings observed during the physical examination.
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings. For example: 'No abnormality detected' or 'Moderate inflammation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible.
Comment	Comment: Additional narrative about the physical examination findings, not captured in other fields.
Maternal complication	Maternal complication: Details about pregnancy complications or birth complications affecting the mother. 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.
Complication	Complication: Identification of the complication. Coding of the 'Complication' with a terminology is desirable, where possible. For example, post partum haemorrhage or pre-eclampsia.
Description	Description: Narrative description of the maternal complication.
Date/Time of onset	Date/Time of onset: Date of onset of complication, as assessed by a clinician. If only a partial date is available, this is acceptable.
Per newborn	Per newborn: Information about an single newborn infant. These data elements may be used to record details about live births or stillborn infants.
Label/name	Label/name: Identification of the newborn. Identification might be by the name of the neonate or a label given to a non-viable fetus.
Delivery outcome	Delivery outcome: Description of the outcome delivery per newborn infant. Coding of the 'Delivery outcome' with an external terminology is recommended. For example: 'Live birth'; 'Stillbirth'; or 'Neonatal death'. This data element is redundant if 'Pregnancy outcome' has been recorded. Please note - in some existing situations the possible value sets for 'Delivery outcome' and 'Pregnancy outcome' may overlap, and it may be necessary for the user interface in an application to present a merged value set.
Date/time of delivery	Date/time of delivery: Date and time of delivery for the newborn. 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.
Assigned sex	Assigned sex: Sex of the newborn assigned at, or near delivery, by direct observation of external genitalia. 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. Male Female Indeterminate
Birth summary	Birth summary: 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.
Description	Description: Narrative description of the newborn, including observed congenital abnormalities.
Birth order	Birth order: *
Gestational age	Gestational age: The length of the pregnancy at the time of delivery of the infant. The value for this data element will usually, but not always, be identical to the 'Pregnancy duration' data element within the EVALUATION.pregnancy_summary in the maternal record. It may also be derived using the 'Agreed date' data element within the EVALUATION.estimated_date_delivery archetype in the maternal record. Usually estimated by Naegele's rule or by ultrasound scan. P0W..P52W Week
Gestational maturity	Gestational maturity: The postnatal gestation estimated by physical examination and/or neuromuscular assessment of newborn. Usually estimated by physical examination and/or neuromuscular assessment of the newborn. P0W..P52W Week
Mode of birth	Mode of birth: Method by which the newborn was delivered. For example: vaginal; forceps rotation; or Caesarean Section. Unassisted Assisted breech delivery Total breech extraction Vacuum extraction Vacuum extraction with rotation Lift-out forceps Low forceps High forceps High forceps with rotation Caesarean - lower uterine segment Caesarean - upper uterine segment
Apgar record	Apgar record: Description about Apgar scores recorded after birth. This data element may be recorded as narrative text or as a numerical score. As different countries record Apgar at different times, the timing of this data element has been left unspecified. However the data element allows 0..* occurrences to enable recording a score for one or more timed Apgar scores to be recorded. These scores can be copied or derived from the 'Total' data element within the OBSERVATION.apgar archetype recorded within the maternal health record. Count Text
Presenting part	Presenting part: Presenting part of the newborn at delivery. The clinical context for recording this data element is only presentation at delivery, not at any other phase of labour. Vertex Breech Face Brow Foot Arm Shoulder
Position	Position: Position of the newborn at delivery. Left occiput anterior/transverse Right occiput anterior/transverse Unknown
Weight	Weight: Weight of the newborn at delivery. 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. 0..1000; 0..10 Units: g kg
Feeding	Feeding: Narrative description about feeding of the newborn.
Newborn complication	Newborn complication: Details about any complications affecting the newborn. 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.
Complication	Complication: Identification of the complication after birth. Coding of the 'Complication' with a terminology is desirable, where possible. For example, neonatal hypoglycaemia or hypothermia.
Description	Description: Narrative description of complication.
