Michigan Birth Defect Registry Implementation Guide for Ambulatory Healthcare Provider Reporting to Central Birth Defect Registries, HL7 Clinical Document Architecture (CDA)
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
Table of Contents Table of Contents... i List of Figures... iv List of Tables... v Preface...x 1.0 Introduction... 1 1.1 Background... 1 1.2 Legal Mandate for Michigan Birth Defects Reporting... 2 1.2.1 Public Health Code as Amended... 2 1.2.2 Data... 2 1.2.3 Rules... 2 1.3 Purpose... 3 1.4 Audience... 3 1.5 Scope... 3 1.6 Use Case, Scenarios, Diagrams... 3 1.6.1 Scenario... 3 1.6.2 Use Case Overview... 4 1.7 Use of Vocabulary Standards... 7 1.8 HIPAA... 7 1.9 Clinical Document Architecture Release 2 (CDA R2)... 7 2.0 Ambulatory Healthcare Provider Birth Defects Report... 9 2.1 Document Constraints... 9 2.2 Parent Template... 10 2.3 Specification... 10 2.4 Birth Defects Header... 10 2.5 Conventions Used in this Guide... 11 2.5.1 Conformance (Optionality Constraints)... 11 2.6 Cardinality... 12 Birth Defect Registry Implementation Guide
2.7 Null Flavor... 12 2.8 Birth Defects Specification Table... 13 2.9 Organization of Implementation Guide... 21 2.9.1 Conventions... 21 2.9.2 Document Content Module... 21 2.9.3 Sections... 21 2.9.4 Entry Content... 21 2.9.5 Vocabulary and Value Sets... 21 2.10 Vocabulary Conformance... 21 2.11 CDA Header Section Value Sets... 22 2.11.1 Marital Status... 22 2.11.2 Religious Affiliation... 22 2.11.3 Race... 24 2.11.4 Ethinicity... 44 2.11.5 Personal Relation Role Type... 44 2.11.6 Guardian... 47 3.0 Document Level Templates... 48 3.1 U.S. Realm Header... 48 3.2 CDA Header Content Modules... 49 3.3 Participants in Birth Defects Header... 50 3.3.1 Record Target... 50 3.3.2 Patient... 51 3.3.3 Patient Contacts... 52 3.3.4 Information Recipient... 52 3.3.5 Address Constraints... 53 3.3.6 Multiple Races... 54 3.3.7 Provider Referred From... 54 3.3.8 Birthplace... 55 4.0 Section Level Templates... 56 4.1 Birth Defect Diagnosis Section... 56 4.1.1 Birth Defect Diagnosis Entry... 57 4.2 Coded Results Section... 61 4.2.1 Simple Observation Constraints Overview... 62 4.3 Payers Section... 64 4.3.1 Payer Type Vocabularies... 65 4.3.2 Payer Role Codes... 66 ii
4.3.3 Payor Role Code Names... 66 4.4 Cytogenetics Section... 66 4.4.1 Genetic Testing Report... 66 4.4.2 Clinical Genomic Statement Cytogenetics... 67 4.4.3 Associated Observation Cells Analyzed Count... 70 4.4.4 Associated Observation Cells Count... 70 4.4.5 Associated Observation Cells Karyotyped Count... 70 4.4.6 Associated Observation Colonies Count... 71 4.4.7 Associated Observation International System for Human Cytogenetic Nomenclature (ISCN) Band Level... 71 4.4.8 Chromosome Analysis Overall Interpretation... 73 4.5 Labor and Delivery History and Physical... 73 4.5.1 Pregnancy History Section... 74 4.5.2 Social History Section... 101 4.6 Labor and Delivery Events Section... 103 4.6.1 Coded Detailed Physical Examination... 105 4.6.2 Procedures and Interventions... 106 4.6.3 Coded Event Outcomes... 134 4.6.4 Medications Administered... 153 4.7 Newborn Delivery... 167 4.7.1 Newborn Delivery Information Section... 167 4.7.2 Coded Detailed Physical Examination Section... 169 4.7.3 Active Problems... 175 4.7.4 Procedures and Interventions... 179 4.7.5 Medications Administered... 186 4.7.6 Coded Event Outcomes... 192 4.8 Care Plan Section... 200 4.9 Disposition Section... 204 Appendix A Reportable Birth Defect Conditions... 1 Appendix B Value Sets... 4 Appendix C Data Element and CDA Element Relationship Table... 119 List of Acronyms... 1 iii
List of Figures Figure 1-1: Birth Defect Sequence Diagram... 6 Figure 2-1: Birth Defects Header - Subject Type Code... 10 Figure 2-2: Birth Defect Header Participant Code Type... 11 Figure 2-3: nullflavor Examples... 12 Figure 2-4: nullflavor attribute required Example... 13 Figure 2-5: Allowed nullflavors when element is required example... 13 Figure 2-6: nullflavor explicitly disallowed example... 13 Figure 2-7: Ambulatory Healthcare Provider Birth Defect Event Report Document Example... 19 Figure 3-1: Example of a US Realm Header... 49 Figure 3-2: Patient Contacts Example... 52 Figure 3-3: Information Recipient Example... 53 Figure 3-4: Address Example... 54 Figure 3-5: sdtc:racecode Example... 54 Figure 3-6: Provider Referred From Example... 55 Figure 3-7: Birthplace Example... 55 Figure 4-1: Birth Defects Diagnosis Section Example... 57 Figure 4-2: Birth Defects Diagnosis Template Example... 60 Figure 4-3: Coded Results Section Example... 61 Figure 4-4: Figure Simple Observation Example... 64 Figure 4-5: Payers Section Example... 65 Figure 4-6: Genetic Testing Report Example... 67 Figure 4-7: Clinical Genomic Example... 68 Figure 4-8: History of Pregnancies Example... 75 Figure 4-9: Coded Social History Section Example... 101 Figure 4-10: Labor and Delivery Events Section Example... 104 Figure 4-11: Newborn Delivery Section Example... 168 Figure 4-12: Active Problems Section Example... 176 Figure 4-13: Procedures and Interventions Section Example... 179 Figure 4-14: Procedure Entry Example... 179 Figure 4-15: Medications Administered Section Example... 186 Figure 4-16: Care Plan Section Example... 202 Figure 4-17: Encounter Entry Example... 204 Figure 4-18: Disposition Section Example... 205 iv
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... 13 Table 2-2: Marital Status Value Set... 22 Table 2-3: Religious Affiliation Value Set... 22 Table 2-4: Race Value Set... 24 Table 2-5: Ethnicity Value Set... 44 Table 2-6: Personal Relationship Role Type Value Set... 44 Table 2-7: Guardian Value Set... 47 Table 3-1: CDA Header Constraints... 50 Table 3-2: Participants in Birth Defects Header... 50 Table 4-1: Birth Defects Diagnosis Section... 56 Table 4-2: Birth Defects Diagnosis Entry Template... 58 Table 4-3: Coded Results Section... 61 Table 4-4: Simple Observation Constraints Overview... 62 Table 4-5: Payers Section... 64 Table 4-6: Payer Type Vocabularies... 65 Table 4-7: Payor Role Codes... 66 Table 4-8: Role Code Names... 66 Table 4-9: Cytogenetics Procedure Type Codes... 72 Table 4-10: Chromosome Analysis Codes... 73 Table 4-11: Labor and Delivery History and Physical Section... 73 Table 4-12: Pregnancy History Section... 74 Table 4-13: Pregnancy Observation Value Set... 75 Table 4-14: Pregnancy Observation Value Sets... 75 Table 4-15: MCH HBS Date of Last Live Birth Metadata... 77 Table 4-16: MCH HBS Date of Last Live Birth Value Set... 78 Table 4-17: MCH HBS Date of Last Other Pregnancy Outcome Metadata... 78 Table 4-18: MCH HBS Date of Last Other Pregnancy Outcome... 79 Table 4-19: MCH HBS Number of Prior Pregnancies Metadata... 79 Table 4-20: MCH HBS Number of Prior Pregnancies Value Set... 80 Table 4-21: MCH HBS Number of Previous Live Births Now Living Metadata... 80 Table 4-22: MCH HBS Number of Previous Live Births Now Living Value Set... 81 Table 4-23: MCH HBS Number of Previous Live Births Now Dead Metadata... 81 Table 4-24: MCH HBS Number of Previous Live Births Now Dead Value Set... 82 Table 4-25: BFDR Number of Preterm Births Value Set Metadata... 82 v
Table 4-26: BFDR Number of Preterm Births Value Set... 83 Table 4-27: MCH HBS Poor Pregnancy Outcome History Metadata... 84 Table 4-28: MCH HBS Poor Pregnancy Outcome History Value Set... 84 Table 4-29: Maternal Risk Factors Value Set... 85 Table 4-30: MCH HBS First Prenatal Care Visit Metadata... 87 Table 4-31: MCH HBS First Prenatal Care Visit Value Set... 87 Table 4-32: MCH HBS Last Prenatal Care Visit Metadata... 88 Table 4-33: MCH HBS Last Prenatal Care Visit Value Set... 88 Table 4-34: MCH HBS Number of Prenatal Care Visits Metadata... 89 Table 4-35: MCH HBS Number Prenatal Care Visits Value Set... 90 Table 4-36: MCH HBS Pre-Pregnancy Weight Metadata... 90 Table 4-37: MCH HBS Pre-Pregnancy Weight Value Set... 91 Table 4-38: BFDR Date of Last Menses Metadata... 91 Table 4-39: BFDR Date of Last Menses Value Set... 92 Table 4-40: BFDR Infertility Treatment Metadata... 93 Table 4-41: BFDR Infertility Treatment Value Set... 93 Table 4-42: BFDR Assistive Reproductive Technology Metadata... 94 Table 4-43: BFDR Assistive Reproductive Technology Value Set... 95 Table 4-44: BFDR Fertility Enhancing Drugs Metadata... 96 Table 4-45: BFDR Fertility Enhancing Drugs Value Set... 97 Table 4-46: BFDR Obstetric Estimate of Gestation Metadata... 100 Table 4-47: BFDR Obstetric Estimate of Gestation Value Set... 101 Table 4-48: Coded Social History Section... 101 Table 4-49: Coded Social History Observation Value Set... 102 Table 4-50: Labor and Delivery Events Section... 103 Table 4-51: Labor and Delivery Coded Detailed Physical Examination Value Set... 105 Table 4-52: BFDR Mother s Delivery Weight Metadata... 105 Table 4-53: BFDR Mother s Delivery Weight Value Set... 106 Table 4-54: Labor and Delivery Procedures and Interventions Value Sets... 106 Table 4-55: BFDR Unplanned Hysterectomy Metadata... 107 Table 4-56: BFDR Unplanned Hysterectomy Value Set... 108 Table 4-57: BFDR Facility Location OR Metadata... 109 Table 4-58: BFDR Facility Location OR Value Set... 109 Table 4-59: BFDR Delivery Metadata... 110 Table 4-60: BFDR Delivery Value Set... 111 Table 4-61: BFDR Unplanned Operation Metadata... 113 Table 4-62: BFDR Unplanned Operation Value Set... 114 Table 4-63: BFDR Transfusion Whole Blood or Packed Red Blood Metadata... 115 Table 4-64: BFDR Transfusion Whole Blood or Packed Red Blood Value Set... 116 vi
Table 4-65: BFDR Epidural Anesthesia Procedure Metadata... 116 Table 4-66: BFDR Epidural Anesthesia Procedure Value Set... 117 Table 4-67: BFDR Spinal Anesthesia Procedure Metadata... 118 Table 4-68: BFDR Spinal Anesthesia Procedure Value Set... 119 Table 4-69: BFDR Route and Method of Delivery Spontaneous Delivery Metadata... 120 Table 4-70: BFDR Route and Method of Delivery Spontaneous Delivery Value Set... 120 Table 4-71: BFDR Route and Method of Delivery Forceps Metadata... 121 Table 4-72: BFDR Route and Method of Delivery Forceps Value Set... 122 Table 4-73: BFDR Route and Method of Delivery Vacuum Metadata... 123 Table 4-74: BFDR Route and Method of Delivery Vacuum Value Set... 124 Table 4-75: BFDR Route and Method of Delivery Cesarean Metadata... 125 Table 4-76: BFDR Route and Method of Delivery Cesarean Value Set... 126 Table 4-77: BFDR Route and Method of Delivery Trial of Labor Metadata... 127 Table 4-78: BFDR Route and Method of Delivery Trial of Labor Value Set... 127 Table 4-79: BFDR Route and Method of Delivery Scheduled Cesarean Metadata... 128 Table 4-80: BFDR Route and Method of Delivery Scheduled Cesarean Value Set... 128 Table 4-81: BFDR Augmentation of Labor Procedure Metadata... 129 Table 4-82: BFDR Augmentation of Labor Procedure Value Set... 130 Table 4-83: BFDR Induction of Labor Metadata... 130 Table 4-84: BFDR Induction of Labor Value Set... 131 Table 4-85: BFDR Cervical Cerclage Metadata... 132 Table 4-86: BFDR Cervical Cerclage Value Set... 132 Table 4-87: BFDR Tocolysis Metadata... 133 Table 4-88: BFDR Tocolysis Value Set... 134 Table 4-89: Labor and Delivery Coded Event Outcome Value Sets... 134 Table 4-90: MCH HBS Number of Live Births Metadata... 135 Table 4-91: MCH HBS Number of Live Births Value Set... 136 Table 4-92: Pregnancy Outcome Value Set... 136 Table 4-93: BFDR Birth Plurality of Delivery Metadata... 137 Table 4-94: BFDR Birth Plurality of Delivery Value Set... 137 Table 4-95: BFDR Fetal Presentation at Birth- Breech Metadata... 138 Table 4-96: BFDR Fetal Presentation at Birth- Breech Value Set... 138 Table 4-97: BFDR Fetal Presentation at Birth- Cephalic Metadata... 139 Table 4-98: BFDR Fetal Presentation at Birth- Cephalic Value Set... 140 Table 4-99: BFDR Fetal Presentation at Birth- Other Metadata... 141 Table 4-100: BFDR Fetal Presentation at Birth- Other Value Set... 142 Table 4-101: BFDR ICU Care Metadata... 143 Table 4-102: BFDR ICU Care Value Set... 144 Table 4-103: BFDR Third Degree Perineal Laceration Metadata... 144 vii
Table 4-104: BFDR Third Degree Perineal Laceration Value Set... 145 Table 4-105: BFDR Fourth Degree Perineal Laceration Metadata... 145 Table 4-106: BFDR Fourth Degree Perineal Laceration Value Set... 146 Table 4-107: BFDR Ruptured Uterus Metadata... 147 Table 4-108: BFDR Ruptured Uterus Value Set... 147 Table 4-109: Meconium Staining Metadata... 148 Table 4-110: Meconium Staining Value Set... 149 Table 4-111: BFDR Premature Rupture Metadata... 149 Table 4-112: BFDR Premature Rupture Value Set... 150 Table 4-113: Precipitous Labor Metadata... 151 Table 4-114: Precipitous Labor Value Set... 151 Table 4-115: Prolonged Labor Metadata... 152 Table 4-116: Prolonged Labor Value Set... 153 Table 4-117: Labor and Delivery Medications Administered Value Set... 153 Table 4-118: BFDR Antibiotics Metadata... 154 Table 4-119: BFDR Antibiotics Value Set... 155 Table 4-120: BFDR Glucocortico Steroids Metadata... 159 Table 4-121: BFDR Glucocortico Steroids Value Set... 160 Table 4-122: BFDR Augmentation of Labor - Medication Metadata... 161 Table 4-123: BFDR Augmentation of Labor - Medication Value Set... 162 Table 4-124: BFDR Epidural Anesthesia Medication Metadata... 162 Table 4-125: BFDR Epidural Anesthesia Medication Value Set... 163 Table 4-126: BFDR Spinal Anesthesia Medication Metadata... 164 Table 4-127: BFDR Spinal Anesthesia Medication Value Set... 165 Table 4-128: Newborn Delivery Information Section... 167 Table 4-129: Coded Detailed Physical Examination Section... 169 Table 4-130: Newborn Coded Vital Signs Value Set... 170 Table 4-131: MCH HBS Birth Weight Metadata... 170 Table 4-132: MCH HBS Birth Weight Value Set... 171 Table 4-133: MCH HBS Birth Height Metadata... 171 Table 4-134: MCH HBS Birth Height Value Set... 172 Table 4-135: Newborn General Appearance Value Set... 172 Table 4-136: MCH HBS 5 Min Apgar Score Metadata... 173 Table 4-137: MCH HBS 5 Min Apgar Score Value Set... 173 Table 4-138: MCH HBS 10 Min Apgar Score Codes... 174 Table 4-139: MCH HBS 10 Min Apgar Score Value Set... 174 Table 4-140: Active Problems Section... 175 Table 4-141: Newborn Delivery Information Active Problems Value Sets... 176 Table 4-142: MCH HBS Seizure or Serious Neurologic Dysfunction Metadata... 176 viii
Table 4-143: MCH HBS Seizure or Serious Neurologic Dysfunction Value Set... 177 Table 4-144: Procedures and Interventions... 179 Table 4-145: Newborn Delivery Information Procedures and Interventions Value Sets... 180 Table 4-146: MCH HBS Antibiotic Administration Procedure Metadata... 181 Table 4-147: MCH HBS Antibiotic Administration Procedure Value Set... 181 Table 4-148: MCH HBS Karyotype Determination Metadata... 182 Table 4-149: MCH HBS Karyotype Determination Value Set... 183 Table 4-150: MCH HBS Assisted Ventilation Immediately Following Delivery Metadata... 183 Table 4-151: MCH HBS Assisted Ventilation Immediately Following Delivery Value Set... 184 Table 4-152: BFDR Total Time on Ventilator Metadata... 184 Table 4-153: BFDR Total Time on Ventilator Value Set... 185 Table 4-154: Medications Administered Section... 186 Table 4-155: Newborn Delivery Medications Administered Product Value Sets... 187 Table 4-156: BFDR Newborn Receiving Surfactant Replacement Therapy Metadata... 187 Table 4-157: BFDR Newborn Receiving Surfactant Replacement Therapy Value Set... 188 Table 4-158: MCH HBS Intramuscular Medication Administration Route Metadata... 189 Table 4-159: MCH HBS Intramuscular Administration Route Value Set... 189 Table 4-160: BFDR IV Medication Administration Metadata... 190 Table 4-161: BFDR IV Medication Administration Route Value Set... 191 Table 4-162: BFDR Neonatal Sepsis Metadata... 191 Table 4-163: BFDR Neonatal Sepsis Value Set... 192 Table 4-164: Newborn Delivery Information Coded Event Outcome Value Sets... 192 Table 4-165: BFDR NICU Care Codes... 193 Table 4-166: BFDR NICU Care Value Set... 194 Table 4-167: MCH HBS Significant Birth Injury Value Set Metadata... 194 Table 4-168: MCH HBS Significant Birth Injury Value Set... 195 Table 4-169: BFDR Birthplace Value Set Metadata... 197 Table 4-170: BFDR Birthplace Value Set... 198 Table 4-171: Cause of Death Codes Metadata... 199 Table 4-172: Cause of Death Value Set Excerpt... 200 Table 4-173: Care Plan Section... 200 ix
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 laura.rappleye@altarum.org. x
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, 2014. Website: http://www.michigan.gov/mdch/0,4612,7-132-2944_4670---,00.html 1
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 1.2.1 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 5805. 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. 1.2.2 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 1978. 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. 1.2.3 Rules The Michigan Birth Defects reporting rules, R 325.9071-9076, 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
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 325.9072 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 1.6.1 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
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. 1.6.2 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 http://www.cdc.gov/ncbddd/birthdefects/facts.html 4
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
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
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 164.512 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) 333.5717 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
management. The second section is the document body which contains the information from the clinical record. 8
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
2.2 Parent Template The Ambulatory Healthcare Provider Birth Defects Event Report uses the Medical Document template (1.3.6.1.4.1.19376.1.5.3.1.1.1) 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='1.3.6.1.4.1.19376.1.5.3.1.4.15.2'/> <relatedsubject> <code code='mth' codesystem=2.16.840.1.113883.5.111 codesystemname='iherolecode'/> <!-- Mother's Id --> <sdtc:id extension"1234567891123" root="1.2.250.1.213.1.4.1"/> <name/> <administrativegendercode code="m" codesystem="2.16.840.1.113883.5.1" 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
Figure 2-2: Birth Defect Header Participant Code Type <templateid root='1.3.6.1.4.1.19376.1.5.3.1.2.4'/> The <templateid> element identifies this person as a patient contact and must be recorded exactly as shown below. <participant typecode='ind'> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.2.4'/> <associatedentity classcode="prs"> <code code="mth" codesystem='1.3.5.1.4.1.19376.1.5.3.3' displayname='mother'/> <!-- Mother's Id --> <id extension="1234567890121" root="1.2.250.1.213.1.4.1"/> <addr/> <telecom/> <associatedperson> <name/> </associatedperson> </associatedentity> </participant> 2.5 Conventions Used in this Guide 2.5.1 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. 14 13 Health Level Seven International. Retrieved from http://www.hl7.org. January 2014. 14 HL7 Implementation Guide for CDA Release 2: IHE Health Story Consolidation, Release 1; (US Realm) Draft Standard for Trial Use. December 2011. 11
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 /> <!--coding an unknown birthdate--> 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 2011. 12
Figure 2-4: nullflavor attribute required Example 1. SHALL contain exactly one [1..1] code/@code="11450-4" Problem List (CodeSystem: LOINC 2.16.840.1.113883.6.1) or 2. SHALL contain exactly one [1..1] effectivetime/@value 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 1.3.6.1.4.1.19376.1.5.3.1.1.1 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
Conformance (Optionalilty) SHALL [1..1] Template Name Section Template Id Value Set Template Id Header Section 2.16.840.1.113883 General.10.20.3 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 2.16.840.1.113883 HL7.10.20.22.1.1 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
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 1.3.6.1.4.1.19376. 1.4.1.3.1 Guardian 1.3.6.1.4.1.19376. 1.5.3.1.2.4 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: id[2]@extension is the child facility's NPI id[2]@root 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
Conformance (Optionalilty) SHALL [1..1] SHALL [1..1] Template Name Participant Section Template Id Value Set Template Id Active Problems 1.3.6.1.4.1.19376. PCC TF-2 Section 1.5.3.1.3.6 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
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 1.3.6.1.4.1.19376. 1.5.3.1.1.21.2.4 Labor and 1.3.6.1.4.1.19376. Delivery Events 1.5.3.1.1.21.2.3 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 1.3.6.1.4.1.19376. 1.5.3.1.1.21.1.1 Value Set Template Id PCC TF Supplement CDA Content Modules (TI) Vol 2: 6.3.3.2.40 PCC TF Supplement CDA Content Modules (TI) Vol 2: 6.3.3.2.39 Further Constraints applied by Ambulatory Healthcare Provider Birth Defects Event Report Specification 17
Conformance (Optionalilty) SHALL [1..1] SHALL [1..1] SHALL [1..1] Template Name Coded Results Section Section Template Id Value Set Template Id 1.3.6.1.4.1.19376. 1.5.3.1.3.28 PCC TF-2 Procedures 2.16.840.1.113883 CCD 3.1.4 Section.10.20.1.12 Procedures Payers Section 1.3.6.1.4.1.19376. PCC TF-2 1.5.3.1.1.5.3.7 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= 1.3. 6.1.4.1.19376.1.5.3.1. 3.28 ]]/entry/observati on[templateid[@root= 1.3.6.1.4.1.19376.1.5. 3.1.4.13 ]] 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. 1.3.6.1.4.1.19376. 1.5.3.1.3.21 1.3.6.1.4.1.19376. 1.5.3.1.3.19 2.16.840.1.1138 83.10.20.20.1.4 IHE PCC 2:6.3.3.2.10 PCC TF-2 An appropriate distinction of None is permitted. An appropriate distinction of None is permitted. 18
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. 1.3.6.1.4.1.19376. 1.5.3.1.3.31 PCC TF-2 ClinicalDocument/co mponent/structuredb ody/component/secti on[templateid[@root = 1.3.6.1.4.1.19376.1.5.3.1.3.31 ]]//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="2.16.840.1.113883.1.3"/> <!-- OIDS for Medical Document, H&P and BxDefect --> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/> <!-- Medical Document --> <templateid root= 2.16.840.1.113883.10.20.3 /> <!-- CDA Header -- ><templateid root='1.3.6.1.4.1.19376.1.5.3.1.1.21.1.4'/> <!-- BxDefect OID --> <id root=' ' extension=' '/> <code code='xx-bxdefect' displayname='bxdefect Event Report' codesystem='2.16.840.1.113883.6.1' codesystemname='loinc'/> <title> Ambulatory Healthcare Provider Report to BxDefect Registry </title> <effectivetime value='20080601012005'/> <confidentialitycode code='n' displayname='normal' codesystem='2.16.840.1.113883.5.25' codesystemname='confidentiality' /> <languagecode code='en-us'/> <!-- one or more patient --> <recordtarget> <patientrole>.. </patientrole> </recordtarget> <!-- one or more author --> <author>.. </author> <!-- one or more participants --> <participant>.. </ participant > <!-- the organization issuing this report and in charge with its lifecycle --> <custodian>.. </custodian> <! one or more health care providers who referred the patient to this provider for care --> <componentof> <encompassingencounter> <encounterparticipant>..</encounterparticipant> 19
</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='1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4'/> <!-- Required Newborn Delivery Information Section content --> </section> </component> <component> <section> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3'/> <!-- Required if known Labor and Delivery Events Section content --> </section> </component> <component> <section> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.3.21'/> <!-- Required Medications Section content --> </section> </component> <component> <section> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.3.28'/> <!-- Required Coded Results Section content --> </section> </component> <component> <section> <templateid root='2.16.840.1.113883.10.20.20.1.4'/> <!-- Required Cytogenetics Section content --> </section> </component> <component> <section> <templateid root= 1.3.6.1.4.1.19376.1.5.3.1.1.21.1.1 /> <!-- Required Labor and Delivery History and Physical Section content --> </section> </component> <component> <section> <templateid root= 1.3.6.1.4.1.19376.1.5.3.1.3.31 /> <!-- Required Care Plan Section content --> </section> </component> </strucuredbody> </component> </ClinicalDocument> 20
2.9 Organization of Implementation Guide 2.9.1 Conventions Conventions describe the rules adhered to in this specification. 2.9.2 Document Content Module The Document Content Module describes the constraints for the CDA header, body and entry sections. 2.9.3 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. 2.9.4 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. 2.9.5 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. 2.10 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
