Michigan Birth Defect Registry

Transcription

1 Michigan Birth Defect Registry Implementation Guide for Ambulatory Healthcare Provider Reporting to Central Birth Defect Registries, HL7 Clinical Document Architecture (CDA)

2 Version 1.2 G. Copeland, R. Humphrys, R. Kommareddi, R. May-Gentile, L. Rappleye, L. Simmons Michigan Birth Defect Registry Implementation Guide for Ambulatory Healthcare Provider Reporting to Central Birth Defect Registries, HL7 Clinical Document Architecture (CDA) August, 2015

3 Table of Contents Table of Contents... i List of Figures... iv List of Tables... v Preface...x 1.0 Introduction Background Legal Mandate for Michigan Birth Defects Reporting Public Health Code as Amended Data Rules Purpose Audience Scope Use Case, Scenarios, Diagrams Scenario Use Case Overview Use of Vocabulary Standards HIPAA Clinical Document Architecture Release 2 (CDA R2) Ambulatory Healthcare Provider Birth Defects Report Document Constraints Parent Template Specification Birth Defects Header Conventions Used in this Guide Conformance (Optionality Constraints) Cardinality Birth Defect Registry Implementation Guide

4 2.7 Null Flavor Birth Defects Specification Table Organization of Implementation Guide Conventions Document Content Module Sections Entry Content Vocabulary and Value Sets Vocabulary Conformance CDA Header Section Value Sets Marital Status Religious Affiliation Race Ethinicity Personal Relation Role Type Guardian Document Level Templates U.S. Realm Header CDA Header Content Modules Participants in Birth Defects Header Record Target Patient Patient Contacts Information Recipient Address Constraints Multiple Races Provider Referred From Birthplace Section Level Templates Birth Defect Diagnosis Section Birth Defect Diagnosis Entry Coded Results Section Simple Observation Constraints Overview Payers Section Payer Type Vocabularies Payer Role Codes ii

5 4.3.3 Payor Role Code Names Cytogenetics Section Genetic Testing Report Clinical Genomic Statement Cytogenetics Associated Observation Cells Analyzed Count Associated Observation Cells Count Associated Observation Cells Karyotyped Count Associated Observation Colonies Count Associated Observation International System for Human Cytogenetic Nomenclature (ISCN) Band Level Chromosome Analysis Overall Interpretation Labor and Delivery History and Physical Pregnancy History Section Social History Section Labor and Delivery Events Section Coded Detailed Physical Examination Procedures and Interventions Coded Event Outcomes Medications Administered Newborn Delivery Newborn Delivery Information Section Coded Detailed Physical Examination Section Active Problems Procedures and Interventions Medications Administered Coded Event Outcomes Care Plan Section Disposition Section Appendix A Reportable Birth Defect Conditions... 1 Appendix B Value Sets... 4 Appendix C Data Element and CDA Element Relationship Table List of Acronyms... 1 iii

6 List of Figures Figure 1-1: Birth Defect Sequence Diagram... 6 Figure 2-1: Birth Defects Header - Subject Type Code Figure 2-2: Birth Defect Header Participant Code Type Figure 2-3: nullflavor Examples Figure 2-4: nullflavor attribute required Example Figure 2-5: Allowed nullflavors when element is required example Figure 2-6: nullflavor explicitly disallowed example Figure 2-7: Ambulatory Healthcare Provider Birth Defect Event Report Document Example Figure 3-1: Example of a US Realm Header Figure 3-2: Patient Contacts Example Figure 3-3: Information Recipient Example Figure 3-4: Address Example Figure 3-5: sdtc:racecode Example Figure 3-6: Provider Referred From Example Figure 3-7: Birthplace Example Figure 4-1: Birth Defects Diagnosis Section Example Figure 4-2: Birth Defects Diagnosis Template Example Figure 4-3: Coded Results Section Example Figure 4-4: Figure Simple Observation Example Figure 4-5: Payers Section Example Figure 4-6: Genetic Testing Report Example Figure 4-7: Clinical Genomic Example Figure 4-8: History of Pregnancies Example Figure 4-9: Coded Social History Section Example Figure 4-10: Labor and Delivery Events Section Example Figure 4-11: Newborn Delivery Section Example Figure 4-12: Active Problems Section Example Figure 4-13: Procedures and Interventions Section Example Figure 4-14: Procedure Entry Example Figure 4-15: Medications Administered Section Example Figure 4-16: Care Plan Section Example Figure 4-17: Encounter Entry Example Figure 4-18: Disposition Section Example iv

7 List of Tables Table 1-1: Prepare and Transport Ambulatory Healthcare Provider Birth Defect Report for Michigan Birth Defects Registry... 5 Table 1-2: Use Case Flow... 6 Table 2-1: Document Specification Table Table 2-2: Marital Status Value Set Table 2-3: Religious Affiliation Value Set Table 2-4: Race Value Set Table 2-5: Ethnicity Value Set Table 2-6: Personal Relationship Role Type Value Set Table 2-7: Guardian Value Set Table 3-1: CDA Header Constraints Table 3-2: Participants in Birth Defects Header Table 4-1: Birth Defects Diagnosis Section Table 4-2: Birth Defects Diagnosis Entry Template Table 4-3: Coded Results Section Table 4-4: Simple Observation Constraints Overview Table 4-5: Payers Section Table 4-6: Payer Type Vocabularies Table 4-7: Payor Role Codes Table 4-8: Role Code Names Table 4-9: Cytogenetics Procedure Type Codes Table 4-10: Chromosome Analysis Codes Table 4-11: Labor and Delivery History and Physical Section Table 4-12: Pregnancy History Section Table 4-13: Pregnancy Observation Value Set Table 4-14: Pregnancy Observation Value Sets Table 4-15: MCH HBS Date of Last Live Birth Metadata Table 4-16: MCH HBS Date of Last Live Birth Value Set Table 4-17: MCH HBS Date of Last Other Pregnancy Outcome Metadata Table 4-18: MCH HBS Date of Last Other Pregnancy Outcome Table 4-19: MCH HBS Number of Prior Pregnancies Metadata Table 4-20: MCH HBS Number of Prior Pregnancies Value Set Table 4-21: MCH HBS Number of Previous Live Births Now Living Metadata Table 4-22: MCH HBS Number of Previous Live Births Now Living Value Set Table 4-23: MCH HBS Number of Previous Live Births Now Dead Metadata Table 4-24: MCH HBS Number of Previous Live Births Now Dead Value Set Table 4-25: BFDR Number of Preterm Births Value Set Metadata v

8 Table 4-26: BFDR Number of Preterm Births Value Set Table 4-27: MCH HBS Poor Pregnancy Outcome History Metadata Table 4-28: MCH HBS Poor Pregnancy Outcome History Value Set Table 4-29: Maternal Risk Factors Value Set Table 4-30: MCH HBS First Prenatal Care Visit Metadata Table 4-31: MCH HBS First Prenatal Care Visit Value Set Table 4-32: MCH HBS Last Prenatal Care Visit Metadata Table 4-33: MCH HBS Last Prenatal Care Visit Value Set Table 4-34: MCH HBS Number of Prenatal Care Visits Metadata Table 4-35: MCH HBS Number Prenatal Care Visits Value Set Table 4-36: MCH HBS Pre-Pregnancy Weight Metadata Table 4-37: MCH HBS Pre-Pregnancy Weight Value Set Table 4-38: BFDR Date of Last Menses Metadata Table 4-39: BFDR Date of Last Menses Value Set Table 4-40: BFDR Infertility Treatment Metadata Table 4-41: BFDR Infertility Treatment Value Set Table 4-42: BFDR Assistive Reproductive Technology Metadata Table 4-43: BFDR Assistive Reproductive Technology Value Set Table 4-44: BFDR Fertility Enhancing Drugs Metadata Table 4-45: BFDR Fertility Enhancing Drugs Value Set Table 4-46: BFDR Obstetric Estimate of Gestation Metadata Table 4-47: BFDR Obstetric Estimate of Gestation Value Set Table 4-48: Coded Social History Section Table 4-49: Coded Social History Observation Value Set Table 4-50: Labor and Delivery Events Section Table 4-51: Labor and Delivery Coded Detailed Physical Examination Value Set Table 4-52: BFDR Mother s Delivery Weight Metadata Table 4-53: BFDR Mother s Delivery Weight Value Set Table 4-54: Labor and Delivery Procedures and Interventions Value Sets Table 4-55: BFDR Unplanned Hysterectomy Metadata Table 4-56: BFDR Unplanned Hysterectomy Value Set Table 4-57: BFDR Facility Location OR Metadata Table 4-58: BFDR Facility Location OR Value Set Table 4-59: BFDR Delivery Metadata Table 4-60: BFDR Delivery Value Set Table 4-61: BFDR Unplanned Operation Metadata Table 4-62: BFDR Unplanned Operation Value Set Table 4-63: BFDR Transfusion Whole Blood or Packed Red Blood Metadata Table 4-64: BFDR Transfusion Whole Blood or Packed Red Blood Value Set vi

9 Table 4-65: BFDR Epidural Anesthesia Procedure Metadata Table 4-66: BFDR Epidural Anesthesia Procedure Value Set Table 4-67: BFDR Spinal Anesthesia Procedure Metadata Table 4-68: BFDR Spinal Anesthesia Procedure Value Set Table 4-69: BFDR Route and Method of Delivery Spontaneous Delivery Metadata Table 4-70: BFDR Route and Method of Delivery Spontaneous Delivery Value Set Table 4-71: BFDR Route and Method of Delivery Forceps Metadata Table 4-72: BFDR Route and Method of Delivery Forceps Value Set Table 4-73: BFDR Route and Method of Delivery Vacuum Metadata Table 4-74: BFDR Route and Method of Delivery Vacuum Value Set Table 4-75: BFDR Route and Method of Delivery Cesarean Metadata Table 4-76: BFDR Route and Method of Delivery Cesarean Value Set Table 4-77: BFDR Route and Method of Delivery Trial of Labor Metadata Table 4-78: BFDR Route and Method of Delivery Trial of Labor Value Set Table 4-79: BFDR Route and Method of Delivery Scheduled Cesarean Metadata Table 4-80: BFDR Route and Method of Delivery Scheduled Cesarean Value Set Table 4-81: BFDR Augmentation of Labor Procedure Metadata Table 4-82: BFDR Augmentation of Labor Procedure Value Set Table 4-83: BFDR Induction of Labor Metadata Table 4-84: BFDR Induction of Labor Value Set Table 4-85: BFDR Cervical Cerclage Metadata Table 4-86: BFDR Cervical Cerclage Value Set Table 4-87: BFDR Tocolysis Metadata Table 4-88: BFDR Tocolysis Value Set Table 4-89: Labor and Delivery Coded Event Outcome Value Sets Table 4-90: MCH HBS Number of Live Births Metadata Table 4-91: MCH HBS Number of Live Births Value Set Table 4-92: Pregnancy Outcome Value Set Table 4-93: BFDR Birth Plurality of Delivery Metadata Table 4-94: BFDR Birth Plurality of Delivery Value Set Table 4-95: BFDR Fetal Presentation at Birth- Breech Metadata Table 4-96: BFDR Fetal Presentation at Birth- Breech Value Set Table 4-97: BFDR Fetal Presentation at Birth- Cephalic Metadata Table 4-98: BFDR Fetal Presentation at Birth- Cephalic Value Set Table 4-99: BFDR Fetal Presentation at Birth- Other Metadata Table 4-100: BFDR Fetal Presentation at Birth- Other Value Set Table 4-101: BFDR ICU Care Metadata Table 4-102: BFDR ICU Care Value Set Table 4-103: BFDR Third Degree Perineal Laceration Metadata vii

10 Table 4-104: BFDR Third Degree Perineal Laceration Value Set Table 4-105: BFDR Fourth Degree Perineal Laceration Metadata Table 4-106: BFDR Fourth Degree Perineal Laceration Value Set Table 4-107: BFDR Ruptured Uterus Metadata Table 4-108: BFDR Ruptured Uterus Value Set Table 4-109: Meconium Staining Metadata Table 4-110: Meconium Staining Value Set Table 4-111: BFDR Premature Rupture Metadata Table 4-112: BFDR Premature Rupture Value Set Table 4-113: Precipitous Labor Metadata Table 4-114: Precipitous Labor Value Set Table 4-115: Prolonged Labor Metadata Table 4-116: Prolonged Labor Value Set Table 4-117: Labor and Delivery Medications Administered Value Set Table 4-118: BFDR Antibiotics Metadata Table 4-119: BFDR Antibiotics Value Set Table 4-120: BFDR Glucocortico Steroids Metadata Table 4-121: BFDR Glucocortico Steroids Value Set Table 4-122: BFDR Augmentation of Labor - Medication Metadata Table 4-123: BFDR Augmentation of Labor - Medication Value Set Table 4-124: BFDR Epidural Anesthesia Medication Metadata Table 4-125: BFDR Epidural Anesthesia Medication Value Set Table 4-126: BFDR Spinal Anesthesia Medication Metadata Table 4-127: BFDR Spinal Anesthesia Medication Value Set Table 4-128: Newborn Delivery Information Section Table 4-129: Coded Detailed Physical Examination Section Table 4-130: Newborn Coded Vital Signs Value Set Table 4-131: MCH HBS Birth Weight Metadata Table 4-132: MCH HBS Birth Weight Value Set Table 4-133: MCH HBS Birth Height Metadata Table 4-134: MCH HBS Birth Height Value Set Table 4-135: Newborn General Appearance Value Set Table 4-136: MCH HBS 5 Min Apgar Score Metadata Table 4-137: MCH HBS 5 Min Apgar Score Value Set Table 4-138: MCH HBS 10 Min Apgar Score Codes Table 4-139: MCH HBS 10 Min Apgar Score Value Set Table 4-140: Active Problems Section Table 4-141: Newborn Delivery Information Active Problems Value Sets Table 4-142: MCH HBS Seizure or Serious Neurologic Dysfunction Metadata viii

11 Table 4-143: MCH HBS Seizure or Serious Neurologic Dysfunction Value Set Table 4-144: Procedures and Interventions Table 4-145: Newborn Delivery Information Procedures and Interventions Value Sets Table 4-146: MCH HBS Antibiotic Administration Procedure Metadata Table 4-147: MCH HBS Antibiotic Administration Procedure Value Set Table 4-148: MCH HBS Karyotype Determination Metadata Table 4-149: MCH HBS Karyotype Determination Value Set Table 4-150: MCH HBS Assisted Ventilation Immediately Following Delivery Metadata Table 4-151: MCH HBS Assisted Ventilation Immediately Following Delivery Value Set Table 4-152: BFDR Total Time on Ventilator Metadata Table 4-153: BFDR Total Time on Ventilator Value Set Table 4-154: Medications Administered Section Table 4-155: Newborn Delivery Medications Administered Product Value Sets Table 4-156: BFDR Newborn Receiving Surfactant Replacement Therapy Metadata Table 4-157: BFDR Newborn Receiving Surfactant Replacement Therapy Value Set Table 4-158: MCH HBS Intramuscular Medication Administration Route Metadata Table 4-159: MCH HBS Intramuscular Administration Route Value Set Table 4-160: BFDR IV Medication Administration Metadata Table 4-161: BFDR IV Medication Administration Route Value Set Table 4-162: BFDR Neonatal Sepsis Metadata Table 4-163: BFDR Neonatal Sepsis Value Set Table 4-164: Newborn Delivery Information Coded Event Outcome Value Sets Table 4-165: BFDR NICU Care Codes Table 4-166: BFDR NICU Care Value Set Table 4-167: MCH HBS Significant Birth Injury Value Set Metadata Table 4-168: MCH HBS Significant Birth Injury Value Set Table 4-169: BFDR Birthplace Value Set Metadata Table 4-170: BFDR Birthplace Value Set Table 4-171: Cause of Death Codes Metadata Table 4-172: Cause of Death Value Set Excerpt Table 4-173: Care Plan Section ix

12 Preface The Michigan Department of Health and Human Services (MDHHS) is supporting eligible professionals meet the Stage 2 Meaningful Use Specialized Registry Objective: Capability to Identify and Report Specific Cases to a Specialized Registry. Michigan s birth defect registry will be accepting birth defect case information in accordance to this implementation guide. For more information on Michigan s process to submit birth defect case reports to meet the specialized registry objective, please contact Laura Rappleye at [email protected]. x

13 1.0 Introduction Birth defects are a serious public health problem across the nation. Every 4 ½ minutes, a baby is born with a major birth defect in the United States. Major birth defects are conditions present at birth that cause structural changes in one or more parts of the body. They can have a serious effect on health, development, or functional ability. About one in every 33 babies is born with a birth defect. Birth defects are a leading cause of infant death, accounting for more than 1 of every 5 infant deaths. In addition, babies born with birth defects have a greater chance of illness and long term disability than babies without birth defects. Birth defects contribute significantly to childhood mortality, morbidity, and long-term disability. Despite the prevalence of birth defects, the reporting of them is lacking. As ambulatory healthcare providers adopt modern electronic health record (EHR) systems, the opportunity to automate and improve birth defect registry reporting is increasing and becoming more feasible. This document provides clear and concise specifications for electronic reporting from ambulatory healthcare provider EHR systems to central birth defect registries) using Health Level Seven (HL7) Clinical Document Architecture (CDA) based standards. This document is designed to guide EHR vendors and public health central birth defect registries in the implementation of standardized electronic reporting. It includes both business rules and standardized specifications. 1.1 Background In 1992, the Michigan Department of Health and Human Services (MDHHS), Division of Vital Records and Health Statistics established the Michigan Birth Defects Registry (MBDR). The MBDR is a confidential and secure registry that relies on reports submitted by all Michigan hospitals and cytogenetic laboratories. In addition to hospitals and cytogenetic laboratories, outpatient pediatric genetic clinics, and other facilities, may report birth defects. The MBDR maintains a file of case reports on children from birth to two years of age born in Michigan or to Michigan residents and diagnosed with a reportable condition in the state of Michigan. About 10,000 Michigan children are born annually with birth defects or other reportable conditions. As of 2013, the MBDR contains over 638,000 reports on more than 307,000 individual children born from 1992 to 2012 with statistical data on the prevalence of birth defects available through the state website 1. Epidemiology and vital records staff analyze registry data and conduct special studies to better understand the impact of birth defects on public health. 1 Michigan Department of Health and Human Services, Birth Defects. January 15, Website: 1

14 The registry enables the collection and development of statistical data on birth defects; surveillance of birth defects; studies of birth defect causes and prevention; and ensures the families of children with birth defects receive appropriate support services. Specifically, the MBDR provides the information needed to compute baseline birth defects incidence and mortality rates and analyze trends; identify and respond to potential clusters; formulate and test hypotheses of causation; plan and develop relevant programs; coordinate assistance for long-term care and follow up; evaluate programs and services; and further educate professionals and the community at large. These activities improve the knowledge concerning the prevention of birth defects and to assure that Michigan children with birth defects have access to available resources and assistance. The ability to meet these goals is largely dependent on the successful functioning of a statewide registry and the quality of the data collected. 1.2 Legal Mandate for Michigan Birth Defects Reporting Public Health Code as Amended The MBDR was established as part of the Public Health Code (Act 368 of 1978) by amending sections 5721 and Section 5721 of Part 57 stipulates that "(1) Each diagnosed incidence of a birth defect, including a congenital or structural malformation, or a biochemical or genetic disease, and any information relevant to incidents of birth defects, shall be reported to the department. (2) The department shall maintain comprehensive statewide records of all information reported to the birth defects registry." The Rules governing reporting, the quality, manner, collection and analysis of the data, and confidentiality regulations are proscribed by the Code and the legislation. Confidentiality of all data is required by law and strictly maintained by the Health Department staff. Section 2631 of the Public Health Code regulates procedures protecting confidentiality and regulating disclosure of data and records Data The MBDR maintains a file of case reports on children diagnosed with a reportable condition at birth through two years of age who were born in Michigan or to a Michigan resident mother. This information is reported to the Registry by hospitals, cytology laboratories, genetics counselors, physicians and others as is authorized by Public Act 236 of 1988 which amended the Public Health Code, Act 368 of The Act directs the Michigan Department of Health and Human Services to establish a comprehensive birth defects registry. The amendment is aimed at improving statewide identification of children with birth defects and facilitating the assessment of service and referral needs for these children Rules The Michigan Birth Defects reporting rules, R , define a reportable defect as "an abnormality of the body's structure or inherent function present at birth, whether the abnormality is detected at the time of delivery or becomes 2

15 apparent at a later date." A registrant is defined as "a child age birth to 2 years who is diagnosed with a reportable birth defect in the state of Michigan." In addition, the rules authorize the Director of the MDHHS to designate case reporting for specific conditions up to the age of 12 years to assure complete case ascertainment. The reports are required for children in an inpatient or outpatient setting or diagnosed by clinical laboratories conducting cytogenetic tests or postmortem examinations. R identifies reportable defects. Reports are to be submitted within 30 days of diagnosis on the confidential Birth Defects Registry report forms provided by the Department of Community Health or by electronic media. 1.3 Purpose This Implementation Guide (IG) contains the necessary specifications for the implementation of standardized data transmissions from an ambulatory healthcare provider EHR to the MBDR. A single standardized method will allow efficient and accurate transmission of birth defects information while reducing the burden on EHR system-specific or registry-specific implementations. 1.4 Audience This IG is designed to provide EHR vendors with the specifications for developing the functionality of the EHR systems used by ambulatory healthcare providers to report information on birth defects patients to the MBDR. The IG may also be informative to ambulatory healthcare providers, MBDR staff, developers, analysts and managers of public health information systems and/or data exchanges. This IG is not intended for use for implementation of birth defects reporting from entities other than ambulatory care settings. 1.5 Scope This IG is intended to provide EHR developers and birth defect registry technical staff with the operational context for use of the ambulatory care electronic birth defect reporting. 1.6 Use Case, Scenarios, Diagrams Scenario There are a variety of scenarios in which a patient encounter includes activities related to birth defects, including diagnosis, referral, treatment, and follow-up. For purposes of this document, an encounter is defined as an interaction between a patient and an ambulatory setting for the purpose of providing healthcare-related service(s). The Use Case is triggered every time the encounter s diagnosis is a birth defect. Scenario: Ambulatory Care Electronic Birth Defect Reporting to a Birth Defect Registry 3

16 User Story Summary: Of the more than 4 million infants born each year in the United States, approximately 120,000 have birth defects. Major birth defects are conditions that: 1) result from a malformation, deformation, or disruption in one or more parts of the body; 2) are present at birth; and 3) have serious, adverse effects on the affected person s health, development, or functioning. Birth defects are a leading cause of morbidity and infant death accounting for more than 20% of infant deaths. 2 Surveillance of birth defects in a population is vital for quantifying the public health impact of birth defects, monitoring trends, forming the basis for etiologic and clinical studies, evaluating prevention strategies and interventions, planning for services, and making informed policy decisions. Many birth defect surveillance programs have instituted mandatory reporting requirements in an effort to receive accurate and complete information about the suspected or diagnosed condition. However, in the existing paper world of medical records, it has made reporting complete and accurate information to public health registries difficult. Reporting only occurs on a targeted basis. Hospitals and health care providers equipped with an electronic means have the capability to submit the information needed. Physicians in settings with limited electronic capabilities are presented with a significant burden when required to report as they must screen for reportable cases then gather and collate the paper documentation from the various testing and diagnostic resources to complete the public health report. This leads to missed cases and undercounting of many conditions. Underreporting of birth defect conditions can slow down progress in measuring the prevalence and impact of these conditions, complicate finding the underlying etiology and delay the development of primary and secondary prevention and intervention strategies. The purpose of the Ambulatory Care Electronic Birth Defect Reporting to a Birth Defect Registry use case is to streamline birth defect reporting to improve the timeliness and completeness of birth defect case information sent to a birth defect or specialized registry while enabling healthcare providers achieve the Meaningful Use Stage 2 Specialized Registry Objective Use Case Overview Use Case Description: This use case describes the automated generation and transmission of birth defects case information from an ambulatory healthcare provider s EHR to public health agencies birth defect or specialized registry. This is intended to provide EHR developers and birth defect registry technical staff with the operational context for use of the ambulatory care electronic birth defect reporting implementation guide. Pre-Conditions: Business, legal and Health Insurance Portability and Accountability Act (HIPAA) policy, procedures and agreements are in place 2 Division of Birth Defects and Developmental Disabilities, NCBDDD, Centers for Disease Control and Prevention (July 19, 2013). Facts About Birth Defects. Retrieved from 4

17 Reportable birth defect case information has been captured and stored in the EHR using the data elements and vocabulary standards referenced in this implementation guide The EHR has the capability to trigger and transmit the generation of electronic report in conformance with the structure and content standards specified in this implementation guide Connectivity to the transport network has been established Table 1-1: Prepare and Transport Ambulatory Healthcare Provider Birth Defect Report for Michigan Birth Defects Registry Actors Ambulatory Healthcare Provider EHR System Intermediary Systems Public Health Agency Birth Defect/Specialized Registry Transport Networks Description An electronic health record with the capability to capture and transform birth defect case information in accordance with the Michigan IG for Ambulatory Healthcare Provider Reporting to the Birth Defect Registry A system performing vocabulary translations, structure and content validations A system collecting electronic birth defect case information Systems providing secure document transport, i.e. Health Information Exchanges (HIE), DIRECT Health Information Service Providers (HISP) Diagnosis and Problem List Triggers: Clinical records of children under the age of 24 months, containing an encounter diagnosis or a problem list reportable birth defect conditions documented in Appendix A Clinical records of children greater than 24 months of age with a previous encounter diagnosis or a problem list reportable birth defect condition with an encounter for treatment for the existing birth defect condition Clinical records of children up to and including 12 years of age for certain medical conditions which are commonly diagnosed after the age of two years containing an encounter diagnosis or a problem list reportable birth defect conditions documented in Appendix A Clinical records of deceased children under the age of 24 months, containing an encounter diagnosis or a problem list reportable birth defect conditions documented in Appendix A Clinical records of deceased children up to and including 12 years of age for certain medical conditions which are commonly diagnosed after the age of two years containing an encounter diagnosis or a 5

18 Table 1-2: Use Case Flow problem list reportable birth defect conditions documented in Appendix A Step Number Step Description 1 EHR captures and stores patient-level birth defect case information 2 EHR generates and transforms an electronic birth defect report in accordance with the Implementation Guide for Ambulatory Healthcare Provider Reporting to the Birth Defect Registry 3 EHR prepares CDA for secure transport 4 CDA sent through a secure transport network 5 EHR logs the transmission information 6 Intermediary system performs translation and validation operations and transforms document into birth defect registry format Figure 1-1: Birth Defect Sequence Diagram Birth Defect CDA Basic Flow EHR 1. Birth Defect Case Information Entered 2. Birth Defect CDA Generated 3. CDA Configured for Secure Transmission 5. Transmission Logged 10. Confirmation Logged Transport Network 4. CDA Transported 9. Confirmation Transported Intermediary System 6. CDA validated, translated and transformed 8. Confirmation of receipt generated and logged Birth Defect Registry 7. Birth Defect Case Information Processed Figure 1-3 illustrates the movement of the birth defects CDA from the EHR, to the central birth defect registry. In the first band, the EHR generates and logs the CDA, then securely passes the CDA through the transport network. An intermediary system translates and transforms the CDA into a format readable by the central birth defect registry. 6

19 Flow Exceptions: Transport network is unavailable EHR, Intermediary system or registry is unavailable Post Conditions: Birth Defect/Specialized Registry surveillance team review case information 1.7 Use of Vocabulary Standards This guide calls for specific vocabulary standards for the exchange of birth defect information. Standard vocabularies, particularly coded data items, enable automated decision support for patient healthcare, as well as for public health surveillance of populations. 1.8 HIPAA Providing information on diagnosed birth defects is permitted under HIPAA and is requested to enhance the ability of the MDHHS to effectively conduct public health surveillance of birth defects. More specifically, 45 Code of Federal Regulations stipulates that personal health information may be disclosed to public health authorities authorized by law to collect or receive the information for the purpose of preventing or controlling disease, injury, or disability, including but not limited to public health surveillance, investigation, and intervention. MDHHS has been authorized by Michigan Compiled Law (MCL) to establish a birth defects registry to develop information on birth defects incidence, the causes of birth defects and the prevention of birth defects. 1.9 Clinical Document Architecture Release 2 (CDA R2) Clinical documents have two key functions: they need to communicate information between health care providers, and they need to comply with local policies, laws and regulations. There are six characteristics of clinical documents defined in the CDA standard. Persistence Stewardship Potential for authentication Context Wholeness Human readability The CDA standard also defines two major sections of a CDA document. The first section of the document is the header, which is use for classification and 7

20 management. The second section is the document body which contains the information from the clinical record. 8

21 2.0 Ambulatory Healthcare Provider Birth Defects Report The Ambulatory Healthcare Provider Birth Defects Event Report contains a cumulative record of a patient s encounters for diagnosis and/or treatment of Birth Defects. This content module inherits from the Medical Documents content module, and so must conform to the requirements of that template as well. 2.1 Document Constraints The Ambulatory Healthcare Provider Birth Defects Event Report specification collects information from several Integrating the Healthcare Enterprise (IHE) Technical Frameworks and Profiles and the HL7 Continuity of Care Document (CCD) IG 3 into one document. These include: IHE Quality, Research, and Public Health (QRPH) Technical Framework Supplements o Birth and Fetal Death Reporting 4 o Health Birth Summary (HBS) 5 o Maternal Child Health (MCH) Birth and Fetal Death Reporting (BFDrpt) 6 o Mother and Child Health (MCH) 7 IHE Patient Care Coordination (PCC) Technical Framework 8 IHE PCC Technical Framework Supplement CDA Content Modules 9 IHE Cardiology Technical Framework Supplement Cardiac Imaging Report Content (CIRC) 10 IG for CDA Release 2 Genetic Testing Report (GTR) 11 IG for Ambulatory Healthcare Provider Reporting to Central Cancer Registries 12 Additional constraints have been placed on certain sections and entries and one new section has been created. All sections and further constraints are fully described and specified in the Section Content Module section of the IG. 3 HL7/ASTM Implementation Guide for CDA R2 Continuity of Care Document (CCD ) Release 1. Copyright 2011: Health Level Seven. 4 IHE QRPH BFDR Trial Implementation. Copyright 2013: IHE International, Inc. 5 IHE QRPH HBS Draft for Public Comment. Copyright: 2012: IHE International, Inc. 6 IHE QRPH MCH BFDrpt Trial Implementation. Copyright 2011: IHE International, Inc. 7 IHE QRPH MCH Trial Implementation. Copyright 2010: IHE International, Inc. 8 IHE Patient Care Coordination Technical Framework, Volume 2 (PCC TF-2): Transaction and Content Modules. Copyright 2013: IHE International, Inc. 9 IHE PCC Technical Framework Supplement, CDA Content Module: Trial Implementation. Copyright 2013: IHE International, Inc. 10 IHE Cariology Technical Framework Supplement, CIRC Content: Trial Implementation. Copyright 2011: IHE International, Inc. 11 Implementation Guide for CDA Release 2 GTR Draft Standard for Trial Use Second Ballot. Copyright 2011: Health Level Seven. 12 Implementation Guide for Ambulatory Healthcare Provider Report to Central Cancer Registries HL7 CDA, Release 1.0. Copyright 2012: Health Level Seven. 9

22 2.2 Parent Template The Ambulatory Healthcare Provider Birth Defects Event Report uses the Medical Document template ( ) as its parent template and inherits all of the constraints from that template. 2.3 Specification This section references content modules using Template ID as the key identifier. Definitions of the modules are found in either the: IHE PCC Volume 2: Final Text IHE PCC Content Modules 2010 Supplement Note: It is important to notice that the BxDefects Report contains information pertaining to a single newborn. In case of multiple births each newborn will be assigned a new CDA if a birth defect is present. The subject participation identifies the subject of a section or entry within a CDA document. This participation is used to identify family members (e.g., in a family history observation), or mother (e.g., in a labor and delivery record) for the purpose of identifying who the particular content in the document applies to when it is other than the patient. 2.4 Birth Defects Header Birth Defects Header shall include the child as the unique patient Role element, while the newborn s mother, and the newborn's father shall be identified, for any sections/entries concerned by means of a subject participation element. Figure 2-1: Birth Defects Header - Subject Type Code <subject typecode='sbj'> <templateid root=' '/> <relatedsubject> <code code='mth' codesystem= codesystemname='iherolecode'/>  <sdtc:id extension" " root=" "/> <name/> <administrativegendercode code="m" codesystem=" " codesystemname='administrativegender'/> <birthtime/> </relatedsubject> </subject> Note: In order to avoid redundant data such as address and telecom to be defined within a <subject> tag each time a section/entry will use it, the mother could be, as well as the father, as a <participant> entity. In this case the related <subject> elements shall refer to it, using the <participant> id for that purpose. In this case, the ID element subject/relatedsubject[/code@code='mth']/subject/[sdtc:id] shall be the same as the one declared in the header for the related participant: participant[/[@typecode='mth']/associatedentity/id 10

23 Figure 2-2: Birth Defect Header Participant Code Type <templateid root=' '/> The <templateid> element identifies this person as a patient contact and must be recorded exactly as shown below. <participant typecode='ind'> <templateid root=' '/> <associatedentity classcode="prs"> <code code="mth" codesystem=' ' displayname='mother'/>  <id extension=" " root=" "/> <addr/> <telecom/> <associatedperson> <name/> </associatedperson> </associatedentity> </participant> 2.5 Conventions Used in this Guide Conformance (Optionality Constraints) The optionality constraints in this implementation guide use the HL7 Consolidated CDA conformance verbs (copyright 2011 Health Level Seven International). The keywords SHALL, SHOULD, MAY, NEED NOT, SHOULD NOT, and SHALL NOT in this document are to be interpreted as described in the HL7 Version 3 Publishing Facilitator's Guide. 13 SHALL: an absolute requirement SHALL NOT: an absolute prohibition against inclusion SHOULD/SHOULD NOT: best practice or recommendation. There may be valid reasons to ignore an item, but the full implications must be understood and carefully weighed before choosing a different course MAY/NEED NOT: truly optional; can be included or omitted as the author decides with no implications The keyword SHALL allow the use of nullflavor unless the requirement is on an attribute or the use of nullflavor is explicitly precluded. The subject of a conformance verb (keyword) in a top-level constraint is the template itself. In nested constraints, the subject is the element in the containing constraint Health Level Seven International. Retrieved from January HL7 Implementation Guide for CDA Release 2: IHE Health Story Consolidation, Release 1; (US Realm) Draft Standard for Trial Use. December

24 2.6 Cardinality Cardinality expresses the number of times an attribute or association may appear in a CDA document instance that conforms to the specifications described within section 4.0. Cardinality is expressed as a minimum and a maximum value separated by.., and enclosed in [ ], e.g., [0..1]. Minimum cardinality is expressed as an integer that is equal to or greater than zero. If the minimum cardinality is zero, the element need only appear in message instances when the sending application has data with which to value the element. Mandatory elements must have a minimum cardinality greater than zero. The maximum cardinality is expressed either as a positive integer (greater than zero and greater than or equal to the minimum cardinality) or as unlimited using an asterisk ( * ). The cardinality indicators may be interpreted as follows: 2.7 Null Flavor 0..1 as zero to one present 1..1 as one and only one present 1..* as one or more present 0..* as zero to many present The nullflavor definitions in this implementation guide use the HL7 Consolidated CDA nullflavor information technology solutions store and manage data, but sometimes data are not available: an item may be unknown, not relevant, or not computable or measureable. 15 In HL7, a flavor of null, or nullflavor, describes the reason for missing data. The following are nullflavor examples. Figure 2-3: nullflavor Examples <birthtime nullflavor= NAV />  Use null flavors for unknown, required, or optional attributes: NI NA NAV UNK No information. This is the most general and default null flavor. Not applicable. Known to have no proper value (e.g., last menstrual period for a male. Temporarily unavailable. Information is not available at this time, but it is expected that it will be available later. Unknown. A proper value is applicable, but is not known. 15 HL7 Implementation Guide for CDA Release 2: IHE Health Story Consolidation, Release 1; (US Realm) Draft Standard for Trial Use. December

25 Figure 2-4: nullflavor attribute required Example 1. SHALL contain exactly one [1..1] Problem List (CodeSystem: LOINC ) or 2. SHALL contain exactly one [1..1] Figure 2-5: Allowed nullflavors when element is required example 1. SHALL contain at least one [1..*] id 2. SHALL contain exactly one [1..1] code 3. SHALL contain exactly one [1..1] effectivetime <entry> <observation classcode="obs" moodcode="evn"> <id nullflavor="ni"/> <code nullflavor="oth"> <originaltext>new Grading system</originaltext> </code> <statuscode code="completed"/> <effectivetime nullflavor="unk"/> <value xsi:type="cd" nullflavor="nav"> <originaltext>spiculated mass grade 5</originalText> </value> </observation> </entry> Figure 2-6: nullflavor explicitly disallowed example 1. SHALL contain exactly one [1..1] effectivetime a. SHALL NOT contain [0..0] nullflavor 2.8 Birth Defects Specification Table Table 2-1: Document Specification Table Template ID TBD Parent Template Medical Document General Description The Ambulatory Healthcare Provider BxDefects Event Report contains a record of a patient s encounter for diagnosis and/or treatment of BxDefects. This content module inherits from the Medical Documents content module, and so must conform to the requirements of that template as well. Document Code LOINC = TBD BxDefect Event Report 13

26 Conformance (Optionalilty) SHALL [1..1] Template Name Section Template Id Value Set Template Id Header Section General Header Constraints for CDA R2 First Name Birth Name Date and Time of Birth Gender Further Constraints applied by Ambulatory Healthcare Provider Birth Defects Event Report Specification recordtarget/patient Role/Patient/name/gi ven recordtarget/patient Role/patient/name/fa mily recordtarget/patient Role/patient/birthTim e recordtarget/patient Role/patient/administ rativegendercode [1..*] Address Useable Period element SHALL be present to indicate the beginning and ending dates the patient indicated that the address was used: ClinicalDocument/rec ordtarget/patientrole/ addr/useableperiod Use attribute SHOULD be present to indicate the purpose of the address (e.g., mailing, home): ClinicalDocument/re cordtarget/patientr ole/addr/@use MAY [0..*] sdtc:racecode HL Implementatio n Guide for CDA Release 2: IHE Health Story Consolidation, Release 1 Newborn Medical Record Number ClinicalDocument/rec ordtarget/patientrole/ patient/sdtc:racecode /@* recordtarget/patientr ole/id 14

27 Conformance (Optionalilty) SHALL [1..1] SHALL [1..1] Template Name Provider Referred From Birthplace Name, State, City, Town, County, or Location of Birth Birth Facility Birth facility Id, name, address Child's Facility Address Child's Facility ID Child Facility's National Provider Identification Number (NPI) Child's Facility Name Section Template Id Guardian Value Set Template Id Cardiac Imaging Report Content (CIRC) Supplement Further Constraints applied by Ambulatory Healthcare Provider Birth Defects Event Report Specification Provider Referred From element SHALL be present. An appropriate distinction of None is permitted: ClinicalDocument/com ponentof/encompassi ngencounter/encount erparticipant//* Birthplace element SHALL be present. An appropriate distinction of None is permitted: ClinicalDocument/rec ordtarget/patientrole/ patient/birthplace//* recordtarget/patientr ole/providerorganizati on recordtarget/patientr ole/providerorganizati on/addr recordtarget/patientr ole/providerorganizati on/id[1] recordtarget/patientr ole/providerorganizati on/id[2] Where: is the child facility's NPI is the NPI's OID recordtarget/patientr ole/providerorganizati on/name The guardians of a patient shall be recorded in the <guardian> element beneath the <patient> element. Guardian element SHALL be present when the patient is a minor child : ClinicalDocument/rec ordtarget/patientrole/ patient/guardian//* 15

28 Conformance (Optionalilty) SHALL [1..1] SHALL [1..1] Template Name Participant Section Template Id Value Set Template Id Active Problems PCC TF-2 Section BxDefects TBD OID PCC Content Diagnosis Module Section Supplement This section documents the ambulatory healthcare provider s diagnosis of the BxDefect(s) after review of all relevant diagnostic examinations and studies. Includes information about the date of diagnosis, the location of the defect. Further Constraints applied by Ambulatory Healthcare Provider Birth Defects Event Report Specification Other contacts are recorded as <participant> elements appearing in the document header. The classcode attribute shall be set to 'IND'. The contacts can be agents of the patient, care givers, emergency contacts, next of kin, or other relations like mother, father respectively. Participant element SHALL be present. An appropriate distinction of None is permitted: ClinicalDocument/Part icipant No Further Constraints This is the key section for the Ambulatory Healthcare Provider BxDefects Event Report and therefore SHALL NOT be null. 16

29 Conformance (Optionalilty) NEWBORN DETAILS SHALL [1..1] SHALL [1..1] SHALL [1..1] Template Name Newborn Delivery Information This section should contain information about: gestational age, size, birth order, Apgar scores, height, weight and cephalic circumference, and resuscitation measures. Section Template Id Labor and Delivery Events This section SHALL contain information pertinent to the labor and delivery process and outcome (e.g. type of labor, method of delivery, membrane detail, placenta detail, admission reason, gestational age at delivery, fetal surveillance, labor complications, and delivery complications). This section shall include the following sections: Problems, Procedures and Interventions, and Event Outcomes subsections. Labor and Delivery History and Physical Value Set Template Id PCC TF Supplement CDA Content Modules (TI) Vol 2: PCC TF Supplement CDA Content Modules (TI) Vol 2: Further Constraints applied by Ambulatory Healthcare Provider Birth Defects Event Report Specification 17

30 Conformance (Optionalilty) SHALL [1..1] SHALL [1..1] SHALL [1..1] Template Name Coded Results Section Section Template Id Value Set Template Id PCC TF-2 Procedures CCD Section Procedures Payers Section PCC TF Further Constraints applied by Ambulatory Healthcare Provider Birth Defects Event Report Specification The Coded Results Section SHALL contain at least one entry for a simple observation for the test result. An appropriate distinction of None is permitted. ClinicalDocument/com ponent/structuredbod y/component/section[t emplateid[@root= ]]/entry/observati on[templateid[@root= ]] No Further Constraints SHALL [1..1] SHALL [1..1] SHALL [1..1] Medications Administered The medications administered section shall contain a description of the relevant medications administered to a patient during the course of an encounter. It shall include entries for medication administration. Medications Section Cytogenetics The Cytogenetic Section resides at the highest level of the Genetic Testing Report and consists of data related to cytogenetic testing such as FISH IHE PCC 2: PCC TF-2 An appropriate distinction of None is permitted. An appropriate distinction of None is permitted. 18

31 Conformance (Optionalilty) Template Name Section Template Id Value Set Template Id Further Constraints applied by Ambulatory Healthcare Provider Birth Defects Event Report Specification The Care Plan Section SHALL contain at least one entry for an encounter for the patient s planned healthcare encounter(s). An appropriate distinction of None is permitted. SHALL [1..1] Care Plan The care plan section shall contain a narrative description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient PCC TF-2 ClinicalDocument/co mponent/structuredb ody/component/secti on[templateid[@root = ]]//entry/e ncounter/performer//* Figure 2-7: Ambulatory Healthcare Provider Birth Defect Event Report Document Example <ClinicalDocument xmlns='urn:hl7-org:v3'> <typeid extension="pocd_hd000040" root=" "/>  <templateid root=' '/>  <templateid root= />  <id root=' ' extension=' '/> <code code='xx-bxdefect' displayname='bxdefect Event Report' codesystem=' ' codesystemname='loinc'/> <title> Ambulatory Healthcare Provider Report to BxDefect Registry </title> <effectivetime value=' '/> <confidentialitycode code='n' displayname='normal' codesystem=' ' codesystemname='confidentiality' /> <languagecode code='en-us'/>  <recordtarget> <patientrole>.. </patientrole> </recordtarget>  <author>.. </author>  <participant>.. </ participant >  <custodian>.. </custodian> <! one or more health care providers who referred the patient to this provider for care --> <componentof> <encompassingencounter> <encounterparticipant>..</encounterparticipant> 19

32 </encompas singencounter> </componentof> <informationrecipient></informationrecipient> <recordtarget> <patientrole> <patient> <birthplace> <place>..</place> </birthplace> </patient> </patientrole> </recordtarget> <! one or more birthplace observations --> <component> <structuredbody> <component> <section> <templateid root=' '/>  </section> </component> <component> <section> <templateid root=' '/>  </section> </component> <component> <section> <templateid root=' '/>  </section> </component> <component> <section> <templateid root=' '/>  </section> </component> <component> <section> <templateid root=' '/>  </section> </component> <component> <section> <templateid root= />  </section> </component> <component> <section> <templateid root= />  </section> </component> </strucuredbody> </component> </ClinicalDocument> 20

33 2.9 Organization of Implementation Guide Conventions Conventions describe the rules adhered to in this specification Document Content Module The Document Content Module describes the constraints for the CDA header, body and entry sections Sections The Section Content Module specifies section-level constraints. For example, the Cytogenetics Genetic Testing Report Section contains a templateid element, a code element, and the results and genetic testing observations Entry Content The Entry Content Module defines the core semantic units of the ambulatory healthcare provider birth defects event report the conformance requirements for CDA clinical statements including associated vocabularies and value sets Vocabulary and Value Sets Vocabularies are groups of terms that are used to create the document. Some of the vocabularies are in general use in the healthcare community; others have been created by the birth defects registry community specifically for birth defects reporting. A value set is a subset of the vocabulary chosen as appropriate for birth defects reporting. Conformance statements indicate whether a specific vocabulary or value is required Vocabulary Conformance This guide calls for specific vocabulary standards for the exchange of BxDefect information. Standard vocabularies, particularly coded data items, enable automated decision support for patient healthcare, as well as for public health surveillance of populations. Public Health Information Network (PHIN) Vocabulary Services seeks to promote the use of standards-based vocabulary within PHIN systems and foster the use and exchange of consistent information among public health partners. These standards are supported by the PHIN Vocabulary Access and Distribution System (VADS) for accessing, searching, and distributing standards-based vocabularies used within PHIN to local, state and national PHIN partner. Furthermore, the templates in this document use terms from several code systems. These vocabularies are defined in various supporting specifications and may be maintained by other bodies, as is the case for the Logical Observation Identifiers 21

34 Names and Codes (LOINC ) and Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT ) vocabularies CDA Header Section Value Sets The following are value sets used in the CDA Header Section, including marital status, religious affiliation, race, ethnicity, personal relation role type, and guardian. However, for a complete list of those value sets used in a CDA, see Appendix B Marital Status Table 2-2: Marital Status Value Set Value Set HL7 Marital Status ID Marital Status Code A D T I L M S P W Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed Print Name Religious Affiliation Table 2-3: Religious Affiliation Value Set Value Set Code System Description HL DYNAMIC Religious Affiliation ID A value set of codes that reflect spiritual faith affiliation Concept Code Concept Name 1001 Adventist 1002 African Religions 1003 Afro-Caribbean Religions 1004 Agnosticism 1005 Anglican 1006 Animism 1061 Assembly of God 1007 Atheism 1008 Babi & Baha'I faiths 1009 Baptist 1010 Bon 22

35 Concept Code Concept Name 1062 Brethren 1011 Cao Dai 1012 Celticism 1013 Christian (non-catholic, non-specific) 1063 Christian Scientist 1064 Church of Christ 1065 Church of God 1014 Confucianism 1066 Congregational 1015 Cyberculture Religions 1067 Disciples of Christ 1016 Divination 1068 Eastern Orthodox 1069 Episcopalian 1070 Evangelical Covenant 1017 Fourth Way 1018 Free Daism 1071 Friends 1072 Full Gospel 1019 Gnosis 1020 Hinduism 1021 Humanism 1022 Independent 1023 Islam 1024 Jainism 1025 Jehovah's Witnesses 1026 Judaism 1027 Latter Day Saints 1028 Lutheran 1029 Mahayana 1030 Meditation 1031 Messianic Judaism 1073 Methodist 1032 Mitraism 1074 Native American 1075 Nazarene 1033 New Age 1034 non-roman Catholic 1035 Occult 1036 Orthodox 1037 Paganism 1038 Pentecostal 1076 Presbyterian 1039 Process, The 1077 Protestant 1078 Protestant, No Denomination 1079 Reformed 1040 Reformed/Presbyterian 1041 Roman Catholic Church 1080 Salvation Army 1042 Satanism 23

36 Concept Code Concept Name 1043 Scientology 1044 Shamanism 1045 Shiite (Islam) 1046 Shinto 1047 Sikism 1048 Spiritualism 1049 Sunni (Islam) 1050 Taoism 1051 Theravada 1081 Unitarian Universalist 1052 Unitarian-Universalism 1082 United Church of Christ 1053 Universal Life Church 1054 Vajrayana (Tibetan) 1055 Veda 1056 Voodoo 1057 Wicca 1058 Yaohushua 1059 Zen Buddhism 1060 Zoroastrianism Race Table 2-4: Race Value Set Value Set Race DYNAMIC Code System(s) Race and Ethnicity - CDC Description A Value Set of codes for Classifying data based upon race. Race is always reported at the discretion of the person for whom this attribute is reported, and reporting must be completed according to Federal guidelines for race reporting. Any code descending from the Race concept (1000-9) in that terminology may be used in the exchange on?oid= &code= Concept Code Concept Name Abenaki Absentee Shawnee Acoma Afghanistani African African American Agdaagux Agua Caliente Agua Caliente Cahuilla Ahtna Ak-Chin 24

37 Concept Code Concept Name Akhiok Akiachak Akiak Akutan Alabama Coushatta Alabama Creek Alabama Quassarte Alakanuk Alamo Navajo Alanvik Alaska Indian Alaska Native Alaskan Athabascan Alatna Aleknagik Aleut Aleut Corporation Aleutian Aleutian Islander Alexander Algonquian Allakaket Allen Canyon Alpine Alsea Alutiiq Aleut Ambler American Indian American Indian or Alaska Native Anaktuvuk Anaktuvuk Pass Andreafsky Angoon Aniak Anvik Apache Arab Arapaho Arctic Arctic Slope Corporation Arctic Slope Inupiat Arikara Arizona Tewa Armenian Aroostook Asian Asian Indian 25