Date/time of onset	Date/time of onset: Date and/or time of onset of the complication.
Protocol
Last updated	Last updated: The date/time the pregnancy summary was last updated.
Breast feeding summary	Breast feeding summary: Summary or persistent information about the all breastfeeding experience of an individual.
Data
Status	Status: * Currently breastfeeding Previous breastfeeding Never breastfed
Description	Description: Narrative description about the overall breastfeeding history for an individual.
Per episode	Per episode: Detail about a discrete episode of breastfeeding activity.
Episode label	Episode label: Identification of an episode of breastfeeding - either as a number in a sequence and/or a named event. For example: '2' as the second episode within a sequence of episodes; or 'James' if describing the breastfeeding after the birth of an infant named James.
Episode description	Episode description: Narrative description about breastfeeding during the identified episode.
Start date	Start date: The date when the episode of breastfeeding commenced.
Stop date	Stop date: The date when the episode of breastfeeding ceased.
Comment	Comment: Additional narrative about all breastfeeding not captured in other fields.
Protocol
Last updated	Last updated: The date when the breast feeding summary was last updated.
Pregnancy finding	Pregnancy finding: An assertion about the current pregnant condition of an individual.
Data
Current status	Current status: The current state of pregnancy for the individual.
Data
Finding	Finding: Is there a pregnancy present? Pregnant Possible pregnancy Not pregnant Unknown
Evidence	Evidence: Description of the evidence identified. Coded Text On history Urine test Blood test Abdominal palpation Vaginal examination Text
Comment	Comment: Additional narrative about the pregnancy, not captured in other fields.
Any event	Any event: *
Data
Finding	Finding: Is there a pregnancy present? Pregnant Possible pregnancy Not pregnant Unknown
Evidence	Evidence: Description of the evidence identified. Coded Text On history Urine test Blood test Abdominal palpation Vaginal examination Text
Comment	Comment: Additional narrative about the pregnancy, not captured in other fields.
Data
Finding	Finding: Is there a pregnancy present? Pregnant Possible pregnancy Not pregnant Unknown
Evidence	Evidence: Description of the evidence identified. Coded Text On history Urine test Blood test Abdominal palpation Vaginal examination Text
Comment	Comment: Additional narrative about the pregnancy, not captured in other fields.
Pregnancy test result	Pregnancy test result: The result of a diagnostic test performed on a specimen in a non-laboratory environment.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Test name	Test name: Name of the test carried out on nvestigation performed on the specimen(s). It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucometer blood sugar'; or 'COVID-19 rapid antigen test'. The name may sometimes include specimen type and/or patient state, such as 'Fasting glucometer blood sugar' or 'Oral COVID-19 RAT'. Urine pregnancy test
Specimen	Specimen: Simple description about the specimen tested. For example: nasal swab; blood; or urine.
Result	Result: * Quantity Coded Text Negative Positive Indeterminate Text
Comment	Comment: Additional narrative about the test result not captured in other fields.
State
Fasting	Fasting: *
Protocol
Method	Method: Description about the method used to carry out the test. For example: manual finger prick. Coding with a terminology is desirable, where possible.
Pregnancy status	Pregnancy status: Pregnancy status
Data
Status	Status: * Current Previous Never
Comment	Comment: *
Protocol
Last updated	Last updated: *
Birth details	Birth details: birth details
Data
Date of birth	Date of birth: The date/time of birth of the individual. May also be used to record the assumed or agreed date/time of birth for operational purposes, if the actual date/time is not formally recorded. Possible alternatives for the date/time of birth of the individual can be recorded using the CLUSTER.DOB_alternative archetype 'Date of birth details' SLOT.
Date of birth alternative	Date of birth alternative: Date of birth details
Possible date/time of birth	Possible date/time of birth: * Partial dates are allowed...XXX
Source	Source: Source of information about the possible date of birth.
Comment	Comment: Additional information about the possible date/time of birth, not captured in other data elements.
Country of birth	Country of birth: The country of birth of the individual.