Names and Codes (LOINC ) and Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT ) vocabularies. 2.11 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. 2.11.1 Marital Status Table 2-2: Marital Status Value Set Value Set HL7 Marital Status ID 2.16.840.1.113883.1.11.12212 Marital Status 2.16.840.1.113883.5.2 Code A D T I L M S P W Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed Print Name 2.11.2 Religious Affiliation Table 2-3: Religious Affiliation Value Set Value Set Code System Description HL7 2.16.840.1.113883.1.11.19185 DYNAMIC Religious Affiliation ID 2.16.840.1.113883.5.1076 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
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
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 2.11.3 Race Table 2-4: Race Value Set Value Set Race 2.16.840.1.113883.1.11.14914 DYNAMIC Code System(s) Race and Ethnicity - CDC 2.16.840.1.113883.6.238 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 http://phinvads.cdc.gov/vads/viewcodesystemconcept.acti on?oid=2.16.840.1.113883.6.238&code=1000-9 Concept Code Concept Name 1006-6 Abenaki 1579-2 Absentee Shawnee 1490-2 Acoma 2126-1 Afghanistani 2060-2 African 2058-6 African American 1994-3 Agdaagux 1212-0 Agua Caliente 1045-4 Agua Caliente Cahuilla 1740-0 Ahtna 1654-3 Ak-Chin 24
Concept Code Concept Name 1993-5 Akhiok 1897-8 Akiachak 1898-6 Akiak 2007-3 Akutan 1187-4 Alabama Coushatta 1194-0 Alabama Creek 1195-7 Alabama Quassarte 1899-4 Alakanuk 1383-9 Alamo Navajo 1744-2 Alanvik 1737-6 Alaska Indian 1735-0 Alaska Native 1739-2 Alaskan Athabascan 1741-8 Alatna 1900-0 Aleknagik 1966-1 Aleut 2008-1 Aleut Corporation 2009-9 Aleutian 2010-7 Aleutian Islander 1742-6 Alexander 1008-2 Algonquian 1743-4 Allakaket 1671-7 Allen Canyon 1688-1 Alpine 1392-0 Alsea 1968-7 Alutiiq Aleut 1845-7 Ambler 1004-1 American Indian 1002-5 American Indian or Alaska Native 1846-5 Anaktuvuk 1847-3 Anaktuvuk Pass 1901-8 Andreafsky 1814-3 Angoon 1902-6 Aniak 1745-9 Anvik 1010-8 Apache 2129-5 Arab 1021-5 Arapaho 1746-7 Arctic 1849-9 Arctic Slope Corporation 1848-1 Arctic Slope Inupiat 1026-4 Arikara 1491-0 Arizona Tewa 2109-7 Armenian 1366-4 Aroostook 2028-9 Asian 2029-7 Asian Indian 25
Concept Code Concept Name 1028-0 Assiniboine 1030-6 Assiniboine Sioux 2119-6 Assyrian 2011-5 Atka 1903-4 Atmautluak 1850-7 Atqasuk 1265-8 Atsina 1234-4 Attacapa 1046-2 Augustine 1124-7 Bad River 2067-7 Bahamian 2030-5 Bangladeshi 1033-0 Bannock 2068-5 Barbadian 1712-9 Barrio Libre 1851-5 Barrow 1587-5 Battle Mountain 1125-4 Bay Mills Chippewa 1747-5 Beaver 2012-3 Belkofski 1852-3 Bering Straits Inupiat 1904-2 Bethel 2031-3 Bhutanese 1567-7 Big Cypress 1905-9 Bill Moore's Slough 1235-1 Biloxi 1748-3 Birch Creek 1417-5 Bishop 2056-0 Black 2054-5 Black or African American 1035-5 Blackfeet 1610-5 Blackfoot Sioux 1126-2 Bois Forte 2061-0 Botswanan 1853-1 Brevig Mission 1418-3 Bridgeport 1568-5 Brighton 1972-9 Bristol Bay Aleut 1906-7 Bristol Bay Yupik 1037-1 Brotherton 1611-3 Brule Sioux 1854-9 Buckland 2032-1 Burmese 1419-1 Burns Paiute 1039-7 Burt Lake Band 1127-0 Burt Lake Chippewa 1412-6 Burt Lake Ottawa 26
Concept Code Concept Name 1047-0 Cabazon 1041-3 Caddo 1054-6 Cahto 1044-7 Cahuilla 1053-8 California Tribes 1907-5 Calista Yupik 2033-9 Cambodian 1223-7 Campo 1068-6 Canadian and Latin American Indian 1069-4 Canadian Indian 1384-7 Canoncito Navajo 1749-1 Cantwell 1224-5 Capitan Grande 2092-5 Carolinian 1689-9 Carson 1076-9 Catawba 1286-4 Cayuga 1078-5 Cayuse 1420-9 Cedarville 1393-8 Celilo 1070-2 Central American Indian 1815-0 Central Council of Tlingit and Haida Tribes 1465-4 Central Pomo 1750-9 Chalkyitsik 2088-3 Chamorro 1908-3 Chefornak 1080-1 Chehalis 1082-7 Chemakuan 1086-8 Chemehuevi 1985-1 Chenega 1088-4 Cherokee 1089-2 Cherokee Alabama 1100-7 Cherokee Shawnee 1090-0 Cherokees of Northeast Alabama 1091-8 Cherokees of Southeast Alabama 1909-1 Chevak 1102-3 Cheyenne 1612-1 Cheyenne River Sioux 1106-4 Cheyenne-Arapaho 1108-0 Chickahominy 1751-7 Chickaloon 1112-2 Chickasaw 1973-7 Chignik 2013-1 Chignik Lagoon 1974-5 Chignik Lake 1816-8 Chilkat 1817-6 Chilkoot 27
Concept Code Concept Name 1055-3 Chimariko 2034-7 Chinese 1855-6 Chinik 1114-8 Chinook 1123-9 Chippewa 1150-2 Chippewa Cree 1011-6 Chiricahua 1752-5 Chistochina 1153-6 Chitimacha 1753-3 Chitina 1155-1 Choctaw 1910-9 Chuathbaluk 1984-4 Chugach Aleut 1986-9 Chugach Corporation 1718-6 Chukchansi 1162-7 Chumash 2097-4 Chuukese 1754-1 Circle 1479-5 Citizen Band Potawatomi 1911-7 Clark's Point 1115-5 Clatsop 1165-0 Clear Lake 1156-9 Clifton Choctaw 1056-1 Coast Miwok 1733-5 Coast Yurok 1492-8 Cochiti 1725-1 Cocopah 1167-6 Coeur D'Alene 1169-2 Coharie 1171-8 Colorado River 1394-6 Columbia 1116-3 Columbia River Chinook 1173-4 Colville 1175-9 Comanche 1755-8 Cook Inlet 1180-9 Coos 1178-3 Coos, Lower Umpqua, Siuslaw 1756-6 Copper Center 1757-4 Copper River 1182-5 Coquilles 1184-1 Costanoan 1856-4 Council 1186-6 Coushatta 1668-3 Cow Creek Umpqua 1189-0 Cowlitz 1818-4 Craig 1191-6 Cree 28
Concept Code Concept Name 1193-2 Creek 1207-0 Croatan 1912-5 Crooked Creek 1209-6 Crow 1613-9 Crow Creek Sioux 1211-2 Cupeno 1225-2 Cuyapaipe 1614-7 Dakota Sioux 1857-2 Deering 1214-6 Delaware 1222-9 Diegueno 1057-9 Digger 1913-3 Dillingham 2070-1 Dominica Islander 2069-3 Dominican 1758-2 Dot Lake 1819-2 Douglas 1759-0 Doyon 1690-7 Dresslerville 1466-2 Dry Creek 1603-0 Duck Valley 1588-3 Duckwater 1519-8 Duwamish 1760-8 Eagle 1092-6 Eastern Cherokee 1109-8 Eastern Chickahominy 1196-5 Eastern Creek 1215-3 Eastern Delaware 1197-3 Eastern Muscogee 1467-0 Eastern Pomo 1580-0 Eastern Shawnee 1233-6 Eastern Tribes 1093-4 Echota Cherokee 1914-1 Eek 1975-2 Egegik 2120-4 Egyptian 1761-6 Eklutna 1915-8 Ekuk 1916-6 Ekwok 1858-0 Elim 1589-1 Elko 1590-9 Ely 1917-4 Emmonak 2110-5 English 1987-7 English Bay 1840-8 Eskimo 1250-0 Esselen 29
Concept Code Concept Name 2062-8 Ethiopian 1094-2 Etowah Cherokee 2108-9 European 1762-4 Evansville 1990-1 Eyak 1604-8 Fallon 2015-6 False Pass 2101-4 Fijian 2036-2 Filipino 1615-4 Flandreau Santee 1569-3 Florida Seminole 1128-8 Fond du Lac 1480-3 Forest County 1252-6 Fort Belknap 1254-2 Fort Berthold 1421-7 Fort Bidwell 1258-3 Fort Hall 1422-5 Fort Independence 1605-5 Fort McDermitt 1256-7 Fort Mcdowell 1616-2 Fort Peck 1031-4 Fort Peck Assiniboine Sioux 1012-4 Fort Sill Apache 1763-2 Fort Yukon 2111-3 French 1071-0 French American Indian 1260-9 Gabrieleno 1764-0 Gakona 1765-7 Galena 1892-9 Gambell 1680-8 Gay Head Wampanoag 1236-9 Georgetown (Eastern Tribes) 1962-0 Georgetown (Yupik-Eskimo) 2112-1 German 1655-0 Gila Bend 1457-1 Gila River Pima-Maricopa 1859-8 Golovin 1918-2 Goodnews Bay 1591-7 Goshute 1129-6 Grand Portage 1262-5 Grand Ronde 1130-4 Grand Traverse Band of Ottawa/Chippewa 1766-5 Grayling 1842-4 Greenland Eskimo 1264-1 Gros Ventres 2087-5 Guamanian 2086-7 Guamanian or Chamorro 30
Concept Code Concept Name 1767-3 Gulkana 1820-0 Haida 2071-9 Haitian 1267-4 Haliwa 1481-1 Hannahville 1726-9 Havasupai 1768-1 Healy Lake 1269-0 Hidatsa 2037-0 Hmong 1697-2 Ho-chunk 1083-5 Hoh 1570-1 Hollywood Seminole 1769-9 Holy Cross 1821-8 Hoonah 1271-6 Hoopa 1275-7 Hoopa Extension 1919-0 Hooper Bay 1493-6 Hopi 1277-3 Houma 1727-7 Hualapai 1770-7 Hughes 1482-9 Huron Potawatomi 1771-5 Huslia 1822-6 Hydaburg 1976-0 Igiugig 1772-3 Iliamna 1359-9 Illinois Miami 1279-9 Inaja-Cosmit 1860-6 Inalik Diomede 1442-3 Indian Township 1360-7 Indiana Miami 2038-8 Indonesian 1861-4 Inupiaq 1844-0 Inupiat Eskimo 1281-5 Iowa 1282-3 Iowa of Kansas-Nebraska 1283-1 Iowa of Oklahoma 1552-9 Iowa Sac and Fox 1920-8 Iqurmuit (Russian Mission) 2121-2 Iranian 2122-0 Iraqi 2113-9 Irish 1285-6 Iroquois 1494-4 Isleta 2127-9 Israeili 2114-7 Italian 1977-8 Ivanof Bay 31
Concept Code 2048-7 Iwo Jiman 2072-7 Jamaican 1313-6 Jamestown 2039-6 Japanese 1495-1 Jemez 1157-7 Jena Choctaw 1013-2 Jicarilla Apache 1297-1 Juaneno 1423-3 Kaibab 1823-4 Kake 1862-2 Kaktovik 1395-3 Kalapuya 1299-7 Kalispel 1921-6 Kalskag 1773-1 Kaltag 1995-0 Karluk 1301-1 Karuk 1824-2 Kasaan 1468-8 Kashia 1922-4 Kasigluk 1117-1 Kathlamet 1303-7 Kaw 1058-7 Kawaiisu 1863-0 Kawerak 1825-9 Kenaitze 1496-9 Keres 1059-5 Kern River 1826-7 Ketchikan 1131-2 Keweenaw 1198-1 Kialegee 1864-8 Kiana 1305-2 Kickapoo 1520-6 Kikiallus 2014-9 King Cove 1978-6 King Salmon 1309-4 Kiowa 1923-2 Kipnuk 2096-6 Kiribati 1865-5 Kivalina 1312-8 Klallam 1317-7 Klamath 1827-5 Klawock 1774-9 Kluti Kaah 1775-6 Knik 1866-3 Kobuk 1996-8 Kodiak 1979-4 Kokhanok Concept Name 32
Concept Code Concept Name 1924-0 Koliganek 1925-7 Kongiganak 1992-7 Koniag Aleut 1319-3 Konkow 1321-9 Kootenai 2040-4 Korean 2093-3 Kosraean 1926-5 Kotlik 1867-1 Kotzebue 1868-9 Koyuk 1776-4 Koyukuk 1927-3 Kwethluk 1928-1 Kwigillingok 1869-7 Kwiguk 1332-6 La Jolla 1226-0 La Posta 1132-0 Lac Courte Oreilles 1133-8 Lac du Flambeau 1134-6 Lac Vieux Desert Chippewa 1497-7 Laguna 1777-2 Lake Minchumina 1135-3 Lake Superior 1617-0 Lake Traverse Sioux 2041-2 Laotian 1997-6 Larsen Bay 1424-1 Las Vegas 1323-5 Lassik 2123-8 Lebanese 1136-1 Leech Lake 1216-1 Lenni-Lenape 1929-9 Levelock 2063-6 Liberian 1778-0 Lime 1014-0 Lipan Apache 1137-9 Little Shell Chippewa 1425-8 Lone Pine 1325-0 Long Island 1048-8 Los Coyotes 1426-6 Lovelock 1618-8 Lower Brule Sioux 1314-4 Lower Elwha 1930-7 Lower Kalskag 1199-9 Lower Muscogee 1619-6 Lower Sioux 1521-4 Lower Skagit 1331-8 Luiseno 1340-9 Lumbee 33
Concept Code Concept Name 1342-5 Lummi 1200-5 Machis Lower Creek Indian 2052-9 Madagascar 1344-1 Maidu 1348-2 Makah 2042-0 Malaysian 2049-5 Maldivian 1427-4 Malheur Paiute 1350-8 Maliseet 1352-4 Mandan 1780-6 Manley Hot Springs 1931-5 Manokotak 1227-8 Manzanita 2089-1 Mariana Islander 1728-5 Maricopa 1932-3 Marshall 2090-9 Marshallese 1454-8 Marshantucket Pequot 1889-5 Mary's Igloo 1681-6 Mashpee Wampanoag 1326-8 Matinecock 1354-0 Mattaponi 1060-3 Mattole 1870-5 Mauneluk Inupiat 1779-8 Mcgrath 1620-4 Mdewakanton Sioux 1933-1 Mekoryuk 2100-6 Melanesian 1356-5 Menominee 1781-4 Mentasta Lake 1228-6 Mesa Grande 1015-7 Mescalero Apache 1838-2 Metlakatla 1072-8 Mexican American Indian 1358-1 Miami 1363-1 Miccosukee 1413-4 Michigan Ottawa 1365-6 Micmac 2085-9 Micronesian 2118-8 Middle Eastern or North African 1138-7 Mille Lacs 1621-2 Miniconjou 1139-5 Minnesota Chippewa 1782-2 Minto 1368-0 Mission Indians 1158-5 Mississippi Choctaw 1553-7 Missouri Sac and Fox 34
Concept Code Concept Name 1370-6 Miwok 1428-2 Moapa 1372-2 Modoc 1729-3 Mohave 1287-2 Mohawk 1374-8 Mohegan 1396-1 Molala 1376-3 Mono 1327-6 Montauk 1237-7 Moor 1049-6 Morongo 1345-8 Mountain Maidu 1934-9 Mountain Village 1159-3 Mowa Band of Choctaw 1522-2 Muckleshoot 1217-9 Munsee 1935-6 Naknek 1498-5 Nambe 2064-4 Namibian 1871-3 Nana Inupiat 1238-5 Nansemond 1378-9 Nanticoke 1937-2 Napakiak 1938-0 Napaskiak 1936-4 Napaumute 1380-5 Narragansett 1239-3 Natchez 2079-2 Native Hawaiian 2076-8 Native Hawaiian or Other Pacific Islander 1240-1 Nausu Waiwash 1382-1 Navajo 1475-3 Nebraska Ponca 1698-0 Nebraska Winnebago 2016-4 Nelson Lagoon 1783-0 Nenana 2050-3 Nepalese 2104-8 New Hebrides 1940-6 New Stuyahok 1939-8 Newhalen 1941-4 Newtok 1387-0 Nez Perce 2065-1 Nigerian 1942-2 Nightmute 1784-8 Nikolai 2017-2 Nikolski 1785-5 Ninilchik 1241-9 Nipmuc 35
Concept Code Concept Name 1346-6 Nishinam 1523-0 Nisqually 1872-1 Noatak 1389-6 Nomalaki 1873-9 Nome 1786-3 Nondalton 1524-8 Nooksack 1874-7 Noorvik 1022-3 Northern Arapaho 1095-9 Northern Cherokee 1103-1 Northern Cheyenne 1429-0 Northern Paiute 1469-6 Northern Pomo 1787-1 Northway 1391-2 Northwest Tribes 1875-4 Nuiqsut 1788-9 Nulato 1943-0 Nunapitchukv 1622-0 Oglala Sioux 2043-8 Okinawan 1016-5 Oklahoma Apache 1042-1 Oklahoma Cado 1160-1 Oklahoma Choctaw 1176-7 Oklahoma Comanche 1218-7 Oklahoma Delaware 1306-0 Oklahoma Kickapoo 1310-2 Oklahoma Kiowa 1361-5 Oklahoma Miami 1414-2 Oklahoma Ottawa 1446-4 Oklahoma Pawnee 1451-4 Oklahoma Peoria 1476-1 Oklahoma Ponca 1554-5 Oklahoma Sac and Fox 1571-9 Oklahoma Seminole 1998-4 Old Harbor 1403-5 Omaha 1288-0 Oneida 1289-8 Onondaga 1140-3 Ontonagon 1405-0 Oregon Athabaskan 1407-6 Osage 1944-8 Oscarville 2500-7 Other Pacific Islander 2131-1 Other Race 1409-2 Otoe-Missouria 1411-8 Ottawa 1999-2 Ouzinkie 36
Concept Code Concept Name 1430-8 Owens Valley 1416-7 Paiute 2044-6 Pakistani 1333-4 Pala 2091-7 Palauan 2124-6 Palestinian 1439-9 Pamunkey 1592-5 Panamint 2102-2 Papua New Guinean 1713-7 Pascua Yaqui 1441-5 Passamaquoddy 1242-7 Paugussett 2018-0 Pauloff Harbor 1334-2 Pauma 1445-6 Pawnee 1017-3 Payson Apache 1335-9 Pechanga 1789-7 Pedro Bay 1828-3 Pelican 1448-0 Penobscot 1450-6 Peoria 1453-0 Pequot 1980-2 Perryville 1829-1 Petersburg 1499-3 Picuris 1981-0 Pilot Point 1945-5 Pilot Station 1456-3 Pima 1623-8 Pine Ridge Sioux 1624-6 Pipestone Sioux 1500-8 Piro 1460-5 Piscataway 1462-1 Pit River 1946-3 Pitkas Point 1947-1 Platinum 1443-1 Pleasant Point Passamaquoddy 1201-3 Poarch Band 1243-5 Pocomoke Acohonock 2094-1 Pohnpeian 1876-2 Point Hope 1877-0 Point Lay 1501-6 Pojoaque 1483-7 Pokagon Potawatomi 2115-4 Polish 2078-4 Polynesian 1464-7 Pomo 1474-6 Ponca 37
Concept Code Concept Name 1328-4 Poospatuck 1315-1 Port Gamble Klallam 1988-5 Port Graham 1982-8 Port Heiden 2000-8 Port Lions 1525-5 Port Madison 1948-9 Portage Creek 1478-7 Potawatomi 1487-8 Powhatan 1484-5 Prairie Band 1625-3 Prairie Island Sioux 1202-1 Principal Creek Indian Nation 1626-1 Prior Lake Sioux 1489-4 Pueblo 1518-0 Puget Sound Salish 1526-3 Puyallup 1431-6 Pyramid Lake 2019-8 Qagan Toyagungin 2020-6 Qawalangin 1541-2 Quapaw 1730-1 Quechan 1084-3 Quileute 1543-8 Quinault 1949-7 Quinhagak 1385-4 Ramah Navajo 1790-5 Rampart 1219-5 Rampough Mountain 1545-3 Rappahannock 1141-1 Red Cliff Chippewa 1950-5 Red Devil 1142-9 Red Lake Chippewa 1061-1 Red Wood 1547-9 Reno-Sparks 1151-0 Rocky Boy's Chippewa Cree 1627-9 Rosebud Sioux 1549-5 Round Valley 1791-3 Ruby 1593-3 Ruby Valley 1551-1 Sac and Fox 1143-7 Saginaw Chippewa 2095-8 Saipanese 1792-1 Salamatof 1556-0 Salinan 1558-6 Salish 1560-2 Salish and Kootenai 1458-9 Salt River Pima-Maricopa 1527-1 Samish 38
Concept Code Concept Name 2080-0 Samoan 1018-1 San Carlos Apache 1502-4 San Felipe 1503-2 San Ildefonso 1506-5 San Juan 1505-7 San Juan De 1504-0 San Juan Pueblo 1432-4 San Juan Southern Paiute 1574-3 San Manual 1229-4 San Pasqual 1656-8 San Xavier 1220-3 Sand Hill 2023-0 Sand Point 1507-3 Sandia 1628-7 Sans Arc Sioux 1508-1 Santa Ana 1509-9 Santa Clara 1062-9 Santa Rosa 1050-4 Santa Rosa Cahuilla 1163-5 Santa Ynez 1230-2 Santa Ysabel 1629-5 Santee Sioux 1510-7 Santo Domingo 1528-9 Sauk-Suiattle 1145-2 Sault Ste. Marie Chippewa 1893-7 Savoonga 1830-9 Saxman 1952-1 Scammon Bay 1562-8 Schaghticoke 1564-4 Scott Valley 2116-2 Scottish 1470-4 Scotts Valley 1878-8 Selawik 1793-9 Seldovia 1657-6 Sells 1566-9 Seminole 1290-6 Seneca 1291-4 Seneca Nation 1292-2 Seneca-Cayuga 1573-5 Serrano 1329-2 Setauket 1795-4 Shageluk 1879-6 Shaktoolik 1576-8 Shasta 1578-4 Shawnee 1953-9 Sheldon's Point 1582-6 Shinnecock 39
Concept Code Concept Name 1880-4 Shishmaref 1584-2 Shoalwater Bay 1586-7 Shoshone 1602-2 Shoshone Paiute 1881-2 Shungnak 1891-1 Siberian Eskimo 1894-5 Siberian Yupik 1607-1 Siletz 2051-1 Singaporean 1609-7 Sioux 1631-1 Sisseton Sioux 1630-3 Sisseton-Wahpeton 1831-7 Sitka 1643-6 Siuslaw 1529-7 Skokomish 1594-1 Skull Valley 1530-5 Skykomish 1794-7 Slana 1954-7 Sleetmute 1531-3 Snohomish 1532-1 Snoqualmie 1336-7 Soboba 1146-0 Sokoagon Chippewa 1882-0 Solomon 2103-0 Solomon Islander 1073-6 South American Indian 1595-8 South Fork Shoshone 2024-8 South Naknek 1811-9 Southeast Alaska 1244-3 Southeastern Indians 1023-1 Southern Arapaho 1104-9 Southern Cheyenne 1433-2 Southern Paiute 1074-4 Spanish American Indian 1632-9 Spirit Lake Sioux 1645-1 Spokane 1533-9 Squaxin Island 2045-3 Sri Lankan 1144-5 St. Croix Chippewa 2021-4 St. George 1963-8 St. Mary's 1951-3 St. Michael 2022-2 St. Paul 1633-7 Standing Rock Sioux 1203-9 Star Clan of Muscogee Creeks 1955-4 Stebbins 1534-7 Steilacoom 40
Concept Code Concept Name 1796-2 Stevens 1647-7 Stewart 1535-4 Stillaguamish 1649-3 Stockbridge 1797-0 Stony River 1471-2 Stonyford 2002-4 Sugpiaq 1472-0 Sulphur Bank 1434-0 Summit Lake 2004-0 Suqpigaq 1536-2 Suquamish 1651-9 Susanville 1245-0 Susquehanock 1537-0 Swinomish 1231-0 Sycuan 2125-3 Syrian 1705-3 Table Bluff 1719-4 Tachi 2081-8 Tahitian 2035-4 Taiwanese 1063-7 Takelma 1798-8 Takotna 1397-9 Talakamish 1799-6 Tanacross 1800-2 Tanaina 1801-0 Tanana 1802-8 Tanana Chiefs 1511-5 Taos 1969-5 Tatitlek 1803-6 Tazlina 1804-4 Telida 1883-8 Teller 1338-3 Temecula 1596-6 Te-Moak Western Shoshone 1832-5 Tenakee Springs 1398-7 Tenino 1512-3 Tesuque 1805-1 Tetlin 1634-5 Teton Sioux 1513-1 Tewa 1307-8 Texas Kickapoo 2046-1 Thai 1204-7 Thlopthlocco 1514-9 Tigua 1399-5 Tillamook 1597-4 Timbi-Sha Shoshone 1833-3 Tlingit 41
Concept Code Concept Name 1813-5 Tlingit-Haida 2073-5 Tobagoan 1956-2 Togiak 1653-5 Tohono O'Odham 1806-9 Tok 2083-4 Tokelauan 1957-0 Toksook 1659-2 Tolowa 1293-0 Tonawanda Seneca 2082-6 Tongan 1661-8 Tonkawa 1051-2 Torres-Martinez 2074-3 Trinidadian 1272-4 Trinity 1837-4 Tsimshian 1205-4 Tuckabachee 1538-8 Tulalip 1720-2 Tule River 1958-8 Tulukskak 1246-8 Tunica Biloxi 1959-6 Tuntutuliak 1960-4 Tununak 1147-8 Turtle Mountain 1294-8 Tuscarora 1096-7 Tuscola 1337-5 Twenty-Nine Palms 1961-2 Twin Hills 1635-2 Two Kettle Sioux 1663-4 Tygh 1807-7 Tyonek 1970-3 Ugashik 1672-5 Uintah Ute 1665-9 Umatilla 1964-6 Umkumiate 1667-5 Umpqua 1884-6 Unalakleet 2025-5 Unalaska 2006-5 Unangan Aleut 2026-3 Unga 1097-5 United Keetowah Band of Cherokee 1118-9 Upper Chinook 1636-0 Upper Sioux 1539-6 Upper Skagit 1670-9 Ute 1673-3 Ute Mountain Ute 1435-7 Utu Utu Gwaitu Paiute 1808-5 Venetie 42
Concept Code Concept Name 2047-9 Vietnamese 1247-6 Waccamaw-Siousan 1637-8 Wahpekute Sioux 1638-6 Wahpeton Sioux 1675-8 Wailaki 1885-3 Wainwright 1119-7 Wakiakum Chinook 1886-1 Wales 1436-5 Walker River 1677-4 Walla-Walla 1679-0 Wampanoag 1064-5 Wappo 1683-2 Warm Springs 1685-7 Wascopum 1598-2 Washakie 1687-3 Washoe 1639-4 Wazhaza Sioux 1400-1 Wenatchee 2075-0 West Indian 1098-3 Western Cherokee 1110-6 Western Chickahominy 1273-2 Whilkut 2106-3 White 1148-6 White Earth 1887-9 White Mountain 1019-9 White Mountain Apache 1888-7 White Mountain Inupiat 1692-3 Wichita 1248-4 Wicomico 1120-5 Willapa Chinook 1694-9 Wind River 1024-9 Wind River Arapaho 1599-0 Wind River Shoshone 1696-4 Winnebago 1700-4 Winnemucca 1702-0 Wintun 1485-2 Wisconsin Potawatomi 1809-3 Wiseman 1121-3 Wishram 1704-6 Wiyot 1834-1 Wrangell 1295-5 Wyandotte 1401-9 Yahooskin 1707-9 Yakama 1709-5 Yakama Cowlitz 1835-8 Yakutat 1065-2 Yana 43
Concept Code 1640-2 Yankton Sioux 1641-0 Yanktonai Sioux 2098-2 Yapese 1711-1 Yaqui 1731-9 Yavapai 1715-2 Yavapai Apache 1437-3 Yerington Paiute 1717-8 Yokuts 1600-6 Yomba 1722-8 Yuchi 1066-0 Yuki 1724-4 Yuman 1896-0 Yupik Eskimo 1732-7 Yurok 2066-9 Zairean 1515-6 Zia 1516-4 Zuni Concept Name 2.11.4 Ethinicity Table 2-5: Ethnicity Value Set Value Set 2.16.840.1.114222.4.11.837 DYNAMIC Code System(s) Race and Ethnicity - CDC 2.16.840.1.113883.6.238 Code Code System Print Name 2135-2 Race and Ethnicity Code Sets Hispanic or Latino 2186-5 Race and Ethnicity Code Sets Not Hispanic or Latino 2.11.5 Personal Relation Role Type Table 2-6: Personal Relationship Role Type Value Set Value Set Personal Relationship Role Type 2.16.840.1.113883.1.11.19563 DYNAMIC Code System(s) RoleCode 2.16.840.1.113883.5.111 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. http://www.hl7.org/memonly/downloads/v3edition.cfm#v32 008 Code FAMMEMB Family member Display Name 44
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
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
2.11.6 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
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 [1..1] @root="2.16.840.1.113883.1.3" o This typeid SHALL contain exactly one [1..1] @extension="pocd_hd000040" SHALL contain exactly one [1..1] templateid such that it o SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.1" 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) (2.16.840.1.113883.10.20.22.5.4) o SHALL contain exactly one [1..1] confidentialitycode, which SHOULD be selected from ValueSet HL7 BasicConfidentialityKind 2.16.840.1.113883.1.11.16926 STATIC 2010-04-21 o SHALL contain exactly one [1..1] languagecode, which SHALL be selected from ValueSet Language 2.16.840.1.113883.1.11.11526 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
Figure 3-1: Example of a US Realm Header <realmcode code="us"/> <typeid root="2.16.840.1.113883.1.3" extension="pocd_hd000040"/> <!-- US General Header Template --> <templateid root="2.16.840.1.113883.10.20.22.1.1"/> <!-- *** Note: The next templateid, code and title will differ depending on what type of document is being sent. *** --> <!-- conforms to the document specific requirements --> <templateid root="2.16.840.1.113883.10.20.22.1.2"/> <id extension="1234" root="2.16.840.1.113883.19.5.99999.1"/> <code codesystem="2.16.840.1.113883.6.1" codesystemname="loinc" code="tbd" displayname="birth Defects Event Report"/> <title> Birth Defects Event Report </title> <effectivetime value="201312150000-0400"/> <confidentialitycode code="n" codesystem="2.16.840.1.113883.5.25"/> <languagecode code="en-us"/> <setid extension="s1234" root="2.16.840.1.113883.19.5.99999.19"/> <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 (1.3.6.1.4.1.19376.1.5.3.1.1.1) and the HL7 General Header Constraints templateid (2.16.840.1.113883.10.20.3). 49
Table 3-1: CDA Header Constraints Realm Constraints Template IDs Required Universal CONF-HP-1 through CONF-HP- 1.3.6.1.4.1.19376.1.5.3.1.1.1 9 CONF-HP-11 through CONF- HP-40 US CONF-HP-1 through CONF-HP- 40 1.3.6.1.4.1.19376.1.5.3.1.1.1 2.16.840.1.113883.10.20.3 3.3 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 3.3.1 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
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) (2.16.840.1.113883.10.20.22.5.2) o This patientrole SHALL contain at least one [1..*] telecom Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet Telecom Use (US Realm Header) 2.16.840.1.113883.11.20.9.20 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) (2.16.840.1.113883.10.20.22.5.1) This patient SHALL contain exactly one [1..1] administrativegendercode, which SHALL be selected from ValueSet Administrative Gender (HL7 V3) 2.16.840.1.113883.1.11.1 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 2.16.840.1.113883.1.11.12212 DYNAMIC This patient MAY contain zero or one [0..1] religiousaffiliationcode, which SHALL be selected from Value Set Religious Affiliation Value Set 2.16.840.1.113883.1.11.19185 DYNAMIC This patient MAY contain zero or one [0..1] racecode, which SHALL be selected from Value Set Race Value Set 2.16.840.1.113883.1.11.14914 DYNAMIC This patient MAY contain zero or one [0..1] ethnicgroupcode, which SHALL be selected from Value Set EthnicityGroup 2.16.840.1.114222.4.11.837 DYNAMIC 51
3.3.3 Patient Contacts Patient Contacts: 1.3.6.1.4.1.19376.1.5.3.1.2.4 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='1.3.6.1.4.1.19376.1.5.3.1.2.4'/> <code code='' displayname='' codesystem='2.16.840.1.113883.5.111' codesystemname='rolecode'/> <addr></addr> <telecom /> <guardianperson> <name></name> </guardianperson> </guardian> 3.3.4 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) (2.16.840.1.113883.10.20.22.5.1.1) This intendedrecipient MAY contain zero or one [0..1] receivedorganization This receivedorganization, if present, SHALL contain exactly one [1..1] name 52
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> 3.3.5 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 with @xsi:type="ivl_ts" 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 [1..1] @use to indicate the purpose of the address, which SHALL be selected from Value Set Postal Address Use 2.16.840.1.113883.1.11.10637 STATIC 2005-05-01 address/city SHALL be selected from Value Set United States Geological Survey (USGS) Geographic Names Information System (GNIS) (Geocodes) 2.16.840.1.114222.4.11.973 address/state SHALL be selected from Value Set FIPS 5-2 2.16.840.1.114222.4.11.830 address/country SHALL be selected from Value Set International Organization for Standardization (ISO) 3166-1 2.16.840.1.114222.4.11.828 53
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="20040815"/> <high value="20090123"/> </useableperiod> </addr> 3.3.6 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 2.16.840.1.114222.4.11.876 DYNAMIC (PHIN VADS link). Figure 3-5: sdtc:racecode Example <sdtc:racecode code=' ' displayname=' ' codesystem=' ' codesystemname=' '/> <sdtc:racecode code=' ' displayname=' ' codesystem=' ' codesystemname=' '/> 3.3.7 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 2.16.840.1.113883.4.6 SHALL contain a typecode= REF 54
Figure 3-6: Provider Referred From Example <componentof> <encompassingencounter xmlns:ihecard= urn:ihe:card > <templateid root= 1.3.6.1.4.1.19376.1.4.1.3.1 /> <effectivetime value= 20110407 /> <responsibleparty> </responsibleparty> <encounterparticipant typecode= REF > <assignedentity> <id root= 2.16.840.1.113883.4.6 extension= /> <code code= codesystem= 2.16.840.1.113883.6.101 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> 3.3.8 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