38 Concept Code Concept Name Assiniboine Assiniboine Sioux Assyrian Atka Atmautluak Atqasuk Atsina Attacapa Augustine Bad River Bahamian Bangladeshi Bannock Barbadian Barrio Libre Barrow Battle Mountain Bay Mills Chippewa Beaver Belkofski Bering Straits Inupiat Bethel Bhutanese Big Cypress Bill Moore's Slough Biloxi Birch Creek Bishop Black Black or African American Blackfeet Blackfoot Sioux Bois Forte Botswanan Brevig Mission Bridgeport Brighton Bristol Bay Aleut Bristol Bay Yupik Brotherton Brule Sioux Buckland Burmese Burns Paiute Burt Lake Band Burt Lake Chippewa Burt Lake Ottawa 26

39 Concept Code Concept Name Cabazon Caddo Cahto Cahuilla California Tribes Calista Yupik Cambodian Campo Canadian and Latin American Indian Canadian Indian Canoncito Navajo Cantwell Capitan Grande Carolinian Carson Catawba Cayuga Cayuse Cedarville Celilo Central American Indian Central Council of Tlingit and Haida Tribes Central Pomo Chalkyitsik Chamorro Chefornak Chehalis Chemakuan Chemehuevi Chenega Cherokee Cherokee Alabama Cherokee Shawnee Cherokees of Northeast Alabama Cherokees of Southeast Alabama Chevak Cheyenne Cheyenne River Sioux Cheyenne-Arapaho Chickahominy Chickaloon Chickasaw Chignik Chignik Lagoon Chignik Lake Chilkat Chilkoot 27

40 Concept Code Concept Name Chimariko Chinese Chinik Chinook Chippewa Chippewa Cree Chiricahua Chistochina Chitimacha Chitina Choctaw Chuathbaluk Chugach Aleut Chugach Corporation Chukchansi Chumash Chuukese Circle Citizen Band Potawatomi Clark's Point Clatsop Clear Lake Clifton Choctaw Coast Miwok Coast Yurok Cochiti Cocopah Coeur D'Alene Coharie Colorado River Columbia Columbia River Chinook Colville Comanche Cook Inlet Coos Coos, Lower Umpqua, Siuslaw Copper Center Copper River Coquilles Costanoan Council Coushatta Cow Creek Umpqua Cowlitz Craig Cree 28

41 Concept Code Concept Name Creek Croatan Crooked Creek Crow Crow Creek Sioux Cupeno Cuyapaipe Dakota Sioux Deering Delaware Diegueno Digger Dillingham Dominica Islander Dominican Dot Lake Douglas Doyon Dresslerville Dry Creek Duck Valley Duckwater Duwamish Eagle Eastern Cherokee Eastern Chickahominy Eastern Creek Eastern Delaware Eastern Muscogee Eastern Pomo Eastern Shawnee Eastern Tribes Echota Cherokee Eek Egegik Egyptian Eklutna Ekuk Ekwok Elim Elko Ely Emmonak English English Bay Eskimo Esselen 29

42 Concept Code Concept Name Ethiopian Etowah Cherokee European Evansville Eyak Fallon False Pass Fijian Filipino Flandreau Santee Florida Seminole Fond du Lac Forest County Fort Belknap Fort Berthold Fort Bidwell Fort Hall Fort Independence Fort McDermitt Fort Mcdowell Fort Peck Fort Peck Assiniboine Sioux Fort Sill Apache Fort Yukon French French American Indian Gabrieleno Gakona Galena Gambell Gay Head Wampanoag Georgetown (Eastern Tribes) Georgetown (Yupik-Eskimo) German Gila Bend Gila River Pima-Maricopa Golovin Goodnews Bay Goshute Grand Portage Grand Ronde Grand Traverse Band of Ottawa/Chippewa Grayling Greenland Eskimo Gros Ventres Guamanian Guamanian or Chamorro 30

43 Concept Code Concept Name Gulkana Haida Haitian Haliwa Hannahville Havasupai Healy Lake Hidatsa Hmong Ho-chunk Hoh Hollywood Seminole Holy Cross Hoonah Hoopa Hoopa Extension Hooper Bay Hopi Houma Hualapai Hughes Huron Potawatomi Huslia Hydaburg Igiugig Iliamna Illinois Miami Inaja-Cosmit Inalik Diomede Indian Township Indiana Miami Indonesian Inupiaq Inupiat Eskimo Iowa Iowa of Kansas-Nebraska Iowa of Oklahoma Iowa Sac and Fox Iqurmuit (Russian Mission) Iranian Iraqi Irish Iroquois Isleta Israeili Italian Ivanof Bay 31

44 Concept Code Iwo Jiman Jamaican Jamestown Japanese Jemez Jena Choctaw Jicarilla Apache Juaneno Kaibab Kake Kaktovik Kalapuya Kalispel Kalskag Kaltag Karluk Karuk Kasaan Kashia Kasigluk Kathlamet Kaw Kawaiisu Kawerak Kenaitze Keres Kern River Ketchikan Keweenaw Kialegee Kiana Kickapoo Kikiallus King Cove King Salmon Kiowa Kipnuk Kiribati Kivalina Klallam Klamath Klawock Kluti Kaah Knik Kobuk Kodiak Kokhanok Concept Name 32

45 Concept Code Concept Name Koliganek Kongiganak Koniag Aleut Konkow Kootenai Korean Kosraean Kotlik Kotzebue Koyuk Koyukuk Kwethluk Kwigillingok Kwiguk La Jolla La Posta Lac Courte Oreilles Lac du Flambeau Lac Vieux Desert Chippewa Laguna Lake Minchumina Lake Superior Lake Traverse Sioux Laotian Larsen Bay Las Vegas Lassik Lebanese Leech Lake Lenni-Lenape Levelock Liberian Lime Lipan Apache Little Shell Chippewa Lone Pine Long Island Los Coyotes Lovelock Lower Brule Sioux Lower Elwha Lower Kalskag Lower Muscogee Lower Sioux Lower Skagit Luiseno Lumbee 33

46 Concept Code Concept Name Lummi Machis Lower Creek Indian Madagascar Maidu Makah Malaysian Maldivian Malheur Paiute Maliseet Mandan Manley Hot Springs Manokotak Manzanita Mariana Islander Maricopa Marshall Marshallese Marshantucket Pequot Mary's Igloo Mashpee Wampanoag Matinecock Mattaponi Mattole Mauneluk Inupiat Mcgrath Mdewakanton Sioux Mekoryuk Melanesian Menominee Mentasta Lake Mesa Grande Mescalero Apache Metlakatla Mexican American Indian Miami Miccosukee Michigan Ottawa Micmac Micronesian Middle Eastern or North African Mille Lacs Miniconjou Minnesota Chippewa Minto Mission Indians Mississippi Choctaw Missouri Sac and Fox 34

47 Concept Code Concept Name Miwok Moapa Modoc Mohave Mohawk Mohegan Molala Mono Montauk Moor Morongo Mountain Maidu Mountain Village Mowa Band of Choctaw Muckleshoot Munsee Naknek Nambe Namibian Nana Inupiat Nansemond Nanticoke Napakiak Napaskiak Napaumute Narragansett Natchez Native Hawaiian Native Hawaiian or Other Pacific Islander Nausu Waiwash Navajo Nebraska Ponca Nebraska Winnebago Nelson Lagoon Nenana Nepalese New Hebrides New Stuyahok Newhalen Newtok Nez Perce Nigerian Nightmute Nikolai Nikolski Ninilchik Nipmuc 35

48 Concept Code Concept Name Nishinam Nisqually Noatak Nomalaki Nome Nondalton Nooksack Noorvik Northern Arapaho Northern Cherokee Northern Cheyenne Northern Paiute Northern Pomo Northway Northwest Tribes Nuiqsut Nulato Nunapitchukv Oglala Sioux Okinawan Oklahoma Apache Oklahoma Cado Oklahoma Choctaw Oklahoma Comanche Oklahoma Delaware Oklahoma Kickapoo Oklahoma Kiowa Oklahoma Miami Oklahoma Ottawa Oklahoma Pawnee Oklahoma Peoria Oklahoma Ponca Oklahoma Sac and Fox Oklahoma Seminole Old Harbor Omaha Oneida Onondaga Ontonagon Oregon Athabaskan Osage Oscarville Other Pacific Islander Other Race Otoe-Missouria Ottawa Ouzinkie 36

49 Concept Code Concept Name Owens Valley Paiute Pakistani Pala Palauan Palestinian Pamunkey Panamint Papua New Guinean Pascua Yaqui Passamaquoddy Paugussett Pauloff Harbor Pauma Pawnee Payson Apache Pechanga Pedro Bay Pelican Penobscot Peoria Pequot Perryville Petersburg Picuris Pilot Point Pilot Station Pima Pine Ridge Sioux Pipestone Sioux Piro Piscataway Pit River Pitkas Point Platinum Pleasant Point Passamaquoddy Poarch Band Pocomoke Acohonock Pohnpeian Point Hope Point Lay Pojoaque Pokagon Potawatomi Polish Polynesian Pomo Ponca 37

50 Concept Code Concept Name Poospatuck Port Gamble Klallam Port Graham Port Heiden Port Lions Port Madison Portage Creek Potawatomi Powhatan Prairie Band Prairie Island Sioux Principal Creek Indian Nation Prior Lake Sioux Pueblo Puget Sound Salish Puyallup Pyramid Lake Qagan Toyagungin Qawalangin Quapaw Quechan Quileute Quinault Quinhagak Ramah Navajo Rampart Rampough Mountain Rappahannock Red Cliff Chippewa Red Devil Red Lake Chippewa Red Wood Reno-Sparks Rocky Boy's Chippewa Cree Rosebud Sioux Round Valley Ruby Ruby Valley Sac and Fox Saginaw Chippewa Saipanese Salamatof Salinan Salish Salish and Kootenai Salt River Pima-Maricopa Samish 38

51 Concept Code Concept Name Samoan San Carlos Apache San Felipe San Ildefonso San Juan San Juan De San Juan Pueblo San Juan Southern Paiute San Manual San Pasqual San Xavier Sand Hill Sand Point Sandia Sans Arc Sioux Santa Ana Santa Clara Santa Rosa Santa Rosa Cahuilla Santa Ynez Santa Ysabel Santee Sioux Santo Domingo Sauk-Suiattle Sault Ste. Marie Chippewa Savoonga Saxman Scammon Bay Schaghticoke Scott Valley Scottish Scotts Valley Selawik Seldovia Sells Seminole Seneca Seneca Nation Seneca-Cayuga Serrano Setauket Shageluk Shaktoolik Shasta Shawnee Sheldon's Point Shinnecock 39

52 Concept Code Concept Name Shishmaref Shoalwater Bay Shoshone Shoshone Paiute Shungnak Siberian Eskimo Siberian Yupik Siletz Singaporean Sioux Sisseton Sioux Sisseton-Wahpeton Sitka Siuslaw Skokomish Skull Valley Skykomish Slana Sleetmute Snohomish Snoqualmie Soboba Sokoagon Chippewa Solomon Solomon Islander South American Indian South Fork Shoshone South Naknek Southeast Alaska Southeastern Indians Southern Arapaho Southern Cheyenne Southern Paiute Spanish American Indian Spirit Lake Sioux Spokane Squaxin Island Sri Lankan St. Croix Chippewa St. George St. Mary's St. Michael St. Paul Standing Rock Sioux Star Clan of Muscogee Creeks Stebbins Steilacoom 40

53 Concept Code Concept Name Stevens Stewart Stillaguamish Stockbridge Stony River Stonyford Sugpiaq Sulphur Bank Summit Lake Suqpigaq Suquamish Susanville Susquehanock Swinomish Sycuan Syrian Table Bluff Tachi Tahitian Taiwanese Takelma Takotna Talakamish Tanacross Tanaina Tanana Tanana Chiefs Taos Tatitlek Tazlina Telida Teller Temecula Te-Moak Western Shoshone Tenakee Springs Tenino Tesuque Tetlin Teton Sioux Tewa Texas Kickapoo Thai Thlopthlocco Tigua Tillamook Timbi-Sha Shoshone Tlingit 41

54 Concept Code Concept Name Tlingit-Haida Tobagoan Togiak Tohono O'Odham Tok Tokelauan Toksook Tolowa Tonawanda Seneca Tongan Tonkawa Torres-Martinez Trinidadian Trinity Tsimshian Tuckabachee Tulalip Tule River Tulukskak Tunica Biloxi Tuntutuliak Tununak Turtle Mountain Tuscarora Tuscola Twenty-Nine Palms Twin Hills Two Kettle Sioux Tygh Tyonek Ugashik Uintah Ute Umatilla Umkumiate Umpqua Unalakleet Unalaska Unangan Aleut Unga United Keetowah Band of Cherokee Upper Chinook Upper Sioux Upper Skagit Ute Ute Mountain Ute Utu Utu Gwaitu Paiute Venetie 42

55 Concept Code Concept Name Vietnamese Waccamaw-Siousan Wahpekute Sioux Wahpeton Sioux Wailaki Wainwright Wakiakum Chinook Wales Walker River Walla-Walla Wampanoag Wappo Warm Springs Wascopum Washakie Washoe Wazhaza Sioux Wenatchee West Indian Western Cherokee Western Chickahominy Whilkut White White Earth White Mountain White Mountain Apache White Mountain Inupiat Wichita Wicomico Willapa Chinook Wind River Wind River Arapaho Wind River Shoshone Winnebago Winnemucca Wintun Wisconsin Potawatomi Wiseman Wishram Wiyot Wrangell Wyandotte Yahooskin Yakama Yakama Cowlitz Yakutat Yana 43

56 Concept Code Yankton Sioux Yanktonai Sioux Yapese Yaqui Yavapai Yavapai Apache Yerington Paiute Yokuts Yomba Yuchi Yuki Yuman Yupik Eskimo Yurok Zairean Zia Zuni Concept Name Ethinicity Table 2-5: Ethnicity Value Set Value Set DYNAMIC Code System(s) Race and Ethnicity - CDC Code Code System Print Name Race and Ethnicity Code Sets Hispanic or Latino Race and Ethnicity Code Sets Not Hispanic or Latino Personal Relation Role Type Table 2-6: Personal Relationship Role Type Value Set Value Set Personal Relationship Role Type DYNAMIC Code System(s) RoleCode Description A Personal Relationship records the role of a person in relation to another person. This value set is to be used when recording the relationships between different people who are not necessarily related by family ties, but also includes family relationships Code FAMMEMB Family member Display Name 44

57 Code CHILD CHILDADOPT DAUADOPT SONADOPT CHLDFOST DAUFOST SONFOST CHILDINLAW DAUINLAW SONINLAW DAUC DAU STPDAU NCHILD SON SONC STPSON STPCHILD EXT AUNT MAUNT PAUNT COUSN MCOUSN PCOUSN GGRPRN GGRFTH GGRMTH MGGRFTH MGGRMTH MGGRPRN PGGRFTH PGGRMTH PGGRPRN GRNDCHILD GRNDDAU GRNDSON GRPRN GRFTH GRMTH MGRFTH MGRMTH MGRPRN PGRFTH PGRMTH PGRPRN NIENEPH NEPHEW NIECE UNCLE MUNCLE Display Name Child Adopted child Adopted daughter Adopted son Foster child Foster daughter Foster son Child in-law Daughter in-law Son in-law Daughter child Natural daughter Stepdaughter Natural child Natural son Son child Stepson Stepchild Extended family member Aunt Maternal aunt Paternal aunt Cousin Maternal cousin Paternal cousin Great grandparent Great grandfather Great grandmother Maternal great grandfather Maternal great grandmother Maternal great grandparent Paternal great grandfather Paternal great grandmother Paternal great grandparent Grandchild Granddaughter Grandson Grandparent Grandfather Grandmother Maternal grandfather Maternal grandmother Maternal grandparent Paternal grandfather Paternal grandmother Paternal grandparent Neice/nephew Nephew Niece Uncle Maternal uncle 45

58 Code PUNCLE PRN FTH MTH NPRN NFTH NFTHF NMTH PRNINLAW FTHINLAW MTHINLAW STPPRN STPFTH STPMTH SIB BRO HSIB HBRO HSIS NSIB NBRO NSIS SIBINLAW BROINLAW SISINLAW SIS STPSIB STPBRO STPSIS SIGOTHR DOMPART SPS HUSB WIFE FRND NBOR ROOM RESPRSN EXCEST GUADLTM GUARD POWATT DPOWATT HPOWATT SPOWATT ONESELF Display Name Paternal uncle Parent Father Mother Natural parent Natural father Natural father of fetus Natural mother Parent in-law Father in-law Mother in-law Step parent Stepfather Stepmother Sibling Brother Half-sibling Half-brother Half-sister Natural sibling Natural brother Natural sister Sibling in-law Brother in-law Sister in-law Sister Step sibling Stepbrother Stepsister Significant other Domestic partner Spouse Husband Wife Unrelated friend Neighbor Roommate Responsible party Executor of estate Guardian ad lidem Guardian Power of attorney Durable power of attorney Healthcare power of attorney Special power of attorney Oneself 46

59 Guardian Table 2-7: Guardian Value Set Concept Code Concept Name Preferred Concept Name CGV Care giver Care giver EMC Emergency contact Emergency contact EXF Extended family Extended family FTH Father Father FCH Foster child Foster child FND Friend Friend GCH Grandchild Grandchild GRP Grandparent Grandparent GRD Guardian Guardian DEP Handicapped dependent Handicapped dependent MTH Mother Mother NCH Natural child Natural child NON None None PAR Parent Parent 47

60 3.0 Document Level Templates 3.1 U.S. Realm Header Every clinical document has a context that describes the patient, the document author, the related encounter, and the metadata about the content of the document. This section describes the Reference Information Model (RIM) classes of the CDA header and sets the context for the rest of the CDA document. This section describes constraints that apply to the header for all documents within the scope of this implementation guide. Header constraints specific to each document type are described in the appropriate document-specific section below. SHALL contain exactly one [1..1] realmcode="us" SHALL contain exactly one [1..1] typeid o This typeid SHALL contain exactly one o This typeid SHALL contain exactly one SHALL contain exactly one [1..1] templateid such that it o SHALL contain exactly one SHALL contain exactly one [1..1] id o This id SHALL be a globally unique identifier for the document SHALL contain exactly one [1..1] code o This code SHALL specify the particular kind of document (e.g. History and Physical, Discharge Summary, Progress Note) SHALL contain exactly one [1..1] title o Can either be a locally defined name or the display name corresponding to clinicaldocument/code SHALL contain exactly one [1..1] effectivetime o The content SHALL be a conformant US Realm Date and Time (DTM.US.FIELDED) ( ) o SHALL contain exactly one [1..1] confidentialitycode, which SHOULD be selected from ValueSet HL7 BasicConfidentialityKind STATIC o SHALL contain exactly one [1..1] languagecode, which SHALL be selected from ValueSet Language DYNAMIC MAY contain zero or one [0..1] setid o If setid is present versionnumber SHALL be present MAY contain zero or one [0..1] versionnumber o If versionnumber is present setid SHALL be present 48

61 Figure 3-1: Example of a US Realm Header <realmcode code="us"/> <typeid root=" " extension="pocd_hd000040"/>  <templateid root=" "/>   <templateid root=" "/> <id extension="1234" root=" "/> <code codesystem=" " codesystemname="loinc" code="tbd" displayname="birth Defects Event Report"/> <title> Birth Defects Event Report </title> <effectivetime value=" "/> <confidentialitycode code="n" codesystem=" "/> <languagecode code="en-us"/> <setid extension="s1234" root=" "/> <versionnumber value="1"/> 3.2 CDA Header Content Modules The CDA Content Header includes requirements for: Various header elements o Name o Address o Telecom elements for identified persons and organizations Basic participations o Record target o Author o Legal authenticator The Ambulatory Healthcare Provider BxDefects Report uses the Header Constraints from the Medical Document Template Specification with two additional constraints, detailed further below: Required Provider Referred From element Required Birth Place element The constraints for encoding of the CDA Header (Level 1) can be found in the CDA for Common Document Types History and Physical Implementation Guide, in section 2.0 CDA Header - General Constraints. IHE Medical Documents SHALL follow all constraints found in that section with the exception of the constraint on realmcode found in CONF-HP-10. IHE Medical Documents which are implemented for the US Realm SHALL follow ALL constraints found in that section, and SHALL use both the IHE Medical Document templateid ( ) and the HL7 General Header Constraints templateid ( ). 49

62 Table 3-1: CDA Header Constraints Realm Constraints Template IDs Required Universal CONF-HP-1 through CONF-HP CONF-HP-11 through CONF- HP-40 US CONF-HP-1 through CONF-HP Participants in Birth Defects Header Table 3-2: Participants in Birth Defects Header Participant Author Data Enterer Informant Information Recipient Legal Authenticator Authenticator Participant Documentation of/ Service Event/ Performer Component of/ Encompassing Encounter/ Encounter Participant Description Care team member who generates content contained in the document Examples: PCP, nurse practitioner, admitting physician Care team member who enters information into the document by transferring content from another source, such as a paper chart Examples: transcriptionist, technician Care team member providing information about a patient contained in the document Examples: PCP, family member, caregiver Care team member who the document is intended for Examples: PCP, caregiver, consulting physician Care team member who authenticates content contained in the document and accepts legal responsibility Examples: PCP, consulting physician, attending physician Care team member who authenticates content contained in the document Examples: PCP, consulting physician, attending physician Other supporting care team members associated with the patient Examples: Caregiver, family member, emergency contact Care team member who performs the service event detailed in the document Examples: PCP, surgeon, consulting physician Care team member who participates in the encounter detailed in the document Examples: PCP, consulting physician, attending physician Record Target The recordtarget records the patient whose health information is described by the clinical document; it must contain at least one patientrole element. Furthermore it identifies the medical record in which the associated document appears. 50

63 3.3.2 Patient Contain at least one [1..*] recordtarget. o Such recordtargets SHALL contain exactly one [1..1] patientrole This patientrole SHALL contain at least one [1..*] id This patientrole SHALL contain at least one [1..*] addr The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) ( ) o This patientrole SHALL contain at least one [1..*] telecom Such telecoms SHOULD contain zero or one which SHALL be selected from ValueSet Telecom Use (US Realm Header) DYNAMIC The patient is the most important person associated with the clinical document. Every clinical document requires at least one patient. This patientrole SHALL contain exactly one [1..1] patient o This patient SHALL contain exactly one [1..1] name The content of name SHALL be a conformant US Realm Patient Name (PTN.US.FIELDED) ( ) This patient SHALL contain exactly one [1..1] administrativegendercode, which SHALL be selected from ValueSet Administrative Gender (HL7 V3) DYNAMIC This patient SHALL contain exactly one [1..1] birthtime o SHALL be precise to year o SHOULD be precise to day This patient SHOULD contain zero or one [0..1] maritalstatuscode, which SHALL be selected from Value Set Marital Status Value Set DYNAMIC This patient MAY contain zero or one [0..1] religiousaffiliationcode, which SHALL be selected from Value Set Religious Affiliation Value Set DYNAMIC This patient MAY contain zero or one [0..1] racecode, which SHALL be selected from Value Set Race Value Set DYNAMIC This patient MAY contain zero or one [0..1] ethnicgroupcode, which SHALL be selected from Value Set EthnicityGroup DYNAMIC 51

64 3.3.3 Patient Contacts Patient Contacts: Patient contacts are recorded as described in HL7 CCD: 3.3 Figure 3-2: Patient Contacts Example o The guardians of a patient shall be recorded in the <guardian> element beneath the <patient> element o Other contacts are recorded as <participant> elements appearing in the document header. The classcode attribute shall be set to 'IND' <guardian classcode='guard'> <templateid root=' '/> <code code='' displayname='' codesystem=' ' codesystemname='rolecode'/> <addr></addr> <telecom /> <guardianperson> <name></name> </guardianperson> </guardian> Information Recipient The informationrecipient element records the intended recipient of the information at the time the document is created. For example, in cases where the intended recipient of the document is the patient's health chart, set the receivedorganization to be the scoping organization for that chart. MAY contain zero or more [0..*] informationrecipient Such informationrecipients, if present, SHALL contain exactly one [1..1] intendedrecipient This intendedrecipient MAY contain zero or one [0..1] informationrecipient This informationrecipient, if present, SHALL contain at least one [1..*] name The content of name SHALL be a conformant US Realm Person Name (PN.US.FIELDED) ( ) This intendedrecipient MAY contain zero or one [0..1] receivedorganization This receivedorganization, if present, SHALL contain exactly one [1..1] name 52

65 Figure 3-3: Information Recipient Example <informationrecipient> <intendedrecipient> <informationrecipient> <name> <given>henry</given> <family>seven</family> </name> </informationrecipient> <receivedorganization> <name>good Health Clinic</name> </receivedorganization> </intendedrecipient> </informationrecipient> Address Constraints SHALL conform to Postal Address (AD) to specialize Address Part (ADXP) o o Postal Address is used to provide a series of addresses, including the purpose of the address (e.g., mailing, home, office addresses), and the beginning and ending dates the patient indicated that the address was used SHALL contain at least one [1..*] useableperiod to indicate patient s address history, such that it SHALL contain exactly one [1..1] low to indicate the time when the patient began living at the address SHALL contain exactly one [1..1] high to indicate the time when the patient stopped living at the address SHOULD contain exactly one to indicate the purpose of the address, which SHALL be selected from Value Set Postal Address Use STATIC address/city SHALL be selected from Value Set United States Geological Survey (USGS) Geographic Names Information System (GNIS) (Geocodes) address/state SHALL be selected from Value Set FIPS address/country SHALL be selected from Value Set International Organization for Standardization (ISO)

66 Figure 3-4: Address Example <addr use="wp"> <streetaddressline>800 Main Street</streetAddressLine> <city>aurora</city> <state>mn</state> <postalcode>55705</postalcode> <country>us</country> <useableperiod xsi:type="ivl_ts"> <low value=" "/> <high value=" "/> </useableperiod> </addr> Multiple Races The racecode extension (sdtc:racecode) allows for multiple races to be reported for a patient. MAY appear after racecode to report multiple races. MAY contain zero or more [0..*] sdtc:racecode to report multiple races, which SHALL be selected from Value Set CDC Detailed Race DYNAMIC (PHIN VADS link). Figure 3-5: sdtc:racecode Example <sdtc:racecode code=' ' displayname=' ' codesystem=' ' codesystemname=' '/> <sdtc:racecode code=' ' displayname=' ' codesystem=' ' codesystemname=' '/> Provider Referred From This observation records the provider that referred the patient to the reporting facility. SHALL be included as an encounterparticipant in the header of the CDA document in the event the patient was referred to this ambulatory healthcare provider o An appropriate nullflavor is permitted o If present, SHALL contain the name of the provider that referred the patient to the reporting facility o If present, SHALL contain the assignedentity@id for the physician s National Provider Identifier (NPI) number, which SHALL be selected from Code System NPI SHALL contain a typecode= REF 54

67 Figure 3-6: Provider Referred From Example <componentof> <encompassingencounter xmlns:ihecard= urn:ihe:card > <templateid root= /> <effectivetime value= /> <responsibleparty> </responsibleparty> <encounterparticipant typecode= REF > <assignedentity> <id root= extension= /> <code code= codesystem= codesystemname= nuccprovidercodes displayname= /> <addr>referring physician address</addr> <telecom>referring physician phone</telecom > <assignedperson> <name>referring physician name</name> </assignedperson> </assignedentity> </encounterparticipant> <location> </location> </encompassingencounter > </componentof> Birthplace This observation records the birthplace of the patient. Figure 3-7: Birthplace Example SHALL be included in the patient section of the header of the CDA document. <recordtarget> <patientrole> <patient> <birthplace> <place> <addr> <city></city> <state></state> <country></country> </addr> </place> </birthplace> </patient> </patientrole> </recordtarget> o An appropriate null flavor is permitted. 55

68 4.0 Section Level Templates 4.1 Birth Defect Diagnosis Section This is the key section for the Ambulatory Healthcare Provider Birth Defects Report and, therefore, SHALL NOT be null. Table 4-1: Birth Defects Diagnosis Section Birth Defect Diagnosis Section TBD OID Template ID Parent ID PCC Active Problem Section CCD 3.5 ( ) General Description This section contains specific detailed information about Birth Defect diagnosis(es) that are currently being monitored for the patient. A separate entry for each Birth Defect diagnosis SHALL be provided. LOINC Code OPT Description xxxxx-x SHALL Birth Defect Diagnosis Entries OPT Description SHALL Problem Concern Entry Entry OID TBD SHALL Birth Defect Diagnosis Entry SPECIFICATION SHALL contain exactly three [3..3] templateid such that it o SHALL contain exactly one Section TBD OID" o SHALL conform to PCC Active Problem Section template and contain exactly one o SHALL conform to CCD Problem Section template and contain exactly one SHALL contain exactly one [1..1] code/@code=" " BxDefect Diagnosis (CodeSystem: LOINC ) SHALL contain exactly one [1..1] title SHALL contain exactly one [1..1] text SHALL contain exactly one [1..1] Problem Concern Entry ( ) such that it o SHALL contain at least one [1..*] entryrelationship This entryrelationship SHALL contain exactly one This entryrelationship SHALL contain exactly one This entryrelationship SHALL contain one or more [1..*] Birth Defect Diagnosis Entry(TBD Entry OID) 56

69 Figure 4-1: Birth Defects Diagnosis Section Example <component> <section> <templateid root=" "/> <templateid root=" "/> <templateid root="tbd"/> <id root=' ' extension=' '/> <title>birth Defect Diagnosis</title> <code code=' ' displayname='problem List' codesystem=' ' codesystemname='loinc'/> <text> Text as described above </text> <entry> <act classcode='act' moodcode='evn'> <templateid root=' '/> <templateid root=' '/> <code nullflavor='na'/> <statuscode code='active'/> <effectivetime> <low value=' '/> <high nullflavor="na" /> </effectivetime> <entryrelationship typecode="subj" inversionind="false" >  <templateid root='tbd'/> </entryrelationship> </act> </entry> </section> </component> Birth Defect Diagnosis Entry A Birth Defects Diagnosis entry collects details of the patient s Birth Defects diagnosis, including primary site, diagnosis date, and Best Method of Confirmation. Standards CCD ASTM/HL7 Continuity of Care Document Parent Template The parent of this template is Problem Concern Entry Note The BxDefect Diagnosis Entry is contained within the Problem Concern Entry ( ), therefore, the Constraints Overview and Specification begin at the level of the entry relationship of the BxDefect Diagnosis Entry. 57

70 Table 4-2: Birth Defects Diagnosis Entry Template Name XPath Card Verb Data Type Fixed Value = 'TBD Code 1..1 SHALL (HL7ActClass) = Code 1..1 SHALL (ActMood) = EVN templat 3..3 SHALL SET<II> 1..1 SHALL TBD 1..1 SHALL 1..1 SHALL Code 1..1 SHALL CD (SNOMED CT) = statusc ode 1..1 SHALL CS (ActStatus) = completed value 1..1 SHALL CD TBD SNOMED Anomalies Diagnosis Date effective Time 1..1 SHALL TS or IVL<TS> qualifier 1..1 SHALL Diagnostic Confirmation Primary Site name 1..1 SHALL CD (LOINC) = value 1..1 SHALL CD code 0..1 SHOULD TBD (Diagnostic Confirmation) PHIN VADS link original 0..1 SHOULD ED Text referenc e/@valu e 0..1 SHOULD targetsit 1..1 SHOULS SET<CD ecode > code 1..1 SHALL (International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), Volume 1 & 2) CDC NCHS Website Link OR International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) CDC NCHS Website link OR Body Site (SNOMED CT) PHIN VADS link SPECIFICATION SHALL contain exactly one Observation (CodeSystem: HL7ActClass ) 58

71 SHALL contain exactly one Event (CodeSystem: ActMood ) SHALL contain exactly three [3..3] templateid such that it o SHALL contain exactly one OID" o SHALL conform to IHE Problem Entry template and contain exactly one [1..1]@root=" " o SHALL conform to CCD Problem Observation template and contain exactly one [1..1]@root=" " SHALL contain exactly one [1..1] code=" " Diagnosis (CodeSystem: SNOMED CT ) SHALL contain exactly one [1..1] statuscode="completed" Completed (CodeSystem: ActStatus ) SHALL contain exactly on [1..1] value (CodeSystem: SNOMED CT ) SHALL contain exactly one [1..1] effectivetime that records the date of initial diagnosis by a recognized medical practitioner for the BxDefect being reported SHALL contain exactly one [1..1] qualifier that provides Diagnostic Confirmation information, indicating the best method used to confirm the presence of the BxDefect being reported, such that o This qualifier SHALL contain exactly one [1..1] name=" " Dx confirmed by (CodeSystem: LOINC ) o This qualifier SHALL contain exactly one [1..1] value This value SHOULD contain zero or one [0..1] code, such that If uncoded, SHALL be a string value describing the best method of diagnosis of the Bxdefect. If coded, SHALL be selected from Value Set Diagnostic Confirmation TBD DYNAMIC This value SHOULD contain zero or one [0..1] originaltext The originaltext, if present, SHOULD contain zero or one [0..1] reference/@value o This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section ) SHOULD contain exactly one [1..1] targetsitecode CD to indicate the anatomic location where the primary defect is present o The targetsitecode SHALL contain exactly one where SHALL be selected from one of the following: Code System International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9- CM)Volume 1 & DYNAMIC 59

72 Code System International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) DYNAMIC Value Set Body Site (SNOMED CT) DYNAMIC Figure 4-2: Birth Defects Diagnosis Template Example <section> <templateid root=" "/> <templateid root=" "/> <templateid root="tbd"/> <title>birth Defect Diagnosis</title> <text></text> <entry> <act classcode='act' moodcode='evn'> <templateid root=' '/> <templateid root=' '/> <code nullflavor='na'/> <statuscode code='active'/> <effectivetime> <low value=' '/> <high nullflavor="na" /> </effectivetime> <entryrelationship typecode="subj" inversionind="false" > <observation classcode='obs' moodcode='evn' negationind="false"> <templateid root=' '/> <templateid root=' '/> <templateid root="tbd"/> <code code=" " codesystem=" " codesystemname="snomed CT" displayname="diagnosis"/> <text> <reference value="" ></reference> </text> <statuscode code="completed"/> <effectivetime> <low value=" "/> <high nullflavor="ni"/> </effectivetime>  <value xsi:type="cd" code="" codesystem="" codesystemname="" displayname="" > <qualifier>  <name code=" " codesystem=" " codesystemname="loinc" displayname="diagnostic Confirmation"/> <value xsi:type="cd" code="" codesystem="" codesystemname="" displayname=""/> </qualifier> </value>  <targetsitecode code="" codesystem="" codesystemname="" displayname="" /> </entryrelationship> </act> </entry> </section> 60

73 4.2 Coded Results Section Table 4-3: Coded Results Section Template ID General Description The results section shall contain a narrative description of the relevant diagnostic procedures the patient received in the past. It shall include entries for procedures and references to procedure reports when known as described in the Entry Content Modules. LOINC Code Opt Description SHALL Relevant diagnostic tests/laboratory data Entries Opt Description SHALL Procedure Entry SHOULD References Entry MAY Simple Observation SPECIFICATION SHALL contain exactly one [1..1] templateid such that it o SHALL contain exactly one SHALL contain exactly one [1..1] code/@code=" " Relevant diagnostic tests and/or laboratory data (CodeSystem: LOINC ) SHALL contain exactly one [1..1] title SHALL contain exactly one [1..1] text SHALL contain at least one [1..*] entry such that it o SHALL contain at least one [1..*] Procedure Entry ( ) o SHOULD contain at least one [1..*] References Entry ( ) o MAY contain at least one [1..*] Simple Observation Entry ( ) Coded Results Section Further Conformance Constraints The Ambulatory Healthcare Provider Birth Defect Event Report uses the IHE PCC Coded Results Section, with one additional constraint: SHALL contain at least one [1..*] Simple Observation Entry for the test result Figure 4-3: Coded Results Section Example <component> <section> <templateid root=' '/> <id root=' ' extension=' '/> <code code=' ' displayname='relevant diagnostic tests/laboratory data' codesystem=' ' codesystemname='loinc'/> <text> 61

74 Text as described above </text> <entry> :  <templateid root=' '/> : </entry> <entry> :  <templateid root=' '/> : </entry> <entry> :  <templateid root=' '/> : </entry> </section> </component> Simple Observation Constraints Overview Simple Observations: The simple observation entry is meant to be an abstract representation of many of the observations used in this specification. It can be made concrete by the specification of a few additional constraints, namely the vocabulary used for codes, and the value representation. A simple observation may also inherit constraints from other specifications (e.g., American Society for Testing and Materials (ASTM)/HL7 Continuity of Care Document (CCD)). Standards CCD: ASTM/HL7 Continuity of Care Document Table 4-4: Simple Observation Constraints Overview Observation[templateId/@root = ' '] Name XPath Card. Verb Data Type Fixed Code 1..1 SHALL (HL7ActClass) = dcode 1..1 SHALL (ActMood) = EVN templat 1..1 SHALL SET<II> 1..1 SHALL id 1..* SHALL II code 1..1 SHALL CD text 1..* SHALL ED referen ce 1..* SHALL 62

75 Name XPath Card. Verb Data Type Fixed Value e statusc ode Result DateTime effectiv etime Result Value value 1..1 SHALL ANY Result interpre 0..* MAY CE Interpretation tationc SPECIFICATION ode method Code targets itecod e 1..1 SHALL CS (ActStatus) = completed 1..1 SHALL TS or IVL<TS> 0..1 MAY SET<CE> 0..1 MAY SET<CD> author 0..1 MAY assign edauth or 1..1 SHALL classc ode 1..1 SHALL (HL7RoleClass) =ASSIGNED id 1..1 SHALL II SHALL contain exactly one Observation (CodeSystem: HL7ActClass ) SHALL contain exactly one Event (CodeSystem: ActMood ) SHALL contain exactly one [1..1] SHALL contain at least one [1..*] id SHALL contain exactly one [1..1] code o For Coded Results, MAY be selected from ValueSet Lab Test Result Name (LOINC) SHALL contain at least one [1..0] text SHALL contain at least one [1..*] reference/@value o This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section ) SHALL contain exactly one [1..1] statuscode="completed" (CodeSystem: ActStatus ) SHALL contain exactly one [1..1] effectivetime o SHOULD be precise to the day SHALL contain exactly one [1..1] value MAY contain zero or more [0..*] interpretationcode MAY contain zero or one [0..1] methodcode. 63

76 MAY contain zero or one [0..1] targetsitecode. MAY contain zero or one [0..1] author such that o The person object including name and id SHALL be included when the author of the observation is not an author of the document o The author, if present, SHALL contain exactly one [1..1] assignedauthor o The author, if present, SHALL contain exactly one (CodeSystem: HL7 roleclass ) o The author, if present, SHALL contain exactly one [1..1] id such that it SHOULD reference the id of the author in the Header Figure 4-4: Figure Simple Observation Example <observation classcode='obs' moodcode='evn'> <templateid root=' '/> <id root='' extension=''/> <code code='' displayname='' codesystem='' codesystemname=''/>  <text><reference value='#xxx'/></text>  <statuscode code='completed'/> <effectivetime value=''/> <repeatnumber value=''/> <value xsi:type='' /> <interpretationcode code='' codesystem='' codesystemname=''/> <methodcode code='' codesystem='' codesystemname=''/> <targetsitecode code='' codesystem='' codesystemname=''/> <author typecode='aut'> <assignedauthor classcode='assigned'> <id... /> </assignedauthor> </author> </observation> 4.3 Payers Section Table 4-5: Payers Section Template ID Parent Template CCD 3.1 ( ) General Description The Payers section contains data on the patient s payers, whether a third party insurance, self-pay, other payer or guarantor, or some combination. LOINC Code OPT Description SHALL Payment Sources Entries Opt Description SHOULD Coverage Entry SPECIFICATION 64

77 SHALL contain exactly two [2..2] templateid such that it o SHALL contain exactly one o SHALL conform to CCD Payers Section and contain exactly one SHALL contain exactly one [1..1] code/@code=" " Payers (CodeSystem: LOINC ) SHALL contain exactly one [1..1] title SHALL contain exactly one [1..1] text SHOULD contain zero or more [0..*] entry such that it o SHALL contain exactly one [1..1] Coverage Entry ( ) Figure 4-5: Payers Section Example <component> <section> <templateid root=' '/> <templateid root=' '/> <id root=' ' extension=' '/> <code code=' ' displayname='payment SOURCES' codesystem=' ' codesystemname='loinc'/> <text> Text as described above </text> <entry> :  <templateid root=' '/> : </entry> </section> </component> Payer Type Vocabularies Table 4-6: Payer Type Vocabularies Vocabulary Description OID HL7 ActCoverageType The HL7 ActCoverageType vocabulary describes payers and programs. Note that HL7 does not have a specific code to identify an individual payer, e.g., in the role of a guarantor or patient. X12 Data Element The X12N 271 implementation guide includes various types of payers. This code set does include a code to identify individual payers

78 4.3.2 Payer Role Codes Table 4-7: Payor Role Codes Code PAYOR GUAR PAT Description Used to indicate that the payer is a payor for a policy or program Used to indicate that the payer is a guarantor for the patient Used to indicate that the payer is the patient Payor Role Code Names Table 4-8: Role Code Names Code System Name Role Code Code System Code PH_RoleCode_HL7_V3 Code System OID Concept Code Concept Name FAMDEP Family dependent FSTUD Full-time student HANDIC Handicapped dependent INJ Injured plaintiff PSTUD Part-time student SELF Self SPON Sponsored dependent STUD Student 4.4 Cytogenetics Section Genetic Testing Report LOINC [Section: templateid ] The Cytogentics Section resides at the highest level of the Genetic Testing Report and consists of data related to cytogentics testing such as FISH. SHALL conform to GTR Test Details Section template (templateid: ) SHALL contain [1..1] code/@code = "TBD" Cytogenetics Section (CodeSystem: LOINC STATIC 2.26) (CONF- GTR-25) SHALL contain [1..1] title = "Cytogenetics" (CONF-GTR-26) SHOULD contain [0..*] entry, such that it o COMP (component) o Contains GTR Clinical Genomic Statement Cytogenetics (templateid: ) 66

79 Figure 4-6: Genetic Testing Report Example <component> <section> <templateid root=" " assigningauthorityname="gtr Test Details Section"/> <templateid root=" " assigningauthorityname="gtr Cytogenetics Section"/> <code code="tbd" codesystem=" " codesystemname="loinc" displayname="cytogenetics Section"/> <title>cytogenetics Section</title> <entry> <observation classcode="obs" moodcode="evn"> <templateid root=" " assigningauthorityname="gtr Clinical Genomic Statement"/> <templateid root=" " assigningauthorityname="gtr Clinical Genomic Statement Cytogenetics"/> <code/> <methodcode/> </observation> </entry> </section> </component> Clinical Genomic Statement Cytogenetics The following section is used to display information related to clinical chromosomal analysis related to chromosomal analysis. Observation: template Id The Clinical Genomic Statement Cytogenetics template is a sub-template of Clinical Genomic Statement. It is used by the Cytogenetic Section to carry the structured data in that section. It further constrains the Interpretive Phenotype Observation abstract template by associating to the Interpretive Phenotype Observation Cytogenetics. SHALL conform to GTR Clinical Genomic Statement template (templateid: ) SHALL contain [1..1] code/@code = " " Chromosome analysis result in ISCN expression in Blood or Tissue by Molecular genetics method (CodeSystem: LOINC STATIC 2.26) (CONFGTR-69) SHALL contain [0..1] value (CONF-GTR-70) MAY contain [0..1] entryrelationship, such that it o contains GTR Interpretive Phenotype Cytogenetics (templateid: ) SHOULD contain [0..1] entryrelationship, such that it o contains GTR Cytogenetics Associated Observation Cells Analyzed Count (templateid: ) SHOULD contain [0..1] entryrelationship, such that it 67

80 o contains GTR Cytogenetics Associated Observation Cells Count (templateid: ) o SHOULD contain [0..1] entryrelationship, such that it o contains GTR Cytogenetics Associated Observation Cells Karyotyped Count (templateid: ) SHOULD contain [0..1] entryrelationship, such that it o contains GTR Cytogenetics Associated Observation Colonies Count (templateid: ) SHOULD contain [0..1] entryrelationship, such that it o contains GTR Cytogenetics Associated Observation ISCN Band Level (templateid ) o contains exactly one [1..1] code o contains zero or more [0..*] value SHALL satisfy: value SHALL be asiigned a string composed using the expression syntax of International System for Human Cytogenetics Nomenclature (ISCN) Figure 4-7: Clinical Genomic Example <?xml version="1.0" encoding="utf-8"?> <observation xmlns:xsi=" xmlns="urn:hl7-org:v3" xsi:schemalocation="urn:hl7-org:v3 CDA.xsd" classcode="obs" moodcode="evn"> <templateid root=" "/> <id root=" "/> <code code=" " codesystemname="loinc" displayname="chromosome analysis result in ISCN expression"/> <statuscode code="completed"/> <effectivetime value=" "/> <value xsi:type="cd" code="47,xy,+21" codesystemname="iscn"/> <methodcode code="la " codesystemname="loinc" displayname="g-banding"/ > <subject> <relatedsubject classcode="prs"> <code displayname="placenta"/> </relatedsubject> </subject> <specimen> <templateid root=" "/> <specimenrole> <specimenplayingentity> <code code=" " codesystemname="snomed" displayname="chorionic villi structure"> <originaltext>placental tissue - Villi</originalText> </code> </specimenplayingentity> </specimenrole> </specimen> <performer typecode="prf"> <templateid root=" "/> <assignedentity> <id root=" "/> <representedorganization> <name>the University of Utah Cytogenetics Program at ARUP Laboratories </name> 68

81 </representedorganization> </assignedentity> </performer> <entryrelationship typecode="subj"> <observation classcode="obs" moodcode="evn"> <templateid root=" "/> <code code=" " codesystemname="loinc" displayname="genomic source class"/> <value xsi:type="cd" code="la6683-3" codesystemname="loinc" displayname="prenatal"/> </observation> </entryrelationship> <entryrelationship typecode="subj"> <observation classcode="obs" moodcode="evn"> <templateid root=" "/> <code code=" " codesystemname="loinc" displayname="cells counted [#] in Blood or Tissue by Molecular genetics method"/> <value xsi:type="int" value="20"/> </observation> </entryrelationship> <entryrelationship typecode="subj"> <observation classcode="obs" moodcode="evn"> <templateid root=" "/> <code nullflavor="na" code=" " codesystemname="loinc" displayname="colonies counted [#] in Blood or Tissue by Molecular genetics method"/> </observation> </entryrelationship> <entryrelationship typecode="subj"> <observation classcode="obs" moodcode="evn"> <templateid root=" "/> <code code=" " codesystemname="loinc" displayname="cells analyzed [#] in Blood or Tissue by Molecular genetics method"/> <value xsi:type="int" value="10"/> </observation> </entryrelationship> <entryrelationship typecode="subj"> <observation classcode="obs" moodcode="evn"> <templateid root=" "/> <code code=" " codesystemname="loinc" displayname="cells karyotyped.total [#] in Blood"/> <value xsi:type="int" value="10"/> </observation> </entryrelationship> <entryrelationship typecode="subj"> <observation classcode="obs" moodcode="evn"> <code code=" " codesystemname="loinc" displayname="iscn band level"/> <value xsi:type="cd" code="la " codesystemname="loinc" displayname="425"/> </observation> </entryrelationship> <entryrelationship typecode="rson"> <observation classcode="obs" moodcode="evn"> <id root=" "/> <code/> </observation> </entryrelationship> <entryrelationship typecode="sprt"> <observation classcode="obs" moodcode="def"> <code code="tbd" codesystemname="loinc" displayname="chromosome analysis result interpretation"/> 69

82 <statuscode code="completed"/> <effectivetime value=" "/> <value xsi:type="cd" code="la " displayname="abnormal"/> </observation> </entryrelationship> </observation> Associated Observation Cells Analyzed Count The following template is used to carry information regarding the number of cells analyzed in a cytogenetics test. Observation: template Id The Clinical Genomic Statement Cytogenetics Cells Analyzed Count template is a sub-template of Clinical Genomic Statement Cytogenetics and is used to carry the number of cells analyzed in a cytogenetics test. SHALL conform to GTR Genomic Associated Observation template (templateid: ) MAY contain [1..1] code/@code = " " Cells analyzed [#] in Blood or Tissue by Molecular genetics method (CodeSystem: LOINC STATIC 2.26) MAY contain [0..1] value, where its data type is INT Associated Observation Cells Count Observation: template Id The Clinical Genomic Statement Cytogenetics Cells Count template is a subtemplate of Clinical Genomic Statement Cytogenetics and is used to carry the number of cells counted in a cytogenetics test. SHALL conform to GTR Genomic Associated Observation template (templateid: ) MAY contain [1..1] code/@code = " " Cells counted [#] in Blood or Tissue by Molecular genetics method (CodeSystem: LOINC STATIC 2.26) SHALL contain [0..1] value, where its data type is INT Associated Observation Cells Karyotyped Count Observation: template Id The Clinical Genomic Statement Cytogenetics Cells Karyotyped Count template is a sub-template of Clinical Genomic Statement and is used to carry the number of 70