Place of birth	Place of birth: Simple representation of the place of birth This data element provides the opportunity for simple detail about the place of birth, such as the city, region, town, or suburb within the identified 'Country of birth'. For example: Kingston (Jamaica); Manhattan (USA); or Box Hill (Australia).
Pregnancy/birth synopsis	Pregnancy/birth synopsis: Narrative description about the entire pregnancy, labour and delivery, including maternal and infant complications. This data element may be derived from the 'Pregnancy synopsis' data element within the EVALUATION.pregnancy_summary archetype in the maternal health record.
Birth plurality	Birth plurality: Term representing the total number of live births and stillbirths resulting from the pregnancy. Coding of the 'birth plurality' term is recommended. For example: singleton; twins; triplets; or quadruplets.The definition of 'stillbirth' may vary in different locations.
Birth summary	Birth summary: 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.
Description	Description: Narrative description of the newborn, including observed congenital abnormalities.
Birth order	Birth order: *
Gestational age	Gestational age: The length of the pregnancy at the time of delivery of the infant. The value for this data element will usually, but not always, be identical to the 'Pregnancy duration' data element within the EVALUATION.pregnancy_summary in the maternal record. It may also be derived using the 'Agreed date' data element within the EVALUATION.estimated_date_delivery archetype in the maternal record. Usually estimated by Naegele's rule or by ultrasound scan. P0W..P52W Week
Gestational maturity	Gestational maturity: The postnatal gestation estimated by physical examination and/or neuromuscular assessment of newborn. Usually estimated by physical examination and/or neuromuscular assessment of the newborn. P0W..P52W Week
Mode of birth	Mode of birth: Method by which the newborn was delivered. For example: vaginal; forceps rotation; or Caesarean Section. Unassisted Assisted breech delivery Total breech extraction Vacuum extraction Vacuum extraction with rotation Lift-out forceps Low forceps High forceps High forceps with rotation Caesarean - lower uterine segment Caesarean - upper uterine segment
Apgar record	Apgar record: Description about Apgar scores recorded after birth. This data element may be recorded as narrative text or as a numerical score. As different countries record Apgar at different times, the timing of this data element has been left unspecified. However the data element allows 0..* occurrences to enable recording a score for one or more timed Apgar scores to be recorded. These scores can be copied or derived from the 'Total' data element within the OBSERVATION.apgar archetype recorded within the maternal health record. Count Text
Protocol
Last updated	Last updated: The date/time the birth details were last updated.
Estimated date of delivery	Estimated date of delivery: Estimated date of delivery for a pregnancy.
Data
By date of conception	By date of conception: The EDD calculated from a known date of conception. The date of conception will be recorded elsewhere in the health record, for example as part of the record for an IVF procedure.
By cycle	By cycle: The EDD estimated from an LNMP and characteristics of the menstrual cycle. The details about the menstrual cycle will be recorded elsewhere in the health record, usually captured using the OBSERVATION.menstruation archetype.
By ultrasound	By ultrasound: Details about an EDD estimated from the findings on a pregnancy ultrasound. Each ultrasound and estimated gestation pair will be captured as a separate instance of this CLUSTER.
Date of ultrasound	Date of ultrasound: The date on which the ultrasound was carried out.
Gestation by scan	Gestation by scan: The gestation estimated from the scan.
Estimated date by ultrasound	Estimated date by ultrasound: Details about an EDD estimated from the findings on a pregnancy ultrasound. Only one 'Agreed EDD' is appropriate at any one time. If the agreed EDD needs to be revised then this should be captured in a new revision of this archetype within a health record.
Agreed EDD	Agreed EDD: Details about the agreed EDD which is used as the basis for clinical decision-making during the pregnancy.
Agreed date	Agreed date: The EDD which is to be used as the basis for clinical decision-making.
Rationale	Rationale: The rationale which explains why the 'Agreed date' has been selected.
Protocol
Last updated	Last updated: The date any EDD was last updated.