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 1.3.6.1.4.1.19376.1.5.3.1.3.6 Parent ID PCC Active Problem Section CCD 3.5 (2.16.840.1.113883.10.20.1.11) 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 1.3.6.1.4.1.19376.1.5.3.1. SHALL Problem Concern Entry 4.5.2 Entry OID TBD SHALL Birth Defect Diagnosis Entry SPECIFICATION SHALL contain exactly three [3..3] templateid such that it o SHALL contain exactly one [1..1] @root="bxdefects Section TBD OID" o SHALL conform to PCC Active Problem Section template and contain exactly one [1..1] @root="1.3.6.1.4.1.19376.1.5.3.1.3.6" o SHALL conform to CCD Problem Section template and contain exactly one [1..1] @root="2.16.840.1.113883.10.20.1.11" SHALL contain exactly one [1..1] code/@code="11450-7" BxDefect Diagnosis (CodeSystem: LOINC 2.16.840.1.113883.6.1) SHALL contain exactly one [1..1] title SHALL contain exactly one [1..1] text SHALL contain exactly one [1..1] Problem Concern Entry (1.3.6.1.4.1.19376.1.5.3.1.4.5.2) such that it o SHALL contain at least one [1..*] entryrelationship This entryrelationship SHALL contain exactly one [1..1] @typecode="subj" This entryrelationship SHALL contain exactly one [1..1] @inversionind="false" This entryrelationship SHALL contain one or more [1..*] Birth Defect Diagnosis Entry(TBD Entry OID) 56
Figure 4-1: Birth Defects Diagnosis Section Example <component> <section> <templateid root="2.16.840.1.113883.10.20.1.11"/> <templateid root="1.3.6.1.4.1.19376.1.5.3.1.3.6"/> <templateid root="tbd"/> <id root=' ' extension=' '/> <title>birth Defect Diagnosis</title> <code code=' 11450-7' displayname='problem List' codesystem='2.16.840.1.113883.6.1' codesystemname='loinc'/> <text> Text as described above </text> <entry> <act classcode='act' moodcode='evn'> <templateid root='2.16.840.1.113883.10.20.1.27'/> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.4.5.2'/> <code nullflavor='na'/> <statuscode code='active'/> <effectivetime> <low value='20110101'/> <high nullflavor="na" /> </effectivetime> <entryrelationship typecode="subj" inversionind="false" > <!-- Required BxDefects Diagnosis Entry element --> <templateid root='tbd'/> </entryrelationship> </act> </entry> </section> </component> 4.1.1 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 1.3.6.1.4.1.19376.1.5.3.1.4.5.2 Note The BxDefect Diagnosis Entry is contained within the Problem Concern Entry (1.3.6.1.4.1.19376.1.5.3.1.4.5.2), therefore, the Constraints Overview and Specification begin at the level of the entry relationship of the BxDefect Diagnosis Entry. 57
Table 4-2: Birth Defects Diagnosis Entry Template Name XPath Card Verb Data Type Fixed Value observation[templateid/@root = 'TBD OID'] @class Code 1..1 SHALL 2.16.840.1.113883.5.6 (HL7ActClass) = OBS @mood Code 1..1 SHALL 2.16.840.1.113883.5.1001 (ActMood) = EVN templat 3..3 SHALL SET<II> eid @root 1..1 SHALL TBD OID @root 1..1 SHALL 1.3.6.1.4.1.19376.1.5.3.1.4.5 @root 1..1 SHALL 2.16.840.1.113883.10.20.1.28 Code 1..1 SHALL CD 2.16.840.1.113883.6.96 (SNOMED CT) = 282291009 statusc ode 1..1 SHALL CS 2.16.840.1.113883.5.14 (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 2.16.840.1.113883.6.1 (LOINC) = 21861-0 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 2.16.840.1.113883.6.103 (International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), Volume 1 & 2) CDC NCHS Website Link OR 2.16.840.1.113883.6.90 International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) CDC NCHS Website link OR 2.16.840.1.113883.3.88.12.3221.8.9 Body Site (SNOMED CT) PHIN VADS link SPECIFICATION SHALL contain exactly one [1..1] @classcode="obs" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) 58
SHALL contain exactly one [1..1] @moodcode="evn" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) SHALL contain exactly three [3..3] templateid such that it o SHALL contain exactly one [1..1] @root="tbd OID" o SHALL conform to IHE Problem Entry template and contain exactly one [1..1]@root="1.3.6.1.4.1.19376.1.5.3.1.4.5" o SHALL conform to CCD Problem Observation template and contain exactly one [1..1]@root="2.16.840.1.113883.10.20.1.28" SHALL contain exactly one [1..1] code="282291009" Diagnosis (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) SHALL contain exactly one [1..1] statuscode="completed" Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14) SHALL contain exactly on [1..1] value (CodeSystem: SNOMED CT 2.16.840.1.113883.6.96) 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="21861-0" Dx confirmed by (CodeSystem: LOINC 2.16.840.1.113883.6.1) o This qualifier SHALL contain exactly one [1..1] value with @xsi:type="cd" 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 4.3.5.1) SHOULD contain exactly one [1..1] targetsitecode with @xsi:type= CD to indicate the anatomic location where the primary defect is present o The targetsitecode SHALL contain exactly one [1..1] @code, where the @code SHALL be selected from one of the following: Code System International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9- CM)Volume 1 & 2 2.16.840.1.113883.6.103 DYNAMIC 59
Code System International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) 2.16.840.1.113883.6.90 DYNAMIC Value Set Body Site (SNOMED CT) 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC Figure 4-2: Birth Defects Diagnosis Template Example <section> <templateid root="2.16.840.1.113883.10.20.1.11"/> <templateid root="1.3.6.1.4.1.19376.1.5.3.1.3.6"/> <templateid root="tbd"/> <title>birth Defect Diagnosis</title> <text></text> <entry> <act classcode='act' moodcode='evn'> <templateid root='2.16.840.1.113883.10.20.1.27'/> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.4.5.2'/> <code nullflavor='na'/> <statuscode code='active'/> <effectivetime> <low value='20110101'/> <high nullflavor="na" /> </effectivetime> <entryrelationship typecode="subj" inversionind="false" > <observation classcode='obs' moodcode='evn' negationind="false"> <templateid root='2.16.840.1.113883.10.20.1.28'/> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/> <templateid root="tbd"/> <code code="282291009" codesystem="2.16.840.1.113883.6.96" codesystemname="snomed CT" displayname="diagnosis"/> <text> <reference value="" ></reference> </text> <statuscode code="completed"/> <effectivetime> <low value="20110101"/> <high nullflavor="ni"/> </effectivetime> <!--The <value> is the condition that was found.--> <value xsi:type="cd" code="" codesystem="" codesystemname="" displayname="" > <qualifier> <!--Best Method of Diagnosis Qualifier--> <name code="21861-0" codesystem="2.16.840.1.113883.6.1" codesystemname="loinc" displayname="diagnostic Confirmation"/> <value xsi:type="cd" code="" codesystem="" codesystemname="" displayname=""/> </qualifier> </value> <!--Primary Site --> <targetsitecode code="" codesystem="" codesystemname="" displayname="" /> </entryrelationship> </act> </entry> </section> 60
4.2 Coded Results Section Table 4-3: Coded Results Section Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.28 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 30954-2 SHALL Relevant diagnostic tests/laboratory data Entries Opt Description 1.3.6.1.4.1.19376.1.5.3.1.4.19 SHALL Procedure Entry 1.3.6.1.4.1.19376.1.5.3.1.4.4 SHOULD References Entry 1.3.6.1.4.1.19376.1.5.3.1.4.13 MAY Simple Observation SPECIFICATION SHALL contain exactly one [1..1] templateid such that it o SHALL contain exactly one [1..1] @root="1.3.6.1.4.1.19376.1.5.3.1.3.28" SHALL contain exactly one [1..1] code/@code="30954-2" Relevant diagnostic tests and/or laboratory data (CodeSystem: LOINC 2.16.840.1.113883.6.1) 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 (1.3.6.1.4.1.19376.1.5.3.1.4.19) o SHOULD contain at least one [1..*] References Entry (1.3.6.1.4.1.19376.1.5.3.1.4.4) o MAY contain at least one [1..*] Simple Observation Entry (1.3.6.1.4.1.19376.1.5.3.1.4.13) 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='1.3.6.1.4.1.19376.1.5.3.1.3.28'/> <id root=' ' extension=' '/> <code code='30954-2' displayname='relevant diagnostic tests/laboratory data' codesystem='2.16.840.1.113883.6.1' codesystemname='loinc'/> <text> 61
Text as described above </text> <entry> : <!-- Required Procedure Entry element --> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/> : </entry> <entry> : <!-- Required if known References Entry element --> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/> : </entry> <entry> : <!-- Required Simple Observation element --> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> : </entry> </section> </component> 4.2.1 Simple Observation Constraints Overview Simple Observations: 1.3.6.1.4.1.19376.1.5.3.1.4.13 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 = '1.3.6.1.4.1.19376.1.5.3.1.4.13'] Name XPath Card. Verb Data Type Fixed Value @class Code 1..1 SHALL 2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moo dcode 1..1 SHALL 2.16.840.1.113883.5.1 001 (ActMood) = EVN templat 1..1 SHALL SET<II> eid @root 1..1 SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.13 id 1..* SHALL II code 1..1 SHALL CD text 1..* SHALL ED referen ce 1..* SHALL 62
Name XPath Card. Verb Data Type Fixed Value /@valu 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 2.16.840.1.113883.5.1 4 (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 2.16.840.1.113883.5.1 10 (HL7RoleClass) =ASSIGNED id 1..1 SHALL II SHALL contain exactly one [1..1] @classcode="obs" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) SHALL contain exactly one [1..1] @moodcode="evn" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001) SHALL contain exactly one [1..1] templateid @root="1.3.6.1.4.1.19376.1.5.3.1.4.13" 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) 2.16.840.1.114222.4.11.1002 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 4.3.5.1) SHALL contain exactly one [1..1] statuscode="completed" (CodeSystem: ActStatus 2.16.840.1.113883.5.14) SHALL contain exactly one [1..1] effectivetime o SHOULD be precise to the day SHALL contain exactly one [1..1] value with @xsi:type="any" MAY contain zero or more [0..*] interpretationcode MAY contain zero or one [0..1] methodcode. 63
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 [1..1] @classcode="assigned" (CodeSystem: HL7 roleclass 2.16.840.1.113883.5.110) 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='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='' extension=''/> <code code='' displayname='' codesystem='' codesystemname=''/> <!-- for CDA --> <text><reference value='#xxx'/></text> <!-- For HL7 Version 3 Messages <text>text</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><!-- for CDA --> </author> </observation> 4.3 Payers Section Table 4-5: Payers Section Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7 Parent Template CCD 3.1 (2.16.840.1.113883.10.20.1.9) 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 48768-6 SHALL Payment Sources Entries Opt Description 1.3.6.1.4.1.19376.1.5.3.1.4.17 SHOULD Coverage Entry SPECIFICATION 64
SHALL contain exactly two [2..2] templateid such that it o SHALL contain exactly one [1..1] @root="1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7" o SHALL conform to CCD Payers Section and contain exactly one [1..1] @root="2.16.840.1.113883.10.20.1.9" SHALL contain exactly one [1..1] code/@code="48768-6" Payers (CodeSystem: LOINC 2.16.840.1.113883.6.1) 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 (1.3.6.1.4.1.19376.1.5.3.1.4.17) Figure 4-5: Payers Section Example <component> <section> <templateid root='2.16.840.1.113883.10.20.1.9'/> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7'/> <id root=' ' extension=' '/> <code code='48768-6' displayname='payment SOURCES' codesystem='2.16.840.1.113883.6.1' codesystemname='loinc'/> <text> Text as described above </text> <entry> : <!-- Required if known Coverage Entry element --> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.4.17'/> : </entry> </section> </component> 4.3.1 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. 2.16.840.1.113883.5.4 2.16.840.1.113883.6.255.1336 65
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 4.3.3 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 2.16.840.1.113883.5.111 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 4.4.1 Genetic Testing Report LOINC - 55228-1 [Section: templateid 2.16.840.1.113883.10.20.20.1.4] 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: 2.16.840.1.113883.10.20.20.1.8) SHALL contain [1..1] code/@code = "TBD" Cytogenetics Section (CodeSystem: 2.16.840.1.113883.6.1 LOINC STATIC 2.26) (CONF- GTR-25) SHALL contain [1..1] title = "Cytogenetics" (CONF-GTR-26) SHOULD contain [0..*] entry, such that it o Has @typecode="comp" COMP (component) o Contains GTR Clinical Genomic Statement Cytogenetics (templateid: 2.16.840.1.113883.10.20.20.2.2) 66
Figure 4-6: Genetic Testing Report Example <component> <section> <templateid root="2.16.840.1.113883.10.20.20.1.8" assigningauthorityname="gtr Test Details Section"/> <templateid root="2.16.840.1.113883.10.20.20.1.4" assigningauthorityname="gtr Cytogenetics Section"/> <code code="tbd" codesystem="2.16.840.1.113883.6.1" codesystemname="loinc" displayname="cytogenetics Section"/> <title>cytogenetics Section</title> <entry> <observation classcode="obs" moodcode="evn"> <templateid root="2.16.840.1.113883.10.20.20.2.1" assigningauthorityname="gtr Clinical Genomic Statement"/> <templateid root="2.16.840.1.113883.10.20.20.2.2" assigningauthorityname="gtr Clinical Genomic Statement Cytogenetics"/> <code/> <methodcode/> </observation> </entry> </section> </component> 4.4.2 Clinical Genomic Statement Cytogenetics The following section is used to display information related to clinical chromosomal analysis related to chromosomal analysis. Observation: template Id 2.16.840.1.113883.10.20.20.2.2 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:2.16.840.1.113883.10.20.20.2) SHALL contain [1..1] code/@code = "62356-1" Chromosome analysis result in ISCN expression in Blood or Tissue by Molecular genetics method (CodeSystem: 2.16.840.1.113883.6.1 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: 2.16.840.1.113883.10.20.20.2.5.1) SHOULD contain [0..1] entryrelationship, such that it o contains GTR Cytogenetics Associated Observation Cells Analyzed Count (templateid: 2.16.840.1.113883.10.20.20.2.2.1) SHOULD contain [0..1] entryrelationship, such that it 67
o contains GTR Cytogenetics Associated Observation Cells Count (templateid: 2.16.840.1.113883.10.20.20.2.2.2) o SHOULD contain [0..1] entryrelationship, such that it o contains GTR Cytogenetics Associated Observation Cells Karyotyped Count (templateid: 2.16.840.1.113883.10.20.20.2.2.3) SHOULD contain [0..1] entryrelationship, such that it o contains GTR Cytogenetics Associated Observation Colonies Count (templateid: 2.16.840.1.113883.10.20.20.2.2.4) SHOULD contain [0..1] entryrelationship, such that it o contains GTR Cytogenetics Associated Observation ISCN Band Level (templateid 2.16.840.1.113883.10.20.20.2.2.5) 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="http://www.w3.org/2001/xmlschema-instance" xmlns="urn:hl7-org:v3" xsi:schemalocation="urn:hl7-org:v3 CDA.xsd" classcode="obs" moodcode="evn"> <templateid root="2.16.840.1.113883.10.20.20.2.2"/> <id root="2.16.840.1.113883.18.12.7.30.9.8.1"/> <code code="62356-1" codesystemname="loinc" displayname="chromosome analysis result in ISCN expression"/> <statuscode code="completed"/> <effectivetime value="200811081213"/> <value xsi:type="cd" code="47,xy,+21" codesystemname="iscn"/> <methodcode code="la14013-9" codesystemname="loinc" displayname="g-banding"/ > <subject> <relatedsubject classcode="prs"> <code displayname="placenta"/> </relatedsubject> </subject> <specimen> <templateid root="2.16.840.1.113883.10.20.20.3.1"/> <specimenrole> <specimenplayingentity> <code code="2049008" codesystemname="snomed" displayname="chorionic villi structure"> <originaltext>placental tissue - Villi</originalText> </code> </specimenplayingentity> </specimenrole> </specimen> <performer typecode="prf"> <templateid root="2.16.840.1.113883.10.20.20.3.5"/> <assignedentity> <id root="2.16.840.1.113883.18.12.7.30.9.2.9"/> <representedorganization> <name>the University of Utah Cytogenetics Program at ARUP Laboratories </name> 68
</representedorganization> </assignedentity> </performer> <entryrelationship typecode="subj"> <observation classcode="obs" moodcode="evn"> <templateid root="2.16.840.1.113883.10.20.20.3.2"/> <code code="48002-0" 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="2.16.840.1.113883.10.20.20.2.2.2"/> <code code="62361-1" 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="2.16.840.1.113883.10.20.20.2.2.4"/> <code nullflavor="na" code="62362-9" 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="2.16.840.1.113883.10.20.20.2.2.1"/> <code code="62360-3" 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="2.16.840.1.113883.10.20.20.2.2.3"/> <code code="55199-4" 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="62358-7" codesystemname="loinc" displayname="iscn band level"/> <value xsi:type="cd" code="la14112-9" codesystemname="loinc" displayname="425"/> </observation> </entryrelationship> <entryrelationship typecode="rson"> <observation classcode="obs" moodcode="evn"> <id root="2.16.840.1.113883.18.12.7.30.9.2.1"/> <code/> </observation> </entryrelationship> <entryrelationship typecode="sprt"> <observation classcode="obs" moodcode="def"> <code code="tbd" codesystemname="loinc" displayname="chromosome analysis result interpretation"/> 69
<statuscode code="completed"/> <effectivetime value="201070201410"/> <value xsi:type="cd" code="la12748-2" displayname="abnormal"/> </observation> </entryrelationship> </observation> 4.4.3 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 2.16.840.1.113883.10.20.20.2.2.1 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: 2.16.840.1.113883.10.20.20.4) MAY contain [1..1] code/@code = "62360-3" Cells analyzed [#] in Blood or Tissue by Molecular genetics method (CodeSystem: 2.16.840.1.113883.6.1 LOINC STATIC 2.26) MAY contain [0..1] value, where its data type is INT. 4.4.4 Associated Observation Cells Count Observation: template Id 2.16.840.1.113883.10.20.20.2.2.2 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: 2.16.840.1.113883.10.20.20.4) MAY contain [1..1] code/@code = "62361-1" Cells counted [#] in Blood or Tissue by Molecular genetics method (CodeSystem: 2.16.840.1.113883.6.1 LOINC STATIC 2.26) SHALL contain [0..1] value, where its data type is INT 4.4.5 Associated Observation Cells Karyotyped Count Observation: template Id 2.16.840.1.113883.10.20.20.2.2.3 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
cells karyotyped in a cytogenetics test. SHALL conform to GTR Genomic Associated Observation template (templateid: 2.16.840.1.113883.10.20.20.4) MAY contain [1..1] code/@code = "55199-4" Cells karyotyped.total [#] in Blood (CodeSystem: 2.16.840.1.113883.6.1 LOINC STATIC 2.26) SHALL contain [0..1] value, where its data type is INT 4.4.6 Associated Observation Colonies Count Observation: template Id 2.16.840.1.113883.10.20.20.2.2.4 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: 2.16.840.1.113883.10.20.20.4) MAY contain [1..1] code/@code = "62362-9" Colonies counted [#] in Blood or Tissue by Molecular genetics method (CodeSystem: 2.16.840.1.113883.6.1 LOINC STATIC 2.26) SHALL contain [0..1] value, where its data type is INT 4.4.7 Associated Observation International System for Human Cytogenetic Nomenclature (ISCN) Band Level Observation: template Id 2.16.840.1.113883.10.20.20.2.2.5 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: 2.16.840.1.113883.10.20.20.4) MAY contain [1..1] code/@code = "62358-7" ISCN band level (CodeSystem: 2.16.840.1.113883.6.1 LOINC STATIC 2.26) MAY contain [0..1] value, which MAY be selected from ValueSet 2.16.840.1.113883.10.20.20.9.13 ISCN band level STATIC, where its data type is CD SHALL satisfy: GTR ClinicalGenomicStatementCytogeneticsISCNBandLevel (self) SHALL satisfy: If self.code@code=62358-7 (LOINC code for ISCN band level), then self.value@code SHALL be drawn from the LOINC Value Set 71
Table 4-9: Cytogenetics Procedure Type Codes LOINC Component 35292-2 Chromosome 11 uniparental disomy 21770-3 Chromosome 12 trisomy 35123-9 Chromosome 14 uniparental disomy 34503-3 Chromosome 15 uniparental disomy 43306-0 Chromosome 21 trisomy 21771-1 Chromosome 21 trisomy 21772-9 Chromosome 7 trisomy 34496-0 Chromosome 7 uniparental disomy 36907-4 Chromosome 8 trisomy 21773-7 Chromosome 8 trisomy 21774-5 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
4.4.8 Chromosome Analysis Overall Interpretation Value Set Chromosome analysis overall interpretation 2.16.840.1.113883.10.20.20.9.3 Code System: LOINC 2.16.840.1.113883.6.1 Table 4-10: Chromosome Analysis Codes Concept Name Concept Code Code System Normal LA6626-1 LOINC Abnormal LA12748-2 LOINC Clinical significance unknown LA14007-1 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 1.3.6.1.4.1.19376.1.5.3.1.1.21.1.1 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 57074-7 SHALL Labor and delivery process 73
Subsections Opt Description Pregnancy History SHALL 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 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 1.3.6.1.4.1.19376.1.5.3.1.3.16.1 4.5.1 Pregnancy History Section Table 4-12: Pregnancy History Section Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 General Description The pregnancy history section contains coded entries describing the patient history of pregnancies. LOINC Code Opt Description 10162-6 SHALL History of Pregnancies Entries Opt Description 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 SHALL Pregnancy Observation ClinicalDocument/recordTarget/component/st ructuredbody/component/section[templateid[ @root=1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4]]/co mponent/section[templateid[@root=1.3.6.1.4. 1.19376.1.5.3.1.4.13.5]]/entry/act/entryRelati onship/observation/code AND ClinicalDocument/recordTarget/component/st ructuredbody/component/section[templateid[ @root=1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4]]/co mponent/section[templateid[@root=1.3.6.1.4. 1.19376.1.5.3.1.4.13.5]]/entry/act/entryRelati onship/observation/value 74
Figure 4-8: History of Pregnancies Example <component> <section> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/> <id root=' ' extension=' '/> <code code='10162-6' displayname='history OF PREGNANCIES' codesystem='2.16.840.1.113883.6.1' codesystemname='loinc'/> <text> Text as described above </text> <entry> <!-- Required Pregnancy Observation element --> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5'/> </entry> </section> </component> 4.5.1.1 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 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Pregnancy Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 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 68499-3 NA MCH HBS Date of Last Live Birth Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.67 TS 68500-8 NA MCH HBS Date of Last Other Pregnancy Outcome Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.70 INT NA MCH HBS Number of Prior Pregnancies Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.71 75
Data Element Type Code Value Sets OID Children Now Living (number) INT 11638-4 NA MCH HBS Number of Previous Live Births Now Living Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.12 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 68496-9 MCH HBS Number of Previous Live Births Now Dead Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.12 2 INT 11637-6 BFDR Number of Preterm Births Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.18 7 CD NA MCH HBS Poor Pregnancy Outcome History Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.14 2 TS TBD Date of Last Fetal Death Value Set TBD OID CD 32399-8 Maternal Risk Factors Value Set TBD OID TS 69044-6 MCH HBS First Prenatal Care Visit Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.13 3 TS 68492-8 MCH HBS Last Prenatal Care Visit Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.13 4 INT 68493-6 MCH HBS Number Prenatal Care Visits Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.13 5 PQ 8348-5 MCH HBS Pre-Pregnancy Weight Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.11 8 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.69 BFDR Infertility Treatment Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.14 3 BFDR Assistive Reproductive Technology Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.14 6 76