83 cells karyotyped in a cytogenetics test. SHALL conform to GTR Genomic Associated Observation template (templateid: ) MAY contain [1..1] code/@code = " " Cells karyotyped.total [#] in Blood (CodeSystem: LOINC STATIC 2.26) SHALL contain [0..1] value, where its data type is INT Associated Observation Colonies Count Observation: template Id The Clinical Genomic Statement Cytogenetics Colonies Count template is a subtemplate of Clinical Genomic Statement and is used to carry the number of colonies counted a cytogenetics test. Colony is a discrete focus of cells that is harvested and stained while attached to the cell culture growth substrate. SHALL conform to GTR Genomic Associated Observation template (templateid: ) MAY contain [1..1] code/@code = " " Colonies counted [#] in Blood or Tissue by Molecular genetics method (CodeSystem: LOINC STATIC 2.26) SHALL contain [0..1] value, where its data type is INT Associated Observation International System for Human Cytogenetic Nomenclature (ISCN) Band Level Observation: template Id The Clinical Genomic Statement Cytogenetics ISCN Band Level template is a subtemplate of Clinical Genomic Statement and is used to carry the ISCN band level of the cytogenetics test. SHALL conform to GTR Genomic Associated Observation template (templateid: ) MAY contain [1..1] code/@code = " " ISCN band level (CodeSystem: LOINC STATIC 2.26) MAY contain [0..1] value, which MAY be selected from ValueSet ISCN band level STATIC, where its data type is CD SHALL satisfy: GTR ClinicalGenomicStatementCytogeneticsISCNBandLevel (self) SHALL satisfy: If self.code@code= (LOINC code for ISCN band level), then self.value@code SHALL be drawn from the LOINC Value Set 71

84 Table 4-9: Cytogenetics Procedure Type Codes LOINC Component Chromosome 11 uniparental disomy Chromosome 12 trisomy Chromosome 14 uniparental disomy Chromosome 15 uniparental disomy Chromosome 21 trisomy Chromosome 21 trisomy Chromosome 7 trisomy Chromosome 7 uniparental disomy Chromosome 8 trisomy Chromosome 8 trisomy Chromosome 9 trisomy Method Type Concept Name Preferred Concept Name Bld/Tiss Chrom11 UpDi Bld/T Chromosome 11 Ql uniparental disomy in Blood or Tissue by Cytogenetics Bld/Tiss Chrom12 Ts Bld/T Ql Chromosome 12 trisomy in Blood or Tissue by Cytogenetics Bld/Tiss Bld/Tiss Chrom14 UpDi Bld/T Ql Chrom15 UpDi Bld/T Ql Chromosome 14 uniparental disomy in Blood or Tissue by Cytogenetics Chromosome 15 uniparental disomy in Blood or Tissue by Cytogenetics Bld/Tiss Chrom21 Ts Bld/T Qn Chromosome 21 trisomy [Percentile] in Blood or Tissue by Cytogenetics Bld/Tiss Chrom21 Ts Bld/T Ql Chromosome 21 trisomy in Blood or Tissue by Cytogenetics Bld/Tiss Chrom7 Ts Bld/T Ql Chromosome 7 trisomy in Blood or Tissue by Cytogenetics Bld/Tiss Chrom7 UpDi Bld/T Ql Chromosome 7 uniparental disomy in Blood or Tissue by Cytogenetics Bld/Tiss Chrom8 Ts Bld/T Qn Chromosome 8 trisomy [Percentile] in Blood or Tissue by Cytogenetics Bld/Tiss Chrom8 Ts Bld/T Ql Chromosome 8 trisomy in Blood or Tissue by Cytogenetics Bld/Tiss Chrom9 Ts Bld/T Ql Chromosome 9 trisomy in Blood or Tissue by Cytogenetics 72

85 4.4.8 Chromosome Analysis Overall Interpretation Value Set Chromosome analysis overall interpretation Code System: LOINC Table 4-10: Chromosome Analysis Codes Concept Name Concept Code Code System Normal LA LOINC Abnormal LA LOINC Clinical significance unknown LA LOINC 4.5 Labor and Delivery History and Physical STANDARDS ASTM/HL7 Continuity of Care Document (CCD) HL7 CDA Release 2.0 (CDAR2) American College of Obstetricians and Gynecologists (ACOG), Antepartum Record (ACOGAR) CDA for Common Document Types History and Physical Notes (DSTU) (CDTHP) Table 4-11: Labor and Delivery History and Physical Section Template ID Parent Template TBD General Description The Labor and Delivery History and Physical (LDHP) content profile represents the patient s history and physical performed during admission to the birthing facility. The LDHP is a Medical Summary and inherits all header constraints from Medical Summary. It also uses parts of the Antepartum History and Physical where needed. LOINC Code Opt Description SHALL Labor and delivery process 73

86 Subsections Opt Description Pregnancy History SHALL This section should contain information about: Maternal prenatal care, Birth plurality, Maternal medical complications during pregnancy, maternal surgical complications during pregnancy, medications used by the mother during pregnancy, antenatal steroids, maternal allergies, gestational age by LMP, gestational age by US, prenatal screening chromosomal analysis, fetal anomalies detected by US, and intrauterine therapy. Subsections Opt Description Coded Social History This section shall include the patient s social history including tobacco, alcohol and drug use (current or prior) as well as other environmental exposures. SHALL Pregnancy History Section Table 4-12: Pregnancy History Section Template ID General Description The pregnancy history section contains coded entries describing the patient history of pregnancies. LOINC Code Opt Description SHALL History of Pregnancies Entries Opt Description SHALL Pregnancy Observation ClinicalDocument/recordTarget/component/st mponent/section[templateid[@root= ]]/entry/act/entryRelati onship/observation/code AND ClinicalDocument/recordTarget/component/st mponent/section[templateid[@root= ]]/entry/act/entryRelati onship/observation/value 74

87 Figure 4-8: History of Pregnancies Example <component> <section> <templateid root=' '/> <id root=' ' extension=' '/> <code code=' ' displayname='history OF PREGNANCIES' codesystem=' ' codesystemname='loinc'/> <text> Text as described above </text> <entry>  <templateid root=' '/> </entry> </section> </component> Pregnancy Observation Table 4-13: Pregnancy Observation Value Set This value set is used in the section Pregnancy History. Pregnancy Observation Value Set TBD OID Template ID Pregnancy Observation Table 4-14: Pregnancy Observation Value Sets A Pregnancy Observation element will use LOINC and/or SNOMED code system to identify its contents as the result type. Codes that are used within the scope of this profile are listed below. Data Element Date of Last Live Birth Date of Last Other Pregnancy Outcome (spontaneous or induced losses or ectopic pregnancies) Number of Prior Pregnancies Code Type LOINC SNOMED Value Sets OID TS NA MCH HBS Date of Last Live Birth Value Set TS NA MCH HBS Date of Last Other Pregnancy Outcome Value Set INT NA MCH HBS Number of Prior Pregnancies Value Set

88 Data Element Type Code Value Sets OID Children Now Living (number) INT NA MCH HBS Number of Previous Live Births Now Living Value Set Number of Previous Live Births Now Dead (do not include this child) Previous Preterm Births Poor Pregnancy Outcomes Date of Last Fetal Death Maternal risk Factors Month Prenatal Care Began Date of Last Prenatal Care Visit Total Number of Prenatal Visits for this Pregnancy Mother's Prepregnancy Weight Mother's prepregnancy Height Date of Last Menses 3 INT MCH HBS Number of Previous Live Births Now Dead Value Set INT BFDR Number of Preterm Births Value Set CD NA MCH HBS Poor Pregnancy Outcome History Value Set TS TBD Date of Last Fetal Death Value Set TBD OID CD Maternal Risk Factors Value Set TBD OID TS MCH HBS First Prenatal Care Visit Value Set TS MCH HBS Last Prenatal Care Visit Value Set INT MCH HBS Number Prenatal Care Visits Value Set PQ MCH HBS Pre-Pregnancy Weight Value Set PQ TBD TBD TS Assisted Method CD Use appropriat e code Assisted Reproductive Technology CD Use appropriat e code BFDR Date of Last Menses Value Set BFDR Infertility Treatment Value Set BFDR Assistive Reproductive Technology Value Set

89 Data Element Type Code Value Sets OID Fertility Enhancing Drugs CD BFDR Fertility Enhancing Drugs Value Set Obstetric Estimate of Gestation 4 BFDR Obstetric Estimate of Gestation Value Set Date of Last Live Birth Table 4-15: MCH HBS Date of Last Live Birth Metadata The MCH HBS Date of Last Live Birth Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set MCH HSB Date of Last Live Birth Value Set Source This is the source of the value set, identifying the originator or IHE Quality Research and Public Health Domain publisher of the information Purpose Brief description about the To Reflect the Date of Last Live Definition Source URI general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Birth Extensional definition: The value set was constructed by enumerating the codes from LOINC Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective The date when the value set is 8/1/2010 Date expected to be effective Expiration The date when the value set is N/A Date no longer expected to be used Creation Date The date of creation of the value 8/1/2010 set Revision The date of revision of the value N/A Date set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE MCH:HBS 77

90 Table 4-16: MCH HBS Date of Last Live Birth Value Set The MCH HBS Date of Last Live Birth Value Set will use the LOINC code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Description To Reflect the Date of Last Live Birth LOINC Code Vocabulary Date last live birth LOINC Description Date of Last Other Pregnancy Outcome Table 4-17: MCH HBS Date of Last Other Pregnancy Outcome Metadata The MCH HBS Date of Last Other Pregnancy Outcome Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set MCH HBS Date of Last Other Pregnancy Outcome Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Definition Source URI Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective The date when the value set is 8/1/2010 Date expected to be effective Expiration The date when the value set is N/A Date no longer expected to be used Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the value set N/A To Reflect the Date of Last Other Pregnancy Outcome Extensional definition: The value set was constructed by enumerating the codes from LOINC 78

91 Element Description Mandatory Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE MCH:HBS Table 4-18: MCH HBS Date of Last Other Pregnancy Outcome Section Template Entry Template Value Set OID Value Set Description To Reflect the Date of Last Other Pregnancy Outcome Vocabulary OID LOINC Code LOINC Description Pending Pending Number of Prior Pregnancies Table 4-19: MCH HBS Number of Prior Pregnancies Metadata The MCH HBS Number of Prior Pregnancies Value Set Metadata shall contain the following content. Element Descritption Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set MCH Number of Prior Pregnancies Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Publich Health Domain Purpose Definition Source URI Version Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set To Reflect the Number of Prior Pregnancies Extensional definition: The value set was constructed by enumerating the codes from LOINC Version 1.0 Status Active (Current) or Inactive Active Effective Date The date when the value set 8/1/2010 is expected to be effective 79

92 Element Descritption Mandatory Expiration The date when the value set N/A Date is no longer expected to be used Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the N/A value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE MCH:HBS Table 4-20: MCH HBS Number of Prior Pregnancies Value Set Section Template Entry Template Value Set OID Value Set Code PHVS_NumberOfPriorPregnancies_NCHS Value Set Description To Reflect the Number of Prior Pregnancies Vocabulary OID LOINC Code LOINC Description Pregnancies Parity Number of Previous Live Births Now Living Table 4-21: MCH HBS Number of Previous Live Births Now Living Metadata Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set MCH HBS Number of Previous Live Births Now Living Value Set Source Purpose Definition Source URI This is the source of the value set, identifying the originator or publisher of the information Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set IHE Quality Research and Public Health Domain To Reflect the Previous Other Pregnancy Outcomes Extensional definition: The value set was constructed by enumerating the codes from LOINC 80

93 Element Description Mandatory Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date Revision Date Groups The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned 8/1/2010 N/A 8/1/2010 N/A IHE MCH:HBS Table 4-22: MCH HBS Number of Previous Live Births Now Living Value Set The MCH HBS Number of Previous Live Births Now Living Value Set will use the LOINC code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_NoOfPreviousLiveBirthsNowLiving_NCHS Value Set Description To Reflect the Previous Other Pregnancy Outcomes LOINC Code Vocabulary Births still living LOINC Description Number of Previous Live Births Now Dead Table 4-23: MCH HBS Number of Previous Live Births Now Dead Metadata The MCH HBS Number of Previous Live Births Now Dead Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set MCH HBS Number of Previous Live Births Now Dead Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Brief description about the general purpose of the value set To Reflect the Previous Other Pregnancy Outcomes 81

94 Element Description Mandatory Definition A text definition describing how concepts in the value set were selected Extensional definition: The value set was constructed by enumerating the codes from Source URI Version Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set LOINC Version 1.0 Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the value 8/1/2010 set Revision Date The date of revision of the value N/A set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE MCH:HBS Table 4-24: MCH HBS Number of Previous Live Births Now Dead Value Set The MCH HBS Number of Previous Live Births Now Dead Value Set will use the LOINC code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Description To Reflect the Previous Other Pregnancy Outcomes Vocabulary Code System Name LOINC LOINC Code LOINC Description Live births.now dead Number of Preterm Births Table 4-25: BFDR Number of Preterm Births Value Set Metadata The BFDR Number of Preterm Births Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set

95 Element Description Mandatory Name This is the name of the value set Number of Preterm Births Value Set Source Purpose Definition Source URI Version This is the source of the value set, identifying the originator or publisher of the information Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set IHE Quality Research and Public Health Domain To reflect the number of preterm births in prior pregnancies Extensional definition: The value set was constructed by enumerating the codes from LOINC Version 1.0 Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2011 expected to be effective Expiration The date when the value set is no N/A Date longer expected to be used Creation Date The date of creation of the value 8/1/2011 set Revision Date The date of revision of the value N/A set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-26: BFDR Number of Preterm Births Value Set The BFDR Number of Preterm Births Value Set will use the LOINC code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set OID Value Set Description To reflect the number of preterm births in prior pregnancies Vocabulary OID LOINC Code Births Preterm (reported) LOINC Description 83

96 Poor Pregnancy Outcome History Table 4-27: MCH HBS Poor Pregnancy Outcome History Metadata The MCH HBS Poor Pregnancy Outcome History Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set MCH HSB Poor Pregnancy Outcome History Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Definition Source URI Version Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set To reflect Risk Factors of Pregnancy Outcome of Perinatal Death History Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT mls/snomed/snomed_main.html Version 1.0 Status Active (Current) or Inactive Active Effective The date when the value set 8/1/2010 Date is expected to be effective Expiration Date The date when the value set is no longer expected to be N/A Revision Date Groups used The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned N/A IHE MCH:HSB Table 4-28: MCH HBS Poor Pregnancy Outcome History Value Set The MCH HBS Poor Pregnancy Outcome History Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set OID

97 Value Set Code PHVS_PoorPregnancyOutcomeHistory_NCHS Value Set Description To reflect Risk Factors of Pregnancy Outcome of Perinatal Death History SNOMED Code Vocabulary SNOMED Description Antenatal care: history of perinatal death (situation) Antenatal care: history of stillbirth (situation) Antenatal care: history of trophoblastic disease (situation) Antenatal care: poor obstetric history (situation) History of Miscarriage History of 1 Miscarriage History of 2 Miscarriage History of 3 Miscarriage History of 4 Miscarriages History of 5 Miscarriages History of 6 Miscarriages History of - antepartum hemorrhage (situation) History of - delivery no details (situation) History of - delivery no details (situation) History of - eclampsia (situation) History of - ectopic pregnancy (situation) History of - obstetric problem (situation) History of - postpartum hemorrhage (situation) History of - premature delivery (situation) History of - prolonged labor (situation) History of - severe pre-eclampsia (situation) History of - stillbirth (situation) History of choriocarcinoma of placenta (situation) History of premature labor (situation) Maternal Risk Factors Table 4-29: Maternal Risk Factors Value Set Section Template Entry Template Value Set OID TBD SNOMED-CT Code 0 No known risk factors SNOMED-CT Description 85

98 SNOMED-CT Code SNOMED-CT Description 1 Diabetes (pre-existing condition) 2 Diabetes (gestational) 3 Hypertension (pre-existing condition) 4 Hypertension (gestational) 5 Hypertension (eclampsia) 6 Previous preterm birth 7 Previous other poor-outcome birth 8 Pregnancy resulted from infertility Tx 9 Previous cesarean delivery 10 Gonorrhea infection 11 Syphilis infection 12 Chlamydia infection 13 Listeria infection 14 Group B Streptococcus infection 15 Cytomegalovirus infection 16 Parovirus infection 17 Toxoplasmsis infection 18 Hepatitus B infection 19 Hepatitus C infection 20 Drug use during pregnancy 21 Cigarette smoking during pregnancy 22 Alcohol use during pregnancy 23 Seizure 24 Obesity 25 HIV 26 Mental Disorder 27 Major Injury 28 Hyper/Hypothyroidism 29 Anemia(chronic, not anemia of pregnancy) 30 HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) 23 Other risk factor 99 Unknown 86

99 First Prenatal Care Visit Table 4-30: MCH HBS First Prenatal Care Visit Metadata The MCH HBS First Prenatal Care Visit Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set MCH HBS First Prenatal Care Visit Value Set Source This is the source of the value set, identifying the IHE Quality Research and Public Health Domain originator or publisher of the information Purpose Brief description about the general purpose of the value To Reflect the First Prenatal Care Visit Definition Source URI Version set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT Snomed/snomed_main.html Version 1.0 Status Active (Current) or Inactive Active Effective Date The date when the value set 8/1/2010 is expected to be effective Expiration Date The date when the value set N/A is no longer expected to be used Creation Date Revision Date Groups The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned 8/1/2010 N/A IHE MCH:HBS Table 4-31: MCH HBS First Prenatal Care Visit Value Set Section Template Entry Template Value Set Value Set Code PHVS_FirstPrenatalCareVisit_NCHS Value Set Description To Reflect the First Prenatal Care Visit 87

100 Vocabulary SNOMED-CT Code SNOMED-CT Description Prenatal initial visit (regime/therapy) Last Prenatal Care Visit Table 4-32: MCH HBS Last Prenatal Care Visit Metadata The MCH HBS Last Prenatal Care Visit Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set MCH HBS Prenatal Care Visit Value Set Source This is the source of the value IHE Quality Research and Public set, identifying the originator or Health Domain publisher of the information Purpose Definition Source URI Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration The date when the value set is N/A Date no longer expected to be used Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the N/A value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE MCH:HBS To Reflect the Last Prenatal Care Visit Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT /Snomed/snomed_main.html Table 4-33: MCH HBS Last Prenatal Care Visit Value Set The MCH HBS Last Prenatal Care Visit Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. 88

101 Section Template Entry Template Value Set Value Set Description To Reflect the Last Prenatal Care Visit Vocabulary SNOMED-CT Code SNOMED-CT Description Pending Pending Number of Prenatal Care Visits Table 4-34: MCH HBS Number of Prenatal Care Visits Metadata The MCH HBS Number Prenatal Care Visits Value Set Metadata shall contain the following content. Element Descritption Mandatory Identifier Name Source Purpose Definition Source URI Version This is the unique identifier of the value set This is the name of the value set This is the source of the value set, identifying the originator or publisher of the information Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set MCH HBS Number Prenatal Care Visits Value Set IHE Quality Research and Publich Health Domain To reflect the Number Prenatal Care Visits Extensional definition: The value set was constructed by enumerating the codes from LOINC Version 1.0 Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set 8/1/2010 N/A 8/1/

102 Element Descritption Mandatory Revision Date Groups The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned N/A IHE MCH:HBS Table 4-35: MCH HBS Number Prenatal Care Visits Value Set The MCH HBS Number Prenatal Care Visits Value Set will use the LOINC code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set OID Value Set Description To reflect the Number Prenatal Care Visits LOINC Code Vocabulary LOINC Description Prenatal visits for this pregnancy Pre-Pregnancy Weight Table 4-36: MCH HBS Pre-Pregnancy Weight Metadata The MCH HBS Pre-Pregnancy Weight Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set MCH HBS Pre-Pregnancy Weight Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Definition Source URI Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set To Reflect the mother s Pre-Pregnancy Weight Extensional definition: The value set was constructed by enumerating the codes from LOINC 90

103 Element Description Mandatory Version A string identifying the Version 1.0 specific version of the value set Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date Revision Date Groups The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned 8/1/2010 N/A 8/1/2010 N/A IHE MCH:HBS Table 4-37: MCH HBS Pre-Pregnancy Weight Value Set The MCH HBS Pre-Pregnancy Weight Value Set will use the LOINC code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set OID Value Set Code PHVS_PrePregnancyWeight_NCHS Value Set Description To Reflect the mother s Pre-Pregnancy Weight LOINC Code Vocabulary LOINC Description Body weight^pre current pregnancy Body weight^pre pregnancy Date of Last Menses Table 4-38: BFDR Date of Last Menses Metadata The BFDR Date of Last Menses Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Date of Last Menses Value Set 91

104 Element Description Mandatory Source This is the source of the value set, identifying the originator or publisher of the information Purpose Definition Source Uniform Resource Identifier (URI) Version Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set IHE Quality Research and Publich Health Domain To reflect the Date of Last Menses Extensional definition: The value set was constructed by enumerating the codes from LOINC Version 1.0 Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date Revision Date Groups The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned 8/1/2010 Not Applicable (N/A) 8/1/2010 N/A IHE BFDR Table 4-39: BFDR Date of Last Menses Value Set The BFDR Date of Last Menses Value Set will use the LOINC code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set OID Value Set Code PHVS_NumberofLiveBirths_NCHS Value Set Description To reflect the Date of Last Menses Vocabulary OID LOINC Code Menstrual period start last LOINC Description Estimated last menstrual period Date last menstrual period 92

105 Infertility Treatment Table 4-40: BFDR Infertility Treatment Metadata The BFDR Infertility Treatment Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Infertility Treatment Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Publich Health Domain Purpose Definition Source Uniform Resource Identifier (URI) Version Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set. To reflect Risk Factors of Pregnancy Infertility Treatment Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT mls/snomed/snomed_main.html Version 1.0 Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date Revision Date Groups The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned 8/1/2010 Not Applicable (N/A) 8/1/2010 N/A IHE BFDR Table 4-41: BFDR Infertility Treatment Value Set The BFDR Infertility Treatment Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template

106 Value Set OID Value Set Code PHVS_InfertilityTreatment_NCHS Value Set Description To reflect Risk Factors of Pregnancy Infertility Treatment Vocabulary OID SNOMED-CT Code Infertility therapy (procedure) SNOMED-CT Description Female infertility therapy (procedure) Artificial insemination by donor (procedure) Artificial insemination by husband (procedure) Artificial insemination with sperm washing and capacitation (procedure) Artificial insemination, heterologous (procedure) Artificial insemination, homologous (procedure) Intracervical artificial insemination (procedure) Intrauterine artificial insemination (procedure) Intrauterine insemination using donor sperm (procedure) Intrauterine insemination using partner sperm (procedure) Intrauterine insemination with controlled ovarian hyperstimulation using donor sperm (procedure) Intrauterine insemination with controlled ovarian hyperstimulation using partner sperm (procedure) Intravaginal artificial insemination (procedure) Subzonal insemination (procedure) Gamete intrauterine transfer (procedure) Gamete intrafallopian transfer (procedure) Endoscopic intrafallopian transfer of gamete (procedure) Fallopian replacement of egg with delayed insemination (procedure) Subzonal insemination Tubal embryo transfer Zygote intrafallopian transfer Assisted fertilization (procedure) Assistive Reproductive Technology Table 4-42: BFDR Assistive Reproductive Technology Metadata The BFDR Assistive Reproductive Technology Value Set Metadata shall contain the following content. 94

107 Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Assistive Reproductive Technology Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Publich Health Domain Purpose Definition Source Uniform Resource Identifier (URI) Version Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set To reflect the Assistive Reproductive Technology as a Risk Factor in Pregnancy Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT mls/snomed/snomed_main.html Version 1.0 Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date Revision Date Groups The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned 8/1/2010 Not Applicable (N/A) 8/1/2010 N/A IHE BFDR Table 4-43: BFDR Assistive Reproductive Technology Value Set Assistive Reproductive Technology Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set OID Value Set Code PHVS_AssistiveReproductiveTechnology_NCHS Value Set Description To reflect the Assistive Reproductive Technology as a Risk Factor in Pregnancy Vocabulary OID

108 SNOMED-CT Code SNOMED-CT Description Test tube ovum fertilization (procedure) Assisted fertilization (procedure) Gamete intrauterine transfer (procedure) Endoscopic intrafallopian transfer of gamete (procedure) Direct injection of sperm into cytoplasm of the oocyte (procedure) Direct intraperitoneal insemination Zona drilling (procedure) Subzonal insemination Gamete intrafallopian transfer (procedure) Fallopian replacement of egg with delayed insemination (procedure) Zygote intrafallopian transfer (procedure) Tubal embryo transfer (procedure) Intraperitoneal insemination In vitro fertilization using donor eggs (procedure) In vitro fertilization with intracytoplasmic sperm injection (procedure) In vitro fertilization with preimplantation genetic diagnosis (procedure) In vitro fertilization using donor egg and intracytoplasmic sperm injection (procedure) In vitro fertilization using donor sperm (procedure) Conceived by in vitro fertilization (finding) Fertility Enhancing Drugs Table 4-44: BFDR Fertility Enhancing Drugs Metadata The BFDR Fertility Enhancing Drugs Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Fertility Enhancing Drugs Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Publich Health Domain Purpose Brief description about the general purpose of the value set To reflect that Fertility Enhancing Drugs were administered as a risk factor for pregnancy 96

109 Element Description Mandatory Definition A text definition describing how concepts in the value set were selected Extensional definition: The value set was constructed by enumerating the codes from Source Uniform Resource Identifier (URI) Version Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set. RxNORM mls/rxnorm/ Version 1.0 Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date Revision Date Groups The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned 8/1/2010 Not Applicable (N/A) 8/1/2010 N/A IHE BFDR Table 4-45: BFDR Fertility Enhancing Drugs Value Set Medication codes indicating Fertility Enhancing Drugs use the RxNorm code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set OID Value Set Description To reflect that Fertility Enhancing Drugs were administered as a Risk Factor in Pregnancy Vocabulary OID RxNorm Code RxNorm Description Clomiphene 50 MG Oral Tablet Follicle Stimulating Hormone 150 UNT/ML / Luteinizing Hormone 150 UNT/ML Injectable Solution Follicle Stimulating Hormone 75 UNT/ML / Luteinizing Hormone 75 UNT/ML Injectable Solution Urofollitropin 150 UNT/ML Injectable Solution Urofollitropin 300 UNT/ML Injectable Solution ML follitropin beta 833 UNT/ML Prefilled Syringe ML follitropin beta 833 UNT/ML Prefilled Syringe 97

110 RxNorm Code RxNorm Description ML follitropin beta 833 UNT/ML Prefilled Syringe follitropin beta 350 UNT per 0.42 ML Prefilled Syringe follitropin beta 75 UNT/ML Injectable Solution follitropin beta 833 UNT/ML Injectable Solution Follitropin Alfa 300 UNT/ML Injectable Solution Follitropin Alfa 600 UNT/ML Injectable Solution follitropin alfa 75 UNT/ACTUAT Prefilled Pen, 12 ACTUAT Follitropin Alfa 75 UNT/ACTUAT Prefilled Syringe, 4 ACTUAT follitropin alfa 75 UNT/ACTUAT Prefilled Syringe, 6 ACTUAT Follitropin Alfa 75 UNT/ML Injectable Solution Chorionic Gonadotropin UNT/ML Injectable Solution chorionic gonadotropin 0.25 MG per 0.5 ML Prefilled Syringe Chorionic Gonadotropin 0.25 MG/ML Injectable Solution Chorionic Gonadotropin 0.5 MG/ML Injectable Solution Chorionic Gonadotropin UNT/ML Injectable Solution Chorionic Gonadotropin 500 UNT/ML Injectable Solution Bromocriptine 2.5 MG Oral Tablet bromocriptine 5 MG (bromocriptine mesylate 5.74 MG) Oral Capsule HR Metformin hydrochloride 1000 MG / saxagliptin 2.5 MG Extended Release Tablet HR Metformin hydrochloride 1000 MG / saxagliptin 5 MG Extended Release Tablet HR Metformin hydrochloride 500 MG / saxagliptin 5 MG Extended Release Tablet Glipizide 2.5 MG / Metformin hydrochloride 250 MG Oral Tablet Glipizide 2.5 MG / Metformin hydrochloride 500 MG Oral Tablet Glipizide 5 MG / Metformin hydrochloride 500 MG Oral Tablet Glyburide 1.25 MG / Metformin hydrochloride 250 MG Oral Tablet Glyburide 2.5 MG / Metformin hydrochloride 500 MG Oral Tablet Glyburide 5 MG / Metformin hydrochloride 500 MG Oral Tablet Metformin hydrochloride 100 MG/ML Oral Solution HR Metformin hydrochloride 1000 MG / pioglitazone 15 MG Extended Release Tablet Metformin hydrochloride 1000 MG / pioglitazone 15 MG Extended Release Tablet 98

111 RxNorm Code RxNorm Description HR Metformin hydrochloride 1000 MG / pioglitazone 30 MG Extended Release Tablet Metformin hydrochloride 1000 MG / pioglitazone 30 MG Extended Release Tablet Metformin hydrochloride 1000 MG / rosiglitazone 2 MG Oral Tablet Metformin hydrochloride 1000 MG / rosiglitazone 4 MG Oral Tablet Metformin hydrochloride 1000 MG / saxagliptin 2.5 MG Extended Release Tablet Metformin hydrochloride 1000 MG / saxagliptin 5 MG Extended Release Tablet Metformin hydrochloride 1000 MG / sitagliptin 50 MG Oral Tablet HR Metformin hydrochloride 1000 MG Extended Release Tablet Metformin hydrochloride 1000 MG Extended Release Tablet Metformin hydrochloride 1000 MG Oral Tablet Metformin hydrochloride 500 MG / pioglitazone 15 MG Oral Tablet Metformin hydrochloride 500 MG / repaglinide 1 MG Oral Tablet Metformin hydrochloride 500 MG / repaglinide 2 MG Oral Tablet Metformin hydrochloride 500 MG / rosiglitazone 1 MG Oral Tablet Metformin hydrochloride 500 MG / rosiglitazone 2 MG Oral Tablet Metformin hydrochloride 500 MG / rosiglitazone 4 MG Oral Tablet Metformin hydrochloride 500 MG / saxagliptin 5 MG Extended Release Tablet Metformin hydrochloride 500 MG / sitagliptin 50 MG Oral Tablet HR Metformin hydrochloride 500 MG Extended Release Tablet Metformin hydrochloride 500 MG Extended Release Tablet Metformin hydrochloride 500 MG Oral Tablet Metformin hydrochloride 625 MG Oral Tablet HR Metformin hydrochloride 750 MG Extended Release Tablet Metformin hydrochloride 750 MG Extended Release Tablet Metformin hydrochloride 850 MG / pioglitazone 15 MG Oral Tablet Metformin hydrochloride 850 MG Oral Tablet 99

112 RxNorm Code RxNorm Description Metformin Oral Tablet Glyburide / Metformin Oral Tablet Metformin / pioglitazone Extended Release Tablet Metformin / pioglitazone Oral Tablet Metformin / repaglinide Oral Tablet Metformin / rosiglitazone Oral Tablet Metformin / saxagliptin Extended Release Tablet Metformin / sitagliptin Oral Tablet Metformin Extended Release Tablet Metformin Oral Solution Metformin Oral Tablet Obstetric Estimate of Gestation Table 4-46: BFDR Obstetric Estimate of Gestation Metadata The BFDR Obstetric Estimate of Gestation Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Obstetric Estimate of Gestation Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Publich Health Domain Purpose Definition Source Uniform Resource Identifier (URI) Version Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set To reflect the Obstetric Estimate of Gestation of the newborn. Extensional definition: The value set was constructed by enumerating the codes from LOINC Version 1.0 Status Active (Current) or Inactive Active Effective Date Expiration Date The date when the value set is expected to be effective The date when the value set is no longer expected to be used 8/1/2010 Not Applicable (N/A) 100

113 Element Description Mandatory Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the N/A value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-47: BFDR Obstetric Estimate of Gestation Value Set The BFDR Obstetric Estimate of Gestation Value Set will use the LOINC code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Code Value Set Description To reflect the Obstetric Estimate of Gestation of the newborn LOINC Code Vocabulary LOINC Description Gestational age Clinical.estimated Gestational age Clinical.estimated from prior assessment Social History Section Table 4-48: Coded Social History Section Template ID Parent Template Social History ( ) General Description The Coded Social History Section collects elements from the parents lifestyle (education, occupation and employment status). Since these elements are refering to both baby s father and mother, the document creator shall use the <subject> tag to determine to whom the data belongs LOINC Code Opt Description SHALL Social History Entries Opt Description SHALL Social History Observation Figure 4-9: Coded Social History Section Example <section> <templateid root=" "/> <templateid root=" "/> <code code=" " codesystem=" " displayname="social HISTORY"/> <title>social HISTORY</title> 101

114 <text> </text> <entry typecode="driv"> <subject> <relatedsubject classcode="prs"> <code code=" " codesystem=" " displayname="biological father"/> <subject> <administrativegendercode code="m" codesystem=" " displayname="male"/> <birthtime value="1965"/> </subject> </relatedsubject> </subject> <observation classcode="obs" moodcode="evn"> <! -- Social history observation template -- > <templateid root=" "/> <templateid root=" "/> <id extension=" " root=" "/> <code code=" " codesystem=" " displayname="education"/> <statuscode code="completed"/> <value xsi:type="cd" code=" " codesystem=" " displayname="higher education"/> </observation> </entry> : <entry typecode="driv"> <subject> <relatedsubject classcode="prs"> <code code=" " codesystem=" " displayname="biological mother"/> <subject> <administrativegendercode code="f" codesystem=" " displayname="female"/> <birthtime value="1970"/> </subject> </relatedsubject> </subject> <observation classcode="obs" moodcode="evn">  <templateid root=" "/> <templateid root=" "/> <id extension=" " root=" "/> <code code=" " codesystem=" " displayname="alcohol intake"/> <statuscode code="completed"/> <value xsi:type="pq" value= 2 /> </observation> </entry> </section> Table 4-49: Coded Social History Observation Value Set Section template ID: TBD This value set contains the value set described in PCC TF - 2: , and adds the following value. 102

115 Data Element Type Code Alcohol intake (glasses/week) Alcohol intake within the pregnancy period PQ Labor and Delivery Events Section Table 4-50: Labor and Delivery Events Section Template ID Parent Template TBD General Description The Labor and Delivery Events Section SHALL include a narrative text containing relevant information collected during the labor and delivery process. LOINC Code Opt Description SHALL Labor and delivery process Subsections Opt Description Coded Detailed Physical SHOULD Examination Procedures and SHOULD Interventions This section SHOULD contain procedures and interventions specific to labor and delivery events. These may include induction, C-section, blood transfusion, vaginal, vaginal birth after cesarean section or cesarean section along with incision type etc. Coded Event Outcomes This section SHOULD contain outcomes related to the labor and delivery process such as live birth or stillborn. The subsection shall include coded event outcomes such as live birth or stillborn and also including maternal death with date/time. Furthermore, Coded Event Outcomes section shall contain a simple Observation using LOINC Code that reports the number of births live or dead that occurred during the delivery event SHALL

116 Subsections Opt Description SHALL Medications Administered This section shall include the following data elements including route, timing and indication: Anesthesia, Sedatives, Tocolytics, Oxytocin, Antihypertensives, Anticonvulsants/Antispasmodi cs, Opiates (IM or IV), Antibiotics, Other Medications Medication Coded Product, ClinicalDocument/component/structuredB = ]]/ substanceadministration/code Route SHALL be coded using HL7 Route of Administration ( ), specifically indicating the route where IV or IM administration route is used: ClinicalDocument/component/structuredB = ]]/ substanceadministration/routecode Figure 4-10: Labor and Delivery Events Section Example <component> <section> <templateid root=' /> <id root=' ' extension=' '/> <code code=' ' displayname='labor and delivery process' codesystem=' ' codesystemname='loinc'/> <text> Text as described above </text> <component> <section> <templateid root=' '/>  </section> </component> <component> <section> <templateid root=' '/>  </section> </component> <component> <section> <templateid root=' '/>  </section> </component> </section> </component> 104

117 4.6.1 Coded Detailed Physical Examination Table 4-51: Labor and Delivery Coded Detailed Physical Examination Value Set Labor and Delivery Coded Detailed Physical Examination Value Set TBD OID This value set is used in the Labor and Delivery Section Coded Detailed Physical Examination subsection (template ID ). Data Element Mother's Weight at Delivery Code Type LOINC SNOMED Value Set OID INT NA BFDR Mother s Delivery Weight Value Set Mother s Delivery Weight Table 4-52: BFDR Mother s Delivery Weight Metadata The BFDR Mother s Delivery Weight Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Mother s Delivery Weight Value Set Source This is the source of the value set, identifying the originator or IHE Quality Research and Public Health Domain publisher of the information Purpose Brief description about the To Reflect the Mother's Delivery Definition Source URI general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Weight Extensional definition: The value set was constructed by enumerating the codes from LOINC Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the value 8/1/2010 set Revision Date The date of revision of the value set N/A 105

118 Element Description Mandatory Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-53: BFDR Mother s Delivery Weight Value Set The BFDR Mother s Delivery Weight Value Set will use the LOINC code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_MothersDeliveryWeight_NCHS Value Set Description To Reflect the Mother's Delivery Weight Vocabulary LOINC Code Body weight^post partum Body weight^ at delivery LOINC Description Procedures and Interventions Table 4-54: Labor and Delivery Procedures and Interventions Value Sets Labor and Delivery Procedures and Interventions Value Set TBD OID This value set is used in the Labor and Delivery Section Procedures and Interventions subsection (template ID ). Data Element Unplanned Hysterectomy Unplanned Operat[ing]ion [room procedure following delivery] Type CD CD Code LOINC SNOMED Mother s Metadata Entry: Mother's facility location Procedure ID Value Set OID BFDR Unplanned Hysterectomy Value Set BFDR Facility Location OR Value Set BFDR Delivery Value Set BFDR Unplanned Operation Value Set

119 Data Element Maternal Transfusion Anesthesia [Epidural or Spinal during labor] Route and Method of Delivery Type CD Code LOINC SNOMED Value Set OID BFDR Transfusion Whole Blood or Packed Red Blood Value Set CD BFDR Epidural Anesthesia - Procedure Value Set BFDR Spinal Anesthesia - Procedure Value Set CD BFDR Route and Method of Delivery Spontaneous Trial of Labor Attempted CD BFDR Route and Method of Delivery - Forceps BFDR Route and Method of Delivery - Vacuum BFDR Route and Method of Delivery - Cesarean BFDR Route Method of Delivery - Trial of Labor BFDR Route and Method of Delivery - Scheduled Cesarean Augmentation of Labor - Procedure Induction of Labor Cervical BFDR Route and Method of Delivery - Cesarean CD BFDR Augmentation of Labor - Procedure CD BFDR Induction of Labor CD BFDR Cervical Cerclage Cerclage Tocolysis CD BFDR Tocolysis Unplanned Hysterectomy Table 4-55: BFDR Unplanned Hysterectomy Metadata The BFDR Unplanned Hysterectomy Value Set Metadata shall contain the following content. 107

120 Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Unplanned Hysterectomy Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Definition Source URI Version Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set To Reflect the Unplanned Hysterectomy as maternal morbidity Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT /Snomed/snomed_main.html Version 1.0 Status Active (Current) or Inactive Active Effective Date The date when the value set 8/1/2010 is expected to be effective Expiration Date The date when the value set is no longer expected to be used N/A Creation Date Revision Date Groups The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned Table 4-56: BFDR Unplanned Hysterectomy Value Set 8/1/2010 N/A IHE BFDR The BFDR Unplanned Hysterectomy Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Description BFDR Unplanned Hysterectomy Value Set Vocabulary SNOMED-CT Code SNOMED-CT Description Emergency cesarean hysterectomy 108

121 Facility Location OR Table 4-57: BFDR Facility Location OR Metadata The BFDR Facility Location OR Codes Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Facility Location OR Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Definition Source URI Version Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set To reflect that the patient (mother) was treated in the OR for an unplanned operation for complications associated with labor and delivery reflecting unplanned operation Extensional definition: The value set was constructed by enumerating the codes from HL7ServiceDeliveryLocation Version 1.0 Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the N/A value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-58: BFDR Facility Location OR Value Set The BFDR Facility Location OR uses the HL7 Service Delivery Location code system to identify its contents. Codes that are used within the scope of this profile are listed below. 109

122 Value Set Value Set Description To reflect that the patient (mother) was treated in the OR for an unplanned operation for complications associated with labor and delivery reflecting unplanned operation HL7 Service Delivery Location Code Vocabulary Inpatient operating room/suite Operating and recovery rooms HL7 Service Delivery Code Description Delivery Table 4-59: BFDR Delivery Metadata The BFDR Delivery Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value BFDR Delivery Value Set set Source This is the source of the value set, identifying the originator or IHE Quality Research and Public Health Domain publisher of the information Purpose Brief description about the general purpose of the value To reflect the Delivery Procedure Definition Source URI set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective The date when the value set is 8/1/2010 Date expected to be effective Expiration The date when the value set is N/A Date no longer expected to be used Creation The date of creation of the 8/1/2010 Date value set Revision The date of revision of the N/A Date value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT nomed/snomed_main.html 110

123 Table 4-60: BFDR Delivery Value Set The BFDR Delivery Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_Delivery_NCHS Value Set Description To Reflect the Delivery Procedure SNOMED-CT Code Vocabulary SNOMED-CT Description Delivery room care (regime/therapy) Normal delivery procedure (procedure) Failed forceps delivery (procedure) Delivery by Ritgen maneuver (procedure) Manually assisted spontaneous delivery (procedure) Delivery of transverse presentation (procedure) High forceps delivery with episiotomy (procedure) Delivery of face presentation (procedure) Subtotal hysterectomy after cesarean delivery (procedure) Low forceps delivery with episiotomy (procedure) Low forceps delivery (procedure) Partial breech delivery with forceps to aftercoming head (procedure) Vaginal delivery, medical personnel present (procedure) Delivery by Scanzoni maneuver (procedure) Mid forceps delivery with episiotomy (procedure) Delivery by vacuum extraction with episiotomy (procedure) Delivery by double application of forceps (procedure) Barton's forceps delivery (procedure) Frank breech delivery (procedure) Delivery by Malstrom's extraction with episiotomy (procedure) Vaginal delivery with forceps including postpartum care (procedure) Spontaneous unassisted delivery, medical personnel present (procedure) Total breech delivery with forceps to aftercoming head (procedure) Delivery of placenta following delivery of infant outside of hospital (procedure) Colpoperineorrhaphy following delivery (procedure) Delivery by vacuum extraction (procedure) Mid forceps delivery (procedure) 111

124 SNOMED-CT Code SNOMED-CT Description Forceps delivery with rotation of fetal head (procedure) Destructive procedure on fetus to facilitate delivery (procedure) Footling breech delivery (procedure) Delivery by Kielland rotation (procedure) High forceps delivery (procedure) Delivery by Malstrom's extraction (procedure) Induction and delivery procedures (procedure) Breech extraction delivery with version (procedure) Spontaneous breech delivery (procedure) Assisted breech delivery (procedure) Forceps cephalic delivery (procedure) High forceps cephalic delivery with rotation (procedure) Midforceps cephalic delivery with rotation (procedure) Barton forceps cephalic delivery with rotation (procedure) DeLee forceps cephalic delivery with rotation (procedure) Piper forceps delivery (procedure) High vacuum delivery (procedure) Low vacuum delivery (procedure) Vacuum delivery before full dilation of cervix (procedure) Cephalic vaginal delivery with abnormal presentation of head at delivery without instrument (procedure) Manipulative cephalic vaginal delivery with abnormal presentation of head at delivery without instrument (procedure) Non-manipulative cephalic vaginal delivery with abnormal presentation of head at delivery without instrument (procedure) Normal delivery procedure (procedure) Water birth delivery (procedure) Normal delivery of placenta (procedure) Piper forceps delivery by application to aftercoming head (procedure) Delivery procedure (procedure) Instrumental delivery (procedure) Nonrotational forceps delivery (procedure) Outlet forceps delivery (procedure) Forceps delivery, face to pubes (procedure) Forceps delivery to the aftercoming head (procedure) Delivery of the after coming head (procedure) Abdominal delivery for shoulder dystocia (procedure) Operation to facilitate delivery (procedure) Placental delivery procedure (procedure) Maneuvers for delivery in shoulder dystocia (procedure) 112

125 SNOMED-CT Code SNOMED-CT Description Breech delivery (procedure) Aspiration curettage of uterus after delivery (procedure) Midforceps delivery without rotation (procedure) Neville-Barnes forceps delivery (procedure) Simpson's forceps delivery (procedure) Breech/instrumental delivery operations (procedure) Dilation/incision of cervix - delivery aid (procedure) Supervision - normal delivery (procedure) Forceps delivery (procedure) Breech presentation, delivery, no version (procedure) Dilatation of cervix for delivery (procedure) Partial breech delivery (procedure) Delivery of vertex presentation (procedure) Intrapartal care: high-risk delivery (regime/therapy) Duhrssen's incisions of cervix to assist delivery (procedure) Pubiotomy to assist delivery (procedure) Dilation and curettage of uterus after delivery (procedure) Analgesia for labor/delivery (procedure) Amniotomy at delivery (procedure) Delivery of placenta by maternal effort (procedure) Unplanned Operation Table 4-61: BFDR Unplanned Operation Metadata The BFDR Unplanned Operation Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value BFDR Unplanned Operation Value Set set Source This is the source of the value IHE Quality Research and Public set, identifying the originator or Health Domain publisher of the information Purpose Definition Source URI Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set To reflect Unplanned Operation as a maternal morbidity Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT Snomed/snomed_main.html 113

126 Element Description Mandatory Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the N/A value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-62: BFDR Unplanned Operation Value Set The BFDR Unplanned Operation Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Description To reflect Unplanned Operation as a maternal morbidity SNOMED-CT Code Vocabulary SNOMED-CT Description Removal of Shirodkar suture from cervix (procedure) Repair of obstetric laceration (procedure) Immediate repair of obstetric laceration (procedure) Immediate repair of minor obstetric laceration (procedure) Immediate repair of obstetric laceration of perineum and sphincter of anus (procedure) Immediate repair of obstetric laceration of uterus or cervix uteri (procedure) Immediate repair of obstetric laceration of vagina and floor of pelvis (procedure) Repair of current obstetric laceration of uterus (procedure) Repair of obstetric laceration of cervix (procedure) Repair of obstetric laceration of lower urinary tract (procedure) Repair of obstetric laceration of bladder (procedure) Repair of obstetric laceration of bladder and urethra (procedure) Repair of obstetric laceration of urethra (procedure) Repair of obstetric laceration of pelvic floor (procedure) 114

127 SNOMED-CT Code SNOMED-CT Description Repair of obstetric laceration of perineum and anal sphincter and mucosa of rectum (procedure) Repair of obstetric laceration of vulva (procedure) Repair of obstetrical laceration of perineum (procedure) Colpoepisiorrhaphy (procedure) Secondary repair of obstetric laceration (procedure) Suture of obstetric laceration of vagina (procedure) Colpoperineorrhaphy following delivery (procedure) Transfusion Whole Blood or Packed Red Blood Table 4-63: BFDR Transfusion Whole Blood or Packed Red Blood Metadata The BFDR Transfusion Whole Blood or Packed Red Blood Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Transfusion Whole Blood or Packed Red Blood Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Definition Source URI Version Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set To reflect Transfusion Whole Blood or Packed Red Blood as a maternal morbidity Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT nomed/snomed_main.html Version 1.0 Status Active (Current) or Inactive Active Effective Date The date when the value set 8/1/2010 is expected to be effective Expiration Date The date when the value set is no longer expected to be N/A used Creation Date The date of creation of the value set Revision Date The date of revision of the value set 8/1/2010 N/A 115

128 Element Description Mandatory Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-64: BFDR Transfusion Whole Blood or Packed Red Blood Value Set The BFDR Transfusion Whole Blood or Packed Red Blood Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_TransfusionWholeBloodOrPackedRBC_NCHS Value Set Description To reflect Transfusion Whole Blood or Packed Red Blood as a maternal morbidity Vocabulary SNOMED-CT Code SNOMED-CT Description Transfusion of whole blood (procedure) Autotransfusion of whole blood (procedure) Intra-arterial blood transfusion (procedure) Transfusing whole blood under pressure (procedure) Transfusion of red blood cells (procedure) Transfusion of leucoreduced red blood cells (procedure) Transfusion of packed red blood cells (procedure) Intravenous blood transfusion of packed cells (procedure) Transfusion of washed red blood cells (procedure) Platelet transfusion (procedure) Intravenous blood transfusion of platelets (procedure) Transfusion of platelet concentrate (procedure) Transfusion of plateletpheresis product (procedure) Transfusion of factor IX (procedure) Transfusion of coagulation factors (procedure) Antihemophilic factor transfusion (procedure) Transfusion antithrombin III factor (procedure) Transfusion of factor VII (procedure) Epidural Anesthesia - Procedure Table 4-65: BFDR Epidural Anesthesia Procedure Metadata The BFDR Epidural Anesthesia - Procedure Value Set Metadata shall contain the following content. 116

129 Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Epidural Anesthesia - Procedure Source Purpose Definition Source URI Version This is the source of the value set, identifying the originator or publisher of the information Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set Value Set IHE Quality Research and Public Health Domain To reflect an Epidural Anesthesia Procedure Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT ls/snomed/snomed_main.html Version 1.0 Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the N/A value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-66: BFDR Epidural Anesthesia Procedure Value Set The BFDR Epidural Anesthesia - Procedure Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_EpiduralAnesthesia_NCHS Value Set Description To Reflect an Epidural Anesthesia Procedure Vocabulary

130 SNOMED-CT Code SNOMED-CT Description Epidural anesthesia (procedure) Epidural injection of anesthetic substance, therapeutic, lumbar, continuous (procedure) Local anesthetic sacral epidural block (procedure) Epidural injection of anesthetic substance, diagnostic, caudal, continuous (procedure) Epidural injection of anesthetic substance, therapeutic, caudal, continuous (procedure) Low dose epidural (procedure) Anesthesia for vaginal delivery (procedure) Spinal Anesthesia Procedure Table 4-67: BFDR Spinal Anesthesia Procedure Metadata The BFDR Spinal Anesthesia - Procedure Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Spinal Anesthesia - Procedure Source Purpose Definition Source URI Version This is the source of the value set, identifying the originator or publisher of the information Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set Value Set IHE Quality Research and Public Health Domain To reflect an Spinal Anesthesia Procedure Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT s/snomed/snomed_main.html Version 1.0 Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the value set N/A 118