Data Element Type Code Value Sets OID Fertility Enhancing Drugs CD 18303800 0 BFDR Fertility Enhancing Drugs Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.14 Obstetric Estimate of Gestation 4 BFDR Obstetric Estimate of Gestation Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.12 4 4.5.1.2 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.67 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 http://loinc.org 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
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 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.67 Value Set Description To Reflect the Date of Last Live Birth LOINC Code Vocabulary 2.16.840.1.113883.6.1 68499-3 Date last live birth LOINC Description 4.5.1.3 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.70 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 http://loinc.org 78
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 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.70 Value Set Description To Reflect the Date of Last Other Pregnancy Outcome Vocabulary OID 2.16.840.1.113883.6.1 LOINC Code LOINC Description Pending Pending 4.5.1.4 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.71 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 http://loinc.org 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
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 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.3.28 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.71 Value Set Code PHVS_NumberOfPriorPregnancies_NCHS Value Set Description To Reflect the Number of Prior Pregnancies Vocabulary OID 2.16.840.1.113883.6.1 LOINC Code LOINC Description 11996-6 Pregnancies 11977-6 Parity 4.5.1.5 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 1.3.6.1.4.1.19376.1.7.3.1.1.1 3.8.123 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 http://loinc.org 80
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 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.123 Value Set Code PHVS_NoOfPreviousLiveBirthsNowLiving_NCHS Value Set Description To Reflect the Previous Other Pregnancy Outcomes LOINC Code Vocabulary 2.16.840.1.113883.6.1 11638-4 Births still living LOINC Description 4.5.1.6 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8. 122 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
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 http://loinc.org 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 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.122 Value Set Description To Reflect the Previous Other Pregnancy Outcomes Vocabulary 2.16.840.1.113883.6.1 Code System Name LOINC LOINC Code LOINC Description 68496-9 Live births.now dead 4.5.1.7 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 1.3.6.1.4.1.19376.1.7.3.1.1.1 value set 3.8.187 82
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 http://loinc.org 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 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.187 Value Set Description To reflect the number of preterm births in prior pregnancies Vocabulary OID 2.16.840.1.113883.6.1 LOINC Code 11637-6 Births Preterm (reported) LOINC Description 83
4.5.1.8 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.1 42 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 http://www.nlm.nih.gov/research/u 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 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.142 84
Value Set Code PHVS_PoorPregnancyOutcomeHistory_NCHS Value Set Description To reflect Risk Factors of Pregnancy Outcome of Perinatal Death History SNOMED Code Vocabulary 2.16.840.1.113883.6.96 SNOMED Description 169583006 Antenatal care: history of perinatal death (situation) 169582001 Antenatal care: history of stillbirth (situation) 169585004 Antenatal care: history of trophoblastic disease (situation) 169584000 Antenatal care: poor obstetric history (situation) 161744009 History of Miscarriage 161747002 History of 1 Miscarriage 161748007 History of 2 Miscarriage 161749004 History of 3 Miscarriage 161750004 History of 4 Miscarriages 161751000 History of 5 Miscarriages 161752007 History of 6 Miscarriages 161804005 History of - antepartum hemorrhage (situation) 275569003 History of - delivery no details (situation) 275569003 History of - delivery no details (situation) 161806007 History of - eclampsia (situation) 161763005 History of - ectopic pregnancy (situation) 161803004 History of - obstetric problem (situation) 161809000 History of - postpartum hemorrhage (situation) 161765003 History of - premature delivery (situation) 161810005 History of - prolonged labor (situation) 161807003 History of - severe pre-eclampsia (situation) 161743003 History of - stillbirth (situation) 428978004 History of choriocarcinoma of placenta (situation) 441493008 History of premature labor (situation) 4.5.1.9 Maternal Risk Factors Table 4-29: Maternal Risk Factors Value Set Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set OID TBD SNOMED-CT Code 0 No known risk factors SNOMED-CT Description 85
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
4.5.1.10 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.133 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 http://www.nlm.nih.gov/research/umls/ 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 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.133 Value Set Code PHVS_FirstPrenatalCareVisit_NCHS Value Set Description To Reflect the First Prenatal Care Visit 87
Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 424441002 Prenatal initial visit (regime/therapy) 4.5.1.11 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.134 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 http://www.nlm.nih.gov/research/umls /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
Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.134 Value Set Description To Reflect the Last Prenatal Care Visit Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description Pending Pending 4.5.1.12 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.1 35 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 http://loinc.org 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 8/1/2010 89
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 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.135 Value Set Description To reflect the Number Prenatal Care Visits LOINC Code Vocabulary 2.16.840.1.113883.6.1 LOINC Description 68493-6 Prenatal visits for this pregnancy 4.5.1.13 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.118 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 http://loinc.org 90
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.2 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.3.28 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.118 Value Set Code PHVS_PrePregnancyWeight_NCHS Value Set Description To Reflect the mother s Pre-Pregnancy Weight LOINC Code Vocabulary 2.16.840.1.113883.6.1 LOINC Description 56077-1 Body weight^pre current pregnancy 8348-5 Body weight^pre pregnancy 4.5.1.14 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.6 9 Name This is the name of the value set BFDR Date of Last Menses Value Set 91
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 http://loinc.org 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 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.69 Value Set Code PHVS_NumberofLiveBirths_NCHS Value Set Description To reflect the Date of Last Menses Vocabulary OID 2.16.840.1.113883.6.1 LOINC Code 3145-0 Menstrual period start last LOINC Description 33066-2 Estimated last menstrual period 8665-2 Date last menstrual period 92
4.5.1.15 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.1 43 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 http://www.nlm.nih.gov/research/u 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 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 93
Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.143 Value Set Code PHVS_InfertilityTreatment_NCHS Value Set Description To reflect Risk Factors of Pregnancy Infertility Treatment Vocabulary OID 2.16.840.1.113883.6.96 SNOMED-CT Code 65046005 Infertility therapy (procedure) SNOMED-CT Description 183036001 Female infertility therapy (procedure) 236896006 Artificial insemination by donor (procedure) 236895005 Artificial insemination by husband (procedure) 57233006 Artificial insemination with sperm washing and capacitation (procedure) 46249006 Artificial insemination, heterologous (procedure) 66601000 Artificial insemination, homologous (procedure) 176844003 Intracervical artificial insemination (procedure) 265064001 Intrauterine artificial insemination (procedure) 426250000 Intrauterine insemination using donor sperm (procedure) 426389008 Intrauterine insemination using partner sperm (procedure) 425644009 Intrauterine insemination with controlled ovarian hyperstimulation using donor sperm (procedure) 426968007 Intrauterine insemination with controlled ovarian hyperstimulation using partner sperm (procedure) 225250007 Intravaginal artificial insemination (procedure) 225249007 Subzonal insemination (procedure) 176843009 Gamete intrauterine transfer (procedure) 236912008 Gamete intrafallopian transfer (procedure) 176996001 Endoscopic intrafallopian transfer of gamete (procedure) 236913003 Fallopian replacement of egg with delayed insemination (procedure) 225249007 Subzonal insemination 236915005 Tubal embryo transfer 236914009 Zygote intrafallopian transfer 63487001 Assisted fertilization (procedure) 4.5.1.16 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
Element Description Mandatory Identifier This is the unique identifier of the value set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.1 46 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 http://www.nlm.nih.gov/research/u 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 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.146 Value Set Code PHVS_AssistiveReproductiveTechnology_NCHS Value Set Description To reflect the Assistive Reproductive Technology as a Risk Factor in Pregnancy Vocabulary OID 2.16.840.1.113883.6.96 95
SNOMED-CT Code SNOMED-CT Description 52637005 Test tube ovum fertilization (procedure) 63487001 Assisted fertilization (procedure) 176843009 Gamete intrauterine transfer (procedure) 176996001 Endoscopic intrafallopian transfer of gamete (procedure) 225244002 Direct injection of sperm into cytoplasm of the oocyte (procedure) 225247009 Direct intraperitoneal insemination 225248004 Zona drilling (procedure) 225249007 Subzonal insemination 236912008 Gamete intrafallopian transfer (procedure) 236913003 Fallopian replacement of egg with delayed insemination (procedure) 236914009 Zygote intrafallopian transfer (procedure) 236915005 Tubal embryo transfer (procedure) 238312005 Intraperitoneal insemination 425866000 In vitro fertilization using donor eggs (procedure) 425901007 426417003 426914002 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) 427664000 In vitro fertilization using donor sperm (procedure) 443633009 Conceived by in vitro fertilization (finding) 4.5.1.17 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.14 4 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
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 http://www.nlm.nih.gov/research/u 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 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.144 Value Set Description To reflect that Fertility Enhancing Drugs were administered as a Risk Factor in Pregnancy Vocabulary OID 2.16.840.1.113883.6.88 RxNorm Code RxNorm Description 197523 Clomiphene 50 MG Oral Tablet 347764 Follicle Stimulating Hormone 150 UNT/ML / Luteinizing Hormone 150 UNT/ML Injectable Solution 314097 Follicle Stimulating Hormone 75 UNT/ML / Luteinizing Hormone 75 UNT/ML Injectable Solution 313561 Urofollitropin 150 UNT/ML Injectable Solution 348522 Urofollitropin 300 UNT/ML Injectable Solution 854749 0.21 ML follitropin beta 833 UNT/ML Prefilled Syringe 854754 0.78 ML follitropin beta 833 UNT/ML Prefilled Syringe 97
RxNorm Code RxNorm Description 854756 1.17 ML follitropin beta 833 UNT/ML Prefilled Syringe 854752 follitropin beta 350 UNT per 0.42 ML Prefilled Syringe 205320 follitropin beta 75 UNT/ML Injectable Solution 389216 follitropin beta 833 UNT/ML Injectable Solution 310413 Follitropin Alfa 300 UNT/ML Injectable Solution 351125 Follitropin Alfa 600 UNT/ML Injectable Solution 847960 follitropin alfa 75 UNT/ACTUAT Prefilled Pen, 12 ACTUAT 847953 Follitropin Alfa 75 UNT/ACTUAT Prefilled Syringe, 4 ACTUAT 847957 follitropin alfa 75 UNT/ACTUAT Prefilled Syringe, 6 ACTUAT 562724 Follitropin Alfa 75 UNT/ML Injectable Solution 896854 Chorionic Gonadotropin 10000 UNT/ML Injectable Solution 727505 chorionic gonadotropin 0.25 MG per 0.5 ML Prefilled Syringe 562725 Chorionic Gonadotropin 0.25 MG/ML Injectable Solution 403979 Chorionic Gonadotropin 0.5 MG/ML Injectable Solution 896854 Chorionic Gonadotropin 10000 UNT/ML Injectable Solution 562828 Chorionic Gonadotropin 500 UNT/ML Injectable Solution 197411 Bromocriptine 2.5 MG Oral Tablet 197412 bromocriptine 5 MG (bromocriptine mesylate 5.74 MG) Oral Capsule 1043563 24 HR Metformin hydrochloride 1000 MG / saxagliptin 2.5 MG Extended Release Tablet 1043570 24 HR Metformin hydrochloride 1000 MG / saxagliptin 5 MG Extended Release Tablet 1043578 24 HR Metformin hydrochloride 500 MG / saxagliptin 5 MG Extended Release Tablet 861731 Glipizide 2.5 MG / Metformin hydrochloride 250 MG Oral Tablet 861736 Glipizide 2.5 MG / Metformin hydrochloride 500 MG Oral Tablet 861740 Glipizide 5 MG / Metformin hydrochloride 500 MG Oral Tablet 861743 Glyburide 1.25 MG / Metformin hydrochloride 250 MG Oral Tablet 861748 Glyburide 2.5 MG / Metformin hydrochloride 500 MG Oral Tablet 861753 Glyburide 5 MG / Metformin hydrochloride 500 MG Oral Tablet 861025 Metformin hydrochloride 100 MG/ML Oral Solution 899989 24 HR Metformin hydrochloride 1000 MG / pioglitazone 15 MG Extended Release Tablet 899994 Metformin hydrochloride 1000 MG / pioglitazone 15 MG Extended Release Tablet 98
RxNorm Code RxNorm Description 899996 24 HR Metformin hydrochloride 1000 MG / pioglitazone 30 MG Extended Release Tablet 900001 Metformin hydrochloride 1000 MG / pioglitazone 30 MG Extended Release Tablet 861760 Metformin hydrochloride 1000 MG / rosiglitazone 2 MG Oral Tablet 861763 Metformin hydrochloride 1000 MG / rosiglitazone 4 MG Oral Tablet 1043568 Metformin hydrochloride 1000 MG / saxagliptin 2.5 MG Extended Release Tablet 1043575 Metformin hydrochloride 1000 MG / saxagliptin 5 MG Extended Release Tablet 861769 Metformin hydrochloride 1000 MG / sitagliptin 50 MG Oral Tablet 860996 24 HR Metformin hydrochloride 1000 MG Extended Release Tablet 860999 Metformin hydrochloride 1000 MG Extended Release Tablet 861004 Metformin hydrochloride 1000 MG Oral Tablet 861783 Metformin hydrochloride 500 MG / pioglitazone 15 MG Oral Tablet 861787 Metformin hydrochloride 500 MG / repaglinide 1 MG Oral Tablet 861790 Metformin hydrochloride 500 MG / repaglinide 2 MG Oral Tablet 861795 Metformin hydrochloride 500 MG / rosiglitazone 1 MG Oral Tablet 861806 Metformin hydrochloride 500 MG / rosiglitazone 2 MG Oral Tablet 861816 Metformin hydrochloride 500 MG / rosiglitazone 4 MG Oral Tablet 1043583 Metformin hydrochloride 500 MG / saxagliptin 5 MG Extended Release Tablet 861819 Metformin hydrochloride 500 MG / sitagliptin 50 MG Oral Tablet 860975 24 HR Metformin hydrochloride 500 MG Extended Release Tablet 860978 Metformin hydrochloride 500 MG Extended Release Tablet 861007 Metformin hydrochloride 500 MG Oral Tablet 861021 Metformin hydrochloride 625 MG Oral Tablet 860981 24 HR Metformin hydrochloride 750 MG Extended Release Tablet 860984 Metformin hydrochloride 750 MG Extended Release Tablet 861822 Metformin hydrochloride 850 MG / pioglitazone 15 MG Oral Tablet 861010 Metformin hydrochloride 850 MG Oral Tablet 99
RxNorm Code RxNorm Description 378730 Metformin Oral Tablet 374635 Glyburide / Metformin Oral Tablet 899988 Metformin / pioglitazone Extended Release Tablet 577093 Metformin / pioglitazone Oral Tablet 802742 Metformin / repaglinide Oral Tablet 378729 Metformin / rosiglitazone Oral Tablet 1043561 Metformin / saxagliptin Extended Release Tablet 700516 Metformin / sitagliptin Oral Tablet 372804 Metformin Extended Release Tablet 406082 Metformin Oral Solution 372803 Metformin Oral Tablet 4.5.1.18 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.12 4 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 http://loinc.org 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
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 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set Code 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.124 Value Set Description To reflect the Obstetric Estimate of Gestation of the newborn LOINC Code Vocabulary 2.16.840.1.113883.6.1 LOINC Description 11884-4 Gestational age Clinical.estimated 53695-3 Gestational age Clinical.estimated from prior assessment 4.5.2 Social History Section Table 4-48: Coded Social History Section Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.16.1 Parent Template Social History (1.3.6.1.4.1.19376.1.5.3.1.3.16) 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 29762-2 SHALL Social History Entries Opt Description 1..3.6.1.4.1.19376.1.5.3.1.4.13.4 SHALL Social History Observation Figure 4-9: Coded Social History Section Example <section> <templateid root="2.16.840.1.113883.10.20.1.15"/> <templateid root="1.3.6.1.4.1.19376.1.5.3.1.3.16.1"/> <code code="29762-2" codesystem="2.16.840.1.113883.6.1" displayname="social HISTORY"/> <title>social HISTORY</title> 101
<text> </text> <entry typecode="driv"> <subject> <relatedsubject classcode="prs"> <code code="9947008" codesystem="2.16.840.1.113883.6.96" displayname="biological father"/> <subject> <administrativegendercode code="m" codesystem="2.16.840.1.113883.5.1" displayname="male"/> <birthtime value="1965"/> </subject> </relatedsubject> </subject> <observation classcode="obs" moodcode="evn"> <! -- Social history observation template -- > <templateid root="2.16.840.1.113883.10.20.1.33"/> <templateid root="1.3.6.1.4.1.19376.1.5.3.1.4.13.4"/> <id extension="123456789" root="2.16.840.1.113883.19"/> <code code="118628001" codesystem="2.16.840.1.113883.6.96" displayname="education"/> <statuscode code="completed"/> <value xsi:type="cd" code="161122005" codesystem="2.16.840.1.113883.6.96" displayname="higher education"/> </observation> </entry> : <entry typecode="driv"> <subject> <relatedsubject classcode="prs"> <code code="65656005" codesystem="2.16.840.1.113883.6.96" displayname="biological mother"/> <subject> <administrativegendercode code="f" codesystem="2.16.840.1.113883.5.1" displayname="female"/> <birthtime value="1970"/> </subject> </relatedsubject> </subject> <observation classcode="obs" moodcode="evn"> <!-- Social history observation template --> <templateid root="2.16.840.1.113883.10.20.1.33"/> <templateid root="1.3.6.1.4.1.19376.1.5.3.1.4.13.4"/> <id extension="123456789" root="2.16.840.1.113883.19"/> <code code="137952002" codesystem="2.16.840.1.113883.6.96" 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 - 2:6.3.4.24.5, and adds the following value. 102
Data Element Type Code Alcohol intake (glasses/week) Alcohol intake within the pregnancy period PQ 137952002 4.6 Labor and Delivery Events Section Table 4-50: Labor and Delivery Events Section Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 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 57074-7 SHALL Labor and delivery process Subsections Opt Description Coded Detailed Physical SHOULD 1.3.6.1.4.1.19376.1.5.3.1.1.9.15.1 Examination Procedures and SHOULD 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 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 11636-8 that reports the number of births live or dead that occurred during the delivery event SHALL 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 103
Subsections Opt Description SHALL 1.3.6.1.4.1.19376.1.5.3.1.3.21 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 ody/component/section[templateid[@root =1.3.6.1.4.1.19376.1.5.3.1.3.21]]/ substanceadministration/code Route SHALL be coded using HL7 Route of Administration (2.16.840.1.113883.12.162), specifically indicating the route where IV or IM administration route is used: ClinicalDocument/component/structuredB ody/component/section[templateid[@root =1.3.6.1.4.1.19376.1.5.3.1.3.21]]/ substanceadministration/routecode Figure 4-10: Labor and Delivery Events Section Example <component> <section> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 /> <id root=' ' extension=' '/> <code code='57074-7' displayname='labor and delivery process' codesystem='2.16.840.1.113883.6.1' codesystemname='loinc'/> <text> Text as described above </text> <component> <section> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.1.9.15.1'/> <!-- Required if known Coded Detailed Physical Examination Section --> </section> </component> <component> <section> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11'/> <!-- Required if known Procedures and Interventions Section --> </section> </component> <component> <section> <templateid root='1.3.6.1.4.1.19376.1.7.3.1.1.13.7'/> <!-- Required if known Coded Event Outcomes Section --> </section> </component> </section> </component> 104
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 1.3.6.1.4.1.19376.1.5.3.1.1.9.15.1). Data Element Mother's Weight at Delivery Code Type LOINC SNOMED Value Set OID INT 11636-8 NA BFDR Mother s Delivery Weight Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.120 4.6.1.1 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.120 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 http://loinc.org 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
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.9.15.1 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.120 Value Set Code PHVS_MothersDeliveryWeight_NCHS Value Set Description To Reflect the Mother's Delivery Weight Vocabulary 2.16.840.1.113883.6.96 LOINC Code 8345-1 Body weight^post partum 69461-2 Body weight^ at delivery LOINC Description 4.6.2 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 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11). 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.103 BFDR Facility Location OR Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.104 BFDR Delivery Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.14 BFDR Unplanned Operation Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.105 106
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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.99 CD BFDR Epidural Anesthesia - Procedure Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.27 BFDR Spinal Anesthesia - Procedure Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.29 CD BFDR Route and Method of Delivery Spontaneous 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.111 Trial of Labor Attempted CD BFDR Route and Method of Delivery - Forceps 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.112 BFDR Route and Method of Delivery - Vacuum 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.113 BFDR Route and Method of Delivery - Cesarean 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.114 BFDR Route Method of Delivery - Trial of Labor 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.115 BFDR Route and Method of Delivery - Scheduled Cesarean 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.116 Augmentation of Labor - Procedure Induction of Labor Cervical BFDR Route and Method of Delivery - Cesarean 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.114 CD BFDR Augmentation of Labor - Procedure 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.22 CD BFDR Induction of Labor CD 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.34 BFDR Cervical Cerclage 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.125 Cerclage Tocolysis CD BFDR Tocolysis 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.128 4.6.2.1 Unplanned Hysterectomy Table 4-55: BFDR Unplanned Hysterectomy Metadata The BFDR Unplanned Hysterectomy Value Set Metadata shall contain the following content. 107
Element Description Mandatory Identifier This is the unique identifier of 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.103 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 http://www.nlm.nih.gov/research/umls /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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.103 Value Set Description BFDR Unplanned Hysterectomy Value Set Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 625654015 Emergency cesarean hysterectomy 108
4.6.2.2 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.10 4 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 http://www.hl7.org 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
Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.104 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 2.16.840.1.113883 1096-7 Inpatient operating room/suite 1094-2 Operating and recovery rooms HL7 Service Delivery Code Description 4.6.2.3 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.14 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 http://www.nlm.nih.gov/research/umls/s nomed/snomed_main.html 110
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.14 Value Set Code PHVS_Delivery_NCHS Value Set Description To Reflect the Delivery Procedure SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 133905007 Delivery room care (regime/therapy) 177184002 Normal delivery procedure (procedure) 1807002 Failed forceps delivery (procedure) 2321005 Delivery by Ritgen maneuver (procedure) 5556001 Manually assisted spontaneous delivery (procedure) 10745001 Delivery of transverse presentation (procedure) 15413009 High forceps delivery with episiotomy (procedure) 16819009 Delivery of face presentation (procedure) 17744000 Subtotal hysterectomy after cesarean delivery (procedure) 17860005 Low forceps delivery with episiotomy (procedure) 18625004 Low forceps delivery (procedure) 19390001 Partial breech delivery with forceps to aftercoming head (procedure) 22633006 Vaginal delivery, medical personnel present (procedure) 25296001 Delivery by Scanzoni maneuver (procedure) 25828002 Mid forceps delivery with episiotomy (procedure) 26313002 Delivery by vacuum extraction with episiotomy (procedure) 29613008 Delivery by double application of forceps (procedure) 30476003 Barton's forceps delivery (procedure) 38479009 Frank breech delivery (procedure) 40219000 Delivery by Malstrom's extraction with episiotomy (procedure) 45718005 Vaginal delivery with forceps including postpartum care (procedure) 48204000 Spontaneous unassisted delivery, medical personnel present (procedure) 54973000 Total breech delivery with forceps to aftercoming head (procedure) 56620000 Delivery of placenta following delivery of infant outside of hospital (procedure) 57411006 Colpoperineorrhaphy following delivery (procedure) 61586001 Delivery by vacuum extraction (procedure) 62508004 Mid forceps delivery (procedure) 111
SNOMED-CT Code SNOMED-CT Description 71166009 Forceps delivery with rotation of fetal head (procedure) 72059007 Destructive procedure on fetus to facilitate delivery (procedure) 72492007 Footling breech delivery (procedure) 89346004 Delivery by Kielland rotation (procedure) 89849000 High forceps delivery (procedure) 90438006 Delivery by Malstrom's extraction (procedure) 177128002 Induction and delivery procedures (procedure) 177152009 Breech extraction delivery with version (procedure) 177157003 Spontaneous breech delivery (procedure) 177158008 Assisted breech delivery (procedure) 177161009 Forceps cephalic delivery (procedure) 177162002 High forceps cephalic delivery with rotation (procedure) 177164001 Midforceps cephalic delivery with rotation (procedure) 177167008 Barton forceps cephalic delivery with rotation (procedure) 177168003 DeLee forceps cephalic delivery with rotation (procedure) 177170007 Piper forceps delivery (procedure) 177173009 High vacuum delivery (procedure) 177174003 Low vacuum delivery (procedure) 177175002 Vacuum delivery before full dilation of cervix (procedure) 177179008 Cephalic vaginal delivery with abnormal presentation of head at delivery without instrument (procedure) 177180006 Manipulative cephalic vaginal delivery with abnormal presentation of head at delivery without instrument (procedure) 177181005 Non-manipulative cephalic vaginal delivery with abnormal presentation of head at delivery without instrument (procedure) 177184002 Normal delivery procedure (procedure) 177185001 Water birth delivery (procedure) 177212000 Normal delivery of placenta (procedure) 199771001 Piper forceps delivery by application to aftercoming head (procedure) 236973005 Delivery procedure (procedure) 236974004 Instrumental delivery (procedure) 236975003 Nonrotational forceps delivery (procedure) 236976002 Outlet forceps delivery (procedure) 236977006 Forceps delivery, face to pubes (procedure) 236978001 Forceps delivery to the aftercoming head (procedure) 236982004 Delivery of the after coming head (procedure) 236989008 Abdominal delivery for shoulder dystocia (procedure) 236991000 Operation to facilitate delivery (procedure) 236994008 Placental delivery procedure (procedure) 237008007 Maneuvers for delivery in shoulder dystocia (procedure) 112
SNOMED-CT Code SNOMED-CT Description 237311001 Breech delivery (procedure) 248273008 Aspiration curettage of uterus after delivery (procedure) 265639000 Midforceps delivery without rotation (procedure) 275168001 Neville-Barnes forceps delivery (procedure) 275169009 Simpson's forceps delivery (procedure) 287976008 Breech/instrumental delivery operations (procedure) 287977004 Dilation/incision of cervix - delivery aid (procedure) 288193006 Supervision - normal delivery (procedure) 302383004 Forceps delivery (procedure) 306727001 Breech presentation, delivery, no version (procedure) 315308008 Dilatation of cervix for delivery (procedure) 359943008 Partial breech delivery (procedure) 384729004 Delivery of vertex presentation (procedure) 386338001 Intrapartal care: high-risk delivery (regime/therapy) 386622003 Duhrssen's incisions of cervix to assist delivery (procedure) 387711001 Pubiotomy to assist delivery (procedure) 391998006 Dilation and curettage of uterus after delivery (procedure) 397990008 Analgesia for labor/delivery (procedure) 408817009 Amniotomy at delivery (procedure) 408819007 Delivery of placenta by maternal effort (procedure) 4.6.2.4 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.105 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 http://www.nlm.nih.gov/research/umls/ Snomed/snomed_main.html 113
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.105 Value Set Description To reflect Unplanned Operation as a maternal morbidity SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 259863001 Removal of Shirodkar suture from cervix (procedure) 372456005 Repair of obstetric laceration (procedure) 177217006 Immediate repair of obstetric laceration (procedure) 177221004 Immediate repair of minor obstetric laceration (procedure) 177219009 Immediate repair of obstetric laceration of perineum and sphincter of anus (procedure) 177218001 Immediate repair of obstetric laceration of uterus or cervix uteri (procedure) 177220003 Immediate repair of obstetric laceration of vagina and floor of pelvis (procedure) 9724000 Repair of current obstetric laceration of uterus (procedure) 31939001 Repair of obstetric laceration of cervix (procedure) 315307003 Repair of obstetric laceration of lower urinary tract (procedure) 61353001 Repair of obstetric laceration of bladder (procedure) 42390009 Repair of obstetric laceration of bladder and urethra (procedure) 36248000 Repair of obstetric laceration of urethra (procedure) 48775002 Repair of obstetric laceration of pelvic floor (procedure) 114
SNOMED-CT Code SNOMED-CT Description 441619002 Repair of obstetric laceration of perineum and anal sphincter and mucosa of rectum (procedure) 112925006 Repair of obstetric laceration of vulva (procedure) 55669006 Repair of obstetrical laceration of perineum (procedure) 367476005 Colpoepisiorrhaphy (procedure) 177227000 Secondary repair of obstetric laceration (procedure) 112926007 Suture of obstetric laceration of vagina (procedure) 57411006 Colpoperineorrhaphy following delivery (procedure) 4.6.2.5 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.99 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 http://www.nlm.nih.gov/research/umls/s 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
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.99 Value Set Code PHVS_TransfusionWholeBloodOrPackedRBC_NCHS Value Set Description To reflect Transfusion Whole Blood or Packed Red Blood as a maternal morbidity Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 33389009 Transfusion of whole blood (procedure) 11397000 Autotransfusion of whole blood (procedure) 180206004 Intra-arterial blood transfusion (procedure) 225284006 Transfusing whole blood under pressure (procedure) 116863004 Transfusion of red blood cells (procedure) 425513008 Transfusion of leucoreduced red blood cells (procedure) 71493000 Transfusion of packed red blood cells (procedure) 180207008 Intravenous blood transfusion of packed cells (procedure) 426290002 Transfusion of washed red blood cells (procedure) 12719002 Platelet transfusion (procedure) 180208003 Intravenous blood transfusion of platelets (procedure) 117078000 Transfusion of platelet concentrate (procedure) 116810007 Transfusion of plateletpheresis product (procedure) 116797000 Transfusion of factor IX (procedure) 74287006 Transfusion of coagulation factors (procedure) 274502001 Antihemophilic factor transfusion (procedure) 425524005 Transfusion antithrombin III factor (procedure) 116798005 Transfusion of factor VII (procedure) 4.6.2.6 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
Element Description Mandatory Identifier This is the unique identifier of 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.27 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 http://www.nlm.nih.gov/research/um 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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.27 Value Set Code PHVS_EpiduralAnesthesia_NCHS Value Set Description To Reflect an Epidural Anesthesia Procedure Vocabulary 2.16.840.1.113883.6.96 117
SNOMED-CT Code SNOMED-CT Description 18946005 Epidural anesthesia (procedure) 58611004 Epidural injection of anesthetic substance, therapeutic, lumbar, continuous (procedure) 180886007 Local anesthetic sacral epidural block (procedure) 112943005 Epidural injection of anesthetic substance, diagnostic, caudal, continuous (procedure) 67716003 Epidural injection of anesthetic substance, therapeutic, caudal, continuous (procedure) 398044000 Low dose epidural (procedure) 64817005 Anesthesia for vaginal delivery (procedure) 4.6.2.7 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.29 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 http://www.nlm.nih.gov/research/uml 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
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.29 Value Set Code PHVS_SpinalAnesthesiaProcedure_NCHS Value Set Description To Reflect an Spinal Anesthesia Procedure SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 108215007 Anesthesia for procedure on spine AND/OR spinal cord (procedure) 15624001 Anesthesia for spinal fluid shunting procedure (procedure) 22048001 Anesthesia for spinal cord procedure (procedure) 40365004 Anesthesia for procedure on lumbosacral spinal cord (procedure) 417724007 Referral to epidural anesthesia for spinal pain (procedure) 434546004 Care of subject following combined spinal-epidural anesthesia (regime/therapy) 57580002 Anesthesia for procedure on thoracic spinal cord (procedure) 86583004 Anesthesia for procedure on cervical spinal cord (procedure) 231255000 Spinal subdural local anesthetic block (procedure) 231043002 Local anesthetic block on spinal nerve root (procedure) 231044008 Local anesthetic block on spinal nerve ganglion (procedure) 231261002 Combined spinal/epidural local anesthetic block (procedure) 303358008 Neurolytic nerve block around spinal cord meninges (procedure) 303356007 Local anesthetic nerve block around spinal cord meninges (procedure) 431928000 Local anesthetic block of spinal nerve root using fluoroscopic guidance (procedure) 231253007 Local anesthetic lumbar intrathecal block (procedure) 9166009 Injection of anesthetic substance, diagnostic, subarachnoid, continuous (procedure) 47188007 Injection of anesthetic substance, therapeutic, subarachnoid, continuous (procedure) 20381001 Injection of anesthetic substance, therapeutic, subarachnoid, differential (procedure) 119
4.6.2.8 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.111 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 http://www.nlm.nih.gov/research/umls/s 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
Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.111 Value Set Code PHVS_RouteMethodOfDeliverySpontaneous_NCHS Value Set Description To Reflect the Route and Method of Delivery as Spontaneous Delivery Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 309469004 Spontaneous vertex delivery (finding) 199329004 Multiple delivery, all spontaneous (finding) 271373005 Deliveries by spontaneous breech delivery (finding) 4.6.2.9 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.112 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 http://www.nlm.nih.gov/research/umls /Snomed/snomed_main.html 121
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.112 Value Set Code PHVS_ RouteMethodOfDeliveryForceps_NCHS Value Set Description To Reflect the Route and Method of Delivery as Forceps Delivery Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 177167008 Barton forceps cephalic delivery with rotation (procedure) 177168003 DeLee forceps cephalic delivery with rotation (procedure) 177161009 Forceps cephalic delivery (procedure) 1807002 Forceps delivery failed (situation) 236978001 Forceps delivery to the aftercoming head (procedure) 236977006 Forceps delivery, face to pubes (procedure) 172524003 Forceps extraction of lens (procedure) 177162002 High forceps cephalic delivery with rotation (procedure) 15413009 High forceps delivery with episiotomy (procedure) 18625004 Low forceps delivery (procedure) 17860005 Low forceps delivery with episiotomy (procedure) 236975003 Nonrotational forceps delivery (procedure) 236976002 Outlet forceps delivery (procedure) 19390001 Partial breech delivery with forceps to aftercoming head (procedure) 177170007 Piper forceps delivery (procedure) 89849000 High forceps delivery (procedure) 71166009 Forceps delivery with rotation of fetal head (procedure) 62508004 Mid forceps delivery (procedure) 54973000 Total breech delivery with forceps to aftercoming head (procedure) 45718005 Vaginal delivery with forceps including postpartum care (procedure) 30476003 Barton's forceps delivery (procedure) 302383004 Forceps delivery (procedure) 122
SNOMED-CT Code SNOMED-CT Description 29613008 Delivery by double application of forceps (procedure) 275169009 Simpson's forceps delivery (procedure) 275168001 Neville-Barnes forceps delivery (procedure) 25828002 Mid forceps delivery with episiotomy (procedure) 4.6.2.10 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.113 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 http://www.nlm.nih.gov/research/umls/ Snomed/snomed_main.html 123
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.113 Value Set Code PHVS_RouteMethodOfDeliveryVacuum_NCHS Value Set Description To Reflect the Route and Method of Delivery as Vacuum Delivery SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 177174003 Low vacuum delivery (procedure) 177173009 High vacuum delivery (procedure) 177176001 Trial of vacuum delivery (procedure) 61586001 Delivery by vacuum extraction (procedure) 90438006 Delivery by Malstrom's extraction (procedure) 40219000 Delivery by Malstrom's extraction with episiotomy (procedure) 26313002 Delivery by vacuum extraction with episiotomy (procedure) 177175002 Vacuum delivery before full dilation of cervix (procedure) 172524003 Forceps extraction of lens (procedure) 177161009 Forceps cephalic delivery (procedure) 177162002 High forceps cephalic delivery with rotation (procedure) 177167008 Barton forceps cephalic delivery with rotation (procedure) 177168003 DeLee forceps cephalic delivery with rotation (procedure) 177170007 Piper forceps delivery (procedure) 17860005 Low forceps delivery with episiotomy (procedure) 1807002 Failed forceps delivery (procedure) 18625004 Low forceps delivery (procedure) 19390001 Partial breech delivery with forceps to aftercoming head (procedure) 236975003 Nonrotational forceps delivery (procedure) 236976002 Outlet forceps delivery (procedure) 236977006 Forceps delivery, faces to pubes (procedure) 236978001 Forceps delivery to the aftercoming head (procedure) 25828002 Mid forceps delivery with episiotomy (procedure) 275168001 Neville-Barnes forceps delivery (procedure) 275169009 Simpson s forceps delivery (procedure) 124
SNOMED-CT Code SNOMED-CT Description 29613008 Delivery by double application of forceps (procedure) 302383004 Forceps delivery (procedure) 30476003 Barton s forceps delivery (procedure) 3190002 Epilation by forceps (procedure) 45718005 Vaginal delivery with forceps including postpartum care (procedure) 54926006 Epilation of eyebrow by forceps (procedure) 54973000 Total breech delivery with forceps to aftercoming head (procedure) 62508004 Mid forceps delivery (procedure) 69422002 Trial forceps delivery (procedure) 71166009 Forceps delivery with rotation of fetal head (procedure) 71580008 Correction of trichiasis by epilation with forceps (procedure) 74004007 Epilation of eyelid by forceps (procedure) 89849000 High forceps delivery (procedure) 4.6.2.11 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.114 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 http://www.nlm.nih.gov/research/uml s/snomed/snomed_main.html 125
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.114 Value Set Code PHVS_RouteMethodOfDeliveryCesarean_NCHS Value Set Description To Reflect the Route and Method of Delivery as Cesarean Delivery Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code 11466000 Cesarean section (procedure) SNOMED-CT Description 177141003 Elective cesarean section (procedure) 177142005 Elective upper segment cesarean section (procedure) 177143000 Elective lower segment cesarean section (procedure) 17744000 Subtotal hysterectomy after cesarean delivery (procedure) 236985002 Emergency lower segment cesarean section (procedure) 236986001 Emergency upper segment cesarean section (procedure) 236987005 Emergency cesarean hysterectomy (procedure) 236988000 Elective cesarean hysterectomy (procedure) 236990004 Postmortem cesarean section (procedure) 24806008 Anesthesia for cesarean hysterectomy (procedure) 274130007 Emergency cesarean section (procedure) 386234001 Cesarean section care (regime/therapy) 398307005 Low cervical cesarean section (procedure) 41059002 Cesarean hysterectomy (procedure) 440073003 Education about vaginal birth after cesarean section (procedure) 4847005 Anesthesia for cesarean section (procedure) 57271003 Extraperitoneal cesarean section (procedure) 84195007 Classical cesarean section (procedure) 89053004 Vaginal cesarean section (procedure) 126
4.6.2.12 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.115 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 http://www.nlm.nih.gov/research/umls/ 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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.115 Value Set Code PHVS_RouteMethodOfDeliveryTrialOfLabor_NCHS Value Set Description To Reflect the Route and Method of Delivery as Trial of Laor 127
Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 90306000 Trial labor (finding) 23332002 Failed trial of labor (disorder) 413339006 Failed trial of labor - delivered (disorder) 4.6.2.13 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.116 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 http://www.nlm.nih.gov/research/umls /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
Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.116 Value Set Code PHVS_RouteMethodOfDeliveryScheduledCesarean_NCHS Value Set Description To Reflect the Route and Method of Delivery as Scheduled Cesarean Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 177141003 Elective cesarean section (procedure) 177142005 Elective upper segment cesarean section (procedure) 177143000 Elective lower segment cesarean section (procedure) 236988000 Elective cesarean hysterectomy (procedure) 4.6.2.14 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.22 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 http://www.nlm.nih.gov/research/um 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 8/1/2010 129
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.22 Value Set Code PHVS_AugmentationOfLaborProcedure_NCHS Value Set Description To reflect a procedure of Augmentation of Labor Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 237001001 Augmentation of labor (procedure) 237002008 Stimulation of labor (procedure) 4.6.2.15 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.34 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 http://www.nlm.nih.gov/research/umls /Snomed/snomed_main.html 130
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.34 Value Set Code PHVS_InductionOfLabor_NCHS Value Set Description To Reflect that there was an Induction of Labor SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 177135005 Oxytocin induction of labor (procedure) 177136006 Prostaglandin induction of labor (procedure) 180221005 Intravenous induction of labor (procedure) 236958009 Induction of labor (procedure) 236969007 Acupuncture for induction of labor (procedure) 308037008 Syntocinon induction of labor (procedure) 31208007 Medical induction of labor (procedure) 408818004 Induction of labor by artificial rupture of membranes (procedure) 315308008 Dilatation of cervix for delivery (procedure) 425861005 Cervical ripening with balloon (procedure) 236965001 Cervical ripening with drug (procedure) 236967009 Cervical ripening with ethinyl estradiol (procedure) 236966000 Cervical ripening with Prostaglandin E2 (procedure) 236968004 Cervical ripening with relaxin (procedure) 236962003 Cervical ripening with Foley catheter (procedure) 236963008 Cervical ripening with tents (procedure) 236964002 Cervical ripening with synthetic tent (procedure) 85179000 Insertion of laminaria into cervix (procedure) 236960006 Sweeping of membrane (procedure) 131
4.6.2.16 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.125 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 http://www.nlm.nih.gov/research/umls /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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.125 Value Set Code PHVS_CervicalCerclage_NCHS Value Set Description To Reflect Obstetric Procedures as Cervical Cerclage 132
SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 265636007 Cerclage of cervix (procedure) SNOMED-CT Description 236946009 Macdonald's cervical cerclage (procedure) 46681009 Cerclage of cervix during pregnancy by abdominal approach (procedure) 90442009 Cerclage of cervix during pregnancy by vaginal approach (procedure) 360399007 Marckwald operation on cervix (procedure) 176785004 Non-obstetric encircling suture of cervical os (procedure) 236947000 Shirodkar's cervical cerclage (procedure) 4.6.2.17 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.128 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 http://www.nlm.nih.gov/research/uml s/snomed/snomed_main.html 133
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.128 Value Set Code PHVS_Tocolysis_NCHS Value Set Description To reflect Obstetric Procedures as Tocolysis SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 103747003 Tocolysis (procedure) SNOMED-CT Description 5048009 External cephalic version with tocolysis (procedure) 237003003 Tocolysis for hypertonicity of uterus (procedure) 4.6.3 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.7). Data Code Type Element LOINC SNOMED Value Set OID Births Live INT 11636-8 NA MCH HBS Number of Live Births Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.68 Pregnancy Outcome CD Pregnancy Outcome Value Set 2.16.840.1.114222.4.11.3071 Plurality BFDR Birth Plurality of Delivery Value Set, 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.132 Presentation Type CD BFDR Fetal Presentation at Birth- Breech Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.108 BFDR Fetal Presentation at Birth- Cephalic Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.109 BFDR Fetal Presentation at Birth- Other Value Set Admission to Intensive Care [unit] 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.110 BFDR ICU Care Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.188 134
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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.100 BFDR Fourth Degree Perineal Laceration Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.101 BFDR Ruptured Uterus Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13. 8.102 Meconium Staining (NCHS) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.36 BFDR Premature Rupture Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.129 Precipitous Labor (NCHS) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.130 Prolonged Labor (NCHS) 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.131 4.6.3.1 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.68 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 http://loinc.org 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
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 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.68 Value Set Code PHVS_NumberofLiveBirths_NCHS Value Set Description To Reflect the Number of Live Births Vocabulary OID 2.16.840.1.113883.6.1 LOINC Code 11636-8 Births.live LOINC Description 4.6.3.2 Pregnancy Outcome Table 4-92: Pregnancy Outcome Value Set Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 Value Set OID 2.16.840.1.114222.4.11.3071 Value Set Code PHVS_PregnancyOutcome_FDD Value Set Description Outcome of pregnancy answer list Concept Code Concept Name 289257009 Mother not delivered (finding) OTH Other 282020008 Premature delivery (finding) 17369002 Spontaneous abortion (disorder) 237364002 Stillbirth (finding) 21243004 Term birth of newborn (finding) UNK Unknown 136
4.6.3.3 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.132 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 http://loinc.org 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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.132 Value Set Code PHVS_BirthPluralityOfDelivery_NCHS 137
Value Set Description To Reflect the Birth Plurality of Delivery Vocabulary 2.16.840.1.113883.6.1 LOINC Code LOINC Description 57722-1 Birth plurality 4.6.3.4 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.108 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 http://www.nlm.nih.gov/research/uml 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
Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.108 Value Set Code PHVS_FetalPresentationAtBirthBreech_NCHS Value Set Description To Reflect the Fetal Presentation at Birth- Breech method of delivery SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 6096002 Breech presentation (finding) SNOMED-CT Description 199354004 Breech presentation - delivered (finding) 199355003 Breech presentation with antenatal problem (finding) 49168004 Complete breech presentation (finding) 249097002 Footling breech presentation (finding) 48906005 Breech presentation, double footling (finding) 58903006 Breech presentation, single footling (finding) 18559007 Frank breech presentation (finding) 38049006 Incomplete breech presentation (finding) 163514003 On examination - breech presentation (finding) 271370008 Deliveries by breech extraction (finding) 237325000 Head entrapment during breech delivery (disorder) 271373005 Deliveries by spontaneous breech delivery (finding) 199751005 Obstructed labor due to breech presentation (finding) 364748006 Finding of position of breech presentation (finding) 79888005 Sacroanterior position (finding) 408812003 Direct sacroanterior position (finding) 64433002 Left sacroanterior position (finding) 79643007 Right sacroanterior position (finding) 249103009 Sacrolateral position (finding) 54486001 Left sacrolateral position (finding) 89550007 Right sacrolateral position (finding) 58261003 Sacroposterior position (finding) 249102004 Direct sacroposterior position (finding) 2138000 Left sacroposterior position (finding) 112073004 Right sacroposterior position (finding) 4.6.3.5 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
Element Description Mandatory Identifier This is the unique identifier of 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.109 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 http://www.nlm.nih.gov/research/umls/ 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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.109 Value Set Code PHVS_FetalPresentationAtBirthCephalic_NCHS Value Set Description To Reflect the Fetal Presentation at Birth- Cephalic method of delivery SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 70028003 Vertex presentation (finding) SNOMED-CT Description 163513009 On examination - vertex presentation (finding) 140
SNOMED-CT Code SNOMED-CT Description 441640001 Vertex presentation with caput succedaneum (finding) 309469004 Spontaneous vertex delivery (finding) 441640001 Vertex presentation with caput succedaneum (finding) 14058000 Asynclitism 46017002 Anterior asynclitism 90731001 Posterior asynclitism 90381008 Occiptoanterior position 408813008 Direct occiptoanterior position 14409005 Left occiptoanterior position 39889007 Right occiptoanterior position 249071008 Occipitolateral position 18905000 Left occipitolateral position 37040008 Right occipitolateral position 37235006 Occiptoposterior position 249070009 Direct occiptoposterior position 31477000 Left occiptoposterior position 36547009 Right occiptoposterior position 4.6.3.6 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.110 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 http://www.nlm.nih.gov/research/uml s/snomed/snomed_main.html 141
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.110 Value Set Code PHVS_FetalPresentationAtBirthCephalic_NCHS Value Set Description To Reflect the Fetal Presentation at Birth- Cephalic method of delivery SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 249079005 Fontanelles presenting (finding) SNOMED-CT Description 249082000 Anterior fontanelle presenting (finding) 249081007 Both fontanelles presenting (finding) 249083005 Posterior fontanelle presenting (finding) 23954006 Acromion presentation (finding) 14058000 Asynclitism (finding) 8014007 Brow presentation (finding) 124736009 Compound presentation (finding) 21882006 Face presentation (finding) 46200004 Funic presentation (finding) 50724007 Longitudinal fetal presentation (finding) 15028002 Abnormal fetal presentation (finding) 142
4.6.3.7 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.188 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 http://www.nlm.nih.gov/research/umls/s 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
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.188 Value Set Description To reflect the that the mother was transferred to ICU following the birth Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 305796008 Seen by intensive care - service (finding) 305797004 Seen by adult intensive care - service (finding) 305644002 Seen by intensive care specialist (finding) 305645001 Seen by adult intensive care specialist (finding) 305465003 Under care of intensive care specialist (finding) 305466002 Under care of adult intensive care specialist (finding) 4.6.3.8 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.100 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 http://www.nlm.nih.gov/research/umls /Snomed/snomed_main.html 144
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.100 Value Set Code PHVS_ThirdDegreePerinealLaceration_NCHS Value Set Description To reflect Third Degree Perineal Laceration as a maternal morbidity SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 10217006 Third degree perineal laceration (disorder) 199930000 Third degree perineal tear during delivery - delivered (disorder) 199931001 Third degree perineal tear during delivery with postnatal problem (disorder) 199934009 Fourth degree perineal tear during delivery - delivered (disorder) 199935005 Fourth degree perineal tear during delivery with postnatal problem (disorder) 4.6.3.9 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.101 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
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 http://www.nlm.nih.gov/research/umls /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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.101 Value Set Code PHVS_FourthDegreePerinealLaceration_NCHS Value Set Description To reflect Fourth Degree Perineal Laceration as a maternal morbidity SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 399031001 Fourth degree perineal laceration (disorder) 16950007 Fourth degree perineal laceration involving anal mucosa (disorder) 34262005 Fourth degree perineal laceration involving rectal mucosa (disorder) 199934009 Fourth degree perineal tear during delivery - delivered (disorder) 199935005 Fourth degree perineal tear during delivery with postnatal problem (disorder) 146
4.6.3.10 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.102 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 http://www.nlm.nih.gov/research/umls /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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.102 Value Set Code PHVS_RupturedUterus_NCHS Value Set Description To reflect Ruptured Uterus as a maternal morbidity Vocabulary 2.16.840.1.113883.6.96 147
SNOMED-CT Code SNOMED-CT Description 199958008 Ruptured uterus before labor (disorder) 199960005 Rupture of uterus before labor - delivered (disorder) 199961009 Rupture of uterus before labor with antenatal problem (disorder) 69270005 Rupture of uterus during AND/OR after labor (disorder) 199964001 Rupture of uterus during and after labor - delivered (disorder) 199965000 Rupture of uterus during and after labor - delivered with postnatal problem (disorder) 15504009 Rupture of gravid uterus (disorder) 49561003 Rupture of gravid uterus before onset of labor (disorder) 34430009 Rupture of uterus (disorder) 4.6.3.11 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.36 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 http://www.nlm.nih.gov/research/umls /Snomed/snomed_main.html 148
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.36 Value Set Code PHVS_MeconiumStaining_NCHS Value Set Description To Reflect that there was moderate or heavy Meconium staining SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 408793000 Meconium stained liquor - grade II (finding) 408794006 Meconium stained liquor - grade III (finding) 289294000 Thick meconium stained liquor (finding) 249136005 Fresh meconium staining liquor (finding) 249137001 Old meconium staining liquor (finding) 4.6.3.12 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.129 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 http://www.nlm.nih.gov/research/umls /Snomed/snomed_main.html 149
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.129 Value Set Code PHVS_PrematureRupture_NCHS Value Set Description To Reflect Onset of labor with Premature Rupture Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 44223004 Premature rupture of membranes (disorder) 288207006 Membrane rupture with delivery delay (disorder) 199658006 Premature rupture of membranes delivered (disorder) 199659003 Premature rupture of membranes with antenatal problem (disorder) 199662000 Premature rupture of membranes with onset of labor after 24 hours of the rupture (disorder) 199660008 Premature rupture of membranes with onset of labor within 24 hours of the rupture (disorder) 199661007 Premature rupture of membranes, labor delayed by therapy (disorder) 312974005 Preterm premature rupture of membranes (disorder) 237267007 Prolonged premature rupture of membranes (disorder) 12729009 Prolonged rupture of membranes 199670005 Prolonged artificial rupture of membranes 199672002 Prolonged artificial rupture of membranes delivered 199673007 Prolonged artificial rupture of membranes with antenatal problem 237267007 Prolonged premature rupture of membranes 237262008 Prolonged spontaneous rupture of membranes 150
4.6.3.13 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.130 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 http://www.nlm.nih.gov/research/umls/ 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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.130 Value Set Code PHVS_PrecipitousLabor_NCHS Value Set Description To Reflect Onset of labor with Precipitous Labor Vocabulary 2.16.840.1.113883.6.96 151
SNOMED-CT Code SNOMED-CT Description 51920004 Precipitate labor (disorder) 199833004 Precipitate labor - delivered (disorder) 199834005 Precipitate labor with antenatal problem (disorder) 4.6.3.14 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.131 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 http://www.nlm.nih.gov/research/umls /Snomed/snomed_main.html 152
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.131 Value Set Code PHVS_ProlongedLabor_NCHS Value Set Description To Reflect Onset of labor with Prolonged Labor Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code 53443007 Prolonged labor (disorder) SNOMED-CT Description 35347003 Delayed delivery after artificial rupture of membranes (disorder) 21987001 Delayed delivery of second of multiple births (disorder) 237321009 Delayed delivery of triplet (disorder) 275429002 Delayed delivery of second twin (disorder) 199860006 Delayed delivery of second twin, triplet etc. (disorder) 199862003 Delayed delivery second twin delivered (disorder) 199863008 Delayed delivery second twin with antenatal problem (disorder) 33627001 Prolonged first stage of labor (disorder) 199847000 Prolonged first stage - delivered (disorder) 199848005 Prolonged first stage with antenatal problem (disorder) 387700009 Prolonged latent phase of labor (disorder) 77259008 Prolonged second stage of labor (disorder) 199857004 Prolonged second stage - delivered (disorder) 199858009 Prolonged second stage with antenatal problem (disorder) 4.6.4 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 1.3.6.1.4.1.19376.1.5.3.1.3.21). Data Element Type Value Set OID Antibiotics CD BFDR Antibiotics Value Set, 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.3 153
Data Element Type Value Set OID Steroids [(glucocorticoids) for CD BFDR Glucocortico Steroids Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.38 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.23 BFDR Epidural Anesthesia - Medication Value Set, 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.26 BFDR Spinal Anesthesia - Medication Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.28 4.6.4.1 Antibiotics Table 4-118: BFDR Antibiotics Metadata Element Description Mandatory Identifier This is the unique identifier of 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.3 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 http://www.nlm.nih.gov/research/umls/rxno 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
Table 4-119: BFDR Antibiotics Value Set Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.3.21 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.3 Value Set Code PHVS_Antibiotics_NCHS Value Set Description To Reflect that antibiotics were administered. RxNORM Description Vocabulary 2.16.840.1.113883.6.88 RxNORM Code 731558 1 ML penicillin G benzathine 300000 UNT/ML / penicillin G procaine 300000 UNT/ML Prefilled Syringe 731538 2 ML penicillin G benzathine 300000 UNT/ML / penicillin G procaine 300000 UNT/ML Prefilled Syringe 731590 4 ML penicillin G benzathine 300000 UNT/ML / penicillin G procaine 300000 UNT/ML Prefilled Syringe 890921 5000 MG Clindamycin 20 MG/ML Prefilled Applicator 248108 Acyclovir 25 MG/ML Injectable Solution 313812 Acyclovir 50 MG/ML Injectable Solution 377143 Acyclovir Injectable Solution 239240 Amphotericin B 5 MG/ML Injectable Solution 376660 Amphotericin B Injectable Solution 789980 Ampicillin (as ampicillin sodium) 100 MG/ML Injectable Solution 313819 Ampicillin (as ampicillin sodium) 250 MG/ML Injectable Solution 378107 Ampicillin / Floxacillin Injectable Solution 376673 Ampicillin / Sulbactam Injectable Solution 240984 Ampicillin 100 MG/ML / Sulbactam 50 MG/ML Injectable Solution 756252 Ampicillin 125 MG / floxacillin 125 MG per 5 ML Elixir 308207 Ampicillin 125 MG/ML Injectable Solution 105134 Ampicillin 167 MG/ML / Floxacillin 167 MG/ML Injectable Solution 993109 Ampicillin 20 MG/ML / Sulbactam 10 MG/ML Injectable Solution 308208 Ampicillin 250 MG/ML / Sulbactam 125 MG/ML Injectable Solution 308208 Ampicillin 30 MG/ML / Sulbactam 15 MG/ML Injectable Solution 370584 Ampicillin Injectable Solution 309051 Cefazolin 10 MG/ML Injectable Solution 796301 Cefazolin 100 MG/ML Injectable Solution 309052 Cefazolin 20 MG/ML Injectable Solution 313920 Cefazolin 200 MG/ML Injectable Solution 309053 Cefazolin 225 MG/ML Injectable Solution 562062 Cefazolin 250 MG/ML Injectable Solution 313929 Cefazolin 330 MG/ML Injectable Solution 155
RxNORM Description RxNORM Code 371324 Cefazolin Injectable Solution 198396 Cefotaxime 20 MG/ML Injectable Solution 309065 Cefotaxime 200 MG/ML Injectable Solution 309068 Cefotaxime 230 MG/ML Injectable Solution 309066 Cefotaxime 300 MG/ML Injectable Solution 309067 Cefotaxime 330 MG/ML Injectable Solution 198395 Cefotaxime 40 MG/ML Injectable Solution 371331 Cefotaxime Injectable Solution 389025 Ceftazidime 10 MG/ML Injectable Solution 309083 Ceftazidime 170 MG/ML Injectable Solution 309082 Ceftazidime 20 MG/ML Injectable Solution 242800 Ceftazidime 200 MG/ML Injectable Solution 249926 Ceftazidime 210 MG/ML Injectable Solution 240447 Ceftazidime 250 MG/ML Injectable Solution 313890 Ceftazidime 280 MG/ML Injectable Solution 309084 Ceftazidime 40 MG/ML Injectable Solution 389026 Ceftazidime 60 MG/ML Injectable Solution 371337 Ceftazidime Injectable Solution 309090 Ceftriaxone 100 MG/ML Injectable Solution 309091 Ceftriaxone 20 MG/ML Injectable Solution 309092 Ceftriaxone 250 MG/ML Injectable Solution 204871 Ceftriaxone 350 MG/ML Injectable Solution 309093 Ceftriaxone 40 MG/ML Injectable Solution 309335 Clindamycin 12 MG/ML Injectable Solution 323888 Clindamycin 150 MG/ML 205964 Clindamycin 150 MG/ML Injectable Solution 309336 Clindamycin 18 MG/ML Injectable Solution 309339 Clindamycin 6 MG/ML Injectable Solution 309336 Clindamycin 900 MG per 50 ML Injectable Solution 205964 Clindamycin 900 MG per 6 ML Injectable Solution 371557 Clindamycin Injectable Solution 310163 Erythromycin 50 MG/ML Injectable Solution 686354 Erythromycin Gluceptate 1 MG/ML Injectable Solution 686447 Erythromycin Gluceptate 50 MG/ML Injectable Solution 597298 Erythromycin lactobionate 50 MG/ML Injectable Solution 252432 Fluconazole 2 MG/ML Injectable Solution 861607 Fluconazole 4 MG/ML Injectable Solution 377071 Fluconazole Injectable Solution 259047 Gentamicin Sulfate (USP) 0.4 MG/ML Injectable Solution 310472 Gentamicin Sulfate (USP) 0.6 MG/ML Injectable Solution 392406 Gentamicin Sulfate (USP) 0.7 MG/ML Injectable Solution 310473 Gentamicin Sulfate (USP) 0.8 MG/ML Injectable Solution 156
RxNORM Description RxNORM Code 310474 Gentamicin Sulfate (USP) 0.9 MG/ML Injectable Solution 242816 Gentamicin Sulfate (USP) 1 MG/ML Injectable Solution 310475 Gentamicin Sulfate (USP) 1.2 MG/ML Injectable Solution 310476 Gentamicin Sulfate (USP) 1.4 MG/ML Injectable Solution 310477 Gentamicin Sulfate (USP) 1.6 MG/ML Injectable Solution 239204 Gentamicin Sulfate (USP) 10 MG/ML Injectable Solution 197736 Gentamicin Sulfate (USP) 2 MG/ML Injectable Solution 310478 Gentamicin Sulfate (USP) 2.4 MG/ML Injectable Solution 484047 Gentamicin Sulfate (USP) 3.6 MG/ML Injectable Solution 313996 Gentamicin Sulfate (USP) 40 MG/ML Injectable Solution 102770 Gentamicin Sulfate (USP) 5 MG/ML Injectable Solution 415059 Gentamicin Sulfate (USP) 50 MG/ML Injectable Solution 102769 Gentamicin Sulfate (USP) 60 MG/ML Injectable Solution 246296 Gentamicin Sulfate (USP) 80 MG/ML Injectable Solution 372302 Gentamicin Sulfate (USP) Injectable Solution 311683 Metronidazole 5 MG/ML Injectable Solution 376657 Metronidazole Injectable Solution 239189 Nafcillin 100 MG/ML Injectable Solution 311895 Nafcillin 20 MG/ML Injectable Solution 239190 Nafcillin 250 MG/ML Injectable Solution 311896 Nafcillin 40 MG/ML Injectable Solution 372980 Nafcillin Injectable Solution 312127 Oxacillin 100 MG/ML Injectable Solution 312130 Oxacillin 167 MG/ML Injectable Solution 312128 Oxacillin 20 MG/ML Injectable Solution 240637 Oxacillin 40 MG/ML Injectable Solution 376698 Oxacillin Injectable Solution 617857 Penicillin G 10000 UNT/ML Injectable Solution 617881 Penicillin G 100000 UNT/ML Injectable Solution 312270 Penicillin G 300000 UNT/ML Injectable Suspension 105078 Penicillin G 375 MG/ML Injectable Solution 824584 Penicillin G benzathine 1,200,000 UNT / penicillin G procaine 1,200,000 UNT per 2 ML Prefilled Syringe 731567 Penicillin G benzathine 1,200,000 UNT per 2 ML Prefilled Syringe 731560 Penicillin G benzathine 150000 UNT/ML / penicillin G procaine 150000 UNT/ML Injectable Solution 623695 Penicillin G benzathine 150000 UNT/ML / penicillin G procaine 150000 UNT/ML Injectable Suspension 731570 Penicillin G benzathine 2,400,000 UNT per 4 ML Prefilled Syringe 623677 Penicillin G benzathine 300000 UNT/ML / penicillin G procaine 300000 UNT/ML Injectable Suspension 157
RxNORM Description RxNORM Code 731575 Penicillin G benzathine 300000 UNT/ML Injectable Suspension 836306 Penicillin G benzathine 450000 UNT/ML / penicillin G procaine 150000 UNT/ML 2 ML Prefilled Syringe 731564 Penicillin G benzathine 600,000 UNT per 1 ML Prefilled Syringe 731564 Penicillin G benzathine 600000 UNT/ML Injectable Suspension 745477 Penicillin G benzathine 900000 UNT/ML / penicillin G procaine 300000 UNT/ML Injectable Suspension 373262 Penicillin G Injectable Solution 373260 Penicillin G Injectable Suspension 745464 Penicillin G Potassium 10000 UNT/ML Injectable Solution 745300 Penicillin G Potassium 100000 UNT/ML Injectable Solution 863538 Penicillin G Potassium 1000000 UNT/ML Injectable Solution 207390 Penicillin G Potassium 20000 UNT/ML Injectable Solution 204466 Penicillin G Potassium 40000 UNT/ML Injectable Solution 207391 Penicillin G Potassium 60000 UNT/ML Injectable Solution 727620 Penicillin G Prefilled Syringe 745462 penicillin G procaine 1,200,000 UNT per 2 ML Prefilled Syringe 745303 penicillin G procaine 300000 UNT/ML Injectable Suspension 745560 penicillin G procaine 600,000 UNT per 1 ML Prefilled Syringe 745561 penicillin G procaine 600,000 UNT/ML Injectable Suspension 745302 Penicillin G Sodium 100000 UNT/ML Injectable Solution 966946 Penicillium camemberti allergenic extract 50 MG/ML Injectable Solution 966947 Penicillium chrysogenum var. chrysogenum extract 1 MG/ML 854131 Penicillium chrysogenum var. chrysogenum extract 100 MG/ML 966949 Penicillium chrysogenum var. chrysogenum extract 100 UNT/ML 883527 Penicillium chrysogenum var. chrysogenum extract 1000 UNT/ML 966951 Penicillium chrysogenum var. chrysogenum extract 10000 UNT/ML 966953 Penicillium chrysogenum var. chrysogenum extract 20000 UNT/ML 966959 Penicillium chrysogenum var. chrysogenum extract 40000 UNT/ML 966959 Penicillium chrysogenum var. chrysogenum extract 50 MG/ML 967963 Penicillium italicum extract 0.05 GM/ML Injectable Solution 966993 Penicillium roquefortii allergenic extract 50 MG/ML Injectable Solution 376858 Piperacillin / tazobactam Injectable Solution 312447 Piperacillin 200 MG/ML / tazobactam 25 MG/ML Injectable Solution 239186 Piperacillin 200 MG/ML Injectable Solution 158
RxNORM Description RxNORM Code 312442 Piperacillin 30 MG/ML Injectable Solution 312446 Piperacillin 40 MG/ML / tazobactam 5 MG/ML Injectable Solution 315178 Piperacillin 40 MG/ML Injectable Solution 312444 Piperacillin 400 MG/ML Injectable Solution 312443 Piperacillin 60 MG/ML / tazobactam 7.5 MG/ML Injectable Solution 1043464 Piperacillin 80 MG/ML / tazobactam 10 MG/ML Injectable Solution 373467 Piperacillin Injectable Solution 796488 Vancomycin 10 MG/ML Injectable Solution 239209 Vancomycin 100 MG/ML Injectable Solution 415868 Vancomycin 3 MG/ML Injectable Solution 998241 Vancomycin 3.5 MG/ML Injectable Solution 415869 Vancomycin 4 MG/ML Injectable Solution 313574 Vancomycin 5 MG/ML Injectable Solution 313572 Vancomycin 50 MG/ML Injectable Solution 998239 Vancomycin 6 MG/ML Injectable Solution 796484 Vancomycin 6.67 MG/ML Injectable Solution 796490 Vancomycin 7 MG/ML Injectable Solution 796492 Vancomycin 8 MG/ML Injectable Solution 796486 Vancomycin 8.33 MG/ML Injectable Solution 375983 Vancomycin Injectable Solution 204534 Zidovudine 10 MG/ML Injectable Solution 379126 Zidovudine Injectable Solution 4.6.4.2 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.38 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
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 http://www.nlm.nih.gov/research/umls/rxn 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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.3.21 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.38 Value Set Description To Reflect administration of Glucocortico Steroids Vocabulary 2.16.840.1.113883.6.88 RxNORM Code RxNORM description 308717 Betamethasone 3 MG/ML Injectable Solution 308718 Betamethasone 4 MG/ML Injectable Solution 578803 Betamethasone 3 MG/ML (as betamethasone sodium phosphate) / Betamethasone acetate 3 MG/ML Injectable Suspension 309697 Dexamethasone 4 MG/ML / Lidocaine 10 MG/ML Injectable Solution 881355 Dexamethasone 0.02 MG/ML Injectable Solution 436510 Dexamethasone 0.133 MG/ML Injectable Solution 309696 Dexamethasone 10 MG/ML Injectable Solution 393267 Dexamethasone 16 MG/ML Injectable Solution 435681 Dexamethasone 2 MG/ML Injectable Solution 315061 Dexamethasone 20 MG/ML Injectable Solution 160