131 Element Description Mandatory Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-68: BFDR Spinal Anesthesia Procedure Value Set The BFDR Spinal Anesthesia - Procedure Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_SpinalAnesthesiaProcedure_NCHS Value Set Description To Reflect an Spinal Anesthesia Procedure SNOMED-CT Code Vocabulary SNOMED-CT Description Anesthesia for procedure on spine AND/OR spinal cord (procedure) Anesthesia for spinal fluid shunting procedure (procedure) Anesthesia for spinal cord procedure (procedure) Anesthesia for procedure on lumbosacral spinal cord (procedure) Referral to epidural anesthesia for spinal pain (procedure) Care of subject following combined spinal-epidural anesthesia (regime/therapy) Anesthesia for procedure on thoracic spinal cord (procedure) Anesthesia for procedure on cervical spinal cord (procedure) Spinal subdural local anesthetic block (procedure) Local anesthetic block on spinal nerve root (procedure) Local anesthetic block on spinal nerve ganglion (procedure) Combined spinal/epidural local anesthetic block (procedure) Neurolytic nerve block around spinal cord meninges (procedure) Local anesthetic nerve block around spinal cord meninges (procedure) Local anesthetic block of spinal nerve root using fluoroscopic guidance (procedure) Local anesthetic lumbar intrathecal block (procedure) Injection of anesthetic substance, diagnostic, subarachnoid, continuous (procedure) Injection of anesthetic substance, therapeutic, subarachnoid, continuous (procedure) Injection of anesthetic substance, therapeutic, subarachnoid, differential (procedure) 119

132 Route and Method of Delivery Spontaneous Delivery Table 4-69: BFDR Route and Method of Delivery Spontaneous Delivery Metadata The BFDR Route and Method of Delivery - Spontaneous Delivery Value Set Metadata Shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Route and Method of Delivery - Spontaneous Delivery Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Definition Source URI Version Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set To reflect the Route and Method of Delivery as Spontaneous Delivery Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT nomed/snomed_main.html Version 1.0 Status Active (Current) or Inactive Active Effective Date The date when the value set 8/1/2010 is expected to be effective Expiration Date The date when the value set is no longer expected to be N/A used Creation Date The date of creation of the value set Revision Date The date of revision of the value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned 8/1/2010 N/A IHE BFDR Table 4-70: BFDR Route and Method of Delivery Spontaneous Delivery Value Set The BFDR Route and Method of Delivery - Spontaneous Delivery Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. 120

133 Section Template Entry Template Value Set Value Set Code PHVS_RouteMethodOfDeliverySpontaneous_NCHS Value Set Description To Reflect the Route and Method of Delivery as Spontaneous Delivery Vocabulary SNOMED-CT Code SNOMED-CT Description Spontaneous vertex delivery (finding) Multiple delivery, all spontaneous (finding) Deliveries by spontaneous breech delivery (finding) Route and Method of Delivery Forceps Table 4-71: BFDR Route and Method of Delivery Forceps Metadata The BFDR Route and Method of Delivery - Forceps Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Route and Method of Delivery - Forceps Value Set Source This is the source of the value IHE Quality Research and Public set, identifying the originator or Health Domain publisher of the information Purpose Definition Source URI Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the value set N/A To reflect the Route and Method of Delivery as Forceps Delivery Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT /Snomed/snomed_main.html 121

134 Element Description Mandatory Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-72: BFDR Route and Method of Delivery Forceps Value Set The BFDR Route and Method of Delivery - Forceps Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_ RouteMethodOfDeliveryForceps_NCHS Value Set Description To Reflect the Route and Method of Delivery as Forceps Delivery Vocabulary SNOMED-CT Code SNOMED-CT Description Barton forceps cephalic delivery with rotation (procedure) DeLee forceps cephalic delivery with rotation (procedure) Forceps cephalic delivery (procedure) Forceps delivery failed (situation) Forceps delivery to the aftercoming head (procedure) Forceps delivery, face to pubes (procedure) Forceps extraction of lens (procedure) High forceps cephalic delivery with rotation (procedure) High forceps delivery with episiotomy (procedure) Low forceps delivery (procedure) Low forceps delivery with episiotomy (procedure) Nonrotational forceps delivery (procedure) Outlet forceps delivery (procedure) Partial breech delivery with forceps to aftercoming head (procedure) Piper forceps delivery (procedure) High forceps delivery (procedure) Forceps delivery with rotation of fetal head (procedure) Mid forceps delivery (procedure) Total breech delivery with forceps to aftercoming head (procedure) Vaginal delivery with forceps including postpartum care (procedure) Barton's forceps delivery (procedure) Forceps delivery (procedure) 122

135 SNOMED-CT Code SNOMED-CT Description Delivery by double application of forceps (procedure) Simpson's forceps delivery (procedure) Neville-Barnes forceps delivery (procedure) Mid forceps delivery with episiotomy (procedure) Route and Method of Delivery Vacuum Table 4-73: BFDR Route and Method of Delivery Vacuum Metadata The BFDR Route and Method of Delivery - Vacuum Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Route and Method of Delivery - Vacuum Value Set Source This is the source of the value IHE Quality Research and Public set, identifying the originator or Health Domain publisher of the information Purpose Definition Source URI Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the N/A value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR To reflect the Route and Method of Delivery as Vacuum Delivery Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT Snomed/snomed_main.html 123

136 Table 4-74: BFDR Route and Method of Delivery Vacuum Value Set The BFDR Route and Method of Delivery - Vacuum Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_RouteMethodOfDeliveryVacuum_NCHS Value Set Description To Reflect the Route and Method of Delivery as Vacuum Delivery SNOMED-CT Code Vocabulary SNOMED-CT Description Low vacuum delivery (procedure) High vacuum delivery (procedure) Trial of vacuum delivery (procedure) Delivery by vacuum extraction (procedure) Delivery by Malstrom's extraction (procedure) Delivery by Malstrom's extraction with episiotomy (procedure) Delivery by vacuum extraction with episiotomy (procedure) Vacuum delivery before full dilation of cervix (procedure) Forceps extraction of lens (procedure) Forceps cephalic delivery (procedure) High forceps cephalic delivery with rotation (procedure) Barton forceps cephalic delivery with rotation (procedure) DeLee forceps cephalic delivery with rotation (procedure) Piper forceps delivery (procedure) Low forceps delivery with episiotomy (procedure) Failed forceps delivery (procedure) Low forceps delivery (procedure) Partial breech delivery with forceps to aftercoming head (procedure) Nonrotational forceps delivery (procedure) Outlet forceps delivery (procedure) Forceps delivery, faces to pubes (procedure) Forceps delivery to the aftercoming head (procedure) Mid forceps delivery with episiotomy (procedure) Neville-Barnes forceps delivery (procedure) Simpson s forceps delivery (procedure) 124

137 SNOMED-CT Code SNOMED-CT Description Delivery by double application of forceps (procedure) Forceps delivery (procedure) Barton s forceps delivery (procedure) Epilation by forceps (procedure) Vaginal delivery with forceps including postpartum care (procedure) Epilation of eyebrow by forceps (procedure) Total breech delivery with forceps to aftercoming head (procedure) Mid forceps delivery (procedure) Trial forceps delivery (procedure) Forceps delivery with rotation of fetal head (procedure) Correction of trichiasis by epilation with forceps (procedure) Epilation of eyelid by forceps (procedure) High forceps delivery (procedure) Route and Method of Delivery - Cesarean Table 4-75: BFDR Route and Method of Delivery Cesarean Metadata The BFDR Route and Method of Delivery - Cesarean Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Route and Method of Delivery - Cesarean Value Set Source This is the source of the value set, identifying the originator or IHE Quality Research and Public Health Domain publisher of the information Purpose Brief description about the To reflect the Route and Method of Definition Source URI general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Delivery as Cesarean Delivery Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT s/snomed/snomed_main.html 125

138 Element Description Mandatory Expiration The date when the value set is no N/A Date longer expected to be used Creation Date The date of creation of the value 8/1/2010 set Revision Date The date of revision of the value N/A set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-76: BFDR Route and Method of Delivery Cesarean Value Set The BFDR Route and Method of Delivery - Vacuum Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_RouteMethodOfDeliveryCesarean_NCHS Value Set Description To Reflect the Route and Method of Delivery as Cesarean Delivery Vocabulary SNOMED-CT Code Cesarean section (procedure) SNOMED-CT Description Elective cesarean section (procedure) Elective upper segment cesarean section (procedure) Elective lower segment cesarean section (procedure) Subtotal hysterectomy after cesarean delivery (procedure) Emergency lower segment cesarean section (procedure) Emergency upper segment cesarean section (procedure) Emergency cesarean hysterectomy (procedure) Elective cesarean hysterectomy (procedure) Postmortem cesarean section (procedure) Anesthesia for cesarean hysterectomy (procedure) Emergency cesarean section (procedure) Cesarean section care (regime/therapy) Low cervical cesarean section (procedure) Cesarean hysterectomy (procedure) Education about vaginal birth after cesarean section (procedure) Anesthesia for cesarean section (procedure) Extraperitoneal cesarean section (procedure) Classical cesarean section (procedure) Vaginal cesarean section (procedure) 126

139 Route of Method and Delivery Trial of Labor Table 4-77: BFDR Route and Method of Delivery Trial of Labor Metadata The BFDR Route and Method of Delivery Trial of Labor Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Route and Method of Delivery Trial of Labor Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Definition Source URI Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration The date when the value set is N/A Date no longer expected to be used Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the N/A value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR To reflect the Route and Method of Delivery as Trial of Labor Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT Snomed/snomed_main.html Table 4-78: BFDR Route and Method of Delivery Trial of Labor Value Set The BFDR Route and Method of Delivery Trial of Labor Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_RouteMethodOfDeliveryTrialOfLabor_NCHS Value Set Description To Reflect the Route and Method of Delivery as Trial of Laor 127

140 Vocabulary SNOMED-CT Code SNOMED-CT Description Trial labor (finding) Failed trial of labor (disorder) Failed trial of labor - delivered (disorder) Route and Method of Delivery Scheduled Cesarean Table 4-79: BFDR Route and Method of Delivery Scheduled Cesarean Metadata The BFDR Route and Method of Delivery Scheduled Cesarean Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Route and Method of Delivery Scheduled Cesarean Value Set Source This is the source of the value IHE Quality Research and Public set, identifying the originator or Health Domain publisher of the information Purpose Definition Source URI Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the N/A value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR To reflect the Route and Method of Delivery as Scheduled Cesarean Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT /Snomed/snomed_main.html Table 4-80: BFDR Route and Method of Delivery Scheduled Cesarean Value Set The BFDR Route and Method of Delivery Scheduled Cesarean Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. 128

141 Section Template Entry Template Value Set Value Set Code PHVS_RouteMethodOfDeliveryScheduledCesarean_NCHS Value Set Description To Reflect the Route and Method of Delivery as Scheduled Cesarean Vocabulary SNOMED-CT Code SNOMED-CT Description Elective cesarean section (procedure) Elective upper segment cesarean section (procedure) Elective lower segment cesarean section (procedure) Elective cesarean hysterectomy (procedure) Augmentation of Labor - Procedure Table 4-81: BFDR Augmentation of Labor Procedure Metadata The BFDR Augmentation of Labor - Procedure Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Augmentation of Labor - Procedure Value Set Source This is the source of the value set, identifying the originator or IHE Quality Research and Public Health Domain publisher of the information Purpose Brief description about the To reflect a procedure of Definition Source URI Version general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set Augmentation of Labor Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT ls/snomed/snomed_main.html Version 1.0 Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the value set 8/1/

142 Element Description Mandatory Revision Date The date of revision of the value N/A set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-82: BFDR Augmentation of Labor Procedure Value Set The BFDR Augmentation of Labor - Procedure Value Set will use the SNOMED- CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_AugmentationOfLaborProcedure_NCHS Value Set Description To reflect a procedure of Augmentation of Labor Vocabulary SNOMED-CT Code SNOMED-CT Description Augmentation of labor (procedure) Stimulation of labor (procedure) Induction of Labor Table 4-83: BFDR Induction of Labor Metadata The BFDR Induction of Labor Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Induction of Labor Value Set Source This is the source of the value set, identifying the originator or IHE Quality Research and Public Health Domain publisher of the information Purpose Brief description about the To reflect that there was an Induction Definition Source URI general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active of Labor Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT /Snomed/snomed_main.html 130

143 Element Description Mandatory Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration The date when the value set is N/A Date no longer expected to be used Creation Date The date of creation of the value 8/1/2010 set Revision Date The date of revision of the value N/A set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-84: BFDR Induction of Labor Value Set The BFDR Induction of Labor Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_InductionOfLabor_NCHS Value Set Description To Reflect that there was an Induction of Labor SNOMED-CT Code Vocabulary SNOMED-CT Description Oxytocin induction of labor (procedure) Prostaglandin induction of labor (procedure) Intravenous induction of labor (procedure) Induction of labor (procedure) Acupuncture for induction of labor (procedure) Syntocinon induction of labor (procedure) Medical induction of labor (procedure) Induction of labor by artificial rupture of membranes (procedure) Dilatation of cervix for delivery (procedure) Cervical ripening with balloon (procedure) Cervical ripening with drug (procedure) Cervical ripening with ethinyl estradiol (procedure) Cervical ripening with Prostaglandin E2 (procedure) Cervical ripening with relaxin (procedure) Cervical ripening with Foley catheter (procedure) Cervical ripening with tents (procedure) Cervical ripening with synthetic tent (procedure) Insertion of laminaria into cervix (procedure) Sweeping of membrane (procedure) 131

144 Cervical Cerclage Table 4-85: BFDR Cervical Cerclage Metadata The BFDR Cervical Cerclage Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value BFDR Cervical Cerclage Value Set set Source This is the source of the value IHE Quality Research and Public set, identifying the originator or Health Domain publisher of the information Purpose Definition Source URI Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the N/A value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-86: BFDR Cervical Cerclage Value Set To reflect Obstetric Procedures as Cervical Cerclage Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT /Snomed/snomed_main.html The BFDR Cervical Cerclage Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_CervicalCerclage_NCHS Value Set Description To Reflect Obstetric Procedures as Cervical Cerclage 132

145 SNOMED-CT Code Vocabulary Cerclage of cervix (procedure) SNOMED-CT Description Macdonald's cervical cerclage (procedure) Cerclage of cervix during pregnancy by abdominal approach (procedure) Cerclage of cervix during pregnancy by vaginal approach (procedure) Marckwald operation on cervix (procedure) Non-obstetric encircling suture of cervical os (procedure) Shirodkar's cervical cerclage (procedure) Tocolysis Table 4-87: BFDR Tocolysis Metadata The BFDR Tocolysis Value Set Metadata Shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value BFDR Tocolysis Value Set set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Definition Source URI Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the N/A value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR To reflect Obstetric Procedures as Tocolysis Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT s/snomed/snomed_main.html 133

146 Table 4-88: BFDR Tocolysis Value Set The BFDR Tocolysis Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_Tocolysis_NCHS Value Set Description To reflect Obstetric Procedures as Tocolysis SNOMED-CT Code Vocabulary Tocolysis (procedure) SNOMED-CT Description External cephalic version with tocolysis (procedure) Tocolysis for hypertonicity of uterus (procedure) Coded Event Outcomes Table 4-89: Labor and Delivery Coded Event Outcome Value Sets Labor and Delivery Coded Event Outcome Value Set TBD OID This value set is used in the Labor and Delivery Section Coded Event Outcome subsection (template ID ). Data Code Type Element LOINC SNOMED Value Set OID Births Live INT NA MCH HBS Number of Live Births Value Set Pregnancy Outcome CD Pregnancy Outcome Value Set Plurality BFDR Birth Plurality of Delivery Value Set, Presentation Type CD BFDR Fetal Presentation at Birth- Breech Value Set BFDR Fetal Presentation at Birth- Cephalic Value Set BFDR Fetal Presentation at Birth- Other Value Set Admission to Intensive Care [unit] BFDR ICU Care Value Set

147 Data Element Perineal Laceration Ruptured Uterus Meconium Staining Premature Rupture Precipitous Labor Prolonged Labor Type CD CD CD CD CD CD Code LOINC SNOMED Value Set OID BFDR Third Degree Perineal Laceration Value Set BFDR Fourth Degree Perineal Laceration Value Set BFDR Ruptured Uterus Value Set Meconium Staining (NCHS) BFDR Premature Rupture Value Set Precipitous Labor (NCHS) Prolonged Labor (NCHS) Number of Live Births Table 4-90: MCH HBS Number of Live Births Metadata The MCH HBS Number of Live Births Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set MCH HBS Number of Live Births Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Publich Health Domain Purpose Definition Source Uniform Resource Identifier (URI) Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active To Reflect the Number of Live Births Extensional definition: The value set was constructed by enumerating the codes from LOINC Effective Date Expiration Date The date when the value set is expected to be effective The date when the value set is no longer expected to be used 8/1/2010 Not Applicable (N/A) 135

148 Element Description Mandatory Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the N/A value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE MCH:HBS Table 4-91: MCH HBS Number of Live Births Value Set The MCH HBS Number of Live Births Value Set will use the LOINC code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set OID Value Set Code PHVS_NumberofLiveBirths_NCHS Value Set Description To Reflect the Number of Live Births Vocabulary OID LOINC Code Births.live LOINC Description Pregnancy Outcome Table 4-92: Pregnancy Outcome Value Set Section Template Entry Template Value Set OID Value Set Code PHVS_PregnancyOutcome_FDD Value Set Description Outcome of pregnancy answer list Concept Code Concept Name Mother not delivered (finding) OTH Other Premature delivery (finding) Spontaneous abortion (disorder) Stillbirth (finding) Term birth of newborn (finding) UNK Unknown 136

149 Birth Plurality of Delivery Table 4-93: BFDR Birth Plurality of Delivery Metadata The BFDR Birth Plurality of Delivery Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Birth Plurality of Delivery Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Definition Source URI Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the N/A value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-94: BFDR Birth Plurality of Delivery Value Set To Reflect the Birth Plurality of Delivery Extensional definition: The value set was constructed by enumerating the codes from LOINC The BFDR Birth Plurality of Delivery Value Set will use the LOINC code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_BirthPluralityOfDelivery_NCHS 137

150 Value Set Description To Reflect the Birth Plurality of Delivery Vocabulary LOINC Code LOINC Description Birth plurality Fetal Presentation at Birth - Breech Table 4-95: BFDR Fetal Presentation at Birth- Breech Metadata The BFDR Fetal Presentation at Birth- Breech Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Fetal Presentation at Birth- Breech Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Definition Source URI Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the N/A value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-96: BFDR Fetal Presentation at Birth- Breech Value Set To Reflect the Fetal Presentation at Birth- Breech method of delivery Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT s/snomed/snomed_main.html The BFDR Fetal Presentation at Birth- Breech Value Set will use the SNOMED- CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. 138

151 Section Template Entry Template Value Set Value Set Code PHVS_FetalPresentationAtBirthBreech_NCHS Value Set Description To Reflect the Fetal Presentation at Birth- Breech method of delivery SNOMED-CT Code Vocabulary Breech presentation (finding) SNOMED-CT Description Breech presentation - delivered (finding) Breech presentation with antenatal problem (finding) Complete breech presentation (finding) Footling breech presentation (finding) Breech presentation, double footling (finding) Breech presentation, single footling (finding) Frank breech presentation (finding) Incomplete breech presentation (finding) On examination - breech presentation (finding) Deliveries by breech extraction (finding) Head entrapment during breech delivery (disorder) Deliveries by spontaneous breech delivery (finding) Obstructed labor due to breech presentation (finding) Finding of position of breech presentation (finding) Sacroanterior position (finding) Direct sacroanterior position (finding) Left sacroanterior position (finding) Right sacroanterior position (finding) Sacrolateral position (finding) Left sacrolateral position (finding) Right sacrolateral position (finding) Sacroposterior position (finding) Direct sacroposterior position (finding) Left sacroposterior position (finding) Right sacroposterior position (finding) Fetal Presentation at Birth- Cephalic Table 4-97: BFDR Fetal Presentation at Birth- Cephalic Metadata The BFDR Fetal Presentation at Birth- Cephalic Value Set Metadata shall contain the following content. 139

152 Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Fetal Presentation at Birth- Cephalic Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Definition Source URI Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the N/A value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-98: BFDR Fetal Presentation at Birth- Cephalic Value Set To Reflect the Fetal Presentation at Birth- Cephalic method of delivery Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT Snomed/snomed_main.html The BFDR Fetal Presentation at Birth- Cephalic Value Set will use the SNOMED- CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_FetalPresentationAtBirthCephalic_NCHS Value Set Description To Reflect the Fetal Presentation at Birth- Cephalic method of delivery SNOMED-CT Code Vocabulary Vertex presentation (finding) SNOMED-CT Description On examination - vertex presentation (finding) 140

153 SNOMED-CT Code SNOMED-CT Description Vertex presentation with caput succedaneum (finding) Spontaneous vertex delivery (finding) Vertex presentation with caput succedaneum (finding) Asynclitism Anterior asynclitism Posterior asynclitism Occiptoanterior position Direct occiptoanterior position Left occiptoanterior position Right occiptoanterior position Occipitolateral position Left occipitolateral position Right occipitolateral position Occiptoposterior position Direct occiptoposterior position Left occiptoposterior position Right occiptoposterior position Fetal Presentation at Birth - Other Table 4-99: BFDR Fetal Presentation at Birth- Other Metadata The BFDR Fetal Presentation at Birth- Other Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Fetal Presentation at Birth- Other Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Definition Source URI Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is expected to be effective 8/1/2010 To Reflect the Fetal Presentation at Birth- Other method of delivery Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT s/snomed/snomed_main.html 141

154 Element Description Mandatory Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the N/A value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-100: BFDR Fetal Presentation at Birth- Other Value Set The BFDR Fetal Presentation at Birth- Other Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_FetalPresentationAtBirthCephalic_NCHS Value Set Description To Reflect the Fetal Presentation at Birth- Cephalic method of delivery SNOMED-CT Code Vocabulary Fontanelles presenting (finding) SNOMED-CT Description Anterior fontanelle presenting (finding) Both fontanelles presenting (finding) Posterior fontanelle presenting (finding) Acromion presentation (finding) Asynclitism (finding) Brow presentation (finding) Compound presentation (finding) Face presentation (finding) Funic presentation (finding) Longitudinal fetal presentation (finding) Abnormal fetal presentation (finding) 142

155 Intensive Care Unit (ICU) Care Table 4-101: BFDR ICU Care Metadata The BFDR ICU Care Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value BFDR ICU Care Value Set set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Definition Source URI Version Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set To reflect the that the mother was transferred to ICU following the birth Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT nomed/snomed_main.html Version 1.0 Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date Revision Date Groups The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned 8/1/2012 N/A 8/1/2012 N/A IHE BFDR 143

156 Table 4-102: BFDR ICU Care Value Set BFDR ICU Care Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Description To reflect the that the mother was transferred to ICU following the birth Vocabulary SNOMED-CT Code SNOMED-CT Description Seen by intensive care - service (finding) Seen by adult intensive care - service (finding) Seen by intensive care specialist (finding) Seen by adult intensive care specialist (finding) Under care of intensive care specialist (finding) Under care of adult intensive care specialist (finding) Third Degree Perineal Laceration Table 4-103: BFDR Third Degree Perineal Laceration Metadata The BFDR Third Degree Perineal Laceration Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Third Degree Perineal Laceration Value Set Source This is the source of the value set, identifying the originator or IHE Quality Research and Public Health Domain publisher of the information Purpose Brief description about the To reflect Third Degree Perineal Definition Source URI general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Laceration as a maternal morbidity Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT /Snomed/snomed_main.html 144

157 Element Description Mandatory Creation Date The date of creation of the value 8/1/2010 set Revision Date The date of revision of the value N/A set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-104: BFDR Third Degree Perineal Laceration Value Set The BFDR Third Degree Perineal Laceration Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_ThirdDegreePerinealLaceration_NCHS Value Set Description To reflect Third Degree Perineal Laceration as a maternal morbidity SNOMED-CT Code Vocabulary SNOMED-CT Description Third degree perineal laceration (disorder) Third degree perineal tear during delivery - delivered (disorder) Third degree perineal tear during delivery with postnatal problem (disorder) Fourth degree perineal tear during delivery - delivered (disorder) Fourth degree perineal tear during delivery with postnatal problem (disorder) Fourth Degree Perineal Laceration Table 4-105: BFDR Fourth Degree Perineal Laceration Metadata The BFDR Fourth Degree Perineal Laceration Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Fourth Degree Perineal Laceration Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain 145

158 Element Description Mandatory Purpose Brief description about the general purpose of the value set To reflect Fourth Degree Perineal Laceration as a maternal morbidity Definition A text definition describing how concepts in the value set were selected Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT Source URI Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration The date when the value set is no N/A Date longer expected to be used Creation Date The date of creation of the value 8/1/2010 set Revision Date The date of revision of the value N/A set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR /Snomed/snomed_main.html Table 4-106: BFDR Fourth Degree Perineal Laceration Value Set The BFDR Fourth Degree Perineal Laceration Value Set will use the SNOMED- CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_FourthDegreePerinealLaceration_NCHS Value Set Description To reflect Fourth Degree Perineal Laceration as a maternal morbidity SNOMED-CT Code Vocabulary SNOMED-CT Description Fourth degree perineal laceration (disorder) Fourth degree perineal laceration involving anal mucosa (disorder) Fourth degree perineal laceration involving rectal mucosa (disorder) Fourth degree perineal tear during delivery - delivered (disorder) Fourth degree perineal tear during delivery with postnatal problem (disorder) 146

159 Ruptured Uterus Table 4-107: BFDR Ruptured Uterus Metadata The BFDR Ruptured Uterus Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Ruptured Uterus Value Set Source This is the source of the value set, identifying the originator or IHE Quality Research and Public Health Domain publisher of the information Purpose Brief description about the To reflect Ruptured Uterus as a Definition Source URI general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the value 8/1/2010 set Revision Date The date of revision of the value N/A set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR maternal morbidity Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT /Snomed/snomed_main.html Table 4-108: BFDR Ruptured Uterus Value Set The BFDR Ruptured Uterus Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_RupturedUterus_NCHS Value Set Description To reflect Ruptured Uterus as a maternal morbidity Vocabulary

160 SNOMED-CT Code SNOMED-CT Description Ruptured uterus before labor (disorder) Rupture of uterus before labor - delivered (disorder) Rupture of uterus before labor with antenatal problem (disorder) Rupture of uterus during AND/OR after labor (disorder) Rupture of uterus during and after labor - delivered (disorder) Rupture of uterus during and after labor - delivered with postnatal problem (disorder) Rupture of gravid uterus (disorder) Rupture of gravid uterus before onset of labor (disorder) Rupture of uterus (disorder) Meconium Staining Table 4-109: Meconium Staining Metadata The Meconium Staining Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set Meconium Staining Value Set Source This is the source of the value set, identifying the originator or IHE Quality Research and Public Health Domain publisher of the information Purpose Brief description about the To reflect that there was moderate or Definition Source URI general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the value 8/1/2010 set Revision Date The date of revision of the value N/A set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR heavy Meconium staining Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT /Snomed/snomed_main.html 148

161 Table 4-110: Meconium Staining Value Set The Meconium Staining Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_MeconiumStaining_NCHS Value Set Description To Reflect that there was moderate or heavy Meconium staining SNOMED-CT Code Vocabulary SNOMED-CT Description Meconium stained liquor - grade II (finding) Meconium stained liquor - grade III (finding) Thick meconium stained liquor (finding) Fresh meconium staining liquor (finding) Old meconium staining liquor (finding) Premature Rupture Table 4-111: BFDR Premature Rupture Metadata The BFDR Premature Rupture Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Premature Rupture Value Set Source This is the source of the value set, identifying the originator or IHE Quality Research and Public Health Domain publisher of the information Purpose Brief description about the To Reflect Onset of labor with Definition Source URI general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Premature Rupture Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT /Snomed/snomed_main.html 149

162 Element Description Mandatory Expiration The date when the value set is no N/A Date longer expected to be used Creation Date The date of creation of the value 8/1/2010 set Revision Date The date of revision of the value N/A set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-112: BFDR Premature Rupture Value Set The BFDR Premature Rupture Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_PrematureRupture_NCHS Value Set Description To Reflect Onset of labor with Premature Rupture Vocabulary SNOMED-CT Code SNOMED-CT Description Premature rupture of membranes (disorder) Membrane rupture with delivery delay (disorder) Premature rupture of membranes delivered (disorder) Premature rupture of membranes with antenatal problem (disorder) Premature rupture of membranes with onset of labor after 24 hours of the rupture (disorder) Premature rupture of membranes with onset of labor within 24 hours of the rupture (disorder) Premature rupture of membranes, labor delayed by therapy (disorder) Preterm premature rupture of membranes (disorder) Prolonged premature rupture of membranes (disorder) Prolonged rupture of membranes Prolonged artificial rupture of membranes Prolonged artificial rupture of membranes delivered Prolonged artificial rupture of membranes with antenatal problem Prolonged premature rupture of membranes Prolonged spontaneous rupture of membranes 150

163 Precipitous Labor Table 4-113: Precipitous Labor Metadata The Precipitous Labor Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set Precipitous Labor Value Set Source This is the source of the value set, identifying the originator or IHE Quality Research and Public Health Domain publisher of the information Purpose Brief description about the To reflect Onset of labor with Definition Source URI general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration The date when the value set is N/A Date no longer expected to be used Creation Date The date of creation of the value 8/1/2010 set Revision Date The date of revision of the value N/A set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Precipitous Labor Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT Snomed/snomed_main.html Table 4-114: Precipitous Labor Value Set The Precipitous Labor Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_PrecipitousLabor_NCHS Value Set Description To Reflect Onset of labor with Precipitous Labor Vocabulary

164 SNOMED-CT Code SNOMED-CT Description Precipitate labor (disorder) Precipitate labor - delivered (disorder) Precipitate labor with antenatal problem (disorder) Prolonged Labor Codes Table 4-115: Prolonged Labor Metadata The Prolonged Labor Value Set Metadata Shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set Prolonged labor Value Set Source This is the source of the value set, identifying the originator or IHE Quality Research and Public Health Domain publisher of the information Purpose Brief description about the To Reflect Onset of labor with Definition Source URI general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration The date when the value set is no N/A Date longer expected to be used Creation Date The date of creation of the value 8/1/2010 set Revision Date The date of revision of the value N/A set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Prolonged Labor Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT /Snomed/snomed_main.html 152

165 Table 4-116: Prolonged Labor Value Set The Prolonged Labor Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_ProlongedLabor_NCHS Value Set Description To Reflect Onset of labor with Prolonged Labor Vocabulary SNOMED-CT Code Prolonged labor (disorder) SNOMED-CT Description Delayed delivery after artificial rupture of membranes (disorder) Delayed delivery of second of multiple births (disorder) Delayed delivery of triplet (disorder) Delayed delivery of second twin (disorder) Delayed delivery of second twin, triplet etc. (disorder) Delayed delivery second twin delivered (disorder) Delayed delivery second twin with antenatal problem (disorder) Prolonged first stage of labor (disorder) Prolonged first stage - delivered (disorder) Prolonged first stage with antenatal problem (disorder) Prolonged latent phase of labor (disorder) Prolonged second stage of labor (disorder) Prolonged second stage - delivered (disorder) Prolonged second stage with antenatal problem (disorder) Medications Administered Table 4-117: Labor and Delivery Medications Administered Value Set Labor and Delivery Medications Administered Value Set TBD OID This value set is used in the Labor and Delivery Section Medications Administered subsection (template ID ). Data Element Type Value Set OID Antibiotics CD BFDR Antibiotics Value Set,

166 Data Element Type Value Set OID Steroids [(glucocorticoids) for CD BFDR Glucocortico Steroids Value Set fetal lung maturation received by the mother prior to delivery] Augmentation of Labor CD BFDR Augmentation of Labor - Medication Value Set, - Medication Anesthesia [Epidural or Spinal during labor] CD BFDR Epidural Anesthesia - Medication Value Set, BFDR Spinal Anesthesia - Medication Value Set Antibiotics Table 4-118: BFDR Antibiotics Metadata Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value BFDR Antibiotics Value Set set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Definition Source URI Version Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set To Reflect that antibiotics were administered Extensional definition: The value set was constructed by enumerating the codes from RxNORM rm/ Version 1.0 Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date Revision Date Groups The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned 8/1/2010 N/A 8/1/2010 N/A IHE BFDR 154

167 Table 4-119: BFDR Antibiotics Value Set Section Template Entry Template Value Set Value Set Code PHVS_Antibiotics_NCHS Value Set Description To Reflect that antibiotics were administered. RxNORM Description Vocabulary RxNORM Code ML penicillin G benzathine UNT/ML / penicillin G procaine UNT/ML Prefilled Syringe ML penicillin G benzathine UNT/ML / penicillin G procaine UNT/ML Prefilled Syringe ML penicillin G benzathine UNT/ML / penicillin G procaine UNT/ML Prefilled Syringe MG Clindamycin 20 MG/ML Prefilled Applicator Acyclovir 25 MG/ML Injectable Solution Acyclovir 50 MG/ML Injectable Solution Acyclovir Injectable Solution Amphotericin B 5 MG/ML Injectable Solution Amphotericin B Injectable Solution Ampicillin (as ampicillin sodium) 100 MG/ML Injectable Solution Ampicillin (as ampicillin sodium) 250 MG/ML Injectable Solution Ampicillin / Floxacillin Injectable Solution Ampicillin / Sulbactam Injectable Solution Ampicillin 100 MG/ML / Sulbactam 50 MG/ML Injectable Solution Ampicillin 125 MG / floxacillin 125 MG per 5 ML Elixir Ampicillin 125 MG/ML Injectable Solution Ampicillin 167 MG/ML / Floxacillin 167 MG/ML Injectable Solution Ampicillin 20 MG/ML / Sulbactam 10 MG/ML Injectable Solution Ampicillin 250 MG/ML / Sulbactam 125 MG/ML Injectable Solution Ampicillin 30 MG/ML / Sulbactam 15 MG/ML Injectable Solution Ampicillin Injectable Solution Cefazolin 10 MG/ML Injectable Solution Cefazolin 100 MG/ML Injectable Solution Cefazolin 20 MG/ML Injectable Solution Cefazolin 200 MG/ML Injectable Solution Cefazolin 225 MG/ML Injectable Solution Cefazolin 250 MG/ML Injectable Solution Cefazolin 330 MG/ML Injectable Solution 155

168 RxNORM Description RxNORM Code Cefazolin Injectable Solution Cefotaxime 20 MG/ML Injectable Solution Cefotaxime 200 MG/ML Injectable Solution Cefotaxime 230 MG/ML Injectable Solution Cefotaxime 300 MG/ML Injectable Solution Cefotaxime 330 MG/ML Injectable Solution Cefotaxime 40 MG/ML Injectable Solution Cefotaxime Injectable Solution Ceftazidime 10 MG/ML Injectable Solution Ceftazidime 170 MG/ML Injectable Solution Ceftazidime 20 MG/ML Injectable Solution Ceftazidime 200 MG/ML Injectable Solution Ceftazidime 210 MG/ML Injectable Solution Ceftazidime 250 MG/ML Injectable Solution Ceftazidime 280 MG/ML Injectable Solution Ceftazidime 40 MG/ML Injectable Solution Ceftazidime 60 MG/ML Injectable Solution Ceftazidime Injectable Solution Ceftriaxone 100 MG/ML Injectable Solution Ceftriaxone 20 MG/ML Injectable Solution Ceftriaxone 250 MG/ML Injectable Solution Ceftriaxone 350 MG/ML Injectable Solution Ceftriaxone 40 MG/ML Injectable Solution Clindamycin 12 MG/ML Injectable Solution Clindamycin 150 MG/ML Clindamycin 150 MG/ML Injectable Solution Clindamycin 18 MG/ML Injectable Solution Clindamycin 6 MG/ML Injectable Solution Clindamycin 900 MG per 50 ML Injectable Solution Clindamycin 900 MG per 6 ML Injectable Solution Clindamycin Injectable Solution Erythromycin 50 MG/ML Injectable Solution Erythromycin Gluceptate 1 MG/ML Injectable Solution Erythromycin Gluceptate 50 MG/ML Injectable Solution Erythromycin lactobionate 50 MG/ML Injectable Solution Fluconazole 2 MG/ML Injectable Solution Fluconazole 4 MG/ML Injectable Solution Fluconazole Injectable Solution Gentamicin Sulfate (USP) 0.4 MG/ML Injectable Solution Gentamicin Sulfate (USP) 0.6 MG/ML Injectable Solution Gentamicin Sulfate (USP) 0.7 MG/ML Injectable Solution Gentamicin Sulfate (USP) 0.8 MG/ML Injectable Solution 156

169 RxNORM Description RxNORM Code Gentamicin Sulfate (USP) 0.9 MG/ML Injectable Solution Gentamicin Sulfate (USP) 1 MG/ML Injectable Solution Gentamicin Sulfate (USP) 1.2 MG/ML Injectable Solution Gentamicin Sulfate (USP) 1.4 MG/ML Injectable Solution Gentamicin Sulfate (USP) 1.6 MG/ML Injectable Solution Gentamicin Sulfate (USP) 10 MG/ML Injectable Solution Gentamicin Sulfate (USP) 2 MG/ML Injectable Solution Gentamicin Sulfate (USP) 2.4 MG/ML Injectable Solution Gentamicin Sulfate (USP) 3.6 MG/ML Injectable Solution Gentamicin Sulfate (USP) 40 MG/ML Injectable Solution Gentamicin Sulfate (USP) 5 MG/ML Injectable Solution Gentamicin Sulfate (USP) 50 MG/ML Injectable Solution Gentamicin Sulfate (USP) 60 MG/ML Injectable Solution Gentamicin Sulfate (USP) 80 MG/ML Injectable Solution Gentamicin Sulfate (USP) Injectable Solution Metronidazole 5 MG/ML Injectable Solution Metronidazole Injectable Solution Nafcillin 100 MG/ML Injectable Solution Nafcillin 20 MG/ML Injectable Solution Nafcillin 250 MG/ML Injectable Solution Nafcillin 40 MG/ML Injectable Solution Nafcillin Injectable Solution Oxacillin 100 MG/ML Injectable Solution Oxacillin 167 MG/ML Injectable Solution Oxacillin 20 MG/ML Injectable Solution Oxacillin 40 MG/ML Injectable Solution Oxacillin Injectable Solution Penicillin G UNT/ML Injectable Solution Penicillin G UNT/ML Injectable Solution Penicillin G UNT/ML Injectable Suspension Penicillin G 375 MG/ML Injectable Solution Penicillin G benzathine 1,200,000 UNT / penicillin G procaine 1,200,000 UNT per 2 ML Prefilled Syringe Penicillin G benzathine 1,200,000 UNT per 2 ML Prefilled Syringe Penicillin G benzathine UNT/ML / penicillin G procaine UNT/ML Injectable Solution Penicillin G benzathine UNT/ML / penicillin G procaine UNT/ML Injectable Suspension Penicillin G benzathine 2,400,000 UNT per 4 ML Prefilled Syringe Penicillin G benzathine UNT/ML / penicillin G procaine UNT/ML Injectable Suspension 157

170 RxNORM Description RxNORM Code Penicillin G benzathine UNT/ML Injectable Suspension Penicillin G benzathine UNT/ML / penicillin G procaine UNT/ML 2 ML Prefilled Syringe Penicillin G benzathine 600,000 UNT per 1 ML Prefilled Syringe Penicillin G benzathine UNT/ML Injectable Suspension Penicillin G benzathine UNT/ML / penicillin G procaine UNT/ML Injectable Suspension Penicillin G Injectable Solution Penicillin G Injectable Suspension Penicillin G Potassium UNT/ML Injectable Solution Penicillin G Potassium UNT/ML Injectable Solution Penicillin G Potassium UNT/ML Injectable Solution Penicillin G Potassium UNT/ML Injectable Solution Penicillin G Potassium UNT/ML Injectable Solution Penicillin G Potassium UNT/ML Injectable Solution Penicillin G Prefilled Syringe penicillin G procaine 1,200,000 UNT per 2 ML Prefilled Syringe penicillin G procaine UNT/ML Injectable Suspension penicillin G procaine 600,000 UNT per 1 ML Prefilled Syringe penicillin G procaine 600,000 UNT/ML Injectable Suspension Penicillin G Sodium UNT/ML Injectable Solution Penicillium camemberti allergenic extract 50 MG/ML Injectable Solution Penicillium chrysogenum var. chrysogenum extract 1 MG/ML Penicillium chrysogenum var. chrysogenum extract 100 MG/ML Penicillium chrysogenum var. chrysogenum extract 100 UNT/ML Penicillium chrysogenum var. chrysogenum extract 1000 UNT/ML Penicillium chrysogenum var. chrysogenum extract UNT/ML Penicillium chrysogenum var. chrysogenum extract UNT/ML Penicillium chrysogenum var. chrysogenum extract UNT/ML Penicillium chrysogenum var. chrysogenum extract 50 MG/ML Penicillium italicum extract 0.05 GM/ML Injectable Solution Penicillium roquefortii allergenic extract 50 MG/ML Injectable Solution Piperacillin / tazobactam Injectable Solution Piperacillin 200 MG/ML / tazobactam 25 MG/ML Injectable Solution Piperacillin 200 MG/ML Injectable Solution 158

171 RxNORM Description RxNORM Code Piperacillin 30 MG/ML Injectable Solution Piperacillin 40 MG/ML / tazobactam 5 MG/ML Injectable Solution Piperacillin 40 MG/ML Injectable Solution Piperacillin 400 MG/ML Injectable Solution Piperacillin 60 MG/ML / tazobactam 7.5 MG/ML Injectable Solution Piperacillin 80 MG/ML / tazobactam 10 MG/ML Injectable Solution Piperacillin Injectable Solution Vancomycin 10 MG/ML Injectable Solution Vancomycin 100 MG/ML Injectable Solution Vancomycin 3 MG/ML Injectable Solution Vancomycin 3.5 MG/ML Injectable Solution Vancomycin 4 MG/ML Injectable Solution Vancomycin 5 MG/ML Injectable Solution Vancomycin 50 MG/ML Injectable Solution Vancomycin 6 MG/ML Injectable Solution Vancomycin 6.67 MG/ML Injectable Solution Vancomycin 7 MG/ML Injectable Solution Vancomycin 8 MG/ML Injectable Solution Vancomycin 8.33 MG/ML Injectable Solution Vancomycin Injectable Solution Zidovudine 10 MG/ML Injectable Solution Zidovudine Injectable Solution Glucocortico Steroids Table 4-120: BFDR Glucocortico Steroids Metadata The BFDR Glucocortico Steroids Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value BFDR Glucocortico Value Set set Source This is the source of the value IHE Quality Research and Public Health set, identifying the originator or Domain publisher of the information Purpose Brief description about the general purpose of the value set To Reflect administration of Glucocortico Steroids 159

172 Element Description Mandatory Definition A text definition describing how concepts in the value set were selected from RxNORM Source URI Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date Revision Date Groups The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned Extensional definition: The value set was constructed by enumerating the codes orm/ 8/1/2010 N/A 8/1/2010 N/A Table 4-121: BFDR Glucocortico Steroids Value Set IHE BFDR The BFDR Glucocortico Steroids Value Set will use the RxNorm code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Description To Reflect administration of Glucocortico Steroids Vocabulary RxNORM Code RxNORM description Betamethasone 3 MG/ML Injectable Solution Betamethasone 4 MG/ML Injectable Solution Betamethasone 3 MG/ML (as betamethasone sodium phosphate) / Betamethasone acetate 3 MG/ML Injectable Suspension Dexamethasone 4 MG/ML / Lidocaine 10 MG/ML Injectable Solution Dexamethasone 0.02 MG/ML Injectable Solution Dexamethasone MG/ML Injectable Solution Dexamethasone 10 MG/ML Injectable Solution Dexamethasone 16 MG/ML Injectable Solution Dexamethasone 2 MG/ML Injectable Solution Dexamethasone 20 MG/ML Injectable Solution 160

173 RxNORM Code RxNORM description Dexamethasone 24 MG/ML Injectable Solution Dexamethasone 3 MG/ML Injectable Solution Dexamethasone 4 MG/ML Injectable Solution Dexamethasone 5 MG/ML Injectable Solution Dexamethasone 8 MG/ML Injectable Solution Dexamethasone 16 MG/ML Injectable Suspension Dexamethasone 8 MG/ML Injectable Suspension Augmentation of Labor Medication Table 4-122: BFDR Augmentation of Labor - Medication Metadata The BFDR Augmentation of Labor - Medication Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Augmentation of Labor - Medication Value Set Source This is the source of the value set, identifying the originator or IHE Quality Research and Public Health Domain publisher of the information Purpose Brief description about the To Reflect a medication used for the Definition Source URI general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is no N/A longer expected to be used Creation Date The date of creation of the value 8/1/2010 set Revision Date The date of revision of the value N/A set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR of Augmentation of Labor Extensional definition: The value set was constructed by enumerating the codes from RxNORM s/rxnorm/ 161

174 Table 4-123: BFDR Augmentation of Labor - Medication Value Set The BFDR Augmentation of Labor - Medication Value Set will use the RxNorm code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_AugmentationOfLaborMedication_NCHS Value Set Description To reflect a medication used for the Augmentation of Labor Vocabulary RxNORM Code RxNORM Description Oxytocin 10 UNT/ML Injectable Solution Epidural Anesthesia Medication Table 4-124: BFDR Epidural Anesthesia Medication Metadata The BFDR Epidural Anesthesia - Medication Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Epidural Anesthesia Medication Value Set Source This is the source of the value set, identifying the originator or IHE Quality Research and Public Health Domain publisher of the information Purpose Brief description about the general purpose of the value To reflect an Epidural Anesthesia Definition Source URI Version set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set Extensional definition: The value set was constructed by enumerating the codes from RxNORM /rxnorm/ Version 1.0 Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the value set 8/1/

175 Element Description Mandatory Revision Date The date of revision of the N/A value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-125: BFDR Epidural Anesthesia Medication Value Set The BFDR Epidural Anesthesia - Medication Value Set will use the RxNorm code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_EpiduralAnesthesiaMedication_NCHS Value Set Description To Reflect an Epidural Anesthesia Medication RxNORM Code Vocabulary RxNORM Description bupivacaine % / fentanyl 5 MCG/ML Injectable Solution bupivacaine 0.05 % / fentanyl 3 MCG/ML Injectable Solution bupivacaine 0.06 % / hydromorphone hydrochloride 2 MG per 100 ML Injectable Solution bupivacaine % / fentanyl 2 MCG/ML Injectable Solution bupivacaine % / fentanyl 5 MCG/ML Injectable Solution bupivacaine % / hydromorphone hydrochloride 10 MCG/ML Injectable Solution bupivacaine % / hydromorphone hydrochloride 5 MCG/ML Injectable Solution bupivacaine 0.1 % / fentanyl 4 MCG/ML Injectable Solution bupivacaine 0.1 % / hydromorphone hydrochloride 10 MCG/ML Injectable Solution bupivacaine 0.1 % Injectable Solution bupivacaine % / fentanyl 2 MCG/ML Injectable Solution bupivacaine % / hydromorphone hydrochloride 20 MCG/ML Injectable Solution bupivacaine % Injectable Solution bupivacaine 0.25 % Injectable Solution bupivacaine % Injectable Solution bupivacaine 0.5 % / epinephrine 1:200,000 Injectable Solution bupivacaine 0.5 % Injectable Solution Bupivacaine MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine MG/ML Injectable Solution 163

176 RxNORM Code RxNORM Description Bupivacaine 1 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1 MG/ML / Fentanyl 0.01 MG/ML Injectable Solution Bupivacaine 1.05 MG/ML Injectable Solution Bupivacaine 1.25 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1.25 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1.25 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1.25 MG/ML / Fentanyl MG/ML Injectable Solution bupivacaine 100 MG per 20 ML Prefilled Syringe bupivacaine 125 MG per 50 ML Prefilled Syringe Bupivacaine 2 MG/ML Injectable Solution Bupivacaine 2.5 MG/ML / Epinephrine MG/ML Injectable Solution Bupivacaine 2.5 MG/ML / Fentanyl 0.02 MG/ML Injectable Solution Bupivacaine 3.75 MG/ML / Lidocaine 10 MG/ML Injectable Solution Bupivacaine 7.5 MG/ML / Epinephrine MG/ML Injectable Solution Bupivacaine 7.5 MG/ML Injectable Solution Bupivacaine 8.25 MG/ML Injectable Solution Bupivacaine Hydrochloride 2 MG/ML Injectable Solution chloroprocaine 2 % Injectable Solution Chloroprocaine hydrochloride 10 MG/ML Injectable Solution Chloroprocaine hydrochloride 30 MG/ML Injectable Solution Bupivacaine 3.75 MG/ML / Lidocaine 10 MG/ML Injectable Solution Dexamethasone 4 MG/ML / Lidocaine 10 MG/ML Injectable Solution Lidocaine 10 MG/ML / Methylprednisolone 40 MG/ML Injectable Solution Spinal Anesthesia - Medication Table 4-126: BFDR Spinal Anesthesia Medication Metadata The BFDR Spinal Anesthesia - Medication Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Spinal Anesthesia Medication Value Set Source This is the source of the value IHE Quality Research and Public set, identifying the originator or Health Domain publisher of the information 164

177 Element Description Mandatory Purpose Brief description about the To reflect an Spinal Anesthesia general purpose of the value set Definition A text definition describing how concepts in the value set were selected Extensional definition: The value set was constructed by enumerating the codes from RxNORM Source URI Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the N/A value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR xnorm/ Table 4-127: BFDR Spinal Anesthesia Medication Value Set The BFDR Spinal Anesthesia - Medication Value Set will use the RxNorm code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_SpinalAnesthesiaMedication_NCHS Value Set Description To Reflect a Spinal Anesthesia RxNORM Code Vocabulary RxNORM Description bupivacaine % / fentanyl 5 MCG/ML Injectable Solution bupivacaine 0.05 % / fentanyl 3 MCG/ML Injectable Solution bupivacaine 0.06 % / hydromorphone hydrochloride 2 MG per 100 ML Injectable Solution bupivacaine % / fentanyl 2 MCG/ML Injectable Solution bupivacaine % / fentanyl 5 MCG/ML Injectable Solution bupivacaine % / hydromorphone hydrochloride 10 MCG/ML Injectable Solution bupivacaine % / hydromorphone hydrochloride 5 MCG/ML Injectable Solution 165