RxNORM Code RxNORM description 197584 Dexamethasone 24 MG/ML Injectable Solution 880649 Dexamethasone 3 MG/ML Injectable Solution 309698 Dexamethasone 4 MG/ML Injectable Solution 105394 Dexamethasone 5 MG/ML Injectable Solution 387080 Dexamethasone 8 MG/ML Injectable Solution 309687 Dexamethasone 16 MG/ML Injectable Suspension 309688 Dexamethasone 8 MG/ML Injectable Suspension 4.6.4.3 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.23 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 http://www.nlm.nih.gov/research/uml s/rxnorm/ 161
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.23 Value Set Code PHVS_AugmentationOfLaborMedication_NCHS Value Set Description To reflect a medication used for the Augmentation of Labor Vocabulary 2.16.840.1.113883.6.88 RxNORM Code RxNORM Description 238013 Oxytocin 10 UNT/ML Injectable Solution 4.6.4.4 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.26 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 http://www.nlm.nih.gov/research/umls /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 8/1/2010 162
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.26 Value Set Code PHVS_EpiduralAnesthesiaMedication_NCHS Value Set Description To Reflect an Epidural Anesthesia Medication RxNORM Code Vocabulary 2.16.840.1.113883.6.88 RxNORM Description 403803 bupivacaine 0.0375 % / fentanyl 5 MCG/ML Injectable Solution 578142 bupivacaine 0.05 % / fentanyl 3 MCG/ML Injectable Solution 898637 bupivacaine 0.06 % / hydromorphone hydrochloride 2 MG per 100 ML Injectable Solution 604078 bupivacaine 0.0625 % / fentanyl 2 MCG/ML Injectable Solution 359521 bupivacaine 0.0625 % / fentanyl 5 MCG/ML Injectable Solution 898639 bupivacaine 0.0625 % / hydromorphone hydrochloride 10 MCG/ML Injectable Solution 991609 bupivacaine 0.0625 % / hydromorphone hydrochloride 5 MCG/ML Injectable Solution 403802 bupivacaine 0.1 % / fentanyl 4 MCG/ML Injectable Solution 991439 bupivacaine 0.1 % / hydromorphone hydrochloride 10 MCG/ML Injectable Solution 389167 bupivacaine 0.1 % Injectable Solution 359517 bupivacaine 0.125 % / fentanyl 2 MCG/ML Injectable Solution 898642 bupivacaine 0.125 % / hydromorphone hydrochloride 20 MCG/ML Injectable Solution 359285 bupivacaine 0.125 % Injectable Solution 282472 bupivacaine 0.25 % Injectable Solution 108469 bupivacaine 0.375 % Injectable Solution 308818 bupivacaine 0.5 % / epinephrine 1:200,000 Injectable Solution 282473 bupivacaine 0.5 % Injectable Solution 578135 Bupivacaine 0.625 MG/ML / Fentanyl 0.0025 MG/ML Injectable Solution 359520 Bupivacaine 0.625 MG/ML / Fentanyl 0.004 MG/ML Injectable Solution 359284 Bupivacaine 0.625 MG/ML Injectable Solution 163
RxNORM Code RxNORM Description 359518 Bupivacaine 1 MG/ML / Fentanyl 0.002 MG/ML Injectable Solution 578143 Bupivacaine 1 MG/ML / Fentanyl 0.003 MG/ML Injectable Solution 359523 Bupivacaine 1 MG/ML / Fentanyl 0.005 MG/ML Injectable Solution 403804 Bupivacaine 1 MG/ML / Fentanyl 0.01 MG/ML Injectable Solution 107627 Bupivacaine 1.05 MG/ML Injectable Solution 700625 Bupivacaine 1.25 MG/ML / Fentanyl 0.0025 MG/ML Injectable Solution 578136 Bupivacaine 1.25 MG/ML / Fentanyl 0.003 MG/ML Injectable Solution 700626 Bupivacaine 1.25 MG/ML / Fentanyl 0.004 MG/ML Injectable Solution 359522 Bupivacaine 1.25 MG/ML / Fentanyl 0.005 MG/ML Injectable Solution 727503 bupivacaine 100 MG per 20 ML Prefilled Syringe 727417 bupivacaine 125 MG per 50 ML Prefilled Syringe 700624 Bupivacaine 2 MG/ML Injectable Solution 317067 Bupivacaine 2.5 MG/ML / Epinephrine 0.005 MG/ML Injectable Solution 403805 Bupivacaine 2.5 MG/ML / Fentanyl 0.02 MG/ML Injectable Solution 415205 Bupivacaine 3.75 MG/ML / Lidocaine 10 MG/ML Injectable Solution 308820 Bupivacaine 7.5 MG/ML / Epinephrine 0.005 MG/ML Injectable Solution 308819 Bupivacaine 7.5 MG/ML Injectable Solution 415410 Bupivacaine 8.25 MG/ML Injectable Solution 477303 Bupivacaine Hydrochloride 2 MG/ML Injectable Solution 992805 chloroprocaine 2 % Injectable Solution 992801 Chloroprocaine hydrochloride 10 MG/ML Injectable Solution 992809 Chloroprocaine hydrochloride 30 MG/ML Injectable Solution 415205 Bupivacaine 3.75 MG/ML / Lidocaine 10 MG/ML Injectable Solution 309697 Dexamethasone 4 MG/ML / Lidocaine 10 MG/ML Injectable Solution 245841 Lidocaine 10 MG/ML / Methylprednisolone 40 MG/ML Injectable Solution 4.6.4.5 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.28 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
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 http://www.nlm.nih.gov/research/umls/r 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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.28 Value Set Code PHVS_SpinalAnesthesiaMedication_NCHS Value Set Description To Reflect a Spinal Anesthesia RxNORM Code Vocabulary 2.16.840.1.113883.6.88 RxNORM Description 403803 bupivacaine 0.0375 % / fentanyl 5 MCG/ML Injectable Solution 578142 bupivacaine 0.05 % / fentanyl 3 MCG/ML Injectable Solution 898637 bupivacaine 0.06 % / hydromorphone hydrochloride 2 MG per 100 ML Injectable Solution 604078 bupivacaine 0.0625 % / fentanyl 2 MCG/ML Injectable Solution 359521 bupivacaine 0.0625 % / fentanyl 5 MCG/ML Injectable Solution 898639 bupivacaine 0.0625 % / hydromorphone hydrochloride 10 MCG/ML Injectable Solution 991609 bupivacaine 0.0625 % / hydromorphone hydrochloride 5 MCG/ML Injectable Solution 165
RxNORM Code RxNORM Description 403802 bupivacaine 0.1 % / fentanyl 4 MCG/ML Injectable Solution 991439 bupivacaine 0.1 % / hydromorphone hydrochloride 10 MCG/ML Injectable Solution 389167 bupivacaine 0.1 % Injectable Solution 359517 bupivacaine 0.125 % / fentanyl 2 MCG/ML Injectable Solution 898642 bupivacaine 0.125 % / hydromorphone hydrochloride 20 MCG/ML Injectable Solution 359285 bupivacaine 0.125 % Injectable Solution 282472 bupivacaine 0.25 % Injectable Solution 108469 bupivacaine 0.375 % Injectable Solution 308818 bupivacaine 0.5 % / epinephrine 1:200,000 Injectable Solution 282473 bupivacaine 0.5 % Injectable Solution 578135 Bupivacaine 0.625 MG/ML / Fentanyl 0.0025 MG/ML Injectable Solution 359520 Bupivacaine 0.625 MG/ML / Fentanyl 0.004 MG/ML Injectable Solution 359284 Bupivacaine 0.625 MG/ML Injectable Solution 359518 Bupivacaine 1 MG/ML / Fentanyl 0.002 MG/ML Injectable Solution 578143 Bupivacaine 1 MG/ML / Fentanyl 0.003 MG/ML Injectable Solution 359523 Bupivacaine 1 MG/ML / Fentanyl 0.005 MG/ML Injectable Solution 403804 Bupivacaine 1 MG/ML / Fentanyl 0.01 MG/ML Injectable Solution 107627 Bupivacaine 1.05 MG/ML Injectable Solution 700625 Bupivacaine 1.25 MG/ML / Fentanyl 0.0025 MG/ML Injectable Solution 578136 Bupivacaine 1.25 MG/ML / Fentanyl 0.003 MG/ML Injectable Solution 700626 Bupivacaine 1.25 MG/ML / Fentanyl 0.004 MG/ML Injectable Solution 359522 Bupivacaine 1.25 MG/ML / Fentanyl 0.005 MG/ML Injectable Solution 727503 bupivacaine 100 MG per 20 ML Prefilled Syringe 727417 bupivacaine 125 MG per 50 ML Prefilled Syringe 700624 Bupivacaine 2 MG/ML Injectable Solution 317067 Bupivacaine 2.5 MG/ML / Epinephrine 0.005 MG/ML Injectable Solution 403805 Bupivacaine 2.5 MG/ML / Fentanyl 0.02 MG/ML Injectable Solution 415205 Bupivacaine 3.75 MG/ML / Lidocaine 10 MG/ML Injectable Solution 308820 Bupivacaine 7.5 MG/ML / Epinephrine 0.005 MG/ML Injectable Solution 308819 Bupivacaine 7.5 MG/ML Injectable Solution 415410 Bupivacaine 8.25 MG/ML Injectable Solution 477303 Bupivacaine Hydrochloride 2 MG/ML Injectable Solution 992805 chloroprocaine 2 % Injectable Solution 992801 Chloroprocaine hydrochloride 10 MG/ML Injectable Solution 992809 Chloroprocaine hydrochloride 30 MG/ML Injectable Solution 415205 Bupivacaine 3.75 MG/ML / Lidocaine 10 MG/ML Injectable Solution 309697 Dexamethasone 4 MG/ML / Lidocaine 10 MG/ML Injectable Solution 166
RxNORM Code RxNORM Description 245841 Lidocaine 10 MG/ML / Methylprednisolone 40 MG/ML Injectable Solution 4.7 Newborn Delivery 4.7.1 Newborn Delivery Information Section Table 4-128: Newborn Delivery Information Section Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 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 57075-4 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 1.3.6.1.4.1.19376.1.5.3.1.1.9.15.1 PCC TF 2:6.3.3.4.30 SHALL 1.3.6.1.4.1.19376.1.5.3.1.3.6 PCC TF 2:6.3.3.2.1 SHALL 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 PCC CDA Supplement 2:6.3.3.8.3 167
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 1.3.6.1.4.1.19376.1.5.3.1.3.21 PCC TF 2:6.3.3.3.3 Route SHALL be coded using HL7 Route of Administration (2.16.840.1.113883.12.162), specifically indicating the route where IV or IM administration route is used: ClinicalDocument/component/structuredB ody/component/section[[templateid[@root =1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4]]/com ponent/section templateid[@root=1.3.6.1.4.1.19376.1.5.3.1.3.21]]/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 =1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4]]/com ponent/section templateid[@root=1.3.6.1.4.1.19376.1.5.3.1.3.21]]/substanceadministration/entryre lationship[@typecode='rson']/observati on[cda:templateid/@root='2.16.840.1.113 883.10.20.1.28'] Coded Event Outcomes SHALL 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Coded Results SHALL 1.3.6.1.4.1.19376.1.5.3.1.3.28 PCC TF 2:6.3.3.5.2 Figure 4-11: Newborn Delivery Section Example <component> <section> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4'/> <id root=' ' extension=' '/> <code code='57075-4' displayname='newborn delivery information from newborn' codesystem='2.16.840.1.113883.6.1' codesystemname='loinc'/> <text>text as described above</text> <component> <section> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.1.9.15.1 /> <!-- Required Coded Detailed Physical Examination Section --> </section> </component> <component> <section> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/> <!-- Required if known Active Problems Section --> </section> </component> <component> 168
<section> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11'/> <!-- Required if known Procedures and Interventions Section --> </section> </component> <component> <section> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.3.21'/> <!-- Required if known Medications Administered Section --> </section> </component> <component> <section> <templateid root='1.3.6.1.4.1.19376.1.7.3.1.1.13.7'/> <!-- Required if known Coded Event Outcomes Section --> </section> </component> </section> </component> 4.7.2 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: 3141-9 the methodcode would be 8339-4 or in the case of stillborn, 57067-1 Weight of Fetus. Table 4-129: Coded Detailed Physical Examination Section Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.15.1 Parent Template Detailed Physical Examination (1.3.6.1.4.1.19376.1.5.3.1.1.9.15) 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 29545-1 SHALL Physical Examination Subsections Opt Description 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 SHOULD Coded Vital Signs Vital signs may be a subsection of the physical examination or they may stand alone 1.3.6.1.4.1.19376.1.5.3.1.1.9.16 SHOULD General Appearance 169
4.7.2.1 Coded Vital Signs This value set is used in the section Coded Detailed Physical Examination: (1.3.6.1.4.1.19376.1.5.3.1.1.9.15.1) Vital Signs Section of the Newborn (template ID 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2). 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 364589006 3141-9 MCH HBS Body Weight^at birth 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.20 PQ 8306-3 Body Height^at birth TBD OID PQ 169876006 8290-9 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.20 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 http://loinc.org 8/1/2010 N/A 8/1/2010 N/A 170
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.20 Value Set Description To Reflect the Birth Weight LOINC Code Vocabulary 2.16.840.1.113883.6.1 3141-9 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 http://loinc.org 171
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 Value Set TBD OID Value Set Description To Reflect the Birth Height LOINC Code Vocabulary 2.16.840.1.113883.6.1 TBD Birth Height LOINC Description 4.7.2.2 General Appearance Table 4-135: Newborn General Appearance Value Set This value set is used in the section Coded Detailed Physical Examination (1.3.6.1.4.1.19376.1.5.3.1.1.9.15.1) General Appearance Section of the Newborn (template ID 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2). Data Element APGAR score : 5 mn APGAR Score : 10 mn Code Type SNOMED LOINC Value sets OID INT 9274-2 MCH HBS 5 Min Apgar Score Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13. 8.12 INT 9271-8 MCH HBS 10 Min Apgar Score Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13. 8.13 172
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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.12 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 http://loinc.org 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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.9.16 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.12 Value Set Code PHVS_ApgarScore5Min_NCHS Value Set Description To reflect the 5 Min Apgar Score Vocabulary OID 2.16.840.1.113883.6.1 173
LOINC Code 9274-2 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.13 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 http://loinc.org 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
Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.9.16 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.13 Value Set Code PHVS_ApgarScore10Min_NCHS Value Set Description To Reflect the 10 Min Apgar Score Vocabulary OID 2.16.840.1.113883.6.1 LOINC Code LOINC Description 9271-8 Score^10M post birth 4.7.3 Active Problems Table 4-140: Active Problems Section Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.6 Parent Template CCD 3.5 (2.16.840.1.113883.10.20.1.11) 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 11450-4 SHALL Problem List Entries Opt Description 1.3.6.1.4.1.19376.1.5.3.1.4.5.2 SHALL Problem Concern Entry SPECIFICATION SHALL contain exactly two [2..2] templateid such that it o SHALL contain exactly one [1..1] @root="1.3.6.1.4.1.19376.1.5.3.1.3.6" o SHALL conform to CCD Problem Section template and contain exactly one [1..1] @root="2.16.840.1.113883.10.20.1.11" SHALL contain exactly one [1..1] code/@code="11450-4" Problem List (CodeSystem: LOINC 2.16.840.1.113883.6.1) 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 (1.3.6.1.4.1.19376.1.5.3.1.4.5.2) 175
Figure 4-12: Active Problems Section Example <component> <section> <templateid root='2.16.840.1.113883.10.20.1.11'/> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/> <id root=' ' extension=' '/> <code code='11450-4' displayname='problem LIST' codesystem='2.16.840.1.113883.6.1' codesystemname='loinc'/> <text> Text as described above </text> <entry> : <!-- Required Problem Concern Entry element --> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.4.5.2'/> : </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 1.3.6.1.4.1.19376.1.5.3.1.3.6). 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.10 4.7.3.1 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.10 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
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 http://www.nlm.nih.gov/research/umls/ 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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.3.6 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.10 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 2.16.840.1.113883.6.96 177
SNOMED-CT Code SNOMED-CT Description 91175000 Seizure (finding) 83752007 Abdominal seizure (finding) 444229001 Afebrile seizure (finding) 41119002 Akinetic seizure without atonia (finding) 41510006 Anoxic seizure (finding) 438156004 Anoxic epileptic seizure (finding) 440443001 Reflex anoxic seizure (finding) 59754009 Brief atonic seizure (finding) 58895005 Central convulsion (finding) 443410001 Childhood seizure (finding) 29963001 Dysmnesic seizure (disorder) 73706008 Epileptic cry (finding) 313307000 Epileptic seizure (finding) 192982004 Epileptic seizures - akinetic (finding) 192981006 Epileptic seizures - atonic (finding) 192991000 Epileptic seizures - clonic (finding) 192993002 Epileptic seizures - tonic (finding) 41497008 Febrile convulsion (finding) 433083002 Complex febrile seizure (finding) 163595003 On examination - febrile convulsion (finding) 307200007 Recurrent febrile convulsion (finding) 432354000 Simple febrile seizure (finding) 246545002 Generalized seizure (finding) 6208003 Clonic seizure (finding) 2665008 Coordinate convulsion (finding) 18191000 Salaam spasm (finding) 54200006 Tonic-clonic seizure (finding) 65155005 Grand mal seizure (finding) 163590008 On examination - grand mal fit (finding) 20544001 Secondarily generalized seizures (finding) 73840001 Ideational partial seizure (finding) 87185006 Long atonic seizure (finding) 19593003 Movement partial seizure (finding) 178
4.7.4 Procedures and Interventions Table 4-144: Procedures and Interventions Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 General Description This section contains a narrative description of the actions performed by a clinician. LOINC Code Opt Description 29544-3 SHALL Procedures Entries Opt Description 1.3.6.1.4.1.19376.1.5.3.1.4.19 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='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11'/> <id root=' ' extension=' '/> <code code='29544-3' displayname='procedures' codesystem='2.16.840.1.113883.6.1' codesystemname='loinc'/> <text> Text as described above </text> <entry> : <!-- Required Procedures element --> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/> : </entry> </section> </component> Figure 4-14: Procedure Entry Example Procedure Entry: 1.3.6.1.4.1.19376.1.5.3.1.4.19 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='1.3.6.1.4.1.19376.1.5.3.1.4.19'/> <templateid root='2.16.840.1.113883.10.20.1.29'/> <templateid root='2.16.840.1.113883.10.20.1.25'/> <id root='' extension=''/> <code code='' codesystem='2.16.840.1.113883.5.4' codesystemname='actcode' /> <text><reference value='#xxx'/></text> 179
<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='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/> <id root='' extension=''/> </act> </entryrelationship> <entryrelationship typecode='rson'> <act classcode='act' moodcode='evn'> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/> <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 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11). 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.178 Karyotype 312948004 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.154 MCH HBS Assisted Ventilation Immediately Following Delivery Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.7 BFDR Total Time on Ventilator Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.91 180
4.7.4.1 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.178 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 http://www.nlm.nih.gov/research/umls/ 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
Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.178 Value Set Code PHVS_AntibioticAdministrationProcedure_NCHS Value Set Description To Reflect Antibiotic Administration Procedure during labor and delivery SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 281790008 Intravenous antibiotic therapy (procedure) 307520009 Intramuscular antibiotic therapy (procedure) 4.7.4.2 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.154 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 http://www.nlm.nih.gov/research/umls/ 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
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.154 Value Set Code PHVS_KaryotypeDetermination_NCHS Value Set Description To Reflect Fetal Autopsy was performed SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 312948004 Karyotype determination (procedure) 444309000 Determination of karyotype from blood specimen (procedure) 4.7.4.3 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.7 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
Element Description Mandatory Source URI Most sources also have a URL or document URI that provides http://www.nlm.nih.gov/research/umls /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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.7 Value Set Description To Reflect that the newborn was provided assisted ventilation immediately following delivery reflecting an abnormal condition of the newborn Vocabulary 2.16.840.1.113883.6.96 SNOMED Code Pending Pending SNOMED Description 4.7.4.4 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.191 the value set Name This is the name of the value set BFDR Total Time on Ventilator Value Set 184
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 http://www.nlm.nih.gov/research/umls/ 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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.91 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 2.16.840.1.113883.6.96 Pending Pending SNOMED-CT Description 185
4.7.5 Medications Administered Table 4-154: Medications Administered Section Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.21 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 18610-6 SHALL Medication Administered Entries Opt Description 1.3.6.1.4.1.19376.1.5.3.1.4.7 SHALL Medications SPECIFICATION SHALL contain exactly one [1..1] templateid such that it o SHALL contain exactly one [1..1] @root="1.3.6.1.4.1.19376.1.5.3.1.3.21" SHALL contain exactly one [1..1] code/@code="18610-6" Medications Administered (CodeSystem: LOINC 2.16.840.1.113883.6.1) 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 (1.3.6.1.4.1.19376.1.5.3.1.4.7) Figure 4-15: Medications Administered Section Example <component> <section> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.3.21'/> <id root=' ' extension=' '/> <code code='18610-6' displayname='medication ADMINISTERED' codesystem='2.16.840.1.113883.6.1' codesystemname='loinc'/> <text> Text as described above </text> <entry> : <!-- Required Medications element --> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/> : </entry> </section> </component> 186
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 1.3.6.1.4.1.19376.1.5.3.1.3.21). 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.11 MCH HBS Intramuscular Medication Administration Route Codes Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.5 BFDR IV Medication Administration Route Value Set, 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.4 BFDR Neonatal Sepsis Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.6 4.7.5.1 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.11 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
Element Description Mandatory Source URI Most sources also have a URL or document URI that provides http://www.nlm.nih.gov/research/umls/rx 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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.3.21 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.11 Value Set Description To reflect that the Newborn received Surfactant Replacement Therapy reflecting an abnormal condition of the newborn RXNORM Code Vocabulary 2.16.840.1.113883.6.88 RXNORM Description 259034 Beractant 25 MG/ML Injectable Suspension 379138 Beractant Injectable Suspension 259611 Calfactant 35 MG/ML Inhalant Solution 379477 Calfactant Inhalant Solution 141920 Colfosceril 13.5 MG/ML Injectable Suspension 385921 Colfosceril Injectable Suspension 259216 Poractant alfa 80 MG/ML Injectable Suspension 375227 Poractant alfa Injectable Suspension 188
4.7.5.2 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.5 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 http://www.hl7.org/memonly/download 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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.3.21 189
Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.5 Value Set Description To reflect that Intramuscular Medication Administration Route was used to administer a medication Data Element Vocabulary 2.16.840.1.113883.12.162 IM Intramuscular HL7 Route of Administration 4.7.5.3 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.4 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 http://www.hl7.org/memonly/downloads/ 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
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.3.21 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.4 Value Set Description To reflect that IV Medication Administration Route was used to administer a medication Data Element Vocabulary 2.16.840.1.113883.12.162 IV Intravenous HL7 Route of Administration 4.7.5.4 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.6 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 http://www.nlm.nih.gov/research/uml 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