178 RxNORM Code RxNORM Description bupivacaine 0.1 % / fentanyl 4 MCG/ML Injectable Solution bupivacaine 0.1 % / hydromorphone hydrochloride 10 MCG/ML Injectable Solution bupivacaine 0.1 % Injectable Solution bupivacaine % / fentanyl 2 MCG/ML Injectable Solution bupivacaine % / hydromorphone hydrochloride 20 MCG/ML Injectable Solution bupivacaine % Injectable Solution bupivacaine 0.25 % Injectable Solution bupivacaine % Injectable Solution bupivacaine 0.5 % / epinephrine 1:200,000 Injectable Solution bupivacaine 0.5 % Injectable Solution Bupivacaine MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine MG/ML Injectable Solution Bupivacaine 1 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1 MG/ML / Fentanyl 0.01 MG/ML Injectable Solution Bupivacaine 1.05 MG/ML Injectable Solution Bupivacaine 1.25 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1.25 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1.25 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1.25 MG/ML / Fentanyl MG/ML Injectable Solution bupivacaine 100 MG per 20 ML Prefilled Syringe bupivacaine 125 MG per 50 ML Prefilled Syringe Bupivacaine 2 MG/ML Injectable Solution Bupivacaine 2.5 MG/ML / Epinephrine MG/ML Injectable Solution Bupivacaine 2.5 MG/ML / Fentanyl 0.02 MG/ML Injectable Solution Bupivacaine 3.75 MG/ML / Lidocaine 10 MG/ML Injectable Solution Bupivacaine 7.5 MG/ML / Epinephrine MG/ML Injectable Solution Bupivacaine 7.5 MG/ML Injectable Solution Bupivacaine 8.25 MG/ML Injectable Solution Bupivacaine Hydrochloride 2 MG/ML Injectable Solution chloroprocaine 2 % Injectable Solution Chloroprocaine hydrochloride 10 MG/ML Injectable Solution Chloroprocaine hydrochloride 30 MG/ML Injectable Solution Bupivacaine 3.75 MG/ML / Lidocaine 10 MG/ML Injectable Solution Dexamethasone 4 MG/ML / Lidocaine 10 MG/ML Injectable Solution 166

179 RxNORM Code RxNORM Description Lidocaine 10 MG/ML / Methylprednisolone 40 MG/ML Injectable Solution 4.7 Newborn Delivery Newborn Delivery Information Section Table 4-128: Newborn Delivery Information Section Template ID General Description The Newborn Delivery Information Section SHALL include a narrative text containing information collected at the birth and up to the transfer of the infant from the birthing room to a postnatal unit. LOINC Code Opt Description SHALL Newborn delivery information from newborn Subsections Opt Description Coded Detailed Physical Examination Section This section SHALL include information about the newborn genitalia; weight; length; head circumference, size (AGA, SGA or LGA); Apgar score assessment ; vital signs, physical exam findings Active Problems This section SHALL describe problems that the newborn might have had during or immediately prior to delivery. Procedures and Interventions This section SHALL include the procedures and interventions received by the newborn such as suction or resuscitation SHALL PCC TF 2: SHALL PCC TF 2: SHALL PCC CDA Supplement 2:

180 Subsections Opt Description Medications Administered This section SHALL include the medication that was administered to the newborn while in the birthing suite such as: Vitamin K (Aquamephyton) injection; erythromycin eye ointment; and resuscitation medications (if any) including date, time, and route of administration. SHALL PCC TF 2: Route SHALL be coded using HL7 Route of Administration ( ), specifically indicating the route where IV or IM administration route is used: ClinicalDocument/component/structuredB ody/component/section[[templateid[@root = ]]/com ponent/section templateid[@root= ]]/substanceadministration/routeco de Medication indication SHALL be coded using SNOMED-CT where Antibiotics are administered for Neonatal Sepsis ClinicalDocument/component/structuredB ody/component/section[[templateid[@root = ]]/com ponent/section templateid[@root= ]]/substanceadministration/entryre lationship[@typecode='rson']/observati on[cda:templateid/@root=' '] Coded Event Outcomes SHALL Coded Results SHALL PCC TF 2: Figure 4-11: Newborn Delivery Section Example <component> <section> <templateid root=' '/> <id root=' ' extension=' '/> <code code=' ' displayname='newborn delivery information from newborn' codesystem=' ' codesystemname='loinc'/> <text>text as described above</text> <component> <section> <templateid root=' />  </section> </component> <component> <section> <templateid root=' '/>  </section> </component> <component> 168

181 <section> <templateid root=' '/>  </section> </component> <component> <section> <templateid root=' '/>  </section> </component> <component> <section> <templateid root=' '/>  </section> </component> </section> </component> Coded Detailed Physical Examination Section Retain Coded Detailed Physical Examination, to include Coded Vital Signs (cf Vital Signs Organizer), physical assessments (e.g., Apgar Score under General Appearance), Birth Weight and Height, et cetera (as Simple Observations). Using the Vital Signs codes already present, but adding a Method Code to indicate a finding at time of birth. The code values to use for Method Code shall use the LOINC codes for these measurements at birth. For the body weight vital sign: the methodcode would be or in the case of stillborn, Weight of Fetus. Table 4-129: Coded Detailed Physical Examination Section Template ID Parent Template Detailed Physical Examination ( ) General Description The Coded Detailed Physical Examination section shall contain a narrative description of the patient s physical findings. It shall include subsections, if known, for the exams that are performed. LOINC Code Opt Description SHALL Physical Examination Subsections Opt Description SHOULD Coded Vital Signs Vital signs may be a subsection of the physical examination or they may stand alone SHOULD General Appearance 169

182 Coded Vital Signs This value set is used in the section Coded Detailed Physical Examination: ( ) Vital Signs Section of the Newborn (template ID ). Table 4-130: Newborn Coded Vital Signs Value Set Data Element Birth Weight (g) Birth Length (inches) Head Circumference Type Code SNOMED LOINC Value Set OID PQ MCH HBS Body Weight^at birth PQ Body Height^at birth TBD OID PQ Birth Weight Table 4-131: MCH HBS Birth Weight Metadata The MCH HBS Birth Weight Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set MCH HBS Birth Weight Value Set Source This is the source of the value set, identifying the originator or IHE Quality Research and Public Health Domain publisher of the information Purpose Brief description about the To Reflect the Birth Weight Definition Source URI general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is expected to be effective Expiration Date The date when the value set is no longer expected to be used Creation Date The date of creation of the value set Revision Date The date of revision of the value set Extensional definition: The value set was constructed by enumerating the codes from LOINC 8/1/2010 N/A 8/1/2010 N/A 170

183 Element Description Mandatory Groups The identifiers of the groups that include this value set. A group may also have an OID assigned. IHE MCH:HBS Table 4-132: MCH HBS Birth Weight Value Set The MCH HBS Birth Weight Value Set will use the LOINC code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Description To Reflect the Birth Weight LOINC Code Vocabulary Birth Weight LOINC Description Birth Height Table 4-133: MCH HBS Birth Height Metadata The MCH HBS Birth Height Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of TBD OID the value set Name This is the name of the value Birth Height Value Set set Source This is the source of the value set, identifying the originator or publisher of the information Purpose Definition Source URI Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is expected to be effective IHE Quality Research and Public Health Domain To Reflect the Birth Height Extensional definition: The value set was constructed by enumerating the codes from LOINC 171

184 Element Description Mandatory Expiration Date The date when the value set is N/A no longer expected to be used Creation Date The date of creation of the value set Revision Date The date of revision of the N/A value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE TBD Table 4-134: MCH HBS Birth Height Value Set The MCH HBS Birth Height Value Set will use the LOINC code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set TBD OID Value Set Description To Reflect the Birth Height LOINC Code Vocabulary TBD Birth Height LOINC Description General Appearance Table 4-135: Newborn General Appearance Value Set This value set is used in the section Coded Detailed Physical Examination ( ) General Appearance Section of the Newborn (template ID ). Data Element APGAR score : 5 mn APGAR Score : 10 mn Code Type SNOMED LOINC Value sets OID INT MCH HBS 5 Min Apgar Score Value Set INT MCH HBS 10 Min Apgar Score Value Set

185 Appearance, Pulse, Grimace, Activity, and Respiration (Apgar) at 5 minutes Table 4-136: MCH HBS 5 Min Apgar Score Metadata The MCH HBS 5 Min Apgar Score Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set MCH HBS 5 Min Apgar Score Value Set Source This is the source of the value set, identifying the originator or IHE Quality Research and Publish Health Domain publisher of the information Purpose Brief description about the general To reflect the 5 Min Apgar Score Definition Source URI purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective The date when the value set is 8/1/2010 Date expected to be effective Expiration The date when the value set is no N/A Date longer expected to be used Creation The date of creation of the value 8/1/2010 Date set Revision The date of revision of the value N/A Date set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE MCH:HBS Extensional definition: The value set was constructed by numerating the codes from LOINC Table 4-137: MCH HBS 5 Min Apgar Score Value Set MCH HBS 5 Min Apgar Score Value Set will use the LOINC code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set OID Value Set Code PHVS_ApgarScore5Min_NCHS Value Set Description To reflect the 5 Min Apgar Score Vocabulary OID

186 LOINC Code Score^5M post birth LOINC Description Apgar at 10 minutes Table 4-138: MCH HBS 10 Min Apgar Score Codes The MCH HBS 10 Min Apgar Score Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set MCH HBS10 Min Apgar Score Value Set Source This is the source of the value set, identifying the IHE Quality Research and Publish Health Domain originator or publisher of the information Purpose Brief description about the general purpose of the value To Reflect the 10 Min Apgar Score Definition Source URI set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective The date when the value set is 8/1/2010 Date expected to be effective Expiration The date when the value set is N/A Date no longer expected to be used Creation The date of creation of the 8/1/2010 Date value set Revision The date of revision of the N/A Date value set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE MCH:HBS Extensional definition: The value set was constructed by enumerating the codes from LOINC Table 4-139: MCH HBS 10 Min Apgar Score Value Set The MCH HBS 10 Min Apgar Score Value Set will use the LOINC code system to identify its contents. Codes that are used within the scope of this profile are listed below. 174

187 Section Template Entry Template Value Set OID Value Set Code PHVS_ApgarScore10Min_NCHS Value Set Description To Reflect the 10 Min Apgar Score Vocabulary OID LOINC Code LOINC Description Score^10M post birth Active Problems Table 4-140: Active Problems Section Template ID Parent Template CCD 3.5 ( ) General Description The active problem section shall contain a narrative description of the conditions currently being monitored for the patient. It shall include entries for patient conditions as described in the Entry Content Module. LOINC Code Opt Description SHALL Problem List Entries Opt Description SHALL Problem Concern Entry SPECIFICATION SHALL contain exactly two [2..2] templateid such that it o SHALL contain exactly one o SHALL conform to CCD Problem Section template and contain exactly one SHALL contain exactly one [1..1] code/@code=" " Problem List (CodeSystem: LOINC ) SHALL contain exactly one [1..1] title SHALL contain exactly one [1..1] text SHALL contain at least one [1..*] entry o SHALL contain exactly one [1..1] Problem Concern Entry ( ) 175

188 Figure 4-12: Active Problems Section Example <component> <section> <templateid root=' '/> <templateid root=' '/> <id root=' ' extension=' '/> <code code=' ' displayname='problem LIST' codesystem=' ' codesystemname='loinc'/> <text> Text as described above </text> <entry> :  <templateid root=' '/> : </entry> </section> </component> Table 4-141: Newborn Delivery Information Active Problems Value Sets Template ID: TBD This value set is used in the Newborn Delivery Information Section Active Problems Subsection (template ID ). A Procedure element will use the SNOMED code system to identify its contents. Codes that are used within the scope of this profile are listed below. Data Element Seizure or serious neurologic dysfunction Type CD Code SNOMED Value Sets OID MCH HBS Seizure or Serious Neurologic Dysfunction Value Set Seizure or Serious Neurologic Dysfunction Table 4-142: MCH HBS Seizure or Serious Neurologic Dysfunction Metadata The MCH HBS Seizure or Serious Neurologic Dysfunction Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set MCH HBS Seizure or Serious Neurologic Dysfunction Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Publish Health Domain 176

189 Element Description Mandatory Purpose Brief description about the general purpose of the value set To Reflect that the newborn suffered a Seizure or Serious Neurologic Dysfunction reflecting an abnormal Definition Source URI Version A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set condition of the newborn Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT Snomed/snomed_main.html Version 1.0 Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date Revision Date Groups The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned 8/1/2010 N/A 8/1/2010 N/A IHE MCH:HBS Table 4-143: MCH HBS Seizure or Serious Neurologic Dysfunction Value Set The MCH HBS Seizure or Serious Neurologic Dysfunction Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Seizure defined as any involuntary repetitive, convulsive movement or behavior. Serious neurologic dysfunction defined as severe alteration of alertness such as obtundation, stupor, or coma, i.e. hypoxicischemic encephalopathy; excludes lethargy or hypotonia in the absence of other neurologic findings. Excludes symptoms associated with central nervous system (CNS) congenital anomalies. Section Template Entry Template Value Set Value Set Code PHVS_SeizureOrSeriousNeurologicDysfunction_NCHS Value Set Description To Reflect that the newborn suffered a Seizure or Serious Neurologic Dysfunction reflecting an abnormal condition of the newborn. Vocabulary

190 SNOMED-CT Code SNOMED-CT Description Seizure (finding) Abdominal seizure (finding) Afebrile seizure (finding) Akinetic seizure without atonia (finding) Anoxic seizure (finding) Anoxic epileptic seizure (finding) Reflex anoxic seizure (finding) Brief atonic seizure (finding) Central convulsion (finding) Childhood seizure (finding) Dysmnesic seizure (disorder) Epileptic cry (finding) Epileptic seizure (finding) Epileptic seizures - akinetic (finding) Epileptic seizures - atonic (finding) Epileptic seizures - clonic (finding) Epileptic seizures - tonic (finding) Febrile convulsion (finding) Complex febrile seizure (finding) On examination - febrile convulsion (finding) Recurrent febrile convulsion (finding) Simple febrile seizure (finding) Generalized seizure (finding) Clonic seizure (finding) Coordinate convulsion (finding) Salaam spasm (finding) Tonic-clonic seizure (finding) Grand mal seizure (finding) On examination - grand mal fit (finding) Secondarily generalized seizures (finding) Ideational partial seizure (finding) Long atonic seizure (finding) Movement partial seizure (finding) 178

191 4.7.4 Procedures and Interventions Table 4-144: Procedures and Interventions Template ID General Description This section contains a narrative description of the actions performed by a clinician. LOINC Code Opt Description SHALL Procedures Entries Opt Description SHALL Procedures This entry provides coded values for actions performed during the encounter. Figure 4-13: Procedures and Interventions Section Example <component> <section> <templateid root=' '/> <id root=' ' extension=' '/> <code code=' ' displayname='procedures' codesystem=' ' codesystemname='loinc'/> <text> Text as described above </text> <entry> :  <templateid root=' '/> : </entry> </section> </component> Figure 4-14: Procedure Entry Example Procedure Entry: The procedure entry is used to record procedures that have occurred, or which are planned for in the future. <procedure classcode='proc' moodcode='evn INT'> <templateid root=' '/> <templateid root=' '/> <templateid root=' '/> <id root='' extension=''/> <code code='' codesystem=' ' codesystemname='actcode' /> <text><reference value='#xxx'/></text> 179

192 <statuscode code='completed active aborted cancelled'/> <effectivetime> <low value=''/> <high value=''/> </effectivetime> <prioritycode code=''/> <approachsitecode code='' displayname='' codesystem='' codesystemname=''/> <targetsitecode code='' displayname='' codesystem='' codesystemname=''/> <author /> <informant /> <entryrelationship typecode='comp' inversionind='true'> <act classcode='act' moodcode=''> <templateid root=' '/> <id root='' extension=''/> </act> </entryrelationship> <entryrelationship typecode='rson'> <act classcode='act' moodcode='evn'> <templateid root=' '/> <id root='' extension=''/> </act> </entryrelationship> </procedure> Table 4-145: Newborn Delivery Information Procedures and Interventions Value Sets Template ID: TBD This value set is used in the Newborn Delivery Information Section Procedures and Interventions subsection (template ID ). A Procedure element will use the SNOMED code system to identify its contents. Codes that are used within the scope of this profile are listed below. Data Element Type Code Value sets OID Antibiotic Administration Procedure CD As appropriate from Value Set MCH HBS Antibiotic Administration Procedure Value Set Karyotype MCH HBS Karyotype Determination Value Set Determination Assisted Ventilation Assisted ventilation for 6 or more hours CD CD As appropriate from Value Set As appropriate from Value Set MCH HBS Assisted Ventilation Immediately Following Delivery Value Set BFDR Total Time on Ventilator Value Set

193 Antibiotic Administration Procedure Table 4-146: MCH HBS Antibiotic Administration Procedure Metadata The MCH HBS Antibiotic Administration Procedure Value Set Metadata shall contain the following content. Element Description Mandatory Identifier Name Source Purpose Definition Source URI Version This is the unique identifier of the value set This is the name of the value set This is the source of the value set, identifying the originator or publisher of the information Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set MCH HBS Antibiotic Administration Procedure Value Set IHE Quality Research and Publish Health Domain To Reflect Antibiotic Administration Procedure during labor and delivery Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT Snomed/snomed_main.html Version 1.0 Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date Revision Date Groups The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned 8/1/2010 N/A 8/1/2010 N/A IHE MCH:HBS Table 4-147: MCH HBS Antibiotic Administration Procedure Value Set The MCH HBS Antibiotic Administration Procedure Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. 181

194 Section Template Entry Template Value Set OID Value Set Code PHVS_AntibioticAdministrationProcedure_NCHS Value Set Description To Reflect Antibiotic Administration Procedure during labor and delivery SNOMED-CT Code Vocabulary SNOMED-CT Description Intravenous antibiotic therapy (procedure) Intramuscular antibiotic therapy (procedure) Karyotype Determination Table 4-148: MCH HBS Karyotype Determination Metadata The MCH HBS Karyotype Determination Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set MCH HBS Karyotype Determination Value Set Source This is the source of the value set, identifying the originator or IHE Quality Research and Publish Health Domain publisher of the information Purpose Brief description about the general purpose of the value To Reflect Fetal Autopsy was performed set Definition A text definition describing how concepts in the value set were selected Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT Source URI Most sources also have a URL or document URI that provides Snomed/snomed_main.html further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date Revision Date The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set 8/1/2010 N/A 8/1/2010 N/A 182

195 Element Description Mandatory Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE MCH:HBS Table 4-149: MCH HBS Karyotype Determination Value Set The MCH HBS Karyotype Determination Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_KaryotypeDetermination_NCHS Value Set Description To Reflect Fetal Autopsy was performed SNOMED-CT Code Vocabulary SNOMED-CT Description Karyotype determination (procedure) Determination of karyotype from blood specimen (procedure) Assisted Ventilation Immediately Following Delivery Table 4-150: MCH HBS Assisted Ventilation Immediately Following Delivery Metadata The MCH HBS Assisted Ventilation Immediately Following Delivery Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set MCH HBS Assisted Ventilation Immediately Following Delivery Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Definition Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected To Reflect that the newborn was provided assisted ventilation immediately following delivery reflecting an abnormal condition of the newborn Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT 183

196 Element Description Mandatory Source URI Most sources also have a URL or document URI that provides /Snomed/snomed_main.html further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date The date when the value set is 8/1/2010 expected to be effective Expiration The date when the value set is no N/A Date longer expected to be used Creation Date The date of creation of the value 8/1/2010 set Revision Date The date of revision of the value N/A set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE MCH:HBS Table 4-151: MCH HBS Assisted Ventilation Immediately Following Delivery Value Set The MCH HBS Assisted Ventilation Immediately Following Delivery Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Description To Reflect that the newborn was provided assisted ventilation immediately following delivery reflecting an abnormal condition of the newborn Vocabulary SNOMED Code Pending Pending SNOMED Description Total Time on Ventilator Table 4-152: BFDR Total Time on Ventilator Metadata The BFDR Total Time on Ventilator Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Total Time on Ventilator Value Set 184

197 Element Description Mandatory Source This is the source of the value set, identifying the originator or publisher of the information Purpose Definition Source URI Version Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set IHE Quality Research and Publish Health Domain To reflect that the total time on ventilator to determine that the newborn was provided assisted ventilation for 6 or more hours reflecting an abnormal condition of the newborn Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT Snomed/snomed_main.html Version 1.0 Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date Revision Date Groups The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned 8/1/2010 N/A 8/1/2010 N/A IHE BFDR Table 4-153: BFDR Total Time on Ventilator Value Set The BFDR Total Time on Ventilator Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set OID Value Set Description To reflect that the total time on ventilator to determine that the newborn was provided assisted ventilation for 6 or more hours reflecting an abnormal condition of the newborn SNOMED-CT Code Vocabulary Pending Pending SNOMED-CT Description 185

198 4.7.5 Medications Administered Table 4-154: Medications Administered Section Template ID General Description The medications administered section shall contain a narrative description of the relevant medications administered to a patient during the course of an encounter. It shall include entries for medication administration as described in the Entry Content Module. LOINC Code Opt Description SHALL Medication Administered Entries Opt Description SHALL Medications SPECIFICATION SHALL contain exactly one [1..1] templateid such that it o SHALL contain exactly one SHALL contain exactly one [1..1] code/@code=" " Medications Administered (CodeSystem: LOINC ) SHALL contain exactly one [1..1] title SHALL contain exactly one [1..1] text SHALL contain at least one [1..*] entry o SHALL contain exactly one [1..1] Medications Entry ( ) Figure 4-15: Medications Administered Section Example <component> <section> <templateid root=' '/> <id root=' ' extension=' '/> <code code=' ' displayname='medication ADMINISTERED' codesystem=' ' codesystemname='loinc'/> <text> Text as described above </text> <entry> :  <templateid root=' '/> : </entry> </section> </component> 186

199 Table 4-155: Newborn Delivery Medications Administered Product Value Sets Newborn Delivery Medications Administered Product Value Set: TBD This value set is used in the Newborn Delivery Information Section Medications Administered Subsection (template ID ). A Medication element will use the RxNORM code system to identify its contents. Codes that are used within the scope of this profile are listed below. Data Element Newborn given Surfactant replacement therapy? Intramuscular Medication Administration Route IV Medication Administration Route Neonatal Sepsis Type SC SC SC Code SNOMED LOINC Use appropriate drug from value set Value Sets OID BFDR Newborn Receiving Surfactant Replacement Therapy Value Set MCH HBS Intramuscular Medication Administration Route Codes Value Set BFDR IV Medication Administration Route Value Set, BFDR Neonatal Sepsis Value Set BFDR Newborn Receiving Surfactant Replacement Therapy Table 4-156: BFDR Newborn Receiving Surfactant Replacement Therapy Metadata The BFDR Newborn Surfactant Replacement Therapy Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR Newborn Receiving Surfactant Replacement Therapy Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Publish Health Domain Purpose Definition Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected To reflect that the Newborn received Surfactant Replacement Therapy reflecting an abnormal condition of the newborn Extensional definition: The value set was constructed by enumerating the codes from RxNORM 187

200 Element Description Mandatory Source URI Most sources also have a URL or document URI that provides norm/ further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date Revision Date Groups The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned 8/1/2010 N/A 8/1/2010 N/A IHE BFDR Table 4-157: BFDR Newborn Receiving Surfactant Replacement Therapy Value Set The BFDR Newborn Receiving Surfactant Replacement Therapy Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Description To reflect that the Newborn received Surfactant Replacement Therapy reflecting an abnormal condition of the newborn RXNORM Code Vocabulary RXNORM Description Beractant 25 MG/ML Injectable Suspension Beractant Injectable Suspension Calfactant 35 MG/ML Inhalant Solution Calfactant Inhalant Solution Colfosceril 13.5 MG/ML Injectable Suspension Colfosceril Injectable Suspension Poractant alfa 80 MG/ML Injectable Suspension Poractant alfa Injectable Suspension 188

201 Intramuscular Medication Administration Route Table 4-158: MCH HBS Intramuscular Medication Administration Route Metadata The MCH HBS Intramuscular Medication Administration Route Value Set Metadata shall contain the following content. Element Description Mandatory Identifier Name Source Purpose Definition Source URI Version This is the unique identifier of the value set This is the name of the value set This is the source of the value set, identifying the originator or publisher of the information Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set MCH HBS Intramuscular Administration Route Value Set IHE Quality Research and Publish Health Domain To reflect that Intramuscular Medication Administration Route was used to administer a medication Extensional definition: The value set was constructed by enumerating the codes from HL7 Route of Administration s/standards_messaging_v251/hl7_m essaging_v251_pdf.zip Version 1.0 Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date Revision Date Groups The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned 8/1/2010 N/A 8/1/2010 N/A IHE MCH:HBS Table 4-159: MCH HBS Intramuscular Administration Route Value Set The route indicating the MCH HBS Intramuscular Administration Route uses the HL7 Route of Administration code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template

202 Value Set Value Set Description To reflect that Intramuscular Medication Administration Route was used to administer a medication Data Element Vocabulary IM Intramuscular HL7 Route of Administration IV Medication Administration Table 4-160: BFDR IV Medication Administration Metadata The BFDR IV Medication Administration Route Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set BFDR IV Medication Administration Route Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Publish Health Domain Purpose Definition Source URI Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active To reflect that IV Medication Administration Route was used to administer a medication Extensional definition: The value set was constructed by enumerating the codes from HL7 Route of Administration Standards_Messaging_v251/HL7_Mess aging_v251_pdf.zip Effective Date Expiration Date Creation Date Revision Date Groups The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned 8/1/2010 N/A 8/1/2010 N/A IHE BFDR 190

203 Table 4-161: BFDR IV Medication Administration Route Value Set Route indicating BFDR IV Medication Administration Route uses the HL7 Route of Administration code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Description To reflect that IV Medication Administration Route was used to administer a medication Data Element Vocabulary IV Intravenous HL7 Route of Administration Neonatal Sepsis Table 4-162: BFDR Neonatal Sepsis Metadata The BFDR Neonatal Sepsis Delivery Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value BFDR Neonatal Sepsis Value Set set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Publish Health Domain Purpose Definition Source URI Version Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set To reflect that the newborn was provided assisted ventilation immediately following delivery reflecting an abnormal condition of the newborn Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT s/snomed/snomed_main.html Version 1.0 Status Active (Current) or Inactive Active Effective Date Expiration Date The date when the value set is expected to be effective The date when the value set is no longer expected to be used 8/1/2010 N/A 191

204 Element Description Mandatory Creation Date The date of creation of the 8/1/2010 value set Revision Date The date of revision of the value N/A set Groups The identifiers of the groups that include this value set. A group may also have an OID assigned IHE BFDR Table 4-163: BFDR Neonatal Sepsis Value Set Problems or indications indicating Neonatal Sepsis use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Description To reflect that the newborn was provided assisted ventilation immediately following delivery reflecting an abnormal condition of the newborn SNOMED-CT Code Vocabulary SNOMED-CT Description Bacterial sepsis of newborn (disorder) Neonatal candida septicemia (disorder) Neonatal disseminated listeriosis (disorder) Neonatal systemic candidosis (disorder) Sepsis of newborn due to anaerobes (disorder) Sepsis of newborn due to Escherichia coli (disorder) Sepsis of newborn due to Staphylococcus aureus (disorder) Sepsis of the newborn (disorder) Septicemia of newborn (disorder) Tetanus neonatorum (disorder) Coded Event Outcomes Table 4-164: Newborn Delivery Information Coded Event Outcome Value Sets Newborn Delivery Information Coded Event Outcome Value Set TBD OID This value set is used in the Newborn Delivery Information Section Coded Event Outcome subsection (template ID ). 192

205 A Procedure element will use the SNOMED code system to identify its contents. Codes that are used within the scope of this profile are listed below. Data Element NICU admission Significant Birth Injury Place of birth (type or birthing place) Rank of birth In case of multiple births Gestational Age at Birth (days) Type CD Code SNOMED LOINC Value Sets OID BFDR NICU Care Value Set CD MCH HBS Significant Birth Injury Value Set CD BFDR Birthplace Value Set INT D Infant expired BL TBD Cause of death ST Cause of Death (ICD-10) Value Set Location of ST death Date of death TS NICU Care Table 4-165: BFDR NICU Care Codes The BFDR NICU Care Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value BFDR NICU Care Value Set set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Definition Source URI Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set To reflect the that the baby was transferred to NICU following the birth Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT Snomed/snomed_main.html 193

206 Element Description Mandatory Version A string identifying the Version 1.0 specific version of the value set Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date Revision Date Groups The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned 8/1/2012 N/A 8/1/2012 N/A IHE BFDR Table 4-166: BFDR NICU Care Value Set The BFDR NICU Care Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Description To reflect the that the baby was transferred to NICU following the birth SNOMED-CT Code Vocabulary SNOMED-CT Description Neonatal intensive care unit (environment) Significant Birth Injury Table 4-167: MCH HBS Significant Birth Injury Value Set Metadata The MCH HBS Significant Birth Injury Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value set MCH HBS Significant Birth Injury Value Set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Publish Health Domain 194

207 Element Description Mandatory Purpose Brief description about the general purpose of the value set To Reflect that the newborn suffered a Significant Birth Injury (skeletal fracture(s), peripheral nerve injury, and/ or soft tissue/solid organ hemorrhage which requires intervention) reflecting an abnormal Definition Source URI Version A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set condition of the newborn Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT. s/snomed/snomed_main.html Version 1.0 Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date Revision Date Groups The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned 8/1/2010 N/A 8/1/2010 N/A IHE MCH:HBS Table 4-168: MCH HBS Significant Birth Injury Value Set The MCH HBS Significant Birth Injury Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Code PHVS_SignificantBirthInjury_NCHS Value Set Description To Reflect that the newborn suffered a Significant Birth Injury (skeletal fracture(s), peripheral nerve injury, and/ or soft tissue/solid organ hemorrhage which requires intervention) reflecting an abnormal condition of the newborn SNOMED-CT Code Vocabulary Birth trauma of fetus (disorder) Birth injury to face (disorder) SNOMED-CT Description 195

208 SNOMED-CT Code Birth injury to scalp (disorder) Caput succedaneum (disorder) Chignon (disorder) SNOMED-CT Description Vacuum extraction chignon (disorder) Fetal monitoring scalp injury (disorder) Electrode injury to scalp during birth (disorder) Sampling injury to scalp during birth (disorder) Scalp injuries due to birth trauma (disorder) Cephalhematoma due to birth trauma (disorder) Scalp abrasions due to birth trauma (disorder) Scalp injury due to vacuum extraction (disorder) Birth trauma deafness (disorder) Birth trauma due to amniocentesis (disorder) Cerebral injury due to birth trauma (disorder) Cerebral hemorrhage due to birth injury (disorder) Extradural hemorrhage in fetus or newborn (disorder) Subdural and cerebral hemorrhage due to birth trauma (disorder) Tentorial tear due to birth trauma (disorder) Cranial nerve injury due to birth trauma (disorder) Facial nerve injury as birth trauma (disorder) Facial palsy as birth trauma (disorder) Erb-Duchenne palsy as birth trauma (disorder) Hematoma of vulva of fetus or newborn as birth trauma (disorder) Injury of spine AND/OR spinal cord as birth trauma (disorder) Injury to brachial plexus as birth trauma (disorder) Brachial plexus palsy due to birth trauma (disorder) Klumpke-Déjerine paralysis as birth trauma (disorder) Kidney injury due to birth trauma (disorder) Laryngeal injury due to birth trauma (disorder) Liver rupture due to birth trauma (disorder) Paralysis from birth trauma (disorder) Spastic paralysis due to birth injury (disorder) Spastic paralysis due to intracranial birth injury (disorder) Spastic paralysis due to spinal birth injury (disorder) Perinatal forceps injury (disorder) Perinatal skin trauma due to obstetric injury (disorder) 196

209 SNOMED-CT Code SNOMED-CT Description Peripheral nerve injury due to birth trauma (disorder) Birth injury to phrenic nerve (disorder) Phrenic nerve paralysis as birth trauma (disorder) Birth plexus injury - whole plexus (disorder) Scalpel wound due to birth trauma (disorder) Skeletal injury due to birth trauma (disorder) Birth dislocation of the shoulder (disorder) Fracture of long bone, as birth trauma (disorder) Birth fracture of radius (disorder) Birth fracture of ulna (disorder) Fracture of clavicle due to birth trauma (disorder) Fracture of femur due to birth trauma (disorder) Fracture of humerus due to birth trauma (disorder) Fracture of nose due to birth trauma (disorder) Fracture of radius and/or ulna due to birth trauma (disorder) Fracture of spine due to birth trauma (disorder) Fracture of tibia and/or fibula due to birth trauma (disorder) Spine dislocation due to birth trauma (disorder) Spine or spinal cord injury due to birth trauma (disorder) Spinal cord laceration due to birth trauma (disorder) Spinal cord rupture due to birth trauma (disorder) Spleen rupture due to birth trauma (disorder) Sternomastoid injury due to birth injury (disorder) Tentorial tear as birth trauma (disorder) Birthplace Table 4-169: BFDR Birthplace Value Set Metadata The Birthplace Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value Birthplace Value Set set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Brief description about the general purpose of the value set To reflect the Place where birth occurred 197

210 Element Description Mandatory Definition A text definition describing how concepts in the value set were selected codes from SNOMED-CT Source URI Most sources also have a URL or document URI that provides further details regarding the value set Version A string identifying the specific Version 1.0 version of the value set Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date Revision Date Groups The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned Extensional definition: The value set was constructed by enumerating the nomed/snomed_main.html 8/1/2012 N/A 8/1/2012 N/A IHE BFDR Table 4-170: BFDR Birthplace Value Set BFDR Birthplace Value Set will use the SNOMED-CT code system to identify its contents. Codes that are used within the scope of this profile are listed below. Section Template Entry Template Value Set Value Set Description To reflect the Place where birth occurred SNOMED-CT Code Vocabulary Home birth (finding) Planned home birth (finding) Unplanned home birth (finding) Ambulance birth (finding) SNOMED-CT Description Free-standing birthing center (environment) Free-standing clinic (environment) 198

211 Cause of Death Table 4-171: Cause of Death Codes Metadata The Cause of Death Value Set Metadata shall contain the following content. Element Description Mandatory Identifier This is the unique identifier of the value set Name This is the name of the value Cause of Death (ICD-10) Value Set set Source This is the source of the value set, identifying the originator or publisher of the information IHE Quality Research and Public Health Domain Purpose Definition Source URI Version Brief description about the general purpose of the value set A text definition describing how concepts in the value set were selected Most sources also have a URL or document URI that provides further details regarding the value set A string identifying the specific version of the value set To reflect the ICD-10 codes and associated cause of-death titles for the most detailed listing of causes of death. Extensional definition: The value set was constructed by enumerating the codes from SNOMED-CT Snomed/snomed_main.html Version 1.0 Status Active (Current) or Inactive Active Effective Date Expiration Date Creation Date Revision Date Groups The date when the value set is expected to be effective The date when the value set is no longer expected to be used The date of creation of the value set The date of revision of the value set The identifiers of the groups that include this value set. A group may also have an OID assigned 12/15/2010 N/A 12/15/2010 N/A CDC NCHS 199

212 Table 4-172: Cause of Death Value Set Excerpt Section Template Entry Template Value Set Value Set Description The list provides ICD-10 codes and associated cause of-death titles for the most detailed listing of causes of death. This list is maintained by CDC NCHS. SNOMED-CT Code Vocabulary R95 Sudden infant death syndrome SNOMED-CT Description P70.1 Syndrome of infant of a diabetic mother P70.0 Syndrome of infant of mother with gestational diabetes Q86.0 Fetal alcohol syndrome (dysmorphic) P50 Fetal blood loss P50.5 Fetal blood loss from cut end of co-twin's cord P50.2 Fetal blood loss from placenta P50.1 Fetal blood loss from ruptured cord P50.0 Fetal blood loss from vasa previa P50.9 Fetal blood loss, unspecified Q86.1 Fetal hydantoin syndrome P05.2 Fetal malnutrition without mention of light or small for gestational ag O68.3 Labor and delivery complicated by biochemical evidence of fetal stress O68.0 Labor and delivery complicated by fetal heart rate anomaly 4.8 Care Plan Section Table 4-173: Care Plan Section Template ID Parent Template CCD 3.16 ( ) General Description The care plan section shall contain a narrative description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient. LOINC Code OPT Description SHALL Plan of Treatment 200

213 Entries Opt Description MAY Observation Requests The care plan may include observation requests in intent, goal or proposal mood to identify intended observations that are part of the care plan, goals of the plan, or proposed observations (e.g., from clinical decision support) MAY Medication The care plan may include medication entries to identify those medications that are or are proposed to be part of the care plan MAY Immunization The care plan may include immunization entries to identify those immunizations that are or are proposed to be part of the care plan MAY Procedure The care plan may include procedure entries to identify those procedures that are or are proposed to be part of the care plan MAY Encounter The care plan may include encounter entries in to identify those encounters that are or are proposed to be part of the care plan. SPECIFICATION SHALL contain exactly two [2..2] templateid such that it o SHALL contain exactly one [1..1]@root=" " o SHALL conform to CCD Plan of Care Section and contain exactly one SHALL contain exactly one [1..1] code/@code=" " Plan of Treatment (CodeSystem: LOINC ) SHALL contain exactly one [1..1] title SHALL contain exactly one [1..1] text MAY contain zero or more [0..*] entry such that it o SHALL contain exactly one [1..1] Observation Request Entry ( ) MAY contain zero or more [0..*] entry such that it o SHALL contain exactly one [1..1] Medications Entry ( ) MAY contain zero or more [0..*] entry such that it o SHALL contain exactly one [1..1] Immunization Entry ( ) MAY contain zero or more [0..*] entry such that it o SHALL contain exactly one [1..1] Procedure Entry ( ) MAY contain zero or more [0..*] entry such that it o SHALL contain exactly one [1..1] Encounters Entry( ) 201

214 Care Plan Section Further Conformance Constraints The Ambulatory Healthcare Provider BxDefect Event Report uses the IHE PCC Care Plan Section, with one additional constraint: SHALL contain at least one [1..*] Encounters Entry ( ) Figure 4-16: Care Plan Section Example <component> <section> <templateid root=' '/> <templateid root=' '/> <id root=' ' extension=' '/> <code code=' ' displayname='treatment PLAN' codesystem=' ' codesystemname='loinc'/> <text> Text as described above </text> <entry> :  <templateid root=' '/> : </entry> </section> </component> Encounters Entry This content module describes an Encounters Entry. An Encounter is an interaction between a patient and care provider(s) for the purpose of providing healthcarerelated service(s). Healthcare services include health assessment. Examples: outpatient visit to multiple departments, home health support (including physical therapy), inpatient hospital stay, emergency room visit, field visit (e.g., traffic accident), office visit, occupational therapy, or telephone call. SPECIFICATION SHALL contain exactly one (CodeSystem: HL7ActClass ) SHALL contain exactly one ARQ EVN" (CodeSystem: HL7ActMood ) such that it o MAY be APT to indicate a scheduled appointment o MAY be ARQ to describe a request for an appointment that has been made but not yet scheduled by a provider o MAY be EVN, to describe an encounter that has already occurred SHALL contain exactly two [2..2] templateid such that it o SHALL contain exactly one 202

215 o When the encounter is in event mood (moodcode='evn'), this entry SHALL conform to the CCD template o When the encounter is in other moods, this entry SHALL conform to the CCD template SHALL contain one or more [1..*] id SHALL contain exactly one [1..1] code, where SHOULD be selected from ValueSet ActEncounterCode DYNAMIC SHALL contain exactly one [1..1] text o The text SHALL contain exactly one [1..1] reference/@value This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section ) SHOULD contain exactly one [1..1] effectivetime to record the time over which the encounter occurred (in EVN mood), or the desired time of the encounter in ARQ or APT mood, such that o When encounter is in EVN or APT mood, SHOULD contain exactly [1..1] effectivetime o When encounter is in ARQ mood, MAY contain exactly one [1..1] effectivetime. When effectivetime is not present, MAY contain exactly one [1..1] prioritycode to indicate that a callback is needed to schedule the appointment SHOULD contain at least one [1..*] performer such that it o SHOULD contain at least one [1..*] performer to identify the provider of the service given during the encounter when the encounter is in EVN mood o MAY contain at least one [1..*] performer to indicate a preference for a specific provider when the encounter is in ARQ mood o MAY contain at least one [1..*] performer to indicate which provider is scheduled to perform the service (provider referred to) when in APT mood MAY contain zero or more [0..*] participant such that it o SHALL contain exactly one Location o (CodeSystem: HL7ActRelationshipType ) SHALL contain exactly one [1..1] participantrole such that it SHALL contain exactly one Service Delivery Location ( ) MAY contain exactly one [1.1] id MAY contain exactly one [1..1] code to classify the Service Delivery Location SHOULD contain exactly one [1..1] addr SHOULD contain exactly one [1..1] telecom SHALL contain exactly one [1..1] playingentity o This playingentity SHALL contain exactly one Place ( o This playingentity SHALL contain exactly one [1..1] name 203

216 Figure 4-17: Encounter Entry Example <encounter classcode='enc' moodcode='apt ARQ EVN'> <templateid root=' '/> <templateid root=' '/> <templateid root=' '/> <id root='' extension=''/> <code code='' codesystem=' ' codesystemname='actencountercode' /> <text><reference value='#xxx'/></text> <effectivetime> <low value=''/> <high value=''/> </effectivetime> <prioritycode code=''/> <performer typecode='prf'> <time><low value=''/><high value=''/></time> <assignedentity>...</assignedentity> </performer> <author /> <informant /> <participant typecode='loc'> <participantrole classcode='sdloc'> <id/> <code/> <addr>...</addr> <telecom value='' use=''/> <playingentity classcode='plc' determinercode='inst'> <name></name> </playingentity> </participantrole> </participant> </encounter> 4.9 Disposition Section The Disposition Section records the status and condition of the patient at the completion of the surgery. It often also states where the patient was transferred to for the next level of care. The template identifier for this section is C83-[CT-139-1]. This section SHALL conform to the HL7 Operative Note Dispositions Section, and SHALL contain a templateid element whose root attribute is MAY contain zero or one [0..1] sdtc:dischargedispositioncode, which SHALL be selected from ValueSet National Uniform Billing Committee (NUBC) UB-04 FL17-Patient Status DYNAMIC or, if access to NUBC is unavailable, from CodeSystem HL7 Discharge Disposition. The prefix sdtc: SHALL be bound to the namespace urn:hl7- org:sdtc. The use of the namespace provides a necessary extension to CDA R2 for the use of the dischargedispositioncode element (CONF:9929). 204

217 Figure 4-18: Disposition Section Example <sdtc:dischargedispositioncode xmlns:sdtc="urn:hl7-org:sdtc" code="self CARE" codesystem=" " codesystemname="hl7 Discharge Disposition"> <originaltext> <reference value=""/> </originaltext> </sdtc:dischargedispositioncode> 205

218 Appendix A Reportable Birth Defect Conditions The following are Michigan reportable birth defects as identified in the following list of medical conditions. Each of these and other medical conditions have been mapped to an ICD-9, ICD-10, and SNOMED code. To view the complete list, go to <insert TBD link>. Congenital Anomalies Congenital anomalies of the central nervous system Congenital anomalies of the eye Congenital anomalies of the ear, face, and neck Congenital anomalies of the heart and circulatory system Congenital anomalies of the respiratory system Cleft palate and cleft lip Congenital anomalies of the upper alimentary canal/ digestive system Congenital anomalies of the genital and urinary systems Congenital anomalies of the musculoskeletal system Congenital anomalies of the integument Chromosomal anomalies Medical Conditions Congenital syphilis Congenital rubella Cytomegalovirus Listeriosis Herpes simplex Malaria Toxoplasmosis Tuberculosis Familial/Congenital Neoplasms Endocrine/Metabolic Disorders Birth Defects Implementation Guide APP-1

219 Diseases of the Blood and Blood Forming Organs Familial hypoplastic anemia Coagulation defects Primary thrombocytopenia Diseases of the Central and Peripheral Nervous System Cerebral lipidoses Cerebral degeneration Hereditary spastic paraplegia Cerebral palsy Werdnig-hoffman disease Disorders of the autonomic nervous system Cerebral palsy and spasms Cerebral cysts Polyneuritis cranialis Hereditary and idiopathic peripheral neuropathy Myoneural disorders Muscular dystrophies and other myopathies Diseases of the Eye Retinal disorders Chorioretinitis Blindness and low vision Hereditary optic atrophy and nystagmus Any other irregular movement of the eye Hearing Deficiency Including, Structural and Functional Deficiencies Diseases of the Heart and Circulatory System Cardiomyopathy Conductive cardiac disorders Dysrhythmias Occlusions of coronary arteries Budd-chiari syndrome Birth Defects Implementation Guide APP-2

220 Diseases of the Gastrointestinal System Anomalies of teeth, jaw or hernia Stricture Volvulus Fistula of organs Diseases of the Genital and Urinary Systems Involving Fistula and Obstruction Fetal/Placental Anomalies Musculoskeletal System Diseases Involving Abnormal Bone Growth Maternal Causes of Fetal Morbidity Infections Alcohol use including fetal alcohol spectrum disorders Cocaine use and other toxic or medicinal agents affecting the fetus Autism Spectrum Disorders Asperger's Syndrome Rett's syndrome Medical Conditions that are commonly diagnosed after the age of 2 years Fetal alcohol spectrum disorders Cystic fibrosis Muscular dystrophy Autism Cerebral palsy Birth Defects Implementation Guide APP-3

221 Appendix B Value Sets A No applicable value sets. B BFDR Antibiotics Section Template Entry Template Value Set Value Set Code PHVS_Antibiotics_NCHS Value Set Description To Reflect that antibiotics were administered. RxNORM Code Vocabulary RxNORM Code ML penicillin G benzathine UNT/ML / penicillin G procaine UNT/ML Prefilled Syringe ML penicillin G benzathine UNT/ML / penicillin G procaine UNT/ML Prefilled Syringe ML penicillin G benzathine UNT/ML / penicillin G procaine UNT/ML Prefilled Syringe MG Clindamycin 20 MG/ML Prefilled Applicator Acyclovir 25 MG/ML Injectable Solution Acyclovir 50 MG/ML Injectable Solution Acyclovir Injectable Solution Amphotericin B 5 MG/ML Injectable Solution Amphotericin B Injectable Solution Ampicillin (as ampicillin sodium) 100 MG/ML Injectable Solution Ampicillin (as ampicillin sodium) 250 MG/ML Injectable Solution Ampicillin / Floxacillin Injectable Solution Ampicillin / Sulbactam Injectable Solution Ampicillin 100 MG/ML / Sulbactam 50 MG/ML Injectable Solution Ampicillin 125 MG / floxacillin 125 MG per 5 ML Elixir Ampicillin 125 MG/ML Injectable Solution Ampicillin 167 MG/ML / Floxacillin 167 MG/ML Injectable Solution Ampicillin 20 MG/ML / Sulbactam 10 MG/ML Injectable Solution Ampicillin 250 MG/ML / Sulbactam 125 MG/ML Injectable Solution Birth Defects Implementation Guide APP-4

222 RxNORM Code RxNORM Code Ampicillin 30 MG/ML / Sulbactam 15 MG/ML Injectable Solution Ampicillin Injectable Solution Cefazolin 10 MG/ML Injectable Solution Cefazolin 100 MG/ML Injectable Solution Cefazolin 20 MG/ML Injectable Solution Cefazolin 200 MG/ML Injectable Solution Cefazolin 225 MG/ML Injectable Solution Cefazolin 250 MG/ML Injectable Solution Cefazolin 330 MG/ML Injectable Solution Cefazolin Injectable Solution Cefotaxime 20 MG/ML Injectable Solution Cefotaxime 200 MG/ML Injectable Solution Cefotaxime 230 MG/ML Injectable Solution Cefotaxime 300 MG/ML Injectable Solution Cefotaxime 330 MG/ML Injectable Solution Cefotaxime 40 MG/ML Injectable Solution Cefotaxime Injectable Solution Ceftazidime 10 MG/ML Injectable Solution Ceftazidime 170 MG/ML Injectable Solution Ceftazidime 20 MG/ML Injectable Solution Ceftazidime 200 MG/ML Injectable Solution Ceftazidime 210 MG/ML Injectable Solution Ceftazidime 250 MG/ML Injectable Solution Ceftazidime 280 MG/ML Injectable Solution Ceftazidime 40 MG/ML Injectable Solution Ceftazidime 60 MG/ML Injectable Solution Ceftazidime Injectable Solution Ceftriaxone 100 MG/ML Injectable Solution Ceftriaxone 20 MG/ML Injectable Solution Ceftriaxone 250 MG/ML Injectable Solution Ceftriaxone 350 MG/ML Injectable Solution Ceftriaxone 40 MG/ML Injectable Solution Clindamycin 12 MG/ML Injectable Solution Clindamycin 150 MG/ML Clindamycin 150 MG/ML Injectable Solution Clindamycin 18 MG/ML Injectable Solution Clindamycin 6 MG/ML Injectable Solution Clindamycin 900 MG per 50 ML Injectable Solution Clindamycin 900 MG per 6 ML Injectable Solution Clindamycin Injectable Solution Erythromycin 50 MG/ML Injectable Solution Erythromycin Gluceptate 1 MG/ML Injectable Solution Birth Defects Implementation Guide APP-5

223 RxNORM Code RxNORM Code Erythromycin Gluceptate 50 MG/ML Injectable Solution Erythromycin lactobionate 50 MG/ML Injectable Solution Fluconazole 2 MG/ML Injectable Solution Fluconazole 4 MG/ML Injectable Solution Fluconazole Injectable Solution Gentamicin Sulfate (USP) 0.4 MG/ML Injectable Solution Gentamicin Sulfate (USP) 0.6 MG/ML Injectable Solution Gentamicin Sulfate (USP) 0.7 MG/ML Injectable Solution Gentamicin Sulfate (USP) 0.8 MG/ML Injectable Solution Gentamicin Sulfate (USP) 0.9 MG/ML Injectable Solution Gentamicin Sulfate (USP) 1 MG/ML Injectable Solution Gentamicin Sulfate (USP) 1.2 MG/ML Injectable Solution Gentamicin Sulfate (USP) 1.4 MG/ML Injectable Solution Gentamicin Sulfate (USP) 1.6 MG/ML Injectable Solution Gentamicin Sulfate (USP) 10 MG/ML Injectable Solution Gentamicin Sulfate (USP) 2 MG/ML Injectable Solution Gentamicin Sulfate (USP) 2.4 MG/ML Injectable Solution Gentamicin Sulfate (USP) 3.6 MG/ML Injectable Solution Gentamicin Sulfate (USP) 40 MG/ML Injectable Solution Gentamicin Sulfate (USP) 5 MG/ML Injectable Solution Gentamicin Sulfate (USP) 50 MG/ML Injectable Solution Gentamicin Sulfate (USP) 60 MG/ML Injectable Solution Gentamicin Sulfate (USP) 80 MG/ML Injectable Solution Gentamicin Sulfate (USP) Injectable Solution Metronidazole 5 MG/ML Injectable Solution Metronidazole Injectable Solution Nafcillin 100 MG/ML Injectable Solution Nafcillin 20 MG/ML Injectable Solution Nafcillin 250 MG/ML Injectable Solution Nafcillin 40 MG/ML Injectable Solution Nafcillin Injectable Solution Oxacillin 100 MG/ML Injectable Solution Oxacillin 167 MG/ML Injectable Solution Oxacillin 20 MG/ML Injectable Solution Oxacillin 40 MG/ML Injectable Solution Oxacillin Injectable Solution Penicillin G UNT/ML Injectable Solution Penicillin G UNT/ML Injectable Solution Penicillin G UNT/ML Injectable Suspension Penicillin G 375 MG/ML Injectable Solution Penicillin G benzathine 1,200,000 UNT / penicillin G procaine 1,200,000 UNT per 2 ML Prefilled Syringe Birth Defects Implementation Guide APP-6

224 RxNORM Code RxNORM Code Penicillin G benzathine 1,200,000 UNT per 2 ML Prefilled Syringe Penicillin G benzathine UNT/ML / penicillin G procaine UNT/ML Injectable Solution Penicillin G benzathine UNT/ML / penicillin G procaine UNT/ML Injectable Suspension Penicillin G benzathine 2,400,000 UNT per 4 ML Prefilled Syringe Penicillin G benzathine UNT/ML / penicillin G procaine UNT/ML Injectable Suspension Penicillin G benzathine UNT/ML Injectable Suspension Penicillin G benzathine UNT/ML / penicillin G procaine UNT/ML 2 ML Prefilled Syringe Penicillin G benzathine 600,000 UNT per 1 ML Prefilled Syringe Penicillin G benzathine UNT/ML Injectable Suspension Penicillin G benzathine UNT/ML / penicillin G procaine UNT/ML Injectable Suspension Penicillin G Injectable Solution Penicillin G Injectable Suspension Penicillin G Potassium UNT/ML Injectable Solution Penicillin G Potassium UNT/ML Injectable Solution Penicillin G Potassium UNT/ML Injectable Solution Penicillin G Potassium UNT/ML Injectable Solution Penicillin G Potassium UNT/ML Injectable Solution Penicillin G Potassium UNT/ML Injectable Solution Penicillin G Prefilled Syringe penicillin G procaine 1,200,000 UNT per 2 ML Prefilled Syringe penicillin G procaine UNT/ML Injectable Suspension penicillin G procaine 600,000 UNT per 1 ML Prefilled Syringe penicillin G procaine 600,000 UNT/ML Injectable Suspension Penicillin G Sodium UNT/ML Injectable Solution Penicillium camemberti allergenic extract 50 MG/ML Injectable Solution Penicillium chrysogenum var. chrysogenum extract 1 MG/ML Penicillium chrysogenum var. chrysogenum extract 100 MG/ML Penicillium chrysogenum var. chrysogenum extract 100 UNT/ML Penicillium chrysogenum var. chrysogenum extract 1000 UNT/ML Penicillium chrysogenum var. chrysogenum extract UNT/ML Penicillium chrysogenum var. chrysogenum extract UNT/ML Penicillium chrysogenum var. chrysogenum extract UNT/ML Penicillium chrysogenum var. chrysogenum extract 50 MG/ML Penicillium italicum extract 0.05 GM/ML Injectable Solution Penicillium roquefortii allergenic extract 50 MG/ML Injectable Solution Piperacillin / tazobactam Injectable Solution Piperacillin 200 MG/ML / tazobactam 25 MG/ML Injectable Solution Birth Defects Implementation Guide APP-7

225 RxNORM Code RxNORM Code Piperacillin 200 MG/ML Injectable Solution Piperacillin 30 MG/ML Injectable Solution Piperacillin 40 MG/ML / tazobactam 5 MG/ML Injectable Solution Piperacillin 40 MG/ML Injectable Solution Piperacillin 400 MG/ML Injectable Solution Piperacillin 60 MG/ML / tazobactam 7.5 MG/ML Injectable Solution Piperacillin 80 MG/ML / tazobactam 10 MG/ML Injectable Solution Piperacillin Injectable Solution Vancomycin 10 MG/ML Injectable Solution Vancomycin 100 MG/ML Injectable Solution Vancomycin 3 MG/ML Injectable Solution Vancomycin 3.5 MG/ML Injectable Solution Vancomycin 4 MG/ML Injectable Solution Vancomycin 5 MG/ML Injectable Solution Vancomycin 50 MG/ML Injectable Solution Vancomycin 6 MG/ML Injectable Solution Vancomycin 6.67 MG/ML Injectable Solution Vancomycin 7 MG/ML Injectable Solution Vancomycin 8 MG/ML Injectable Solution Vancomycin 8.33 MG/ML Injectable Solution Vancomycin Injectable Solution Zidovudine 10 MG/ML Injectable Solution Zidovudine Injectable Solution BFDR Assistive Reproductive Technology Section Template Entry Template Value Set OID Value Set Code PHVS_AssistiveReproductiveTechnology_NCHS Value Set Description To reflect the Assistive Reproductive Technology as a Risk Factor in Pregnancy Vocabulary OID SNOMED-CT Code SNOMED-CT Description Test tube ovum fertilization (procedure) Assisted fertilization (procedure) Gamete intrauterine transfer (procedure) Endoscopic intrafallopian transfer of gamete (procedure) Direct injection of sperm into cytoplasm of the oocyte (procedure) Direct intraperitoneal insemination Birth Defects Implementation Guide APP-8

226 SNOMED-CT Code Zona drilling (procedure) Subzonal insemination SNOMED-CT Description Gamete intrafallopian transfer (procedure) Fallopian replacement of egg with delayed insemination (procedure) Zygote intrafallopian transfer (procedure) Tubal embryo transfer (procedure) Intraperitoneal insemination In vitro fertilization using donor eggs (procedure) In vitro fertilization with intracytoplasmic sperm injection (procedure) In vitro fertilization with preimplantation genetic diagnosis (procedure) In vitro fertilization using donor egg and intracytoplasmic sperm injection (procedure) In vitro fertilization using donor sperm (procedure) Conceived by in vitro fertilization (finding) BFDR Augmentation of Labor Medication Section Template Entry Template Value Set Value Set Code PHVS_AugmentationOfLaborMedication_NCHS Value Set Description To reflect a medication used for the Augmentation of Labor Vocabulary RxNORM Code RxNORM Description Oxytocin 10 UNT/ML Injectable Solution BFDR Augmentation of Labor Procedure Section Template Entry Template Value Set Value Set Code PHVS_AugmentationOfLaborProcedure_NCHS Value Set Description To reflect a procedure of Augmentation of Labor Vocabulary Birth Defects Implementation Guide APP-9

227 SNOMED-CT Code SNOMED-CT Description Augmentation of labor (procedure) Stimulation of labor (procedure) BFDR Birthplace Section Template Entry Template Value Set Value Set Description To reflect the Place where birth occurred Vocabulary SNOMED-CT Code SNOMED-CT Description Home birth (finding) Planned home birth (finding) Unplanned home birth (finding) Ambulance birth (finding) Free-standing birthing center (environment) Free-standing clinic (environment) BFDR Birth Plurality of Delivery Section Template Entry Template Value Set OID Value Set Code PHVS_BirthPluralityOfDelivery_NCHS Value Set Description To Reflect the Birth Plurality of Delivery Vocabulary LOINC Code LOINC Description Birth plurality Birth Defects Implementation Guide APP-10

228 BFDR Cervical Cerclage Section Template Entry Template Value Set Value Set Code PHVS_CervicalCerclage_NCHS Value Set Description To Reflect Obstetric Procedures as Cervical Cerclage SNOMED-CT Code Vocabulary Cerclage of cervix (procedure) SNOMED-CT Description Macdonald's cervical cerclage (procedure) Cerclage of cervix during pregnancy by abdominal approach (procedure) Cerclage of cervix during pregnancy by vaginal approach (procedure) Marckwald operation on cervix (procedure) Non-obstetric encircling suture of cervical os (procedure) Shirodkar's cervical cerclage (procedure) BFDR Date of Last Menses Section Template Entry Template Value Set OID Value Set Code PHVS_NumberofLiveBirths_NCHS Value Set Description To reflect the Date of Last Menses Vocabulary OID LOINC Code LOINC Description Menstrual period start.last Estimated last menstrual period Date last menstrual period BFDR Delivery Section Template Entry Template Value Set Value Set Code PHVS_Delivery_NCHS Value Set Description To Reflect the Delivery Procedure Vocabulary Birth Defects Implementation Guide APP-11

229 SNOMED-CT Code SNOMED-CT Description Delivery room care (regime/therapy) Normal delivery procedure (procedure) Failed forceps delivery (procedure) Delivery by Ritgen maneuver (procedure) Manually assisted spontaneous delivery (procedure) Delivery of transverse presentation (procedure) High forceps delivery with episiotomy (procedure) Delivery of face presentation (procedure) Subtotal hysterectomy after cesarean delivery (procedure) Low forceps delivery with episiotomy (procedure) Low forceps delivery (procedure) Partial breech delivery with forceps to aftercoming head (procedure) Vaginal delivery, medical personnel present (procedure) Delivery by Scanzoni maneuver (procedure) Mid forceps delivery with episiotomy (procedure) Delivery by vacuum extraction with episiotomy (procedure) Delivery by double application of forceps (procedure) Barton's forceps delivery (procedure) Frank breech delivery (procedure) Delivery by Malstrom's extraction with episiotomy (procedure) Vaginal delivery with forceps including postpartum care (procedure) Spontaneous unassisted delivery, medical personnel present (procedure) Total breech delivery with forceps to aftercoming head (procedure) Delivery of placenta following delivery of infant outside of hospital (procedure) Colpoperineorrhaphy following delivery (procedure) Delivery by vacuum extraction (procedure) Mid forceps delivery (procedure) Forceps delivery with rotation of fetal head (procedure) Destructive procedure on fetus to facilitate delivery (procedure) Footling breech delivery (procedure) Delivery by Kielland rotation (procedure) High forceps delivery (procedure) Delivery by Malstrom's extraction (procedure) Induction and delivery procedures (procedure) Breech extraction delivery with version (procedure) Spontaneous breech delivery (procedure) Assisted breech delivery (procedure) Forceps cephalic delivery (procedure) Birth Defects Implementation Guide APP-12

230 SNOMED-CT Code SNOMED-CT Description High forceps cephalic delivery with rotation (procedure) Midforceps cephalic delivery with rotation (procedure) Barton forceps cephalic delivery with rotation (procedure) DeLee forceps cephalic delivery with rotation (procedure) Piper forceps delivery (procedure) High vacuum delivery (procedure) Low vacuum delivery (procedure) Vacuum delivery before full dilation of cervix (procedure) Cephalic vaginal delivery with abnormal presentation of head at delivery without instrument (procedure) Manipulative cephalic vaginal delivery with abnormal presentation of head at delivery without instrument (procedure) Non-manipulative cephalic vaginal delivery with abnormal presentation of head at delivery without instrument (procedure) Normal delivery procedure (procedure) Water birth delivery (procedure) Normal delivery of placenta (procedure) Piper forceps delivery by application to aftercoming head (procedure) Delivery procedure (procedure) Instrumental delivery (procedure) Nonrotational forceps delivery (procedure) Outlet forceps delivery (procedure) Forceps delivery, face to pubes (procedure) Forceps delivery to the aftercoming head (procedure) Delivery of the after coming head (procedure) Abdominal delivery for shoulder dystocia (procedure) Operation to facilitate delivery (procedure) Placental delivery procedure (procedure) Maneuvers for delivery in shoulder dystocia (procedure) Breech delivery (procedure) Aspiration curettage of uterus after delivery (procedure) Midforceps delivery without rotation (procedure) Neville-Barnes forceps delivery (procedure) Simpson's forceps delivery (procedure) Breech/instrumental delivery operations (procedure) Dilation/incision of cervix - delivery aid (procedure) Supervision - normal delivery (procedure) Forceps delivery (procedure) Breech presentation, delivery, no version (procedure) Dilatation of cervix for delivery (procedure) Partial breech delivery (procedure) Delivery of vertex presentation (procedure) Birth Defects Implementation Guide APP-13

231 SNOMED-CT Code SNOMED-CT Description Intrapartal care: high-risk delivery (regime/therapy) Duhrssen's incisions of cervix to assist delivery (procedure) Pubiotomy to assist delivery (procedure) Dilation and curettage of uterus after delivery (procedure) Analgesia for labor/delivery (procedure) Amniotomy at delivery (procedure) Delivery of placenta by maternal effort (procedure) BFDR Epidural Anesthesia Medication Section Template Entry Template Value Set Value Set Code PHVS_EpiduralAnesthesiaMedication_NCHS Value Set Description To Reflect an Epidural Anesthesia Medication RxNORM Code Vocabulary RxNORM Description bupivacaine % / fentanyl 5 MCG/ML Injectable Solution bupivacaine 0.05 % / fentanyl 3 MCG/ML Injectable Solution bupivacaine 0.06 % / hydromorphone hydrochloride 2 MG per 100 ML Injectable Solution bupivacaine % / fentanyl 2 MCG/ML Injectable Solution bupivacaine % / fentanyl 5 MCG/ML Injectable Solution bupivacaine % / hydromorphone hydrochloride 10 MCG/ML Injectable Solution bupivacaine % / hydromorphone hydrochloride 5 MCG/ML Injectable Solution bupivacaine 0.1 % / fentanyl 4 MCG/ML Injectable Solution bupivacaine 0.1 % / hydromorphone hydrochloride 10 MCG/ML Injectable Solution bupivacaine 0.1 % Injectable Solution bupivacaine % / fentanyl 2 MCG/ML Injectable Solution bupivacaine % / hydromorphone hydrochloride 20 MCG/ML Injectable Solution bupivacaine % Injectable Solution bupivacaine 0.25 % Injectable Solution bupivacaine % Injectable Solution bupivacaine 0.5 % / epinephrine 1:200,000 Injectable Solution bupivacaine 0.5 % Injectable Solution Bupivacaine MG/ML / Fentanyl MG/ML Injectable Solution Birth Defects Implementation Guide APP-14

232 RxNORM Code RxNORM Description Bupivacaine MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine MG/ML Injectable Solution Bupivacaine 1 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1 MG/ML / Fentanyl 0.01 MG/ML Injectable Solution Bupivacaine 1.05 MG/ML Injectable Solution Bupivacaine 1.25 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1.25 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1.25 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1.25 MG/ML / Fentanyl MG/ML Injectable Solution bupivacaine 100 MG per 20 ML Prefilled Syringe bupivacaine 125 MG per 50 ML Prefilled Syringe Bupivacaine 2 MG/ML Injectable Solution Bupivacaine 2.5 MG/ML / Epinephrine MG/ML Injectable Solution Bupivacaine 2.5 MG/ML / Fentanyl 0.02 MG/ML Injectable Solution Bupivacaine 3.75 MG/ML / Lidocaine 10 MG/ML Injectable Solution Bupivacaine 7.5 MG/ML / Epinephrine MG/ML Injectable Solution Bupivacaine 7.5 MG/ML Injectable Solution Bupivacaine 8.25 MG/ML Injectable Solution Bupivacaine Hydrochloride 2 MG/ML Injectable Solution chloroprocaine 2 % Injectable Solution Chloroprocaine hydrochloride 10 MG/ML Injectable Solution Chloroprocaine hydrochloride 30 MG/ML Injectable Solution Bupivacaine 3.75 MG/ML / Lidocaine 10 MG/ML Injectable Solution Dexamethasone 4 MG/ML / Lidocaine 10 MG/ML Injectable Solution Lidocaine 10 MG/ML / Methylprednisolone 40 MG/ML Injectable Solution Birth Defects Implementation Guide APP-15

233 BFDR Epidural Anesthesia Procedure Section Template Entry Template Value Set Value Set Code PHVS_EpiduralAnesthesia_NCHS Value Set Description To Reflect an Epidural Anesthesia Procedure SNOMED-CT Code Vocabulary SNOMED-CT Description Epidural anesthesia (procedure) Epidural injection of anesthetic substance, therapeutic, lumbar, continuous (procedure) Local anesthetic sacral epidural block (procedure) Epidural injection of anesthetic substance, diagnostic, caudal, continuous (procedure) Epidural injection of anesthetic substance, therapeutic, caudal, continuous (procedure) Low dose epidural (procedure) Anesthesia for vaginal delivery (procedure) BFDR Facility Location OR Value Set Value Set Description To reflect that the patient (mother) was treated in the OR for an unplanned operation for complications associated with labor and delivery reflecting unplanned operation HL7 Service Delivery Location Code Vocabulary Inpatient operating room/suite Operating and recovery rooms Code Description BFDR Fertility Enhancing Drugs Section Template Entry Template Value Set OID Value Set Description To reflect that Fertility Enhancing Drugs were administered as a Risk Factor in Pregnancy Vocabulary OID Birth Defects Implementation Guide APP-16

234 RxNorm Code Clomiphene 50 MG Oral Tablet RxNorm Description Follicle Stimulating Hormone 150 UNT/ML / Luteinizing Hormone 150 UNT/ML Injectable Solution Follicle Stimulating Hormone 75 UNT/ML / Luteinizing Hormone 75 UNT/ML Injectable Solution Urofollitropin 150 UNT/ML Injectable Solution Urofollitropin 300 UNT/ML Injectable Solution ML follitropin beta 833 UNT/ML Prefilled Syringe ML follitropin beta 833 UNT/ML Prefilled Syringe ML follitropin beta 833 UNT/ML Prefilled Syringe follitropin beta 350 UNT per 0.42 ML Prefilled Syringe follitropin beta 75 UNT/ML Injectable Solution follitropin beta 833 UNT/ML Injectable Solution Follitropin Alfa 300 UNT/ML Injectable Solution Follitropin Alfa 600 UNT/ML Injectable Solution follitropin alfa 75 UNT/ACTUAT Prefilled Pen, 12 ACTUAT Follitropin Alfa 75 UNT/ACTUAT Prefilled Syringe, 4 ACTUAT follitropin alfa 75 UNT/ACTUAT Prefilled Syringe, 6 ACTUAT Follitropin Alfa 75 UNT/ML Injectable Solution Chorionic Gonadotropin UNT/ML Injectable Solution chorionic gonadotropin 0.25 MG per 0.5 ML Prefilled Syringe Chorionic Gonadotropin 0.25 MG/ML Injectable Solution Chorionic Gonadotropin 0.5 MG/ML Injectable Solution Chorionic Gonadotropin UNT/ML Injectable Solution Chorionic Gonadotropin 500 UNT/ML Injectable Solution Bromocriptine 2.5 MG Oral Tablet bromocriptine 5 MG (bromocriptine mesylate 5.74 MG) Oral Capsule HR Metformin hydrochloride 1000 MG / saxagliptin 2.5 MG Extended Release Tablet HR Metformin hydrochloride 1000 MG / saxagliptin 5 MG Extended Release Tablet HR Metformin hydrochloride 500 MG / saxagliptin 5 MG Extended Release Tablet Glipizide 2.5 MG / Metformin hydrochloride 250 MG Oral Tablet Glipizide 2.5 MG / Metformin hydrochloride 500 MG Oral Tablet Glipizide 5 MG / Metformin hydrochloride 500 MG Oral Tablet Glyburide 1.25 MG / Metformin hydrochloride 250 MG Oral Tablet Birth Defects Implementation Guide APP-17

235 RxNorm Code RxNorm Description Glyburide 2.5 MG / Metformin hydrochloride 500 MG Oral Tablet Glyburide 5 MG / Metformin hydrochloride 500 MG Oral Tablet Metformin hydrochloride 100 MG/ML Oral Solution HR Metformin hydrochloride 1000 MG / pioglitazone 15 MG Extended Release Tablet Metformin hydrochloride 1000 MG / pioglitazone 15 MG Extended Release Tablet HR Metformin hydrochloride 1000 MG / pioglitazone 30 MG Extended Release Tablet Metformin hydrochloride 1000 MG / pioglitazone 30 MG Extended Release Tablet Metformin hydrochloride 1000 MG / rosiglitazone 2 MG Oral Tablet Metformin hydrochloride 1000 MG / rosiglitazone 4 MG Oral Tablet Metformin hydrochloride 1000 MG / saxagliptin 2.5 MG Extended Release Tablet Metformin hydrochloride 1000 MG / saxagliptin 5 MG Extended Release Tablet Metformin hydrochloride 1000 MG / sitagliptin 50 MG Oral Tablet HR Metformin hydrochloride 1000 MG Extended Release Tablet Metformin hydrochloride 1000 MG Extended Release Tablet Metformin hydrochloride 1000 MG Oral Tablet Metformin hydrochloride 500 MG / pioglitazone 15 MG Oral Tablet Metformin hydrochloride 500 MG / repaglinide 1 MG Oral Tablet Metformin hydrochloride 500 MG / repaglinide 2 MG Oral Tablet Metformin hydrochloride 500 MG / rosiglitazone 1 MG Oral Tablet Metformin hydrochloride 500 MG / rosiglitazone 2 MG Oral Tablet Metformin hydrochloride 500 MG / rosiglitazone 4 MG Oral Tablet Metformin hydrochloride 500 MG / saxagliptin 5 MG Extended Release Tablet Metformin hydrochloride 500 MG / sitagliptin 50 MG Oral Tablet HR Metformin hydrochloride 500 MG Extended Release Tablet Metformin hydrochloride 500 MG Extended Release Tablet Metformin hydrochloride 500 MG Oral Tablet Birth Defects Implementation Guide APP-18

236 RxNorm Code RxNorm Description Metformin hydrochloride 625 MG Oral Tablet HR Metformin hydrochloride 750 MG Extended Release Tablet Metformin hydrochloride 750 MG Extended Release Tablet Metformin hydrochloride 850 MG / pioglitazone 15 MG Oral Tablet Metformin hydrochloride 850 MG Oral Tablet Metformin Oral Tablet Glyburide / Metformin Oral Tablet Metformin / pioglitazone Extended Release Tablet Metformin / pioglitazone Oral Tablet Metformin / repaglinide Oral Tablet Metformin / rosiglitazone Oral Tablet Metformin / saxagliptin Extended Release Tablet Metformin / sitagliptin Oral Tablet Metformin Extended Release Tablet Metformin Oral Solution Metformin Oral Tablet BFDR Fetal Presentation at Birth - Breech Section Template Entry Template Value Set Value Set Code PHVS_FetalPresentationAtBirthBreech_NCHS Value Set Description To Reflect the Fetal Presentation at Birth - Breech method of delivery SNOMED-CT Code Vocabulary Breech presentation (finding) SNOMED-CT Description Breech presentation - delivered (finding) Breech presentation with antenatal problem (finding) Complete breech presentation (finding) Footling breech presentation (finding) Breech presentation, double footling (finding) Breech presentation, single footling (finding) Frank breech presentation (finding) Incomplete breech presentation (finding) Birth Defects Implementation Guide APP-19

237 SNOMED-CT Code SNOMED-CT Description On examination - breech presentation (finding) Deliveries by breech extraction (finding) Head entrapment during breech delivery (disorder) Deliveries by spontaneous breech delivery (finding) Obstructed labor due to breech presentation (finding) Finding of position of breech presentation (finding) Sacroanterior position (finding) Direct sacroanterior position (finding) Left sacroanterior position (finding) Right sacroanterior position (finding) Sacrolateral position (finding) Left sacrolateral position (finding) Right sacrolateral position (finding) Sacroposterior position (finding) Direct sacroposterior position (finding) Left sacroposterior position (finding) Right sacroposterior position (finding) BFDR Fetal Presentation at Birth - Cephalic Section Template Entry Template Value Set Value Set Code PHVS_FetalPresentationAtBirthCephalic_NCHS Value Set Description To Reflect the Fetal Presentation at Birth - Cephalic method of delivery SNOMED-CT Code Vocabulary Vertex presentation (finding) SNOMED-CT Description On examination - vertex presentation (finding) Vertex presentation with caput succedaneum (finding) Spontaneous vertex delivery (finding) Vertex presentation with caput succedaneum (finding) Asynclitism Anterior asynclitism Posterior asynclitism Occiptoanterior position Direct occiptoanterior position Left occiptoanterior position Right occiptoanterior position Birth Defects Implementation Guide APP-20

238 SNOMED-CT Code SNOMED-CT Description Occipitolateral position Left occipitolateral position Right occipitolateral position Occiptoposterior position Direct occiptoposterior position Left occiptoposterior position Right occiptoposterior position BFDR Fetal Presentation at Birth - Other Section Template Entry Template Value Set Value Set Code PHVS_FetalPresentationAtBirthCephalic_NCHS Value Set Description To Reflect the Fetal Presentation at Birth - Cephalic method of delivery SNOMED-CT Code Vocabulary Fontanelles presenting (finding) SNOMED-CT Description Anterior fontanelle presenting (finding) Both fontanelles presenting (finding) Posterior fontanelle presenting (finding) Acromion presentation (finding) Asynclitism (finding) Brow presentation (finding) Compound presentation (finding) Face presentation (finding) Funic presentation (finding) Longitudinal fetal presentation (finding) Abnormal fetal presentation (finding) Birth Defects Implementation Guide APP-21

239 BFDR Fourth Degree Perineal Laceration Section Template Entry Template Value Set Value Set Code PHVS_FourthDegreePerinealLaceration_NCHS Value Set Description To reflect Fourth Degree Perineal Laceration as a maternal morbidity SNOMED-CT Code Vocabulary SNOMED-CT Description Fourth degree perineal laceration (disorder) Fourth degree perineal laceration involving anal mucosa (disorder) Fourth degree perineal laceration involving rectal mucosa (disorder) Fourth degree perineal tear during delivery - delivered (disorder) Fourth degree perineal tear during delivery with postnatal problem (disorder) BFDR Glucocortico Steroids Section Template Entry Template Value Set Value Set Description To Reflect administration of Glucocortico Steroids RxNORM Code Vocabulary RxNORM Description Betamethasone 3 MG/ML Injectable Solution Betamethasone 4 MG/ML Injectable Solution Betamethasone 3 MG/ML (as betamethasone sodium phosphate) / Betamethasone acetate 3 MG/ML Injectable Suspension Dexamethasone 4 MG/ML / Lidocaine 10 MG/ML Injectable Solution Dexamethasone 0.02 MG/ML Injectable Solution Dexamethasone MG/ML Injectable Solution Dexamethasone 10 MG/ML Injectable Solution Dexamethasone 16 MG/ML Injectable Solution Dexamethasone 2 MG/ML Injectable Solution Dexamethasone 20 MG/ML Injectable Solution Dexamethasone 24 MG/ML Injectable Solution Birth Defects Implementation Guide APP-22

240 RxNORM Code RxNORM Description Dexamethasone 3 MG/ML Injectable Solution Dexamethasone 4 MG/ML Injectable Solution Dexamethasone 5 MG/ML Injectable Solution Dexamethasone 8 MG/ML Injectable Solution Dexamethasone 16 MG/ML Injectable Suspension Dexamethasone 8 MG/ML Injectable Suspension BFDR ICU Care Section Template Entry Template Value Set Value Set Description To reflect the that the mother was transferred to ICU following the birth SNOMED-CT Code Vocabulary SNOMED-CT Description Seen by intensive care - service (finding) Seen by adult intensive care - service (finding) Seen by intensive care specialist (finding) Seen by adult intensive care specialist (finding) Under care of intensive care specialist (finding) Under care of adult intensive care specialist (finding) BFDR Induction of Labor Section Template Entry Template Value Set Value Set Code PHVS_InductionOfLabor_NCHS Value Set Description To Reflect that there was an Induction of Labor Vocabulary SNOMED-CT Code SNOMED-CT Description Oxytocin induction of labor (procedure) Prostaglandin induction of labor (procedure) Intravenous induction of labor (procedure) Induction of labor (procedure) Acupuncture for induction of labor (procedure) Syntocinon induction of labor (procedure) Birth Defects Implementation Guide APP-23

241 SNOMED-CT Code SNOMED-CT Description Medical induction of labor (procedure) Induction of labor by artificial rupture of membranes (procedure) Dilatation of cervix for delivery (procedure) Cervical ripening with balloon (procedure) Cervical ripening with drug (procedure) Cervical ripening with ethinyl estradiol (procedure) Cervical ripening with Prostaglandin E2 (procedure) Cervical ripening with relaxin (procedure) Cervical ripening with Foley catheter (procedure) Cervical ripening with tents (procedure) Cervical ripening with synthetic tent (procedure) Insertion of laminaria into cervix (procedure) Sweeping of membrane (procedure) BFDR Infertility Treatment Section Template Entry Template Value Set OID Value Set Code PHVS_InfertilityTreatment_NCHS Value Set Description To reflect Risk Factors of Pregnancy Infertility Treatment Vocabulary OID SNOMED-CT Code Infertility therapy (procedure) SNOMED-CT Description Female infertility therapy (procedure) Artificial insemination by donor (procedure) Artificial insemination by husband (procedure) Artificial insemination with sperm washing and capacitation (procedure) Artificial insemination, heterologous (procedure) Artificial insemination, homologous (procedure) Intracervical artificial insemination (procedure) Intrauterine artificial insemination (procedure) Intrauterine insemination using donor sperm (procedure) Intrauterine insemination using partner sperm (procedure) Intrauterine insemination with controlled ovarian hyperstimulation using donor sperm (procedure) Intrauterine insemination with controlled ovarian hyperstimulation using partner sperm (procedure) Birth Defects Implementation Guide APP-24

242 SNOMED-CT Code SNOMED-CT Description Intravaginal artificial insemination (procedure) Subzonal insemination (procedure) Gamete intrauterine transfer (procedure) Gamete intrafallopian transfer (procedure) Endoscopic intrafallopian transfer of gamete (procedure) Fallopian replacement of egg with delayed insemination (procedure) Subzonal insemination Tubal embryo transfer Zygote intrafallopian transfer Assisted fertilization (procedure) BFDR IV Medication Administration Route Section Template Entry Template Value Set Value Set Description To reflect that IV Medication Administration Route was used to administer a medication Data Element Vocabulary IV Intravenous HL7 Route of Administration BFDR Mother s Delivery Weight Section Template Entry Template Value Set Value Set Code PHVS_MothersDeliveryWeight_NCHS Value Set Description To Reflect the Mother's Delivery Weight Vocabulary SNOMED-CT Code SNOMED-CT Description Body weight^post partum Body weight^ at delivery Birth Defects Implementation Guide APP-25

243 BFDR Neonatal Sepsis Section Template Entry Template Value Set Value Set Description To reflect that the newborn was provided assisted ventilation immediately following delivery reflecting an abnormal condition of the newborn SNOMED-CT Code Vocabulary SNOMED-CT Description Bacterial sepsis of newborn (disorder) Neonatal candida septicemia (disorder) Neonatal disseminated listeriosis (disorder) Neonatal systemic candidosis (disorder) Sepsis of newborn due to anaerobes (disorder) Sepsis of newborn due to Escherichia coli (disorder) Sepsis of newborn due to Staphylococcus aureus (disorder) Sepsis of the newborn (disorder) Septicemia of newborn (disorder) Tetanus neonatorum (disorder) BFDR Newborn Receiving Surfactant Replacement Therapy Section Template Entry Template Value Set Value Set Description To reflect that the Newborn received Surfactant Replacement Therapy reflecting an abnormal condition of the newborn RXNORM Code Vocabulary RXNORM Description Beractant 25 MG/ML Injectable Suspension Beractant Injectable Suspension Calfactant 35 MG/ML Inhalant Solution Calfactant Inhalant Solution Colfosceril 13.5 MG/ML Injectable Suspension Colfosceril Injectable Suspension Poractant alfa 80 MG/ML Injectable Suspension Poractant alfa Injectable Suspension Birth Defects Implementation Guide APP-26

244 BFDR NICU Care Section Template Entry Template Value Set Value Set Description To reflect the that the baby was transferred to NICU following the birth SNOMED-CT Code Vocabulary SNOMED-CT Description Neonatal intensive care unit (environment) BFDR Number of Preterm Births Section Template Entry Template Value Set OID Value Set Description To reflect the number of preterm births in prior pregnancies Vocabulary OID LOINC Code LOINC Description Births Preterm (reported) BFDR Obstetric Estimate of Gestation Section Template Entry Template Value Set Value Set Description To reflect the Obstetric Estimate of Gestation of the newborn. Vocabulary LOINC Code LOINC Description Gestational age Clinical.estimated Gestational age Clinical.estimated from prior assessment BFDR Premature Rupture Section Template Entry Template Value Set Value Set Code PHVS_PrematureRupture_NCHS Birth Defects Implementation Guide APP-27

245 Value Set Description To Reflect Onset of labor with Premature Rupture SNOMED-CT Code Vocabulary SNOMED-CT Description Premature rupture of membranes (disorder) Membrane rupture with delivery delay (disorder) Premature rupture of membranes delivered (disorder) Premature rupture of membranes with antenatal problem (disorder) Premature rupture of membranes with onset of labor after 24 hours of the rupture (disorder) Premature rupture of membranes with onset of labor within 24 hours of the rupture (disorder) Premature rupture of membranes, labor delayed by therapy (disorder) Preterm premature rupture of membranes (disorder) Prolonged premature rupture of membranes (disorder) Prolonged rupture of membranes Prolonged artificial rupture of membranes Prolonged artificial rupture of membranes delivered Prolonged artificial rupture of membranes with antenatal problem Prolonged premature rupture of membranes Prolonged spontaneous rupture of membranes BFDR Route and Method of Delivery Cesarean Delivery Section Template Entry Template Value Set Value Set Code Value Set Description PHVS_RouteMethodOfDeliveryCesarean_NCHS To Reflect the Route and Method of Delivery as Cesarean Delivery Vocabulary SNOMED-CT Code Cesarean section (procedure) SNOMED-CT Description Elective cesarean section (procedure) Elective upper segment cesarean section (procedure) Elective lower segment cesarean section (procedure) Subtotal hysterectomy after cesarean delivery (procedure) Emergency lower segment cesarean section (procedure) Birth Defects Implementation Guide APP-28

246 SNOMED-CT Code SNOMED-CT Description Emergency upper segment cesarean section (procedure) Emergency cesarean hysterectomy (procedure) Elective cesarean hysterectomy (procedure) Postmortem cesarean section (procedure) Anesthesia for cesarean hysterectomy (procedure) Emergency cesarean section (procedure) Cesarean section care (regime/therapy) Low cervical cesarean section (procedure) Cesarean hysterectomy (procedure) Education about vaginal birth after cesarean section (procedure) Anesthesia for cesarean section (procedure) Extraperitoneal cesarean section (procedure) Classical cesarean section (procedure) Vaginal cesarean section (procedure) BFDR Route and Method of Delivery Forceps Delivery Section Template Entry Template Value Set Value Set Code PHVS_ RouteMethodOfDeliveryForceps_NCHS Value Set Description To Reflect the Route and Method of Delivery as Forceps Delivery SNOMED-CT Code Vocabulary SNOMED-CT Description Barton forceps cephalic delivery with rotation (procedure) DeLee forceps cephalic delivery with rotation (procedure) Forceps cephalic delivery (procedure) Forceps delivery failed (situation) Forceps delivery to the aftercoming head (procedure) Forceps delivery, face to pubes (procedure) Forceps extraction of lens (procedure) High forceps cephalic delivery with rotation (procedure) High forceps delivery with episiotomy (procedure) Low forceps delivery (procedure) Low forceps delivery with episiotomy (procedure) Nonrotational forceps delivery (procedure) Birth Defects Implementation Guide APP-29

247 SNOMED-CT Code SNOMED-CT Description Outlet forceps delivery (procedure) Partial breech delivery with forceps to aftercoming head (procedure) Piper forceps delivery (procedure) High forceps delivery (procedure) Forceps delivery with rotation of fetal head (procedure) Mid forceps delivery (procedure) Total breech delivery with forceps to aftercoming head (procedure) Vaginal delivery with forceps including postpartum care (procedure) Barton's forceps delivery (procedure) Forceps delivery (procedure) Delivery by double application of forceps (procedure) Simpson's forceps delivery (procedure) Neville-Barnes forceps delivery (procedure) Mid forceps delivery with episiotomy (procedure) BFDR Route and Method of Delivery Scheduled Cesarean Section Template Entry Template Value Set Value Set Code PHVS_RouteMethodOfDeliveryScheduledCesarean_NCHS Value Set Description To Reflect the Route and Method of Delivery as Scheduled Cesarean SNOMED-CT Code Vocabulary SNOMED-CT Description Elective cesarean section (procedure) Elective upper segment cesarean section (procedure) Elective lower segment cesarean section (procedure) Elective cesarean hysterectomy (procedure) BFDR Route and Method of Delivery Spontaneous Delivery Section Template Entry Template Value Set Value Set Code PHVS_RouteMethodOfDeliverySpontaneous_NCHS Birth Defects Implementation Guide APP-30

248 Value Set Description To Reflect the Route and Method of Delivery as Spontaneous Delivery SNOMED-CT Code Vocabulary SNOMED-CT Description Spontaneous vertex delivery (finding) Multiple delivery, all spontaneous (finding) Deliveries by spontaneous breech delivery (finding) BFDR Route and Method of Delivery Trial of Labor Section Template Entry Template Value Set Value Set Code PHVS_RouteMethodOfDeliveryTrialOfLabor_NCHS Value Set Description To Reflect the Route and Method of Delivery as Trial of Laor Delivery SNOMED-CT Code Vocabulary Trial labor (finding) Failed trial of labor (disorder) SNOMED-CT Description Failed trial of labor - delivered (disorder) BFDR Route and Method of Delivery Vaccum Delivery Section Template Entry Template Value Set Value Set Code PHVS_RouteMethodOfDeliveryVacuum_NCHS Value Set Description To Reflect the Route and Method of Delivery as Vacuum Delivery SNOMED-CT Code Vocabulary SNOMED-CT Description Low vacuum delivery (procedure) High vacuum delivery (procedure) Trial of vacuum delivery (procedure) Delivery by vacuum extraction (procedure) Delivery by Malstrom's extraction (procedure) Delivery by Malstrom's extraction with episiotomy (procedure) Delivery by vacuum extraction with episiotomy (procedure) Vacuum delivery before full dilation of cervix (procedure) Birth Defects Implementation Guide APP-31

249 SNOMED-CT Code SNOMED-CT Description Forceps extraction of lens (procedure) Forceps cephalic delivery (procedure) High forceps cephalic delivery with rotation (procedure) Barton forceps cephalic delivery with rotation (procedure) DeLee forceps cephalic delivery with rotation (procedure) Piper forceps delivery (procedure) Low forceps delivery with episiotomy (procedure) Failed forceps delivery (procedure) Low forceps delivery (procedure) Partial breech delivery with forceps to aftercoming head (procedure) Nonrotational forceps delivery (procedure) Outlet forceps delivery (procedure) Forceps delivery, faces to pubes (procedure) Forceps delivery to the aftercoming head (procedure) Mid forceps delivery with episiotomy (procedure) Neville-Barnes forceps delivery (procedure) Simpson s forceps delivery (procedure) Delivery by double application of forceps (procedure) Forceps delivery (procedure) Barton s forceps delivery (procedure) Epilation by forceps (procedure) Vaginal delivery with forceps including postpartum care (procedure) Epilation of eyebrow by forceps (procedure) Total breech delivery with forceps to aftercoming head (procedure) Mid forceps delivery (procedure) Trial forceps delivery (procedure) Forceps delivery with rotation of fetal head (procedure) Correction of trichiasis by epilation with forceps (procedure) Epilation of eyelid by forceps (procedure) High forceps delivery (procedure) Birth Defects Implementation Guide APP-32

250 BFDR Ruptured Uterus Section Template Entry Template Value Set Value Set Code PHVS_RupturedUterus_NCHS Value Set Description To reflect Ruptured Uterus as a maternal morbidity SNOMED-CT Code Vocabulary SNOMED-CT Description Ruptured uterus before labor (disorder) Rupture of uterus before labor - delivered (disorder) Rupture of uterus before labor with antenatal problem (disorder) Rupture of uterus during AND/OR after labor (disorder) Rupture of uterus during and after labor - delivered (disorder) Rupture of uterus during and after labor - delivered with postnatal problem (disorder) Rupture of gravid uterus (disorder) Rupture of gravid uterus before onset of labor (disorder) Rupture of uterus (disorder) BFDR Spinal Anesthesia Medication Section Template Entry Template Value Set Value Set Code PHVS_SpinalAnesthesiaMedication_NCHS Value Set Description To Reflect a Spinal Anesthesia RxNORM Code Vocabulary RxNORM Description bupivacaine % / fentanyl 5 MCG/ML Injectable Solution bupivacaine 0.05 % / fentanyl 3 MCG/ML Injectable Solution bupivacaine 0.06 % / hydromorphone hydrochloride 2 MG per 100 ML Injectable Solution bupivacaine % / fentanyl 2 MCG/ML Injectable Solution bupivacaine % / fentanyl 5 MCG/ML Injectable Solution bupivacaine % / hydromorphone hydrochloride 10 MCG/ML Injectable Solution bupivacaine % / hydromorphone hydrochloride 5 MCG/ML Injectable Solution bupivacaine 0.1 % / fentanyl 4 MCG/ML Injectable Solution Birth Defects Implementation Guide APP-33

251 RxNORM Code RxNORM Description bupivacaine 0.1 % / hydromorphone hydrochloride 10 MCG/ML Injectable Solution bupivacaine 0.1 % Injectable Solution bupivacaine % / fentanyl 2 MCG/ML Injectable Solution bupivacaine % / hydromorphone hydrochloride 20 MCG/ML Injectable Solution bupivacaine % Injectable Solution bupivacaine 0.25 % Injectable Solution bupivacaine % Injectable Solution bupivacaine 0.5 % / epinephrine 1:200,000 Injectable Solution bupivacaine 0.5 % Injectable Solution Bupivacaine MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine MG/ML Injectable Solution Bupivacaine 1 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1 MG/ML / Fentanyl 0.01 MG/ML Injectable Solution Bupivacaine 1.05 MG/ML Injectable Solution Bupivacaine 1.25 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1.25 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1.25 MG/ML / Fentanyl MG/ML Injectable Solution Bupivacaine 1.25 MG/ML / Fentanyl MG/ML Injectable Solution bupivacaine 100 MG per 20 ML Prefilled Syringe bupivacaine 125 MG per 50 ML Prefilled Syringe Bupivacaine 2 MG/ML Injectable Solution Bupivacaine 2.5 MG/ML / Epinephrine MG/ML Injectable Solution Bupivacaine 2.5 MG/ML / Fentanyl 0.02 MG/ML Injectable Solution Bupivacaine 3.75 MG/ML / Lidocaine 10 MG/ML Injectable Solution Bupivacaine 7.5 MG/ML / Epinephrine MG/ML Injectable Solution Birth Defects Implementation Guide APP-34

252 RxNORM Code RxNORM Description Bupivacaine 7.5 MG/ML Injectable Solution Bupivacaine 8.25 MG/ML Injectable Solution Bupivacaine Hydrochloride 2 MG/ML Injectable Solution chloroprocaine 2 % Injectable Solution Chloroprocaine hydrochloride 10 MG/ML Injectable Solution Chloroprocaine hydrochloride 30 MG/ML Injectable Solution Bupivacaine 3.75 MG/ML / Lidocaine 10 MG/ML Injectable Solution Dexamethasone 4 MG/ML / Lidocaine 10 MG/ML Injectable Solution Lidocaine 10 MG/ML / Methylprednisolone 40 MG/ML Injectable Solution BFDR Spinal Anesthesia Procedure Section Template Entry Template Value Set Value Set Code PHVS_SpinalAnesthesiaProcedure_NCHS Value Set Description To Reflect an Spinal Anesthesia Procedure SNOMED-CT Code Vocabulary SNOMED-CT Description Anesthesia for procedure on spine AND/OR spinal cord (procedure) Anesthesia for spinal fluid shunting procedure (procedure) Anesthesia for spinal cord procedure (procedure) Anesthesia for procedure on lumbosacral spinal cord (procedure) Referral to epidural anesthesia for spinal pain (procedure) Care of subject following combined spinal-epidural anesthesia (regime/therapy) Anesthesia for procedure on thoracic spinal cord (procedure) Anesthesia for procedure on cervical spinal cord (procedure) Spinal subdural local anesthetic block (procedure) Local anesthetic block on spinal nerve root (procedure) Local anesthetic block on spinal nerve ganglion (procedure) Combined spinal/epidural local anesthetic block (procedure) Neurolytic nerve block around spinal cord meninges (procedure) Local anesthetic nerve block around spinal cord meninges (procedure) Birth Defects Implementation Guide APP-35

253 SNOMED-CT Code SNOMED-CT Description Local anesthetic block of spinal nerve root using fluoroscopic guidance (procedure) Local anesthetic lumbar intrathecal block (procedure) Injection of anesthetic substance, diagnostic, subarachnoid, continuous (procedure) Injection of anesthetic substance, therapeutic, subarachnoid, continuous (procedure) Injection of anesthetic substance, therapeutic, subarachnoid, differential (procedure) BFDR Third Degree Perineal Laceration Section Template Entry Template Value Set Value Set Code PHVS_ThirdDegreePerinealLaceration_NCHS Value Set Description To reflect Third Degree Perineal Laceration as a maternal morbidity SNOMED-CT Code Vocabulary SNOMED-CT Description Third degree perineal laceration (disorder) Third degree perineal tear during delivery - delivered (disorder) Third degree perineal tear during delivery with postnatal problem (disorder) Fourth degree perineal tear during delivery - delivered (disorder) Fourth degree perineal tear during delivery with postnatal problem (disorder) BFDR Tocolysis Section Template Entry Template Value Set Value Set Code PHVS_Tocolysis_NCHS Value Set Description To reflect Obstetric Procedures as Tocolysis Vocabulary SNOMED-CT Code SNOMED-CT Description Tocolysis (procedure) External cephalic version with tocolysis (procedure) Tocolysis for hypertonicity of uterus (procedure) Birth Defects Implementation Guide APP-36

254 BFDR Total Time on Ventilator Section Template Entry Template Value Set OID Value Set Description To reflect that the total time on ventilator to determine that the newborn was provided assisted ventilation for 6 or more hours reflecting an abnormal condition of the newborn SNOMED-CT Code Vocabulary Pending SNOMED-CT Description BFDR Transfusion Whole Blood or Packed Red Blood Section Template Entry Template Value Set Value Set Code PHVS_TransfusionWholeBloodOrPackedRBC_NCHS Value Set Description To reflect Transfusion Whole Blood or Packed Red Blood as a maternal morbidity SNOMED-CT Code Vocabulary SNOMED-CT Description Transfusion of whole blood (procedure) Autotransfusion of whole blood (procedure) Intra-arterial blood transfusion (procedure) Transfusing whole blood under pressure (procedure) Transfusion of red blood cells (procedure) Transfusion of leucoreduced red blood cells (procedure) Transfusion of packed red blood cells (procedure) Intravenous blood transfusion of packed cells (procedure) Transfusion of washed red blood cells (procedure) Platelet transfusion (procedure) Intravenous blood transfusion of platelets (procedure) Transfusion of platelet concentrate (procedure) Transfusion of plateletpheresis product (procedure) Transfusion of factor IX (procedure) Transfusion of coagulation factors (procedure) Antihemophilic factor transfusion (procedure) Transfusion antithrombin III factor (procedure) Transfusion of factor VII (procedure) Birth Defects Implementation Guide APP-37

255 BFDR Unplanned Hysterectomy Section Template Entry Template Value Set Value Set Description BFDR Unplanned Hysterectomy Value Set Vocabulary SNOMED-CT Code SNOMED-CT Description Emergency cesarean hysterectomy BFDR Unplanned Operation Section Template Entry Template Value Set Value Set Description To reflect Unplanned Operation as a maternal morbidity SNOMED-CT Code Vocabulary SNOMED-CT Description Removal of Shirodkar suture from cervix (procedure) Repair of obstetric laceration (procedure) Immediate repair of obstetric laceration (procedure) Immediate repair of minor obstetric laceration (procedure) Immediate repair of obstetric laceration of perineum and sphincter of anus (procedure) Immediate repair of obstetric laceration of uterus or cervix uteri (procedure) Immediate repair of obstetric laceration of vagina and floor of pelvis (procedure) Repair of current obstetric laceration of uterus (procedure) Repair of obstetric laceration of cervix (procedure) Repair of obstetric laceration of lower urinary tract (procedure) Repair of obstetric laceration of bladder (procedure) Repair of obstetric laceration of bladder and urethra (procedure) Repair of obstetric laceration of urethra (procedure) Repair of obstetric laceration of pelvic floor (procedure) Repair of obstetric laceration of perineum and anal sphincter and mucosa of rectum (procedure) Repair of obstetric laceration of vulva (procedure) Repair of obstetrical laceration of perineum (procedure) Colpoepisiorrhaphy (procedure) Birth Defects Implementation Guide APP-38

256 SNOMED-CT Code SNOMED-CT Description Secondary repair of obstetric laceration (procedure) Suture of obstetric laceration of vagina (procedure) Colpoperineorrhaphy following delivery (procedure) C Cause of Death Section Template Entry Template Value Set Value Set Description The list provides ICD-10 codes and associated cause of-death titles for the most detailed listing of causes of death. This list is maintained by CDC NCHS. SNOMED-CT Code Vocabulary R95 Sudden infant death syndrome SNOMED-CT Description P70.1 Syndrome of infant of a diabetic mother P70.0 Syndrome of infant of mother with gestational diabetes Q86.0 Fetal alcohol syndrome (dysmorphic) P50 Fetal blood loss P50.5 Fetal blood loss from cut end of co-twin's cord P50.2 Fetal blood loss from placenta P50.1 Fetal blood loss from ruptured cord P50.0 Fetal blood loss from vasa previa P50.9 Fetal blood loss, unspecified Q86.1 Fetal hydantoin syndrome P05.2 Fetal malnutrition without mention of light or small for gestational ag O68.3 Labor and delivery complicated by biochemical evidence of fetal stress O68.0 Labor and delivery complicated by fetal heart rate anomaly Birth Defects Implementation Guide APP-39

257 CDC Detailed Race Value Set Race DYNAMIC Code System(s) Race and Ethnicity - CDC Description Concept Code A Value Set of codes for Classifying data based upon race. Race is always reported at the discretion of the person for whom this attribute is reported, and reporting must be completed according to Federal guidelines for race reporting. Any code descending from the Race concept (1000-9) in that terminology may be used in the exchange &code= Abenaki Absentee Shawnee Acoma Afghanistani African African American Agdaagux Agua Caliente Agua Caliente Cahuilla Ahtna Ak-Chin Akhiok Akiachak Akiak Akutan Alabama Coushatta Alabama Creek Alabama Quassarte Alakanuk Alamo Navajo Alanvik Alaska Indian Alaska Native Alaskan Athabascan Alatna Aleknagik Aleut Aleut Corporation Concept Name Birth Defects Implementation Guide APP-40

258 Concept Code Concept Name Aleutian Aleutian Islander Alexander Algonquian Allakaket Allen Canyon Alpine Alsea Alutiiq Aleut Ambler American Indian American Indian or Alaska Native Anaktuvuk Anaktuvuk Pass Andreafsky Angoon Aniak Anvik Apache Arab Arapaho Arctic Arctic Slope Corporation Arctic Slope Inupiat Arikara Arizona Tewa Armenian Aroostook Asian Asian Indian Assiniboine Assiniboine Sioux Assyrian Atka Atmautluak Atqasuk Atsina Birth Defects Implementation Guide APP-41

259 Concept Code Attacapa Augustine Bad River Bahamian Bangladeshi Bannock Barbadian Barrio Libre Barrow Battle Mountain Bay Mills Chippewa Beaver Belkofski Bering Straits Inupiat Bethel Bhutanese Big Cypress Bill Moore's Slough Biloxi Birch Creek Bishop Black Black or African American Blackfeet Blackfoot Sioux Bois Forte Botswanan Brevig Mission Bridgeport Brighton Bristol Bay Aleut Bristol Bay Yupik Brotherton Brule Sioux Buckland Burmese Burns Paiute Concept Name Birth Defects Implementation Guide APP-42

260 Concept Code Concept Name Burt Lake Band Burt Lake Chippewa Burt Lake Ottawa Cabazon Caddo Cahto Cahuilla California Tribes Calista Yupik Cambodian Campo Canadian and Latin American Indian Canadian Indian Canoncito Navajo Cantwell Capitan Grande Carolinian Carson Catawba Cayuga Cayuse Cedarville Celilo Central American Indian Central Council of Tlingit and Haida Tribes Central Pomo Chalkyitsik Chamorro Chefornak Chehalis Chemakuan Chemehuevi Chenega Cherokee Cherokee Alabama Cherokee Shawnee Cherokees of Northeast Alabama Birth Defects Implementation Guide APP-43

261 Concept Code Concept Name Cherokees of Southeast Alabama Chevak Cheyenne Cheyenne River Sioux Cheyenne-Arapaho Chickahominy Chickaloon Chickasaw Chignik Chignik Lagoon Chignik Lake Chilkat Chilkoot Chimariko Chinese Chinik Chinook Chippewa Chippewa Cree Chiricahua Chistochina Chitimacha Chitina Choctaw Chuathbaluk Chugach Aleut Chugach Corporation Chukchansi Chumash Chuukese Circle Citizen Band Potawatomi Clark's Point Clatsop Clear Lake Clifton Choctaw Coast Miwok Birth Defects Implementation Guide APP-44

262 Concept Code Concept Name Coast Yurok Cochiti Cocopah Coeur D'Alene Coharie Colorado River Columbia Columbia River Chinook Colville Comanche Cook Inlet Coos Coos, Lower Umpqua, Siuslaw Copper Center Copper River Coquilles Costanoan Council Coushatta Cow Creek Umpqua Cowlitz Craig Cree Creek Croatan Crooked Creek Crow Crow Creek Sioux Cupeno Cuyapaipe Dakota Sioux Deering Delaware Diegueno Digger Dillingham Dominica Islander Birth Defects Implementation Guide APP-45

263 Concept Code Dominican Dot Lake Douglas Doyon Dresslerville Dry Creek Duck Valley Duckwater Duwamish Eagle Eastern Cherokee Eastern Chickahominy Eastern Creek Eastern Delaware Eastern Muscogee Eastern Pomo Eastern Shawnee Eastern Tribes Echota Cherokee Eek Egegik Egyptian Eklutna Ekuk Ekwok Elim Elko Ely Emmonak English English Bay Eskimo Esselen Ethiopian Etowah Cherokee European Evansville Concept Name Birth Defects Implementation Guide APP-46

264 Concept Code Concept Name Eyak Fallon False Pass Fijian Filipino Flandreau Santee Florida Seminole Fond du Lac Forest County Fort Belknap Fort Berthold Fort Bidwell Fort Hall Fort Independence Fort McDermitt Fort Mcdowell Fort Peck Fort Peck Assiniboine Sioux Fort Sill Apache Fort Yukon French French American Indian Gabrieleno Gakona Galena Gambell Gay Head Wampanoag Georgetown (Eastern Tribes) Georgetown (Yupik-Eskimo) German Gila Bend Gila River Pima-Maricopa Golovin Goodnews Bay Goshute Grand Portage Grand Ronde Birth Defects Implementation Guide APP-47

265 Concept Code Concept Name Grand Traverse Band of Ottawa/Chippewa Grayling Greenland Eskimo Gros Ventres Guamanian Guamanian or Chamorro Gulkana Haida Haitian Haliwa Hannahville Havasupai Healy Lake Hidatsa Hmong Ho-chunk Hoh Hollywood Seminole Holy Cross Hoonah Hoopa Hoopa Extension Hooper Bay Hopi Houma Hualapai Hughes Huron Potawatomi Huslia Hydaburg Igiugig Iliamna Illinois Miami Inaja-Cosmit Inalik Diomede Indian Township Indiana Miami Birth Defects Implementation Guide APP-48

266 Concept Code Concept Name Indonesian Inupiaq Inupiat Eskimo Iowa Iowa of Kansas-Nebraska Iowa of Oklahoma Iowa Sac and Fox Iqurmuit (Russian Mission) Iranian Iraqi Irish Iroquois Isleta Israeili Italian Ivanof Bay Iwo Jiman Jamaican Jamestown Japanese Jemez Jena Choctaw Jicarilla Apache Juaneno Kaibab Kake Kaktovik Kalapuya Kalispel Kalskag Kaltag Karluk Karuk Kasaan Kashia Kasigluk Kathlamet Birth Defects Implementation Guide APP-49

267 Concept Code Kaw Kawaiisu Kawerak Kenaitze Keres Kern River Ketchikan Keweenaw Kialegee Kiana Kickapoo Kikiallus King Cove King Salmon Kiowa Kipnuk Kiribati Kivalina Klallam Klamath Klawock Kluti Kaah Knik Kobuk Kodiak Kokhanok Koliganek Kongiganak Koniag Aleut Konkow Kootenai Korean Kosraean Kotlik Kotzebue Koyuk Koyukuk Concept Name Birth Defects Implementation Guide APP-50

268 Concept Code Concept Name Kwethluk Kwigillingok Kwiguk La Jolla La Posta Lac Courte Oreilles Lac du Flambeau Lac Vieux Desert Chippewa Laguna Lake Minchumina Lake Superior Lake Traverse Sioux Laotian Larsen Bay Las Vegas Lassik Lebanese Leech Lake Lenni-Lenape Levelock Liberian Lime Lipan Apache Little Shell Chippewa Lone Pine Long Island Los Coyotes Lovelock Lower Brule Sioux Lower Elwha Lower Kalskag Lower Muscogee Lower Sioux Lower Skagit Luiseno Lumbee Lummi Birth Defects Implementation Guide APP-51

269 Concept Code Concept Name Machis Lower Creek Indian Madagascar Maidu Makah Malaysian Maldivian Malheur Paiute Maliseet Mandan Manley Hot Springs Manokotak Manzanita Mariana Islander Maricopa Marshall Marshallese Marshantucket Pequot Mary's Igloo Mashpee Wampanoag Matinecock Mattaponi Mattole Mauneluk Inupiat Mcgrath Mdewakanton Sioux Mekoryuk Melanesian Menominee Mentasta Lake Mesa Grande Mescalero Apache Metlakatla Mexican American Indian Miami Miccosukee Michigan Ottawa Micmac Birth Defects Implementation Guide APP-52

270 Concept Code Concept Name Micronesian Middle Eastern or North African Mille Lacs Miniconjou Minnesota Chippewa Minto Mission Indians Mississippi Choctaw Missouri Sac and Fox Miwok Moapa Modoc Mohave Mohawk Mohegan Molala Mono Montauk Moor Morongo Mountain Maidu Mountain Village Mowa Band of Choctaw Muckleshoot Munsee Naknek Nambe Namibian Nana Inupiat Nansemond Nanticoke Napakiak Napaskiak Napaumute Narragansett Natchez Native Hawaiian Birth Defects Implementation Guide APP-53

271 Concept Code Concept Name Native Hawaiian or Other Pacific Islander Nausu Waiwash Navajo Nebraska Ponca Nebraska Winnebago Nelson Lagoon Nenana Nepalese New Hebrides New Stuyahok Newhalen Newtok Nez Perce Nigerian Nightmute Nikolai Nikolski Ninilchik Nipmuc Nishinam Nisqually Noatak Nomalaki Nome Nondalton Nooksack Noorvik Northern Arapaho Northern Cherokee Northern Cheyenne Northern Paiute Northern Pomo Northway Northwest Tribes Nuiqsut Nulato Nunapitchukv Birth Defects Implementation Guide APP-54

272 Concept Code Oglala Sioux Okinawan Oklahoma Apache Oklahoma Cado Oklahoma Choctaw Oklahoma Comanche Oklahoma Delaware Oklahoma Kickapoo Oklahoma Kiowa Oklahoma Miami Oklahoma Ottawa Oklahoma Pawnee Oklahoma Peoria Oklahoma Ponca Oklahoma Sac and Fox Oklahoma Seminole Old Harbor Omaha Oneida Onondaga Ontonagon Oregon Athabaskan Osage Oscarville Other Pacific Islander Other Race Otoe-Missouria Ottawa Ouzinkie Owens Valley Paiute Pakistani Pala Palauan Palestinian Pamunkey Panamint Concept Name Birth Defects Implementation Guide APP-55

273 Concept Code Concept Name Papua New Guinean Pascua Yaqui Passamaquoddy Paugussett Pauloff Harbor Pauma Pawnee Payson Apache Pechanga Pedro Bay Pelican Penobscot Peoria Pequot Perryville Petersburg Picuris Pilot Point Pilot Station Pima Pine Ridge Sioux Pipestone Sioux Piro Piscataway Pit River Pitkas Point Platinum Pleasant Point Passamaquoddy Poarch Band Pocomoke Acohonock Pohnpeian Point Hope Point Lay Pojoaque Pokagon Potawatomi Polish Polynesian Birth Defects Implementation Guide APP-56

274 Concept Code Concept Name Pomo Ponca Poospatuck Port Gamble Klallam Port Graham Port Heiden Port Lions Port Madison Portage Creek Potawatomi Powhatan Prairie Band Prairie Island Sioux Principal Creek Indian Nation Prior Lake Sioux Pueblo Puget Sound Salish Puyallup Pyramid Lake Qagan Toyagungin Qawalangin Quapaw Quechan Quileute Quinault Quinhagak Ramah Navajo Rampart Rampough Mountain Rappahannock Red Cliff Chippewa Red Devil Red Lake Chippewa Red Wood Reno-Sparks Rocky Boy's Chippewa Cree Rosebud Sioux Birth Defects Implementation Guide APP-57

275 Concept Code Concept Name Round Valley Ruby Ruby Valley Sac and Fox Saginaw Chippewa Saipanese Salamatof Salinan Salish Salish and Kootenai Salt River Pima-Maricopa Samish Samoan San Carlos Apache San Felipe San Ildefonso San Juan San Juan De San Juan Pueblo San Juan Southern Paiute San Manual San Pasqual San Xavier Sand Hill Sand Point Sandia Sans Arc Sioux Santa Ana Santa Clara Santa Rosa Santa Rosa Cahuilla Santa Ynez Santa Ysabel Santee Sioux Santo Domingo Sauk-Suiattle Sault Ste. Marie Chippewa Birth Defects Implementation Guide APP-58

276 Concept Code Savoonga Saxman Scammon Bay Schaghticoke Scott Valley Scottish Scotts Valley Selawik Seldovia Sells Seminole Seneca Seneca Nation Seneca-Cayuga Serrano Setauket Shageluk Shaktoolik Shasta Shawnee Sheldon's Point Shinnecock Shishmaref Shoalwater Bay Shoshone Shoshone Paiute Shungnak Siberian Eskimo Siberian Yupik Siletz Singaporean Sioux Sisseton Sioux Sisseton-Wahpeton Sitka Siuslaw Skokomish Concept Name Birth Defects Implementation Guide APP-59

277 Concept Code Concept Name Skull Valley Skykomish Slana Sleetmute Snohomish Snoqualmie Soboba Sokoagon Chippewa Solomon Solomon Islander South American Indian South Fork Shoshone South Naknek Southeast Alaska Southeastern Indians Southern Arapaho Southern Cheyenne Southern Paiute Spanish American Indian Spirit Lake Sioux Spokane Squaxin Island Sri Lankan St. Croix Chippewa St. George St. Mary's St. Michael St. Paul Standing Rock Sioux Star Clan of Muscogee Creeks Stebbins Steilacoom Stevens Stewart Stillaguamish Stockbridge Stony River Birth Defects Implementation Guide APP-60

278 Concept Code Concept Name Stonyford Sugpiaq Sulphur Bank Summit Lake Suqpigaq Suquamish Susanville Susquehanock Swinomish Sycuan Syrian Table Bluff Tachi Tahitian Taiwanese Takelma Takotna Talakamish Tanacross Tanaina Tanana Tanana Chiefs Taos Tatitlek Tazlina Telida Teller Temecula Te-Moak Western Shoshone Tenakee Springs Tenino Tesuque Tetlin Teton Sioux Tewa Texas Kickapoo Thai Birth Defects Implementation Guide APP-61

279 Concept Code Thlopthlocco Tigua Tillamook Timbi-Sha Shoshone Tlingit Tlingit-Haida Tobagoan Togiak Tohono O'Odham Tok Tokelauan Toksook Tolowa Tonawanda Seneca Tongan Tonkawa Torres-Martinez Trinidadian Trinity Tsimshian Tuckabachee Tulalip Tule River Tulukskak Tunica Biloxi Tuntutuliak Tununak Turtle Mountain Tuscarora Tuscola Twenty-Nine Palms Twin Hills Two Kettle Sioux Tygh Tyonek Ugashik Uintah Ute Concept Name Birth Defects Implementation Guide APP-62

280 Concept Code Concept Name Umatilla Umkumiate Umpqua Unalakleet Unalaska Unangan Aleut Unga United Keetowah Band of Cherokee Upper Chinook Upper Sioux Upper Skagit Ute Ute Mountain Ute Utu Utu Gwaitu Paiute Venetie Vietnamese Waccamaw-Siousan Wahpekute Sioux Wahpeton Sioux Wailaki Wainwright Wakiakum Chinook Wales Walker River Walla-Walla Wampanoag Wappo Warm Springs Wascopum Washakie Washoe Wazhaza Sioux Wenatchee West Indian Western Cherokee Western Chickahominy Whilkut Birth Defects Implementation Guide APP-63

281 Concept Code White White Earth White Mountain White Mountain Apache White Mountain Inupiat Wichita Wicomico Willapa Chinook Wind River Wind River Arapaho Wind River Shoshone Winnebago Winnemucca Wintun Wisconsin Potawatomi Wiseman Wishram Wiyot Wrangell Wyandotte Yahooskin Yakama Yakama Cowlitz Yakutat Yana Yankton Sioux Yanktonai Sioux Yapese Yaqui Yavapai Yavapai Apache Yerington Paiute Yokuts Yomba Yuchi Yuki Yuman Concept Name Birth Defects Implementation Guide APP-64

282 Concept Code Yupik Eskimo Yurok Zairean Zia Zuni Concept Name D No applicable value sets. E Ethnicity Value Set DYNAMIC Code System(s) Race and Ethnicity - CDC Code Code System Print Name Race and Ethnicity Code Sets Hispanic or Latino Race and Ethnicity Code Sets Not Hispanic or Latino F FIPS 5-2 Value Set State Code System State codes for U.S. based on FIPS 5-2 Value Set OID Concept Code Concept Name 01 Alabama 02 Alaska 60 American Samoa 04 Arizona 05 Arkansas 81 Baker Island Birth Defects Implementation Guide APP-65

283 Concept Code Concept Name 06 California 08 Colorado 09 Connecticut 10 Delaware 11 District of Columbia 64 Federated States of Micronesia 12 Florida 13 Georgia 66 Guam 15 Hawaii 84 Howland Island 16 Idaho 17 Illinois 18 Indiana 19 Iowa 86 Jarvis Island 67 Johnston Atoll 20 Kansas 21 Kentucky 89 Kingman Reef 22 Louisiana 23 Maine 68 Marshall Islands 24 Maryland 25 Massachusetts 26 Michigan 71 Midway Islands 27 Minnesota 28 Mississippi 29 Missouri 30 Montana 76 Navassa Island 31 Nebraska 32 Nevada 33 New Hampshire 34 New Jersey 35 New Mexico 36 New York 37 North Carolina Birth Defects Implementation Guide APP-66

284 Concept Code 38 North Dakota 69 Northern Mariana Islands 39 Ohio 40 Oklahoma 41 Oregon 70 Palau 95 Palmyra Atoll 42 Pennsylvania 72 Puerto Rico 44 Rhode Island 45 South Carolina 46 South Dakota 47 Tennessee 48 Texas 74 U.S. Minor Outlying Islands 49 Utah 50 Vermont 78 Virgin Islands of the U.S. 51 Virginia 79 Wake Island 53 Washington 54 West Virginia 55 Wisconsin 56 Wyoming Concept Name G Guardian Concept Code Concept Name Preferred Concept Name CGV Care giver Care giver EMC Emergency contact Emergency contact EXF Extended family Extended family FTH Father Father FCH Foster child Foster child FND Friend Friend GCH Grandchild Grandchild Birth Defects Implementation Guide APP-67

285 Concept Code Concept Name Preferred Concept Name GRP Grandparent Grandparent GRD Guardian Guardian DEP Handicapped dependent Handicapped dependent MTH Mother Mother NCH Natural child Natural child NON None None PAR Parent Parent H No applicable value sets. I ISO Value Set Country Value Set DYNAMIC Code System(s) ISO Country Codes: Description A value set of codes for the representation of names of countries, territories and areas of geographical interest. Note: This table provides the ISO code elements available in the alpha-2 code of ISO's country code standard Concept Code Concept Name AFG AFGHANISTAN ALA ÅLAND ISLANDS ALB ALBANIA DZA ALGERIA Birth Defects Implementation Guide APP-68

286 Concept Code Concept Name ASM AMERICAN SAMOA AND ANDORRA AGO ANGOLA AIA ANGUILLA ATA ANTARCTICA ATG ANTIGUA AND BARBUDA ARG ARGENTINA ARM ARMENIA ABW ARUBA AUS AUSTRALIA AUT AUSTRIA AZE AZERBAIJAN BHS BAHAMAS BHR BAHRAIN BGD BANGLADESH BRB BARBADOS BLR BELARUS BEL BELGIUM BLZ BELIZE BEN BENIN BMU BERMUDA BTN BHUTAN BOL BOLIVIA BIH BOSNIA AND HERZEGOVINA BWA BOTSWANA BVT BOUVET ISLAND BRA BRAZIL IOT BRITISH INDIAN OCEAN TERRITORY BRN BRUNEI DARUSSALAM BGR BULGARIA BFA BURKINA FASO BDI BURUNDI KHM CAMBODIA CMR CAMEROON Birth Defects Implementation Guide APP-69

287 Concept Code Concept Name CAN CANADA CPV CAPE VERDE CYM CAYMAN ISLANDS CAF CENTRAL AFRICAN REPUBLIC TCD CHAD CHL CHILE CHN CHINA CXR CHRISTMAS ISLAND CCK COCOS (KEELING) ISLANDS COL COLOMBIA COM COMOROS COG CONGO COD CONGO, THE DEMOCRATIC REPUBLIC OF THE COK COOK ISLANDS CRI COSTA RICA CIV CÔTE D'IVOIRE HRV CROATIA CUB CUBA CYP CYPRUS CZE CZECH REPUBLIC DNK DENMARK DJI DJIBOUTI DMA DOMINICA DOM DOMINICAN REPUBLIC ECU ECUADOR EGY EGYPT SLV EL SALVADOR GNQ EQUATORIAL GUINEA ERI ERITREA EST ESTONIA ETH ETHIOPIA FLK FALKLAND ISLANDS (MALVINAS) FRO FAROE ISLANDS FJI FIJI Birth Defects Implementation Guide APP-70

288 Concept Code Concept Name FIN FINLAND FRA FRANCE GUF FRENCH GUIANA PYF FRENCH POLYNESIA ATF FRENCH SOUTHERN TERRITORIES GAB GABON GMB GAMBIA GEO GEORGIA DEU GERMANY GHA GHANA GIB GIBRALTAR GRC GREECE GRL GREENLAND GRD GRENADA GLP GUADELOUPE GUM GUAM GTM GUATEMALA GGY GUERNSEY GIN GUINEA GNB GUINEA-BISSAU GUY GUYANA HTI HAITI HMD HEARD ISLAND AND MCDONALD ISLANDS VAT HOLY SEE (VATICAN CITY STATE) HND HONDURAS HKG HONG KONG HUN HUNGARY ISL ICELAND IND INDIA IDN INDONESIA IRN IRAN, ISLAMIC REPUBLIC OF IRQ IRAQ IRL IRELAND IMN ISLE OF MAN Birth Defects Implementation Guide APP-71

289 Concept Code Concept Name ISR ISRAEL ITA ITALY JAM JAMAICA JPN JAPAN JEY JERSEY JOR JORDAN KAZ KAZAKHSTAN KEN KENYA KIR KIRIBATI PRK KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF KOR KOREA, REPUBLIC OF KWT KUWAIT KGZ KYRGYZSTAN LAO LAO PEOPLE'S DEMOCRATIC REPUBLIC LVA LATVIA LBN LEBANON LSO LESOTHO LBR LIBERIA LBY LIBYAN ARAB JAMAHIRIYA LIE LIECHTENSTEIN LTU LITHUANIA LUX LUXEMBOURG MAC MACAO MKD MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MDG MADAGASCAR MWI MALAWI MYS MALAYSIA MDV MALDIVES MLI MALI MLT MALTA MHL MARSHALL ISLANDS MTQ MARTINIQUE MRT MAURITANIA MUS MAURITIUS Birth Defects Implementation Guide APP-72

290 Concept Code Concept Name MYT MAYOTTE MEX MEXICO FSM MICRONESIA, FEDERATED STATES OF MDA MOLDOVA, REPUBLIC OF MCO MONACO MNG MONGOLIA MNE MONTENEGRO MSR MONTSERRAT MAR MOROCCO MOZ MOZAMBIQUE MMR MYANMAR NAM NAMIBIA NRU NAURU NPL NEPAL NLD NETHERLANDS ANT NETHERLANDS ANTILLES NCL NEW CALEDONIA NZL NEW ZEALAND NIC NICARAGUA NER NIGER NGA NIGERIA NIU NIUE NFK NORFOLK ISLAND MNP NORTHERN MARIANA ISLANDS NOR NORWAY OMN OMAN PAK PAKISTAN PLW PALAU PSE PALESTINIAN TERRITORY, OCCUPIED PAN PANAMA PNG PAPUA NEW GUINEA PRY PARAGUAY PER PERU PHL PHILIPPINES Birth Defects Implementation Guide APP-73

291 Concept Code Concept Name PCN PITCAIRN POL POLAND PRT PORTUGAL PRI PUERTO RICO QAT QATAR REU RÉUNION ROU ROMANIA RUS RUSSIAN FEDERATION RWA RWANDA SMR SAN MARINO STP SAO TOME AND PRINCIPE SAU SAUDI ARABIA SEN SENEGAL SRB SERBIA SYC SEYCHELLES SLE SIERRA LEONE SGP SINGAPORE SVK SLOVAKIA SVN SLOVENIA SLB SOLOMON ISLANDS SOM SOMALIA ZAF SOUTH AFRICA SGS SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS ESP SPAIN LKA SRI LANKA SDN SUDAN SUR SURINAME SJM SVALBARD AND JAN MAYEN SWZ SWAZILAND SWE SWEDEN CHE SWITZERLAND SYR SYRIAN ARAB REPUBLIC TWN TAIWAN, PROVINCE OF CHINA TJK TAJIKISTAN Birth Defects Implementation Guide APP-74

292 Concept Code Concept Name TZA TANZANIA, UNITED REPUBLIC OF THA THAILAND TLS TIMOR-LESTE TGO TOGO TKL TOKELAU TON TONGA TTO TRINIDAD AND TOBAGO TUN TUNISIA TUR TURKEY TKM TURKMENISTAN TCA TURKS AND CAICOS ISLANDS TUV TUVALU UGA UGANDA UKR UKRAINE ARE UNITED ARAB EMIRATES GBR UNITED KINGDOM USA UNITED STATES UMI UNITED STATES MINOR OUTLYING ISLANDS URY URUGUAY UZB UZBEKISTAN VUT VANUATU VEN VENEZUELA VNM VIET NAM VGB VIRGIN ISLANDS, BRITISH VIR VIRGIN ISLANDS, U.S. WLF WALLIS AND FUTUNA ESH WESTERN SAHARA YEM YEMEN ZMB ZAMBIA ZWE ZIMBABWE Birth Defects Implementation Guide APP-75

293 J No applicable value sets. K No applicable value sets. L No applicable value sets. M Marital Status Value Set HL7 Marital Status ID Marital Status Code Print Name A Annulled D Divorced T Domestic partner I Interlocutory L Legally Separated M Married S Never Married P Polygamous W Widowed Birth Defects Implementation Guide APP-76

294 Maternal Risk Factors Section Template Entry Template Value Set TBD SNOMED-CT Code SNOMED-CT Description 0 No known risk factors 1 Diabetes (pre-existing condition) 2 Diabetes (gestational) 3 Hypertension (pre-existing condition) 4 Hypertension (gestational) 5 Hypertension (eclampsia) 6 Previous preterm birth 7 Previous other poor-outcome birth 8 Pregnancy resulted from infertility Tx 9 Previous cesarean delivery 10 Gonorrhea infection 11 Syphilis infection 12 Chlamydia infection 13 Listeria infection 14 Group B Streptococcus infection 15 Cytomegalovirus infection 16 Parovirus infection 17 Toxoplasmsis infection 18 Hepatitus B infection 19 Hepatitus C infection 20 Drug use during pregnancy 21 Cigarette smoking during pregnancy 22 Alcohol use during pregnancy 23 Seizure 24 Obesity 25 HIV 26 Mental Disorder 27 Major Injury 28 Hyper/Hypothyroidism 29 Anemia(chronic, not anemia of pregnancy) 30 HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) 23 Other risk factor Birth Defects Implementation Guide APP-77

295 SNOMED-CT Code 99 Unknown SNOMED-CT Description MCH HBS 5 Min Apgar Score Section Template Entry Template Value Set OID Value Set Code PHVS_ApgarScore5Min_NCHS Value Set Description To reflect the 5 Min Apgar Score Vocabulary OID LOINC Code LOINC Description Score^5M post birth MCH HBS 10 Min Apgar Score Section Template Entry Template Value Set OID Value Set Code PHVS_ApgarScore10Min_NCHS Value Set Description To Reflect the 10 Min Apgar Score Vocabulary OID LOINC Code LOINC Description Score^10M post birth MCH HBS Antibiotic Administration Procedure Section Template Entry Template Value Set Value Set Code PHVS_AntibioticAdministrationProcedure_NCHS Value Set Description To Reflect Antibiotic Administration Procedure during labor and delivery SNOMED-CT Code Vocabulary SNOMED-CT Description Intravenous antibiotic therapy (procedure) Intramuscular antibiotic therapy (procedure) Birth Defects Implementation Guide APP-78

296 MCH HBS Assisted Ventilation Immediately Following Delivery Value Set Section Template Entry Template Value Set Value Set Description To Reflect that the newborn was provided assisted ventilation immediately following delivery reflecting an abnormal condition of the newborn SNOMED-CT Code Vocabulary Pending Pending SNOMED-CT Description MCH HBS Birth Height Section Template Entry Template Value Set TBD OID Value Set Description To Reflect the Birth Height Vocabulary LOINC Code LOINC Description TBD Birth Height MCH HBS Birth Weight Section Template Entry Template Value Set Value Set Description To Reflect the Birth Weight Vocabulary LOINC Code LOINC Description Birth Weight Birth Defects Implementation Guide APP-79

297 MCH HBS Date of Last Live Birth Section Template Entry Template Value Set Value Set Description To Reflect the Date of Last Live Birth Vocabulary LOINC Code LOINC Description Date last live birth MCH HBS Date of Last Other Pregnancy Outcome Section Template Entry Template Value Set OID Value Set Description To Reflect the Date of Last Other Pregnancy Outcome Vocabulary OID LOINC Code LOINC Description Pending Pending MCH HBS First Prenatal Care Visit Section Template Entry Template Value Set Value Set Code PHVS_FirstPrenatalCareVisit_NCHS Value Set Description To Reflect the First Prenatal Care Visit Vocabulary SNOMED-CT Code SNOMED-CT Description Prenatal initial visit (regime/therapy) MCH HBS Intramuscular Medication Administration Route Section Template Entry Template Value Set Value Set Description To reflect that Intramuscular Medication Administration Route was used to administer a medication Birth Defects Implementation Guide APP-80

298 Vocabulary Data Element HL7 Route of Administration IM Intramuscular MCH HBS Karyotype Determination Section Template Entry Template Value Set Value Set Code PHVS_KaryotypeDetermination_NCHS Value Set Description To Reflect Fetal Autopsy was performed Vocabulary SNOMED-CT Code SNOMED-CT Description Karyotype determination (procedure) Determination of karyotype from blood specimen (procedure) MCH HBS Last Prenatal Care Visit Section Template Entry Template Value Set Value Set Description To Reflect the Last Prenatal Care Visit Vocabulary SNOMED-CT Code SNOMED-CT Description Pending Pending MCH HBS Number of Live Births Section Template Entry Template Value Set OID Value Set Code PHVS_NumberofLiveBirths_NCHS Value Set Description To Reflect the Number of Live Births Vocabulary OID LOINC Code LOINC Description Births.live Birth Defects Implementation Guide APP-81

299 MCH HBS Number Prenatal Care Visits Section Template Entry Template Value Set Value Set Description To reflect the Number Prenatal Care Visits Vocabulary LOINC Code LOINC Description Prenatal visits for this pregnancy MCH HBS Number of Previous Live Births Now Dead Section Template Entry Template Value Set Value Set Description To Reflect the Previous Other Pregnancy Outcomes Vocabulary LOINC Code LOINC Description Live births.now dead MCH HBS Number of Previous Live Births Now Living Section Template Entry Template Value Set Value Set Code PHVS_NoOfPreviousLiveBirthsNowLiving_NCHS Value Set Description To Reflect the Previous Other Pregnancy Outcomes Vocabulary LOINC Code LOINC Description Births.still living MCH HBS Number of Prior Pregnancies Section Template Entry Template Value Set OID Value Set Code PHVS_NumberOfPriorPregnancies_NCHS Value Set Description To Reflect the Number of Prior Pregnancies Birth Defects Implementation Guide APP-82

300 Vocabulary OID Code System Name LOINC LOINC Code LOINC Description Pregnancies Parity MCH HBS Poor Pregnancy Outcome History Section Template Entry Template Value Set Value Set Code PHVS_PoorPregnancyOutcomeHistory_NCHS Value Set Description To reflect Risk Factors of Pregnancy Outcome of Perinatal Death History SNOMED-CT Code Vocabulary SNOMED-CT Description Antenatal care: history of perinatal death (situation) Antenatal care: history of stillbirth (situation) Antenatal care: history of trophoblastic disease (situation) Antenatal care: poor obstetric history (situation) History of Miscarriage History of 1 Miscarriage History of 2 Miscarriage History of 3 Miscarriage History of 4 Miscarriages History of 5 Miscarriages History of 6 Miscarriages History of - antepartum hemorrhage (situation) History of - delivery no details (situation) History of - delivery no details (situation) History of - eclampsia (situation) History of - ectopic pregnancy (situation) History of - obstetric problem (situation) History of - postpartum hemorrhage (situation) History of - premature delivery (situation) History of - prolonged labor (situation) History of - severe pre-eclampsia (situation) History of - stillbirth (situation) Birth Defects Implementation Guide APP-83

301 SNOMED-CT Code SNOMED-CT Description History of choriocarcinoma of placenta (situation) History of premature labor (situation) MCH HBS Pre-Pregnancy Weight Section Template Entry Template Value Set Value Set Code PHVS_PrePregnancyWeight_NCHS Value Set Description To Reflect the mother s Pre-Pregnancy Weight Vocabulary LOINC Code LOINC Description Body weight^pre current pregnancy Body weight^pre pregnancy MCH HBS Seizure or Serious Neurologic Dysfunction Section Template Entry Template Value Set Value Set Code PHVS_SeizureOrSeriousNeurologicDysfunction_NCHS Value Set Description To Reflect that the newborn suffered a Seizure or Serious Neurologic Dysfunction reflecting an abnormal condition of the newborn. Vocabulary SNOMED-CT Code Seizure (finding) Afebrile seizure (finding) SNOMED-CT Description Akinetic seizure without atonia (finding) Anoxic seizure (finding) Anoxic epileptic seizure (finding) Reflex anoxic seizure (finding) Brief atonic seizure (finding) Central convulsion (finding) Epileptic seizure (finding) Epileptic seizures - akinetic (finding) Epileptic seizures - atonic (finding) Birth Defects Implementation Guide APP-84

302 SNOMED-CT Code SNOMED-CT Description Epileptic seizures - clonic (finding) Epileptic seizures - tonic (finding) Complex febrile seizure (finding) Generalized seizure (finding) Clonic seizure (finding) Coordinate convulsion (finding) Tonic-clonic seizure (finding) Grand mal seizure (finding) On examination - grand mal fit (finding) Secondarily generalized seizures (finding) Long atonic seizure (finding) Movement partial seizure (finding) Paralysis from birth trauma (disorder) Spastic paralysis due to birth injury (disorder) Spastic paralysis due to intracranial birth injury (disorder) Spastic paralysis due to spinal birth injury (disorder) Neonatal encephalopathy (disorder) Neonatal asphyxial encephalopathy (disorder) Postnatal hypoxic encephalopathy (disorder) MCH HBS Significant Birth Injury Section Template Entry Template Value Set Value Set Code PHVS_SignificantBirthInjury_NCHS Value Set Description To Reflect that the newborn suffered a Significant Birth Injury (skeletal fracture(s), peripheral nerve injury, and/ or soft tissue/solid organ hemorrhage which requires intervention) reflecting an abnormal condition of the newborn Vocabulary SNOMED-CT Code SNOMED-CT Description Birth trauma of fetus (disorder) Birth injury to face (disorder) Birth injury to scalp (disorder) Caput succedaneum (disorder) Chignon (disorder) Vacuum extraction chignon (disorder) Birth Defects Implementation Guide APP-85

303 SNOMED-CT Code SNOMED-CT Description Fetal monitoring scalp injury (disorder) Electrode injury to scalp during birth (disorder) Sampling injury to scalp during birth (disorder) Scalp injuries due to birth trauma (disorder) Cephalhematoma due to birth trauma (disorder) Scalp abrasions due to birth trauma (disorder) Scalp injury due to vacuum extraction (disorder) Birth trauma deafness (disorder) Birth trauma due to amniocentesis (disorder) Cerebral injury due to birth trauma (disorder) Cerebral hemorrhage due to birth injury (disorder) Extradural hemorrhage in fetus or newborn (disorder) Subdural and cerebral hemorrhage due to birth trauma (disorder) Tentorial tear due to birth trauma (disorder) Cranial nerve injury due to birth trauma (disorder) Facial nerve injury as birth trauma (disorder) Facial palsy as birth trauma (disorder) Erb-Duchenne palsy as birth trauma (disorder) Hematoma of vulva of fetus or newborn as birth trauma (disorder) Injury of spine AND/OR spinal cord as birth trauma (disorder) Injury to brachial plexus as birth trauma (disorder) Brachial plexus palsy due to birth trauma (disorder) Klumpke-Déjerine paralysis as birth trauma (disorder) Kidney injury due to birth trauma (disorder) Laryngeal injury due to birth trauma (disorder) Liver rupture due to birth trauma (disorder) Paralysis from birth trauma (disorder) Spastic paralysis due to birth injury (disorder) Spastic paralysis due to intracranial birth injury (disorder) Spastic paralysis due to spinal birth injury (disorder) Perinatal forceps injury (disorder) Perinatal skin trauma due to obstetric injury (disorder) Peripheral nerve injury due to birth trauma (disorder) Birth injury to phrenic nerve (disorder) Phrenic nerve paralysis as birth trauma (disorder) Birth plexus injury - whole plexus (disorder) Birth Defects Implementation Guide APP-86

304 SNOMED-CT Code SNOMED-CT Description Scalpel wound due to birth trauma (disorder) Skeletal injury due to birth trauma (disorder) Birth dislocation of the shoulder (disorder) Fracture of long bone, as birth trauma (disorder) Birth fracture of radius (disorder) Birth fracture of ulna (disorder) Fracture of clavicle due to birth trauma (disorder) Fracture of femur due to birth trauma (disorder) Fracture of humerus due to birth trauma (disorder) Fracture of nose due to birth trauma (disorder) Fracture of radius and/or ulna due to birth trauma (disorder) Fracture of spine due to birth trauma (disorder) Fracture of tibia and/or fibula due to birth trauma (disorder) Spine dislocation due to birth trauma (disorder) Spine or spinal cord injury due to birth trauma (disorder) Spinal cord laceration due to birth trauma (disorder) Spinal cord rupture due to birth trauma (disorder) Spleen rupture due to birth trauma (disorder) Sternomastoid injury due to birth injury (disorder) Tentorial tear as birth trauma (disorder) Meconium Staining Section Template Entry Template Value Set Value Set Code PHVS_MeconiumStaining_NCHS Value Set Description To Reflect that there was moderate or heavy Meconium staining SNOMED-CT Code Vocabulary SNOMED-CT Description Meconium stained liquor - grade II (finding) Meconium stained liquor - grade III (finding) Thick meconium stained liquor (finding) Fresh meconium staining liquor (finding) Old meconium staining liquor (finding) Birth Defects Implementation Guide APP-87

305 N No applicable value sets. O No applicable value sets. P Personal Relationship Role Type Value Set Personal Relationship Role Type DYNAMIC Code System(s) RoleCode Description A Personal Relationship records the role of a person in relation to another person. This value set is to be used when recording the relationships between different people who are not necessarily related by family ties, but also includes family relationships Code FAMMEMB Family member CHILD Child CHILDADOPT Adopted child DAUADOPT Adopted daughter SONADOPT Adopted son CHLDFOST Foster child DAUFOST Foster daughter SONFOST Foster son CHILDINLAW Child in-law DAUINLAW Daughter in-law SONINLAW Son in-law DAUC Daughter child DAU Natural daughter STPDAU Stepdaughter NCHILD Natural child SON Natural son Display Name Birth Defects Implementation Guide APP-88

306 Code Display Name SONC Son child STPSON Stepson STPCHILD Stepchild EXT Extended family member AUNT Aunt MAUNT Maternal aunt PAUNT Paternal aunt COUSN Cousin MCOUSN Maternal cousin PCOUSN Paternal cousin GGRPRN Great grandparent GGRFTH Great grandfather GGRMTH Great grandmother MGGRFTH Maternal great grandfather MGGRMTH Maternal great grandmother MGGRPRN Maternal great grandparent PGGRFTH Paternal great grandfather PGGRMTH Paternal great grandmother PGGRPRN Paternal great grandparent GRNDCHILD Grandchild GRNDDAU Granddaughter GRNDSON Grandson GRPRN Grandparent GRFTH Grandfather GRMTH Grandmother MGRFTH Maternal grandfather MGRMTH Maternal grandmother MGRPRN Maternal grandparent PGRFTH Paternal grandfather PGRMTH Paternal grandmother PGRPRN Paternal grandparent NIENEPH Neice/nephew NEPHEW Nephew NIECE Niece UNCLE Uncle MUNCLE Maternal uncle PUNCLE Paternal uncle PRN Parent FTH Father MTH Mother NPRN Natural parent Birth Defects Implementation Guide APP-89

307 Code Display Name NFTH Natural father NFTHF Natural father of fetus NMTH Natural mother PRNINLAW Parent in-law FTHINLAW Father in-law MTHINLAW Mother in-law STPPRN Step parent STPFTH Stepfather STPMTH Stepmother SIB Sibling BRO Brother HSIB Half-sibling HBRO Half-brother HSIS Half-sister NSIB Natural sibling NBRO Natural brother NSIS Natural sister SIBINLAW Sibling in-law BROINLAW Brother in-law SISINLAW Sister in-law SIS Sister STPSIB Step sibling STPBRO Stepbrother STPSIS Stepsister SIGOTHR Significant other DOMPART Domestic partner SPS Spouse HUSB Husband WIFE Wife FRND Unrelated friend NBOR Neighbor ROOM Roommate RESPRSN Responsible party EXCEST Executor of estate GUADLTM Guardian ad lidem GUARD Guardian POWATT Power of attorney DPOWATT Durable power of attorney HPOWATT Healthcare power of attorney SPOWATT Special power of attorney ONESELF Oneself Birth Defects Implementation Guide APP-90

308 Precipitous Labor Section Template Entry Template Value Set Value Set Code PHVS_PrecipitousLabor_NCHS Value Set Description To Reflect Onset of labor with Precipitous Labor Vocabulary SNOMED-CT Code SNOMED-CT Description Precipitate labor (disorder) Precipitate labor - delivered (disorder) Precipitate labor with antenatal problem (disorder) Pregnancy Outcomes Section Template Entry Template Value Set OID Value Set Code PHVS_PregnancyOutcome_FDD Value Set Description Outcome of pregnancy answer list Concept Code Concept Name Mother not delivered (finding) OTH Other Premature delivery (finding) Spontaneous abortion (disorder) Stillbirth (finding) Term birth of newborn (finding) UNK Unknown Prolonged Labor Section Template Entry Template Value Set Value Set Code PHVS_ProlongedLabor_NCHS Value Set Description To Reflect Onset of labor with Prolonged Labor Vocabulary Birth Defects Implementation Guide APP-91

309 SNOMED-CT Code SNOMED-CT Description Prolonged labor (disorder) Delayed delivery after artificial rupture of membranes (disorder) Delayed delivery of second of multiple births (disorder) Delayed delivery of triplet (disorder) Delayed delivery of second twin (disorder) Delayed delivery of second twin, triplet etc. (disorder) Delayed delivery second twin delivered (disorder) Delayed delivery second twin with antenatal problem (disorder) Prolonged first stage of labor (disorder) Prolonged first stage - delivered (disorder) Prolonged first stage with antenatal problem (disorder) Prolonged latent phase of labor (disorder) Prolonged second stage of labor (disorder) Prolonged second stage - delivered (disorder) Prolonged second stage with antenatal problem (disorder) Q No applicable value sets. R Race Value Set Race DYNAMIC Code System(s) Race and Ethnicity - CDC Description A Value Set of codes for Classifying data based upon race. Race is always reported at the discretion of the person for whom this attribute is reported, and reporting must be completed according to Federal guidelines for race reporting. Any code descending from the Race concept (1000-9) in that terminology may be used in the exchange on?oid= &code= Birth Defects Implementation Guide APP-92

310 Concept Code Concept Name Abenaki Absentee Shawnee Acoma Afghanistani African African American Agdaagux Agua Caliente Agua Caliente Cahuilla Ahtna Ak-Chin Akhiok Akiachak Akiak Akutan Alabama Coushatta Alabama Creek Alabama Quassarte Alakanuk Alamo Navajo Alanvik Alaska Indian Alaska Native Alaskan Athabascan Alatna Aleknagik Aleut Aleut Corporation Aleutian Aleutian Islander Alexander Algonquian Allakaket Allen Canyon Alpine Alsea Alutiiq Aleut Ambler American Indian American Indian or Alaska Native Anaktuvuk Anaktuvuk Pass Andreafsky Angoon Aniak Anvik Birth Defects Implementation Guide APP-93

311 Concept Code Concept Name Apache Arab Arapaho Arctic Arctic Slope Corporation Arctic Slope Inupiat Arikara Arizona Tewa Armenian Aroostook Asian Asian Indian Assiniboine Assiniboine Sioux Assyrian Atka Atmautluak Atqasuk Atsina Attacapa Augustine Bad River Bahamian Bangladeshi Bannock Barbadian Barrio Libre Barrow Battle Mountain Bay Mills Chippewa Beaver Belkofski Bering Straits Inupiat Bethel Bhutanese Big Cypress Bill Moore's Slough Biloxi Birch Creek Bishop Black Black or African American Blackfeet Blackfoot Sioux Bois Forte Botswanan Brevig Mission Birth Defects Implementation Guide APP-94

312 Concept Code Concept Name Bridgeport Brighton Bristol Bay Aleut Bristol Bay Yupik Brotherton Brule Sioux Buckland Burmese Burns Paiute Burt Lake Band Burt Lake Chippewa Burt Lake Ottawa Cabazon Caddo Cahto Cahuilla California Tribes Calista Yupik Cambodian Campo Canadian and Latin American Indian Canadian Indian Canoncito Navajo Cantwell Capitan Grande Carolinian Carson Catawba Cayuga Cayuse Cedarville Celilo Central American Indian Central Council of Tlingit and Haida Tribes Central Pomo Chalkyitsik Chamorro Chefornak Chehalis Chemakuan Chemehuevi Chenega Cherokee Cherokee Alabama Cherokee Shawnee Cherokees of Northeast Alabama Cherokees of Southeast Alabama Birth Defects Implementation Guide APP-95

313 Concept Code Concept Name Chevak Cheyenne Cheyenne River Sioux Cheyenne-Arapaho Chickahominy Chickaloon Chickasaw Chignik Chignik Lagoon Chignik Lake Chilkat Chilkoot Chimariko Chinese Chinik Chinook Chippewa Chippewa Cree Chiricahua Chistochina Chitimacha Chitina Choctaw Chuathbaluk Chugach Aleut Chugach Corporation Chukchansi Chumash Chuukese Circle Citizen Band Potawatomi Clark's Point Clatsop Clear Lake Clifton Choctaw Coast Miwok Coast Yurok Cochiti Cocopah Coeur D'Alene Coharie Colorado River Columbia Columbia River Chinook Colville Comanche Cook Inlet Birth Defects Implementation Guide APP-96

314 Concept Code Concept Name Coos Coos, Lower Umpqua, Siuslaw Copper Center Copper River Coquilles Costanoan Council Coushatta Cow Creek Umpqua Cowlitz Craig Cree Creek Croatan Crooked Creek Crow Crow Creek Sioux Cupeno Cuyapaipe Dakota Sioux Deering Delaware Diegueno Digger Dillingham Dominica Islander Dominican Dot Lake Douglas Doyon Dresslerville Dry Creek Duck Valley Duckwater Duwamish Eagle Eastern Cherokee Eastern Chickahominy Eastern Creek Eastern Delaware Eastern Muscogee Eastern Pomo Eastern Shawnee Eastern Tribes Echota Cherokee Eek Egegik Birth Defects Implementation Guide APP-97

315 Concept Code Concept Name Egyptian Eklutna Ekuk Ekwok Elim Elko Ely Emmonak English English Bay Eskimo Esselen Ethiopian Etowah Cherokee European Evansville Eyak Fallon False Pass Fijian Filipino Flandreau Santee Florida Seminole Fond du Lac Forest County Fort Belknap Fort Berthold Fort Bidwell Fort Hall Fort Independence Fort McDermitt Fort Mcdowell Fort Peck Fort Peck Assiniboine Sioux Fort Sill Apache Fort Yukon French French American Indian Gabrieleno Gakona Galena Gambell Gay Head Wampanoag Georgetown (Eastern Tribes) Georgetown (Yupik-Eskimo) German Gila Bend Birth Defects Implementation Guide APP-98

316 Concept Code Concept Name Gila River Pima-Maricopa Golovin Goodnews Bay Goshute Grand Portage Grand Ronde Grand Traverse Band of Ottawa/Chippewa Grayling Greenland Eskimo Gros Ventres Guamanian Guamanian or Chamorro Gulkana Haida Haitian Haliwa Hannahville Havasupai Healy Lake Hidatsa Hmong Ho-chunk Hoh Hollywood Seminole Holy Cross Hoonah Hoopa Hoopa Extension Hooper Bay Hopi Houma Hualapai Hughes Huron Potawatomi Huslia Hydaburg Igiugig Iliamna Illinois Miami Inaja-Cosmit Inalik Diomede Indian Township Indiana Miami Indonesian Inupiaq Inupiat Eskimo Iowa Birth Defects Implementation Guide APP-99

317 Concept Code Concept Name Iowa of Kansas-Nebraska Iowa of Oklahoma Iowa Sac and Fox Iqurmuit (Russian Mission) Iranian Iraqi Irish Iroquois Isleta Israeili Italian Ivanof Bay Iwo Jiman Jamaican Jamestown Japanese Jemez Jena Choctaw Jicarilla Apache Juaneno Kaibab Kake Kaktovik Kalapuya Kalispel Kalskag Kaltag Karluk Karuk Kasaan Kashia Kasigluk Kathlamet Kaw Kawaiisu Kawerak Kenaitze Keres Kern River Ketchikan Keweenaw Kialegee Kiana Kickapoo Kikiallus King Cove King Salmon Birth Defects Implementation Guide APP-100

318 Concept Code Concept Name Kiowa Kipnuk Kiribati Kivalina Klallam Klamath Klawock Kluti Kaah Knik Kobuk Kodiak Kokhanok Koliganek Kongiganak Koniag Aleut Konkow Kootenai Korean Kosraean Kotlik Kotzebue Koyuk Koyukuk Kwethluk Kwigillingok Kwiguk La Jolla La Posta Lac Courte Oreilles Lac du Flambeau Lac Vieux Desert Chippewa Laguna Lake Minchumina Lake Superior Lake Traverse Sioux Laotian Larsen Bay Las Vegas Lassik Lebanese Leech Lake Lenni-Lenape Levelock Liberian Lime Lipan Apache Little Shell Chippewa Birth Defects Implementation Guide APP-101

319 Concept Code Concept Name Lone Pine Long Island Los Coyotes Lovelock Lower Brule Sioux Lower Elwha Lower Kalskag Lower Muscogee Lower Sioux Lower Skagit Luiseno Lumbee Lummi Machis Lower Creek Indian Madagascar Maidu Makah Malaysian Maldivian Malheur Paiute Maliseet Mandan Manley Hot Springs Manokotak Manzanita Mariana Islander Maricopa Marshall Marshallese Marshantucket Pequot Mary's Igloo Mashpee Wampanoag Matinecock Mattaponi Mattole Mauneluk Inupiat Mcgrath Mdewakanton Sioux Mekoryuk Melanesian Menominee Mentasta Lake Mesa Grande Mescalero Apache Metlakatla Mexican American Indian Miami Birth Defects Implementation Guide APP-102

320 Concept Code Concept Name Miccosukee Michigan Ottawa Micmac Micronesian Middle Eastern or North African Mille Lacs Miniconjou Minnesota Chippewa Minto Mission Indians Mississippi Choctaw Missouri Sac and Fox Miwok Moapa Modoc Mohave Mohawk Mohegan Molala Mono Montauk Moor Morongo Mountain Maidu Mountain Village Mowa Band of Choctaw Muckleshoot Munsee Naknek Nambe Namibian Nana Inupiat Nansemond Nanticoke Napakiak Napaskiak Napaumute Narragansett Natchez Native Hawaiian Native Hawaiian or Other Pacific Islander Nausu Waiwash Navajo Nebraska Ponca Nebraska Winnebago Nelson Lagoon Nenana Birth Defects Implementation Guide APP-103

321 Concept Code Concept Name Nepalese New Hebrides New Stuyahok Newhalen Newtok Nez Perce Nigerian Nightmute Nikolai Nikolski Ninilchik Nipmuc Nishinam Nisqually Noatak Nomalaki Nome Nondalton Nooksack Noorvik Northern Arapaho Northern Cherokee Northern Cheyenne Northern Paiute Northern Pomo Northway Northwest Tribes Nuiqsut Nulato Nunapitchukv Oglala Sioux Okinawan Oklahoma Apache Oklahoma Cado Oklahoma Choctaw Oklahoma Comanche Oklahoma Delaware Oklahoma Kickapoo Oklahoma Kiowa Oklahoma Miami Oklahoma Ottawa Oklahoma Pawnee Oklahoma Peoria Oklahoma Ponca Oklahoma Sac and Fox Oklahoma Seminole Old Harbor Birth Defects Implementation Guide APP-104

322 Concept Code Concept Name Omaha Oneida Onondaga Ontonagon Oregon Athabaskan Osage Oscarville Other Pacific Islander Other Race Otoe-Missouria Ottawa Ouzinkie Owens Valley Paiute Pakistani Pala Palauan Palestinian Pamunkey Panamint Papua New Guinean Pascua Yaqui Passamaquoddy Paugussett Pauloff Harbor Pauma Pawnee Payson Apache Pechanga Pedro Bay Pelican Penobscot Peoria Pequot Perryville Petersburg Picuris Pilot Point Pilot Station Pima Pine Ridge Sioux Pipestone Sioux Piro Piscataway Pit River Pitkas Point Platinum Birth Defects Implementation Guide APP-105

323 Concept Code Concept Name Pleasant Point Passamaquoddy Poarch Band Pocomoke Acohonock Pohnpeian Point Hope Point Lay Pojoaque Pokagon Potawatomi Polish Polynesian Pomo Ponca Poospatuck Port Gamble Klallam Port Graham Port Heiden Port Lions Port Madison Portage Creek Potawatomi Powhatan Prairie Band Prairie Island Sioux Principal Creek Indian Nation Prior Lake Sioux Pueblo Puget Sound Salish Puyallup Pyramid Lake Qagan Toyagungin Qawalangin Quapaw Quechan Quileute Quinault Quinhagak Ramah Navajo Rampart Rampough Mountain Rappahannock Red Cliff Chippewa Red Devil Red Lake Chippewa Red Wood Reno-Sparks Rocky Boy's Chippewa Cree Rosebud Sioux Birth Defects Implementation Guide APP-106

324 Concept Code Concept Name Round Valley Ruby Ruby Valley Sac and Fox Saginaw Chippewa Saipanese Salamatof Salinan Salish Salish and Kootenai Salt River Pima-Maricopa Samish Samoan San Carlos Apache San Felipe San Ildefonso San Juan San Juan De San Juan Pueblo San Juan Southern Paiute San Manual San Pasqual San Xavier Sand Hill Sand Point Sandia Sans Arc Sioux Santa Ana Santa Clara Santa Rosa Santa Rosa Cahuilla Santa Ynez Santa Ysabel Santee Sioux Santo Domingo Sauk-Suiattle Sault Ste. Marie Chippewa Savoonga Saxman Scammon Bay Schaghticoke Scott Valley Scottish Scotts Valley Selawik Seldovia Sells Birth Defects Implementation Guide APP-107

325 Concept Code Concept Name Seminole Seneca Seneca Nation Seneca-Cayuga Serrano Setauket Shageluk Shaktoolik Shasta Shawnee Sheldon's Point Shinnecock Shishmaref Shoalwater Bay Shoshone Shoshone Paiute Shungnak Siberian Eskimo Siberian Yupik Siletz Singaporean Sioux Sisseton Sioux Sisseton-Wahpeton Sitka Siuslaw Skokomish Skull Valley Skykomish Slana Sleetmute Snohomish Snoqualmie Soboba Sokoagon Chippewa Solomon Solomon Islander South American Indian South Fork Shoshone South Naknek Southeast Alaska Southeastern Indians Southern Arapaho Southern Cheyenne Southern Paiute Spanish American Indian Spirit Lake Sioux Birth Defects Implementation Guide APP-108

326 Concept Code Concept Name Spokane Squaxin Island Sri Lankan St. Croix Chippewa St. George St. Mary's St. Michael St. Paul Standing Rock Sioux Star Clan of Muscogee Creeks Stebbins Steilacoom Stevens Stewart Stillaguamish Stockbridge Stony River Stonyford Sugpiaq Sulphur Bank Summit Lake Suqpigaq Suquamish Susanville Susquehanock Swinomish Sycuan Syrian Table Bluff Tachi Tahitian Taiwanese Takelma Takotna Talakamish Tanacross Tanaina Tanana Tanana Chiefs Taos Tatitlek Tazlina Telida Teller Temecula Te-Moak Western Shoshone Tenakee Springs Birth Defects Implementation Guide APP-109

327 Concept Code Tenino Tesuque Tetlin Teton Sioux Tewa Texas Kickapoo Thai Thlopthlocco Tigua Tillamook Timbi-Sha Shoshone Tlingit Tlingit-Haida Tobagoan Togiak Tohono O'Odham Tok Tokelauan Toksook Tolowa Tonawanda Seneca Tongan Tonkawa Torres-Martinez Trinidadian Trinity Tsimshian Tuckabachee Tulalip Tule River Tulukskak Tunica Biloxi Tuntutuliak Tununak Turtle Mountain Tuscarora Tuscola Twenty-Nine Palms Twin Hills Two Kettle Sioux Tygh Tyonek Ugashik Uintah Ute Umatilla Umkumiate Umpqua Concept Name Birth Defects Implementation Guide APP-110

328 Concept Code Concept Name Unalakleet Unalaska Unangan Aleut Unga United Keetowah Band of Cherokee Upper Chinook Upper Sioux Upper Skagit Ute Ute Mountain Ute Utu Utu Gwaitu Paiute Venetie Vietnamese Waccamaw-Siousan Wahpekute Sioux Wahpeton Sioux Wailaki Wainwright Wakiakum Chinook Wales Walker River Walla-Walla Wampanoag Wappo Warm Springs Wascopum Washakie Washoe Wazhaza Sioux Wenatchee West Indian Western Cherokee Western Chickahominy Whilkut White White Earth White Mountain White Mountain Apache White Mountain Inupiat Wichita Wicomico Willapa Chinook Wind River Wind River Arapaho Wind River Shoshone Winnebago Winnemucca Birth Defects Implementation Guide APP-111

329 Concept Code Concept Name Wintun Wisconsin Potawatomi Wiseman Wishram Wiyot Wrangell Wyandotte Yahooskin Yakama Yakama Cowlitz Yakutat Yana Yankton Sioux Yanktonai Sioux Yapese Yaqui Yavapai Yavapai Apache Yerington Paiute Yokuts Yomba Yuchi Yuki Yuman Yupik Eskimo Yurok Zairean Zia Zuni Religious Affiliation Value Set HL DYNAMIC Code System ID Code System Name Religious Affiliation Code System Code PH_ReligiousAffiliation_HL7_V3 Description A value set of codes that reflect spiritual faith affiliation Code Display Definition 1001 Adventist 1002 African Religions 1003 Afro-Carribbean Religions 1004 Agnosticism 1005 Anglican Birth Defects Implementation Guide APP-112

330 Code Display Definition 1006 Animism 1007 Atheism 1008 Babi & Baha l faiths 1009 Baptist 1010 Bon 1011 Cao Dai 1012 Celticism 1013 Christian (non-catholic, non-specific) 1014 Confucianism 1015 Cyberculture Religions 1016 Divination 1017 Fourth Way 1018 Free Daism 1019 Gnosis 1020 Hinduism 1021 Humanism 1022 Independent 1023 Islam 1024 Jainism 1025 Jehovah s Witnesses 1026 Judaism 1027 Latter Day Saints 1028 Lutheran 1029 Mahayana 1030 Meditation 1031 Messianic Judaism 1032 Mitraism 1033 New Age 1034 Non-Roman Catholic 1035 Occult 1036 Orthodox 1037 Paganism 1038 Pentecostal 1039 Process, The 1040 Rerformed/Presbyterian 1041 Roman Catholic Church 1042 Satanism 1043 Scientology Birth Defects Implementation Guide APP-113

331 Code Display Definition 1044 Shamanism 1045 Shiite (Islam) 1046 Shinto 1047 Sikism 1048 Spiritualism 1049 Sunni (Islam) 1050 Taoism 1051 Theravada 1052 Unitarian-Universalism 1053 Universal Life Church 1054 Vajrayana (Tibetan) 1055 Veda 1056 Voodoo 1057 Wicca 1058 Yaohushua 1059 Zen Buddhism 1060 Zoroastrianism 1061 Assembly of God 1062 Brethren 1063 Christian Scientist 1064 Church of Christ 1065 Church of God 1066 Congregational 1067 Disciples of Christ 1068 Eastern Orthodox 1069 Episcopalian 1070 Evangelical Covenant 1071 Friends 1072 Full Gospel 1073 Methodist 1074 Native American 1075 Nazarene 1076 Presbyterian 1077 Protestant 1078 Protestant, No Denomination 1079 Rerformed 1080 Salvation Army 1081 Unitarian Universalist Birth Defects Implementation Guide APP-114

332 Code 1082 United Church of Christ Display Definition Role Codes Value Set OID Code System Name RoleCode Code System Code PH_RoleCode_HL7_V3 Code System OID Description This value set contains personal and legal relationship roles which may exist between individuals and which are relevant for the healthcare setting. Code FAMMEMB Family member CHILD Child CHILDADOPT Adopted child DAUADOPT Adopted daughter SONADOPT Adopted son CHLDFOST Foster child DAUFOST Foster daughter SONFOST Foster son CHILDINLAW Child in-law DAUINLAW Daughter in-law SONINLAW Son in-law DAUC Daughter child DAU Natural daughter STPDAU Stepdaughter NCHILD Natural child SON Natural son SONC Son child STPSON Stepson STPCHILD Stepchild EXT Extended family member AUNT Aunt MAUNT Maternal aunt PAUNT Paternal aunt COUSN Cousin MCOUSN Maternal cousin PCOUSN Paternal cousin Display Name Birth Defects Implementation Guide APP-115

333 Code Display Name GGRPRN Great grandparent GGRFTH Great grandfather GGRMTH Great grandmother MGGRFTH Maternal great grandfather MGGRMTH Maternal great grandmother MGGRPRN Maternal great grandparent PGGRFTH Paternal great grandfather PGGRMTH Paternal great grandmother PGGRPRN Paternal great grandparent GRNDCHILD Grandchild GRNDDAU Granddaughter GRNDSON Grandson GRPRN Grandparent GRFTH Grandfather GRMTH Grandmother MGRFTH Maternal grandfather MGRMTH Maternal grandmother MGRPRN Maternal grandparent PGRFTH Paternal grandfather PGRMTH Paternal grandmother PGRPRN Paternal grandparent NIENEPH Neice/nephew NEPHEW Nephew NIECE Niece UNCLE Uncle MUNCLE Maternal uncle PUNCLE Paternal uncle PRN Parent FTH Father MTH Mother NPRN Natural parent NFTH Natural father NFTHF Natural father of fetus NMTH Natural mother PRNINLAW Parent in-law FTHINLAW Father in-law MTHINLAW Mother in-law STPPRN Step parent Birth Defects Implementation Guide APP-116

334 Code Display Name STPFTH Stepfather STPMTH Stepmother SIB Sibling BRO Brother HSIB Half-sibling HBRO Half-brother HSIS Half-sister NSIB Natural sibling NBRO Natural brother NSIS Natural sister SIBINLAW Sibling in-law BROINLAW Brother in-law SISINLAW Sister in-law SIS Sister STPSIB Step sibling STPBRO Stepbrother STPSIS Stepsister SIGOTHR Significant other DOMPART Domestic partner SPS Spouse HUSB Husband WIFE Wife FRND Unrelated friend NBOR Neighbor ROOM Roommate RESPRSN Responsible party EXCEST Executor of estate GUADLTM Guardian ad lidem GUARD Guardian POWATT Power of attorney DPOWATT Durable power of attorney HPOWATT Healthcare power of attorney SPOWATT Special power of attorney ONESELF Oneself Birth Defects Implementation Guide APP-117

335 S No applicable value sets. T No applicable value sets. U USGS GNIS Value Set Code PHVS_City_USGS_GNIS Value Set Name City Value Set OID Value Set Description US Geological Survey Geographic Names Information System - location codes 34BBC-617F-DD11-B38D-00188B Birth Defects Implementation Guide APP-118

336 Appendix C Data Element and CDA Element Relationship Table The following table provides the data elements, template ID, CDA document location (XPath mapping), vocabulary constraints, and optionality for the Ambulatory Healthcare Provider BxDefects Event Report. Appendix B contains a list of namespaces and vocabulary/value sets. Data Elements Cross Reference NBDPN ID Data Element Opt Template ID XPATH Mapping Date Case Report Exported SHALL [General Header Constraints for CDA R2] Report Type SHALL [General Header Constraints for CDA R2] Child s Legal Name Child s Last Name Child s Name Suffix Child s First Name Child s Middle Name Child s Maiden Name SHALL [General Header Constraints for CDA R2] SHALL [General Header Constraints for CDA R2] SHOULD [General Header Constraints for CDA R2] SHALL [General Header Constraints for CDA R2] SHALL [General Header Constraints for CDA R2] SHOULD [General Header Constraints for CDA R2] ClinicalDocument/effective Time/@value ClinicalDocument/relatedD ocument/@typecode ClinicalDocument/recordTa rget/patientrole/patient/na me[@use='l'] ClinicalDocument/recordTa rget/patientrole/patient/na me/family ClinicalDocument/recordTa rget/patientrole/patient/na me/suffix ClinicalDocument/recordTa rget/patientrole/patient/na me/given[1] ClinicalDocument/recordTa rget/patientrole/patient/na me/given[2] ClinicalDocument/recordTa rget/patientrole/patient/na me/family[@qualifier='br'] Birth Defects Implementation Guide APP-119

337 NBDPN ID Data Element Opt Template ID XPATH Mapping Child s Name Alias Child s Address (Street Address, City, State, Zip Code, Country) Address History SHOULD [General Header Constraints for CDA R2] SHALL [General Header Constraints for CDA R2] SHALL [General Header Constraints for CDA R2] Address Use SHOULD [General Header Constraints for CDA R2] Patient Telephone Child s Sex/Gender Child s Date of Birth Child s Medical Record Number Child s Social Security Number SHOULD [General Header Constraints for CDA R2] SHALL [General Header Constraints for CDA R2] SHALL [General Header Constraints for CDA R2] SHALL [General Header Constraints for CDA R2] SHALL [General Header Constraints for CDA R2] Child s Race SHALL [General Header Constraints for CDA R2] sdtc:race (racecode extension) MAY [HL7 Implementation Guide for CDA Release 2: IHE Health Story Consolidation, Release 1] ClinicalDocument/recordTa rget/patientrole/patient/na me[@use='a'] ClinicalDocument/recordTa rget/patientrole/addr/* ClinicalDocument/recordTa rget/patientrole/addr/usea bleperiod/* ClinicalDocument/recordTa rget/patientrole/addr/@use ClinicalDocument/recordTa rget/patientrole/telecom/@ value ClinicalDocument/recordTa rget/patientrole/patient/ad ministrativegendercode/@ * ClinicalDocument/recordTa rget/patientrole/patient/birt htime/@value ClinicalDocument/recordTa rget/patientrole/id[not(@ro ot= ' ')]/@ extension ClinicalDocument/recordTa rget/patientrole/id[@root=' ']/@ extension ClinicalDocument/recordTa rget/patientrole/patient/rac ecode/@* ClinicalDocument/recordTa rget/patientrole/patient/sdt c:racecode Birth Defects Implementation Guide APP-120

338 NBDPN ID Data Element Opt Template ID XPATH Mapping Child s Ethnicity Child s Birth Place Child s Facility Address Child s Facility ID Child s Facility's NPI ID SHALL [General Header Constraints for CDA R2] SHALL SHALL SHALL SHALL ClinicalDocument/recordTa rget/patientrole/patient/eth nicgroupcode/@* ClinicalDocument/recordTa rget/patientrole/patient/birt hplace/place/addr/* recordtarget/patientrole/pr oviderorganization/addr recordtarget/patientrole/pr oviderorganization/id[1] recordtarget/patientrole/pr oviderorganization/id[2] Where: id[2]@extension is the child facility's NPI id[2]@root is the NPI's OID Child s Facility's OID ID Child s Facility Name Physician of Record Physician ID (NPI) Physician Address (Street Address, City, State, Zip Code, Country) Physician Type of Physician Provider Organization ID SHALL SHALL SHALL [General Header Constraints for CDA R2] SHALL [General Header Constraints for CDA R2] SHOULD [General Header Constraints for CDA R2] SHOULD [General Header Constraints for CDA R2] SHALL [General Header Constraints for CDA R2] SHALL [General Header Constraints for CDA R2] recordtarget/patientrole/pr oviderorganization/id[3] recordtarget/patientrole/pr oviderorganization/name ClinicalDocument/documen tationof/serviceevent/perfo rmer/assignedentity/assign edperson/name/* ClinicalDocument/documen tationof/serviceevent/perfo rmer/assignedentity/id[@ro ot=' '] /@extension ClinicalDocument/documen tationof/serviceevent/perfo rmer/assignedentity/addr/* ClinicalDocument/documen tationof/serviceevent/perfo rmer/assignedentity/teleco m ClinicalDocument/documen tationof/serviceevent/perfo ClinicalDocument/documen tationof/serviceevent/perfo rmer/assignedentity/repres entedorganization/* Birth Defects Implementation Guide APP-121

339 NBDPN ID Data Element Opt Template ID XPATH Mapping MOTHER Reporting Source Name Provider Referred From Provider Referred From ID (NPI) Mother s Medical Record Number Mother s Address (residence) State, county, city, town or location Mother s Mailing Address (if different) Mother s First Name Mother s Birth Name Mother s name prior to first marriage Mother s Date of Birth Mother s Birthplace Name of State, territory, or country Mother s Race Ethnicity Value Set (CDC) SHALL [General Header Constraints for CDA R2] SHOULD [Encompassing Encounter] SHOULD [Encompassing Encounter] SHOULD SHOULD SHOULD SHALL SHOULD SHOULD SHOULD SHOULD ClinicalDocument/documen tationof/serviceevent/perfo rmer/assignedentity/repres entedorganization/* ClinicalDocument/compone ntof/encompassingencount er/encounterparticipant/ass ignedentity/representedorg anization/* ClinicalDocument/compone ntof/encompassingencount er/encounterparticipant/ass ignedentity/id[@root=' ']/@exten sion section/subject[typecode=' section/subject[typecode=' section/subject[typecode=' section/subject[typecode=' e/given section/subject[typecode=' e/family section/subject[typecode=' Time section/subject[typecode=' place/place section/subject[typecode=' sdtc: racecode/@code Birth Defects Implementation Guide APP-122

340 NBDPN ID Data Element Opt Template ID XPATH Mapping FATHER Mother s Ethnicity Ethnicity Value Set (CDC) Mother's Social Security Number Father s Current Legal Name First, middle, last, suffix Father s Date of Birth Father s Social Security Number Father s Race Ethnicity Value Set (CDC) Father s Ethnicity Ethnicity Value Set (CDC) Newborn Delivery Information Section Place of Birth (type or birthing place) SHOULD SHOULD MAY MAY MAY MAY MAY SHALL SHOULD [Coded Event Outcomes Section] section/subject[typecode=' SBJ']/relatedSubject[/cod@ code='mth']/ sdtc: ethnicgroupcode/@code section/subject[typecode=' section/subject[typecode=' e /given /middle /birthname /suffix section/subject[typecode=' Time section/subject[typecode=' section/subject[typecode=' racecode/@code section/subject[typecode=' sdtc: ethnicgroupcode/@code ClinicalDocument/compo nent/structuredbody/com ponent/section[templatei d[@root=' ']] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/entry/act/entryrelationshi p/observation[templateid[ro ot= ']] and [code/@code= ]/value/@value Birth Defects Implementation Guide APP-123

341 NBDPN ID Data Element Opt Template ID XPATH Mapping Birth Weight (The weight of the infant at birth) Birth Length (The length of the infant at birth) Birth Length Unit Head Circumference SHALL [Coded Detailed Physical Examination] [Coded Vital Signs Section] SHALL [Coded Detailed Physical Examination] [Coded Vital Signs Section] SHALL [Coded Detailed Physical Examination] [Coded Vital Signs Section] SHALL [Coded Detailed Physical Examination] [Coded Vital Signs Section] ClinicalDocument/compone nt/structuredbody/compone =' ']]/component/secti ]]/entry/act/entryrelations hip/observation[templateid[ root= ']] and [code/@code= ]/value/@value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/entry/act/entryrelations hip/observation[templateid[ root= ']] and [code/@code= ]/value/@value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/entry/act/entryrelations hip/observation[templateid[ root= ']] and [code/@code= ]/value/@unit ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/entry/act/entryrelations hip/observation[templateid[ root= ']] and [code/@code= ]/value/@value Birth Defects Implementation Guide APP-124

342 NBDPN ID Data Element Opt Template ID XPATH Mapping Head Circumference Unit Apgar Score: 5 Minute Apgar Score: 10 Minute Gestational age at Birth SHALL [Coded Detailed Physical Examination] [Coded Vital Signs Section] SHALL [Coded Detailed Physical Examination] [General Appearance] SHALL [Coded Detailed Physical Examination] [General Appearance] SHALL [Coded Event Outcomes Section] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/entry/act/entryrelations hip/observation[templateid[ root= ']] and [code/@code= ]/value/@unit ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/ component/section [templateid[root= ]]/en try/act/entryrelationship/ob servation/[code/@code= ]/value/ ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/ component/section [templateid[root= ]]/en try/act/entryrelationship/ob servation/[code/@code= ]/value/ ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/entry/act/entryrelationshi p/observation[templateid[ro ot= ']] and [code/@code= ] /value/ Birth Defects Implementation Guide APP-125

343 NBDPN ID Data Element Opt Template ID XPATH Mapping Rank of Birth In case of multiple births (Birth Order / Set Order) Birth Status or Birth Outcome NICU Admission SHOULD [Coded Event Outcomes Section] SHALL [Coded Event Outcomes Section] SHALL [Coded Event Outcomes Section] Infant Expired SHOULD [Coded Event Outcomes Section] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/entry/act/entryrelationshi p/observation[templateid[ro ot= ']] and [code/@code= ]/value/@value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/entry/act/entryrelationshi p/observation[templateid[ro ot= ']] and [code/@code= ] /value/@value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/entry/act/entryrelationshi p/observation/code ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/entry/act/entryrelationshi p/observation[templateid[ro ot= ']] and [code/@code= TBD Birth Defects Implementation Guide APP-126

344 NBDPN ID Data Element Opt Template ID XPATH Mapping Cause of Death SHALL Can add nullfactor Location of Death Significant Birth Injury Antibiotic Administration Procedure Karyotype Determination [Coded Event Outcomes Section] SHOULD [Coded Event Outcomes Section] SHALL [Coded Event Outcomes Section] SHOULD [Procedures and Interventions] [Procedures] SHOULD [Procedures and Interventions] ClinicalDocument/compone nt/structuredbody/compone =' ']]/component/secti ]]/entry/act/entryrelationshi p/observation[templateid[ro ot= ']] and ] /value/@value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/entry/act/entryrelationshi p/observation[templateid[ro ot= ']] and [code/@code= ]/value/@value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root = ]]/component/sectio n[templateid[@root= ]]/ entry/act/entryrelationship/ observation/ ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/entry/procedure [templateid[root= ']]/cod e ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/entry/procedure/code Birth Defects Implementation Guide APP-127

345 NBDPN ID Data Element Opt Template ID XPATH Mapping Assisted Ventilation [required immediately following delivery] Assisted Ventilation for 6 or More Hours Newborn Given Surfactant Replacement Therapy? Intramuscular Medication Administration Route IV Medication Administration Route SHALL [Procedures and Interventions] [Procedures] SHALL [Procedures and Interventions] [Procedures] SHALL [Medication Administration Section] SHOULD [Medication Administration Section] SHOULD [Medication Administration Section] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/entry/procedure [templateid[root= ']]/cod e ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/entry/procedure [templateid[root= ']]/cod e ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/ substanceadministration/co de ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/ substanceadministration/ro utecode ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/ substanceadministration/ro utecode Birth Defects Implementation Guide APP-128

346 NBDPN ID Data Element Opt Template ID XPATH Mapping Neonatal Sepsis Seizure or Serious Neurologic Dysfunction SHOULD [Medication Administration Section] SHOULD [Active Problems] Labor and Delivery Section SHALL Plurality (The number of babies resulting from a single pregnancy) SHOULD [Coded Event Outcomes Section] Births Live SHOULD [Coded Event Outcomes Section] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/ substanceadministration/en tryrelationship[@typecode ='RSON']/observation[temp lateid/@root= ]/code ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root = ]]/ component/section[templat eid[@root= ]]/entry/act/entr yrelationship/observation/c ode ClinicalDocument/compo nent/structuredbody/com ponent/section[templatei d[@root=' ']] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/entry/act/entryrelationshi p/observation[templateid[ro ot=' ']] and [code/@code= ]/value/@value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/component/secti on[templateid[@root= ]]/entry/act/entryrelationshi p/observation[templateid[ro ot=' ']] and [code/@code= ]/value Birth Defects Implementation Guide APP-129

347 NBDPN ID Data Element Opt Template ID XPATH Mapping Pregnancy Outcome Presentation Type Admission to Intensive Care [unit] Perineal Laceration Ruptured Uterus SHOULD [Coded Event Outcomes Section] SHALL [Coded Event Outcomes Section] SHALL [Coded Event Outcomes Section] SHALL [Coded Event Outcomes Section] SHALL [Coded Event Outcomes Section] ClinicalDocument/compone nt/structuredbody/compone =' ']]/component/secti ]]/entry/act/entryrelationshi p/observation[templateid[ro ot=' ']]/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mponent/section[templateid yrelationship/observation/c ode ClinicalDocument/recordTa rget/component/structured Body/component/section[te mponent/section[templateid yrelationship/observation/c ode CodeClinicalDocument/rec ordtarget/component/struct uredbody/component/secti ]]/component/section[temp ]]/entry/a ct/entryrelationship/observ ation/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mponent/section[templateid yrelationship/observation/c ode Birth Defects Implementation Guide APP-130

348 NBDPN ID Data Element Opt Template ID XPATH Mapping Meconium Staining Premature Rupture Precipitous Labor Prolonged Labor Unplanned Hysterectomy Unplanned Operat[ing]ion [room procedure following delivery] SHALL [Coded Event Outcomes Section] SHALL [Coded Event Outcomes Section] SHALL [Coded Event Outcomes Section] SHALL [Coded Event Outcomes Section] SHOULD [Procedures and Interventions] SHOULD [Procedures and Interventions] ClinicalDocument/recordTa rget/component/structured Body/component/section[te mponent/section[templateid yrelationship/observation/c ode ClinicalDocument/recordTa rget/component/structured Body/component/section[te mponent/section[templateid yrelationship/observation/c ode ClinicalDocument/recordTa rget/component/structured Body/component/section[te mponent/section[templateid yrelationship/observation/c ode ClinicalDocument/recordTa rget/component/structured Body/component/section[te mponent/section[templateid yrelationship/observation/c ode ClinicalDocument/recordTa rget/component/structured Body/component/section[te mponent/section[templateid edure/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mponent/section[templateid edure/code Birth Defects Implementation Guide APP-131

349 NBDPN ID Data Element Opt Template ID XPATH Mapping Maternal Transfusion Anesthesia [Epidural or Spinal during labor] Route and Method of Delivery Trial of Labor Attempted Augmentation of Labor - Procedure Induction of Labor SHOULD [Procedures and Interventions] SHALL [Procedures and Interventions] SHOULD [Procedures and Interventions] SHOULD [Procedures and Interventions] SHOULD [Procedures and Interventions] SHOULD [Procedures and Interventions] ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root= ]]/co mponent/section[templateid [@root= ]]/entry/proc edure/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root= ]]/co mponent/section[templateid [@root= ]]/entry/proc edure/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root= ]]/co mponent/section[templateid [@root= ]]/entry/proc edure/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root= ]]/co mponent/section[templateid [@root= ]]/entry/proc edure/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root= ]]/co mponent/section[templateid [@root= ]]/entry/proc edure/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root= ]]/co mponent/section[templateid [@root= ]]/entry/proc edure/code Birth Defects Implementation Guide APP-132

350 NBDPN ID Data Element Opt Template ID XPATH Mapping Cervical Cerclage SHOULD [Procedures and Interventions] Tocolysis SHOULD [Procedures and Interventions] Antibiotics SHOULD [Medications Administered] Steroids SHOULD [Medications Administered] Augmentation of Labor - Medication SHOULD [Medications Administered] Anesthesia SHOULD [Medications Administered] ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root= ]]/co mponent/section[templateid [@root= ]]/entry/proc edure/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root= ]]/co mponent/section[templateid [@root= ]]/entry/proc edure/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root= ]]/co mponent/section[templateid [@root= ]]/substanceadm inistration/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root= ]]/co mponent/section[templateid [@root= ]]/substanceadm inistration/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root= ]]/co mponent/section[templateid [@root= ]]/substanceadm inistration/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root= ]]/co mponent/section[templateid [@root= ]]/substanceadm inistration/code Birth Defects Implementation Guide APP-133

351 NBDPN ID Data Element Opt Template ID XPATH Mapping Mother's Weight at Delivery Labor and Delivery History and Physical Month Prenatal Care Began Date of Last Prenatal Care Visit Total Number of Prenatal Visits for this Pregnancy SHOULD [Code Detailed Physical Examination] [Coded Vital Signs Section] SHALL SHALL Can add nullfactor SHALL Can add nullfactor SHALL Can add nullfactor [Pregnancy History Section] [Pregnancy Observation] [Pregnancy History Section] [Pregnancy Observation] [Pregnancy History Section] [Pregnancy Observation] ClinicalDocument/recordTa rget/component/structured Body/component/section[te mponent/section[templateid ryrelationship/observation/ [methodcode= ]/value ClinicalDocument/compo nent/structuredbody/com ponent/section[templatei ]] ClinicalDocument/compone nt/structuredbody/compone = ']]/component/secti ]]/entry/act/entryrelationsh ip/observation[templateid[r oot=' ']] and ]/effectivetime ClinicalDocument/compone nt/structuredbody/compone = ']]/component/secti ]]/entry/act/entryrelationsh ip/observation[templateid[r oot=' ']] and ]/ effectivetime ClinicalDocument/compone nt/structuredbody/compone = ']]/component/secti ]]/entry/act/entryrelationsh ip/observation[templateid[r oot=' ']] and ]/value Birth Defects Implementation Guide APP-134

352 NBDPN ID Data Element Opt Template ID XPATH Mapping Mother's Prepregnancy Weight Maternal Risk Factors Children Now Living (number) Number of Previous Live Births Now Dead (do not include this child) SHALL Can add nullfactor [Pregnancy History Section] [Pregnancy Observation] SHOULD [Pregnancy History Section] [Pregnancy Observation] SHOULD [Pregnancy History Section] [Pregnancy Observation] SHOULD [Pregnancy History Section] [Pregnancy Observation] ClinicalDocument/compone nt/structuredbody/compone = ']]/component/secti ]]/entry/act/entryrelationsh ip/observation[templateid[r oot=' ']] and ]/value ClinicalDocument/compone nt/structuredbody/compone = ']]/component/secti ]]/entry/act/entryrelationsh ip/observation[templateid[r oot=' ']] and ]/value ClinicalDocument/compone nt/structuredbody/compone = ']]/component/secti ]]/entry/act/entryrelationsh ip/observation[templateid[r oot=' ']] and ]/value ClinicalDocument/compone nt/structuredbody/compone = ']]/component/secti ]]/entry/act/entryrelationsh ip/observation[templateid[r oot=' ']] and ]/value Birth Defects Implementation Guide APP-135

353 NBDPN ID Data Element Opt Template ID XPATH Mapping Date of Last Live Birth Date of Last Other Pregnancy Outcome (spontaneous or induced losses or ectopic pregnancies) Date of Last Fetal Death Previous Preterm Births SHOULD [Pregnancy History Section] [Pregnancy Observation] SHOULD [Pregnancy History Section] [Pregnancy Observation] SHOULD [Pregnancy History Section] [Pregnancy Observation] SHOULD [Pregnancy History Section] [Pregnancy Observation] ClinicalDocument/compone nt/structuredbody/compone = ']]/component/secti ]]/entry/act/entryrelationsh ip/observation[templateid[r oot=' ']] and ]/value ClinicalDocument/compone nt/structuredbody/compone = ']]/component/secti ]]/entry/act/entryrelationsh ip/observation[templateid[r oot=' ']] and ]/value ClinicalDocument/compone nt/structuredbody/compone = ']]/component/secti ]]/entry/act/entryrelationsh ip/observation[templateid[r oot=' ']] and TBD ]/value ClinicalDocument/compone nt/structuredbody/compone = ']]/component/secti ]]/entry/act/entryrelationsh ip/observation[templateid[r oot=' ']] and ]/value Birth Defects Implementation Guide APP-136

354 NBDPN ID Data Element Opt Template ID XPATH Mapping Date of Last Menses Poor Pregnancy Outcomes Assisted Method Assisted Reproductive Technology Fertility Enhancing Drugs SHALL [Pregnancy History Section] [Pregnancy Observation] SHOULD [Pregnancy History Section] [Pregnancy Observation] SHALL [Pregnancy History Section] [Pregnancy Observation] SHOULD [Pregnancy History Section] [Pregnancy Observation] SHOULD [Pregnancy History Section] [Pregnancy Observation] ClinicalDocument/compone nt/structuredbody/compone = ']]/component/secti ]]/entry/act/entryrelationsh ip/observation[templateid[r oot=' ] /effectivetime/low ClinicalDocument/compone nt/structuredbody/compone = ']]/component/secti ]]/entry/act/entryrelationsh ip/observation[templateid[r oot=' ']]/code ClinicalDocument/compone nt/structuredbody/compone = ']]/component/secti ]]/entry/act/entryrelationsh ip/observation[templateid[r oot=' ']]/code ClinicalDocument/compone nt/structuredbody/compone = ']]/component/secti ]]/entry/act/entryrelationsh ip/observation[templateid[r oot=' ']]/code ClinicalDocument/compone nt/structuredbody/compone = ']]/component/secti ]]/entry/act/entryrelationsh ip/observation[templateid[r oot=' ']]/code Birth Defects Implementation Guide APP-137

355 NBDPN ID Data Element Opt Template ID XPATH Mapping Obstetric Estimate of Gestation Alcohol Intake (Glasses/Week) SHOULD [Pregnancy History Section] [Pregnancy Observation] SHALL Can add nullfactor [Coded Social History] [Social History Observation] Payers Section SHALL Payer Type SHOULD [Coverage Entry] Medicaid ID Number Name of Insured SHALL [Coverage Entry] SHALL [Coverage Entry] ClinicalDocument/compone nt/structuredbody/compone = ]]/component/section ]]/e ntry/act/entryrelationship/o bservation/code ClinicalDocument/compone nt/structuredbody/compone = ]]/component/section ]]/ component/section[templat ]]/entry/ob ]/value ClinicalDocument/compo nent/structuredbody/com ponent/section[templatei ']] ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/act[template ']]/entryRelati ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/act[template ']]/entryRelati onship/act/code/act/particip COV ]/par PAT ClinicalDocument/compone nt/structurebody/componen ' ']]/entry/act[templateI and ']]/parti e='ind']/playaingentity/nam e/* Birth Defects Implementation Guide APP-138

356 NBDPN ID Data Element Opt Template ID XPATH Mapping Insurance Company [Payor Source] BxDefects Diagnosis Section BxDefect Diagnosis Entry BxDefect Diagnosis Code SHALL [Coverage Entry] ClinicalDocument/compone nt/structurebody/componen ' ']]/entry/act[templateI and ']]/perf ='PAT']/representedOrgani zation/name/* SHALL SECTION OID ClinicalDocument/compo nent/structuredbody/com ponent/section[templatei SECTION OID TBD ']] SHALL Entry OID TBD ClinicalDocument/compone nt/structuredbody/compone ='SECTION OID TBD ]]/entry/act/entryrelati onship/observation[templat OID TBD']] SHALL Entry OID TBD [BxDefect Diagnosis Entry] Diagnosis Date SHALL Entry OID TBD [BxDefect Diagnosis Entry] Diagnostic Confirmation SHOULD Entry OID TBD [BxDefect Diagnosis Entry] ClinicalDocument/compone nt/structuredbody/compone ='SECTION OID TBD ]]/entry/act/entryrelati onship/observation[templat OID ClinicalDocument/compone nt/structuredbody/compone ='SECTION OID TBD']]/entry/act/entryRelati onship/observation[templat Entry OID value ClinicalDocument/compone nt/structuredbody/compone ='SECTION OID TBD']]/entry/act/entryRelati onship/observation[templat OID TBD']]/value/qualifier[name[ Birth Defects Implementation Guide APP-139

357 NBDPN ID Data Element Opt Template ID XPATH Mapping Primary Site SHOULD Entry OID TBD [BxDefect Diagnosis Entry] Active Problems Section SHALL Start and Stop Date of Problem SHALL Problem Code SHALL [Problem Concern Entry] Coded Results Section SHALL Procedure Entry Procedure Type Procedure Date Time SHALL SHALL SHALL Result Value SHALL [Simple Observation] Result Text SHALL [Simple Observation] ClinicalDocument/compone nt/structuredbody/compone ='SECTION OID TBD']]/entry/act/entryRelati onship/observation[templat OID ClinicalDocument/compo nent/structuredbody/com ponent/section[title='acti ve Problems Section'] ClinicalDocument/compone nt/structuredbody/compone nt/section[title='active Problems Section']/entry/act/effective Time ClinicalDocument/compone nt/structuredbody/compone nt/section[title='active Problems Section']/entry/act/entryRel ationship/observation/value ClinicalDocument/compo nent/structuredbody/com ponent/section[templatei ']] ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/procedure ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/procedure/cod ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/procedure/effe ctivetime/* ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/observation/co ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/observation/tex t Birth Defects Implementation Guide APP-140

358 NBDPN ID Data Element Opt Template ID XPATH Mapping Result Date Time SHALL [Simple Observation] Facility SHALL [Simple Observation] Facility ID SHALL [Simple Observation] Procedures Section SHALL Procedure Activity Entry Procedure Type Body Site of Procedure Procedure Date Time SHALL SHOULD SHALL SHALL Medications Section SHALL Medications Entry SHALL [Medications] ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/observation/eff ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/observation/au thor/assignedauthor/repres entedorganization/name ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/observation/au thor/assignedauthor/repres entedorganization/id ClinicalDocument/compo nent/structuredbody/com ponent/section[templatei ']] ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/procedure ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/procedure/cod ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/procedure/targ ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/procedure/effe ctivetime/* ClinicalDocument/compo nent/structuredbody/com ponent/section[templatei ']] ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/substanceAdm inistration Birth Defects Implementation Guide APP-141

359 NBDPN ID Data Element Opt Template ID XPATH Mapping Start Date SHOULD [Medications] Stop Date SHOULD [Medications] Frequency SHALL [Medications] Route SHOULD [Medications] Dose SHOULD [Medications] Site MAY [Medications] Rate SHOULD [Medications] Consumable SHALL Product Entry SHALL ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/substanceAdm inistration/effectivetime[1]/l ow ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/substanceAdm inistration/effectivetime[1]/ high ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/substanceAdm inistration/effectivetime[2]/ ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/substanceAdm ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/substanceAdm ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/substanceAdm inistration/approachsitecod e ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/entry/substanceAdm inistration/ratequantity ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/entry/substanceAdm inistration/consumable ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/entry/substanceAdm inistration/consumable/man ufacturedproduct Birth Defects Implementation Guide APP-142

360 NBDPN ID Data Element Opt Template ID XPATH Mapping Medication Brand Name SHALL [Product Entry] Strength SHOULD [Product Entry] Coded Product Name Medications Administered Section (medications that are administered during the encounter) Medications Entry Medication Start Date Medication Stop Date Administration Timing (Frequency) SHOULD [Product Entry] SHALL SHALL [Medications] SHOULD [Medications] SHOULD [Medications] SHOULD [Medications] ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/substanceAdm inistration/consumable/man ufacturedproduct/manufact uredmaterial/name ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/substanceAdm inistration/consumable/man ufacturedproduct/manufact uredmaterial/code/originalt ext ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/substanceAdm inistration/consumable/man ufacturedproduct/manufact ClinicalDocument/compo nent/structuredbody/com ponent/section[templatei ']] ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/substanceAdm inistration ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/substanceAdm inistration/effectivetime[1]/l ow ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/substanceAdm inistration/effectivetime[1]/ high ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/substanceAdm inistration/effectivetime[2]/ Birth Defects Implementation Guide APP-143

361 NBDPN ID Data Element Opt Template ID XPATH Mapping Route SHOULD [Medications] Dose SHOULD [Medications] Site of Medication Administration MAY [Medications] Rate SHOULD [Medications] Consumable SHALL Product Entry SHALL Product SHALL [Medications] Strength SHOULD [Product Entry] ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/substanceAdm ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/substanceAdm ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/substanceAdm inistration/approachsitecod e ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/entry/substanceAdm inistration/ratequantity ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/entry/substanceAdm inistration/consumable ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/entry/substanceAdm inistration/consumable/man ufacturedproduct ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/entry/substanceAdm inistration/consumable/man ufacturedproduct/manufact uredmaterial/name ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/entry/substanceAdm inistration/consumable/man ufacturedproduct/manufact uredmaterial/code/originalt ext Birth Defects Implementation Guide APP-144

362 NBDPN ID Data Element Opt Template ID XPATH Mapping Code SHOULD [Product Entry] Cytogenetics Section SHALL [GTR Cytogenetics Section] Cytogenetic Analysis Cytogenetic Techniques Specimen Type SHALL SHALL SHALL ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/substanceAdm inistration/consumable/man ufacturedproduct/manufact ClinicalDocument/compone nt/structuredbody/compone =' ']] ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/observation[t ]] and ]/value ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/observation[t ]]/m ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/observation[t ]]/s =" ]]/ specimenrole/specimenpl ayingentity/code/* Karyotype SHALL ClinicalDocument/compone nt/structuredbody/compone =' ']]/entry/observation[t ]]/ entryrelationship/observati ]] and ] /@value Birth Defects Implementation Guide APP-145

363 NBDPN ID Data Element Opt Template ID XPATH Mapping Result SHALL Report as N or A ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/entry/observation[t emplateid[@root= ]]/e ntryrelationship/observatio n/[code@code= TBD ] /@value Care Plan Section SHALL Provider Referred To SHALL [Encounters] ClinicalDocument/compo nent/structuredbody/com ponent/section[templatei d[@root=' ']] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =' ']]/entry/encounter/perf ormer/assignedentity/assig nedperson/name/* Birth Defects Implementation Guide APP-146

364 List of Acronyms Acronym ACOG ACOGAR AD ADXP APGAR ASTM BFDR BL BxDefects CCD CD CDA CDAR CDC CDTHP CGS CIRC CM CNS CONF DSTU ED EHR Acronym Definition American College of Obstetricians and Gynecologists American College of Obstetricians and Gynecologists Antepartum Record Postal Address Address Part Appearance, Pulse, Grimace, Activity, and Respiration American Society for Testing and Materials Birth and Fetal Death Report Boolean Birth Defects Continuity of Care Document Concept Description Clinical Document Architecture Clinical Document Architecture Release Centers for Disease Control and Prevention Common Document Types History and Physical Child Growth Summary Cardiac Imaging Report Content Centimeters Central Nervous System Conformance Draft Standard for Trial Use Encoded Data Electronic Health Record Birth Defects Implementation Guide LOA-1

365 Acronym Acronym Definition FIPS FISH GNIS GTR HBS HIE HIPAA HISP HL7 HP ICU ID IG IHE INT ISCN ISO IVL<TS> LDHP LDR LOINC MBDR MCH MCL MDHHS Federal Information Processing Standard Fluorescence In Situ Hybridization Geographic Names Information System Genetic Testing Report Health Birth Summary Health Information Exchange Health Insurance Portability and Accountability Act Health Information Service Provider Health Level Seven History and Physical Intensive Care Unit Identification Implementation Guide Integrating the Healthcare Enterprise Integer International System for Human Cytogenetic Nomenclature International Organization for Standardization Interval of Time Labor and Delivery History and Physical Labor and Delivery Record Logical Observation Identifiers Names and Codes Michigan Birth Defects Registry Maternal Child Health Michigan Compiled Law Michigan Department of Health and Human Services Birth Defects Implementation Guide LOA-2

366 Acronym MiHIN ML MG NA NAV NCHS NCR NI NICU NPI NUBC OID PCC PCP PHIN PQ RIM QRPH Acronym Definition Michigan Health Information Network Milliliter Milligram Not Applicable Temporarily Unavailable National Center for Health Statistics Neonatal Care Reports No Information Neonatal Intensive Care Unit National Provider Identification Number National Uniform Billing Committee Object Identifier Patient Care Coordiantion Primary Care Provider Public Health Information Network Physical Quantity Reference Information Model Quality, Research, and Public Health R2 Release 2 SNOMED SNOMED CT SOM ST TBD Systematized Nomenclature of Medicine Systematized Nomenclature of Medicine--Clinical Terms State of Michigan String To Be Determined Birth Defects Implementation Guide LOA-3

367 Acronym Acronym Definition TF TS UNK URI URL USGS VADS Technical Framework Time Stamp Unknown Uniform Resource Identifier Uniform Resource Locator United States Geological Survey Vocabulary Access and Distribution System Birth Defects Implementation Guide LOA-4