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.3.21 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.6 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 2.16.840.1.113883.6.96 SNOMED-CT Description 276669000 Bacterial sepsis of newborn (disorder) 211420008 Neonatal candida septicemia (disorder) 359646002 Neonatal disseminated listeriosis (disorder) 403000003 Neonatal systemic candidosis (disorder) 206380000 Sepsis of newborn due to anaerobes (disorder) 206379003 Sepsis of newborn due to Escherichia coli (disorder) 206378006 Sepsis of newborn due to Staphylococcus aureus (disorder) 206376005 Sepsis of the newborn (disorder) 41229001 Septicemia of newborn (disorder) 43424001 Tetanus neonatorum (disorder) 4.7.6 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.7). 192
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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.1 98 CD MCH HBS Significant Birth Injury Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.9 CD 21842-0 BFDR Birthplace Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.1 86 INT 73771-8 D 268477000 Infant expired BL TBD Cause of death ST 152527006 Cause of Death (ICD-10) Value Set 2.16.840.1.114222.4.11.3593 Location of ST 58332-8 death Date of death TS 31211-6 4.7.6.1 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.198 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 http://www.nlm.nih.gov/research/umls/ Snomed/snomed_main.html 193
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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.198 Value Set Description To reflect the that the baby was transferred to NICU following the birth SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 405269005 Neonatal intensive care unit (environment) 4.7.6.2 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.9 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
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. http://www.nlm.nih.gov/research/uml 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 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.9 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 2.16.840.1.113883.6.96 56110009 Birth trauma of fetus (disorder) 206253009 Birth injury to face (disorder) SNOMED-CT Description 195
SNOMED-CT Code 37384000 Birth injury to scalp (disorder) 82729001 Caput succedaneum (disorder) 302962000 Chignon (disorder) SNOMED-CT Description 206201001 Vacuum extraction chignon (disorder) 268822004 Fetal monitoring scalp injury (disorder) 276704001 Electrode injury to scalp during birth (disorder) 276705000 Sampling injury to scalp during birth (disorder) 206199003 Scalp injuries due to birth trauma (disorder) 206200000 Cephalhematoma due to birth trauma (disorder) 206203003 Scalp abrasions due to birth trauma (disorder) 403849006 Scalp injury due to vacuum extraction (disorder) 129631008 Birth trauma deafness (disorder) 206251006 Birth trauma due to amniocentesis (disorder) 240312009 Cerebral injury due to birth trauma (disorder) 206196005 Cerebral hemorrhage due to birth injury (disorder) 206195009 Extradural hemorrhage in fetus or newborn (disorder) 206188000 Subdural and cerebral hemorrhage due to birth trauma (disorder) 206192007 Tentorial tear due to birth trauma (disorder) 206234004 Cranial nerve injury due to birth trauma (disorder) 55712002 Facial nerve injury as birth trauma (disorder) 84947004 Facial palsy as birth trauma (disorder) 111465000 Erb-Duchenne palsy as birth trauma (disorder) 50263004 Hematoma of vulva of fetus or newborn as birth trauma (disorder) 16581008 Injury of spine AND/OR spinal cord as birth trauma (disorder) 53785005 Injury to brachial plexus as birth trauma (disorder) 206226005 Brachial plexus palsy due to birth trauma (disorder) 81774005 Klumpke-Déjerine paralysis as birth trauma (disorder) 240317003 Kidney injury due to birth trauma (disorder) 240316007 Laryngeal injury due to birth trauma (disorder) 206245001 Liver rupture due to birth trauma (disorder) 371129000 Paralysis from birth trauma (disorder) 40980002 Spastic paralysis due to birth injury (disorder) 28534004 Spastic paralysis due to intracranial birth injury (disorder) 79591004 Spastic paralysis due to spinal birth injury (disorder) 403848003 Perinatal forceps injury (disorder) 403847008 Perinatal skin trauma due to obstetric injury (disorder) 196
SNOMED-CT Code SNOMED-CT Description 206235003 Peripheral nerve injury due to birth trauma (disorder) 206233005 Birth injury to phrenic nerve (disorder) 28778005 Phrenic nerve paralysis as birth trauma (disorder) 206228006 Birth plexus injury - whole plexus (disorder) 206247009 Scalpel wound due to birth trauma (disorder) 240314005 Skeletal injury due to birth trauma (disorder) 206216003 Birth dislocation of the shoulder (disorder) 20596003 Fracture of long bone, as birth trauma (disorder) 275365008 Birth fracture of radius (disorder) 275366009 Birth fracture of ulna (disorder) 206209004 Fracture of clavicle due to birth trauma (disorder) 206213006 Fracture of femur due to birth trauma (disorder) 206211008 Fracture of humerus due to birth trauma (disorder) 240315006 Fracture of nose due to birth trauma (disorder) 268824003 Fracture of radius and/or ulna due to birth trauma (disorder) 64728002 Fracture of spine due to birth trauma (disorder) 206214000 Fracture of tibia and/or fibula due to birth trauma (disorder) 206221000 Spine dislocation due to birth trauma (disorder) 206220004 Spine or spinal cord injury due to birth trauma (disorder) 206223002 Spinal cord laceration due to birth trauma (disorder) 206224008 Spinal cord rupture due to birth trauma (disorder) 268826001 Spleen rupture due to birth trauma (disorder) 206252004 Sternomastoid injury due to birth injury (disorder) 30671001 Tentorial tear as birth trauma (disorder) 4.7.6.3 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.186 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
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 http://www.nlm.nih.gov/research/umls/s 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 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.9 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.186 Value Set Description To reflect the Place where birth occurred SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 169813005 Home birth (finding) 408839006 Planned home birth (finding) 408838003 Unplanned home birth (finding) 169817006 Ambulance birth (finding) SNOMED-CT Description 91154008 Free-standing birthing center (environment) 67190003 Free-standing clinic (environment) 198
4.7.6.4 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 2.16.840.1.114222.4.11.3593 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 http://www.nlm.nih.gov/research/umls/ 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
Table 4-172: Cause of Death Value Set Excerpt Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 2.16.840.1.114222.4.11.3593 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 2.16.840.1.113883.6.3 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 1.3.6.1.4.1.19376.1.5.3.1.3.31 Parent Template CCD 3.16 (2.16.840.1.113883.10.20.1.10) 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 18776-5 SHALL Plan of Treatment 200
Entries Opt Description 1.3.6.1.4.1.19376.1.5.3.1.1.20.3.1 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). 1.3.6.1.4.1.19376.1.5.3.1.4.7 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. 1.3.6.1.4.1.19376.1.5.3.1.4.12 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. 1.3.6.1.4.1.19376.1.5.3.1.4.19 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. 1.3.6.1.4.1.19376.1.5.3.1.4.14 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="1.3.6.1.4.1.19376.1.5.3.1.3.31" o SHALL conform to CCD Plan of Care Section and contain exactly one [1..1] @root="2.16.840.1.113883.10.20.1.10". SHALL contain exactly one [1..1] code/@code="18776-5" Plan of Treatment (CodeSystem: LOINC 2.16.840.1.113883.6.1) 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 (1.3.6.1.4.1.19376.1.5.3.1.1.20.3.1) MAY contain zero or more [0..*] entry such that it o SHALL contain exactly one [1..1] Medications Entry (1.3.6.1.4.1.19376.1.5.3.1.4.7) MAY contain zero or more [0..*] entry such that it o SHALL contain exactly one [1..1] Immunization Entry (1.3.6.1.4.1.19376.1.5.3.1.4.12) MAY contain zero or more [0..*] entry such that it o SHALL contain exactly one [1..1] Procedure Entry (1.3.6.1.4.1.19376.1.5.3.1.4.19) MAY contain zero or more [0..*] entry such that it o SHALL contain exactly one [1..1] Encounters Entry(1.3.6.1.4.1.19376.1.5.3.1.4.14) 201
4.8.1.1 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 (1.3.6.1.4.1.19376.1.5.3.1.4.14) Figure 4-16: Care Plan Section Example <component> <section> <templateid root='2.16.840.1.113883.10.20.1.10'/> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/> <id root=' ' extension=' '/> <code code='18776-5' displayname='treatment PLAN' codesystem='2.16.840.1.113883.6.1' codesystemname='loinc'/> <text> Text as described above </text> <entry> : <!-- Required Encounters element --> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.4.14'/> : </entry> </section> </component> 4.8.1.2 Encounters Entry 1.3.6.1.4.1.19376.1.5.3.1.4.14 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 [1..1] @classcode="enc" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) SHALL contain exactly one [1..1] @moodcode="apt ARQ EVN" (CodeSystem: HL7ActMood 2.16.840.1.113883.5.1001) 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 [1..1] @root="1.3.6.1.4.1.19376.1.5.3.1.4.14" 202
o When the encounter is in event mood (moodcode='evn'), this entry SHALL conform to the CCD template 2.16.840.1.113883.10.20.1.21 o When the encounter is in other moods, this entry SHALL conform to the CCD template 2.16.840.1.113883.10.20.1.25 SHALL contain one or more [1..*] id SHALL contain exactly one [1..1] code, where the @code SHOULD be selected from ValueSet ActEncounterCode 2.16.840.1.113883.5.4 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 4.3.5.1) 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 [1..1] @typecode="loc" Location o (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) SHALL contain exactly one [1..1] participantrole such that it SHALL contain exactly one [1.1] @classcode="sdloc" Service Delivery Location (2.16.840.1.113883.5.111) 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 [1.1] @classcode="plc" Place (2.16.840.1.113883.5.41 o This playingentity SHALL contain exactly one [1..1] name 203
Figure 4-17: Encounter Entry Example <encounter classcode='enc' moodcode='apt ARQ EVN'> <templateid root='1.3.6.1.4.1.19376.1.5.3.1.4.14'/> <templateid root='2.16.840.1.113883.10.20.1.21'/> <templateid root='2.16.840.1.113883.10.20.1.25'/> <id root='' extension=''/> <code code='' codesystem='2.16.840.1.113883.5.4' 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 2.16.840.1.113883.10.20.7.11 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 2.16.840.1.113883.10.20.7.11 MAY contain zero or one [0..1] sdtc:dischargedispositioncode, which SHALL be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 National Uniform Billing Committee (NUBC) UB-04 FL17-Patient Status DYNAMIC or, if access to NUBC is unavailable, from CodeSystem 2.16.840.1.113883.12.112 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
Figure 4-18: Disposition Section Example <sdtc:dischargedispositioncode xmlns:sdtc="urn:hl7-org:sdtc" code="self CARE" codesystem="2.16.840.1.113883.12.112" codesystemname="hl7 Discharge Disposition"> <originaltext> <reference value=""/> </originaltext> </sdtc:dischargedispositioncode> 205
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
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
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
Appendix B Value Sets A No applicable value sets. B BFDR Antibiotics Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.3.21 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.3 Value Set Code PHVS_Antibiotics_NCHS Value Set Description To Reflect that antibiotics were administered. RxNORM Code Vocabulary 2.16.840.1.113883.6.88 RxNORM Code 731558 1 ML penicillin G benzathine 300000 UNT/ML / penicillin G procaine 300000 UNT/ML Prefilled Syringe 731538 2 ML penicillin G benzathine 300000 UNT/ML / penicillin G procaine 300000 UNT/ML Prefilled Syringe 731590 4 ML penicillin G benzathine 300000 UNT/ML / penicillin G procaine 300000 UNT/ML Prefilled Syringe 890921 5000 MG Clindamycin 20 MG/ML Prefilled Applicator 248108 Acyclovir 25 MG/ML Injectable Solution 313812 Acyclovir 50 MG/ML Injectable Solution 377143 Acyclovir Injectable Solution 239240 Amphotericin B 5 MG/ML Injectable Solution 376660 Amphotericin B Injectable Solution 789980 Ampicillin (as ampicillin sodium) 100 MG/ML Injectable Solution 313819 Ampicillin (as ampicillin sodium) 250 MG/ML Injectable Solution 378107 Ampicillin / Floxacillin Injectable Solution 376673 Ampicillin / Sulbactam Injectable Solution 240984 Ampicillin 100 MG/ML / Sulbactam 50 MG/ML Injectable Solution 756252 Ampicillin 125 MG / floxacillin 125 MG per 5 ML Elixir 308207 Ampicillin 125 MG/ML Injectable Solution 105134 Ampicillin 167 MG/ML / Floxacillin 167 MG/ML Injectable Solution 993109 Ampicillin 20 MG/ML / Sulbactam 10 MG/ML Injectable Solution 308208 Ampicillin 250 MG/ML / Sulbactam 125 MG/ML Injectable Solution Birth Defects Implementation Guide APP-4
RxNORM Code RxNORM Code 308208 Ampicillin 30 MG/ML / Sulbactam 15 MG/ML Injectable Solution 370584 Ampicillin Injectable Solution 309051 Cefazolin 10 MG/ML Injectable Solution 796301 Cefazolin 100 MG/ML Injectable Solution 309052 Cefazolin 20 MG/ML Injectable Solution 313920 Cefazolin 200 MG/ML Injectable Solution 309053 Cefazolin 225 MG/ML Injectable Solution 562062 Cefazolin 250 MG/ML Injectable Solution 313929 Cefazolin 330 MG/ML Injectable Solution 371324 Cefazolin Injectable Solution 198396 Cefotaxime 20 MG/ML Injectable Solution 309065 Cefotaxime 200 MG/ML Injectable Solution 309068 Cefotaxime 230 MG/ML Injectable Solution 309066 Cefotaxime 300 MG/ML Injectable Solution 309067 Cefotaxime 330 MG/ML Injectable Solution 198395 Cefotaxime 40 MG/ML Injectable Solution 371331 Cefotaxime Injectable Solution 389025 Ceftazidime 10 MG/ML Injectable Solution 309083 Ceftazidime 170 MG/ML Injectable Solution 309082 Ceftazidime 20 MG/ML Injectable Solution 242800 Ceftazidime 200 MG/ML Injectable Solution 249926 Ceftazidime 210 MG/ML Injectable Solution 240447 Ceftazidime 250 MG/ML Injectable Solution 313890 Ceftazidime 280 MG/ML Injectable Solution 309084 Ceftazidime 40 MG/ML Injectable Solution 389026 Ceftazidime 60 MG/ML Injectable Solution 371337 Ceftazidime Injectable Solution 309090 Ceftriaxone 100 MG/ML Injectable Solution 309091 Ceftriaxone 20 MG/ML Injectable Solution 309092 Ceftriaxone 250 MG/ML Injectable Solution 204871 Ceftriaxone 350 MG/ML Injectable Solution 309093 Ceftriaxone 40 MG/ML Injectable Solution 309335 Clindamycin 12 MG/ML Injectable Solution 323888 Clindamycin 150 MG/ML 205964 Clindamycin 150 MG/ML Injectable Solution 309336 Clindamycin 18 MG/ML Injectable Solution 309339 Clindamycin 6 MG/ML Injectable Solution 309336 Clindamycin 900 MG per 50 ML Injectable Solution 205964 Clindamycin 900 MG per 6 ML Injectable Solution 371557 Clindamycin Injectable Solution 310163 Erythromycin 50 MG/ML Injectable Solution 686354 Erythromycin Gluceptate 1 MG/ML Injectable Solution Birth Defects Implementation Guide APP-5
RxNORM Code RxNORM Code 686447 Erythromycin Gluceptate 50 MG/ML Injectable Solution 597298 Erythromycin lactobionate 50 MG/ML Injectable Solution 252432 Fluconazole 2 MG/ML Injectable Solution 861607 Fluconazole 4 MG/ML Injectable Solution 377071 Fluconazole Injectable Solution 259047 Gentamicin Sulfate (USP) 0.4 MG/ML Injectable Solution 310472 Gentamicin Sulfate (USP) 0.6 MG/ML Injectable Solution 392406 Gentamicin Sulfate (USP) 0.7 MG/ML Injectable Solution 310473 Gentamicin Sulfate (USP) 0.8 MG/ML Injectable Solution 310474 Gentamicin Sulfate (USP) 0.9 MG/ML Injectable Solution 242816 Gentamicin Sulfate (USP) 1 MG/ML Injectable Solution 310475 Gentamicin Sulfate (USP) 1.2 MG/ML Injectable Solution 310476 Gentamicin Sulfate (USP) 1.4 MG/ML Injectable Solution 310477 Gentamicin Sulfate (USP) 1.6 MG/ML Injectable Solution 239204 Gentamicin Sulfate (USP) 10 MG/ML Injectable Solution 197736 Gentamicin Sulfate (USP) 2 MG/ML Injectable Solution 310478 Gentamicin Sulfate (USP) 2.4 MG/ML Injectable Solution 484047 Gentamicin Sulfate (USP) 3.6 MG/ML Injectable Solution 313996 Gentamicin Sulfate (USP) 40 MG/ML Injectable Solution 102770 Gentamicin Sulfate (USP) 5 MG/ML Injectable Solution 415059 Gentamicin Sulfate (USP) 50 MG/ML Injectable Solution 102769 Gentamicin Sulfate (USP) 60 MG/ML Injectable Solution 246296 Gentamicin Sulfate (USP) 80 MG/ML Injectable Solution 372302 Gentamicin Sulfate (USP) Injectable Solution 311683 Metronidazole 5 MG/ML Injectable Solution 376657 Metronidazole Injectable Solution 239189 Nafcillin 100 MG/ML Injectable Solution 311895 Nafcillin 20 MG/ML Injectable Solution 239190 Nafcillin 250 MG/ML Injectable Solution 311896 Nafcillin 40 MG/ML Injectable Solution 372980 Nafcillin Injectable Solution 312127 Oxacillin 100 MG/ML Injectable Solution 312130 Oxacillin 167 MG/ML Injectable Solution 312128 Oxacillin 20 MG/ML Injectable Solution 240637 Oxacillin 40 MG/ML Injectable Solution 376698 Oxacillin Injectable Solution 617857 Penicillin G 10000 UNT/ML Injectable Solution 617881 Penicillin G 100000 UNT/ML Injectable Solution 312270 Penicillin G 300000 UNT/ML Injectable Suspension 105078 Penicillin G 375 MG/ML Injectable Solution 824584 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
RxNORM Code RxNORM Code 731567 Penicillin G benzathine 1,200,000 UNT per 2 ML Prefilled Syringe 731560 Penicillin G benzathine 150000 UNT/ML / penicillin G procaine 150000 UNT/ML Injectable Solution 623695 Penicillin G benzathine 150000 UNT/ML / penicillin G procaine 150000 UNT/ML Injectable Suspension 731570 Penicillin G benzathine 2,400,000 UNT per 4 ML Prefilled Syringe 623677 Penicillin G benzathine 300000 UNT/ML / penicillin G procaine 300000 UNT/ML Injectable Suspension 731575 Penicillin G benzathine 300000 UNT/ML Injectable Suspension 836306 Penicillin G benzathine 450000 UNT/ML / penicillin G procaine 150000 UNT/ML 2 ML Prefilled Syringe 731564 Penicillin G benzathine 600,000 UNT per 1 ML Prefilled Syringe 731564 Penicillin G benzathine 600000 UNT/ML Injectable Suspension 745477 Penicillin G benzathine 900000 UNT/ML / penicillin G procaine 300000 UNT/ML Injectable Suspension 373262 Penicillin G Injectable Solution 373260 Penicillin G Injectable Suspension 745464 Penicillin G Potassium 10000 UNT/ML Injectable Solution 745300 Penicillin G Potassium 100000 UNT/ML Injectable Solution 863538 Penicillin G Potassium 1000000 UNT/ML Injectable Solution 207390 Penicillin G Potassium 20000 UNT/ML Injectable Solution 204466 Penicillin G Potassium 40000 UNT/ML Injectable Solution 207391 Penicillin G Potassium 60000 UNT/ML Injectable Solution 727620 Penicillin G Prefilled Syringe 745462 penicillin G procaine 1,200,000 UNT per 2 ML Prefilled Syringe 745303 penicillin G procaine 300000 UNT/ML Injectable Suspension 745560 penicillin G procaine 600,000 UNT per 1 ML Prefilled Syringe 745561 penicillin G procaine 600,000 UNT/ML Injectable Suspension 745302 Penicillin G Sodium 100000 UNT/ML Injectable Solution 966946 Penicillium camemberti allergenic extract 50 MG/ML Injectable Solution 966947 Penicillium chrysogenum var. chrysogenum extract 1 MG/ML 854131 Penicillium chrysogenum var. chrysogenum extract 100 MG/ML 966949 Penicillium chrysogenum var. chrysogenum extract 100 UNT/ML 883527 Penicillium chrysogenum var. chrysogenum extract 1000 UNT/ML 966951 Penicillium chrysogenum var. chrysogenum extract 10000 UNT/ML 966953 Penicillium chrysogenum var. chrysogenum extract 20000 UNT/ML 966959 Penicillium chrysogenum var. chrysogenum extract 40000 UNT/ML 966959 Penicillium chrysogenum var. chrysogenum extract 50 MG/ML 967963 Penicillium italicum extract 0.05 GM/ML Injectable Solution 966993 Penicillium roquefortii allergenic extract 50 MG/ML Injectable Solution 376858 Piperacillin / tazobactam Injectable Solution 312447 Piperacillin 200 MG/ML / tazobactam 25 MG/ML Injectable Solution Birth Defects Implementation Guide APP-7
RxNORM Code RxNORM Code 239186 Piperacillin 200 MG/ML Injectable Solution 312442 Piperacillin 30 MG/ML Injectable Solution 312446 Piperacillin 40 MG/ML / tazobactam 5 MG/ML Injectable Solution 315178 Piperacillin 40 MG/ML Injectable Solution 312444 Piperacillin 400 MG/ML Injectable Solution 312443 Piperacillin 60 MG/ML / tazobactam 7.5 MG/ML Injectable Solution 1043464 Piperacillin 80 MG/ML / tazobactam 10 MG/ML Injectable Solution 373467 Piperacillin Injectable Solution 796488 Vancomycin 10 MG/ML Injectable Solution 239209 Vancomycin 100 MG/ML Injectable Solution 415868 Vancomycin 3 MG/ML Injectable Solution 998241 Vancomycin 3.5 MG/ML Injectable Solution 415869 Vancomycin 4 MG/ML Injectable Solution 313574 Vancomycin 5 MG/ML Injectable Solution 313572 Vancomycin 50 MG/ML Injectable Solution 998239 Vancomycin 6 MG/ML Injectable Solution 796484 Vancomycin 6.67 MG/ML Injectable Solution 796490 Vancomycin 7 MG/ML Injectable Solution 796492 Vancomycin 8 MG/ML Injectable Solution 796486 Vancomycin 8.33 MG/ML Injectable Solution 375983 Vancomycin Injectable Solution 204534 Zidovudine 10 MG/ML Injectable Solution 379126 Zidovudine Injectable Solution BFDR Assistive Reproductive Technology Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.146 Value Set Code PHVS_AssistiveReproductiveTechnology_NCHS Value Set Description To reflect the Assistive Reproductive Technology as a Risk Factor in Pregnancy Vocabulary OID 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 52637005 Test tube ovum fertilization (procedure) 63487001 Assisted fertilization (procedure) 176843009 Gamete intrauterine transfer (procedure) 176996001 Endoscopic intrafallopian transfer of gamete (procedure) 225244002 Direct injection of sperm into cytoplasm of the oocyte (procedure) 225247009 Direct intraperitoneal insemination Birth Defects Implementation Guide APP-8
SNOMED-CT Code 225248004 Zona drilling (procedure) 225249007 Subzonal insemination SNOMED-CT Description 236912008 Gamete intrafallopian transfer (procedure) 236913003 Fallopian replacement of egg with delayed insemination (procedure) 236914009 Zygote intrafallopian transfer (procedure) 236915005 Tubal embryo transfer (procedure) 238312005 Intraperitoneal insemination 425866000 In vitro fertilization using donor eggs (procedure) 425901007 In vitro fertilization with intracytoplasmic sperm injection (procedure) 426417003 In vitro fertilization with preimplantation genetic diagnosis (procedure) 426914002 In vitro fertilization using donor egg and intracytoplasmic sperm injection (procedure) 427664000 In vitro fertilization using donor sperm (procedure) 443633009 Conceived by in vitro fertilization (finding) BFDR Augmentation of Labor Medication Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.23 Value Set Code PHVS_AugmentationOfLaborMedication_NCHS Value Set Description To reflect a medication used for the Augmentation of Labor Vocabulary 2.16.840.1.113883.6.88 RxNORM Code RxNORM Description 238013 Oxytocin 10 UNT/ML Injectable Solution BFDR Augmentation of Labor Procedure Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.22 Value Set Code PHVS_AugmentationOfLaborProcedure_NCHS Value Set Description To reflect a procedure of Augmentation of Labor Vocabulary 2.16.840.1.113883.6.96 Birth Defects Implementation Guide APP-9
SNOMED-CT Code SNOMED-CT Description 237001001 Augmentation of labor (procedure) 237002008 Stimulation of labor (procedure) BFDR Birthplace Section Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.9 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.186 Value Set Description To reflect the Place where birth occurred Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 169813005 Home birth (finding) 408839006 Planned home birth (finding) 408838003 Unplanned home birth (finding) 169817006 Ambulance birth (finding) 91154008 Free-standing birthing center (environment) 67190003 Free-standing clinic (environment) BFDR Birth Plurality of Delivery Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.132 Value Set Code PHVS_BirthPluralityOfDelivery_NCHS Value Set Description To Reflect the Birth Plurality of Delivery Vocabulary 2.16.840.1.113883.6.1 LOINC Code LOINC Description 57722-1 Birth plurality Birth Defects Implementation Guide APP-10
BFDR Cervical Cerclage Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.125 Value Set Code PHVS_CervicalCerclage_NCHS Value Set Description To Reflect Obstetric Procedures as Cervical Cerclage SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 265636007 Cerclage of cervix (procedure) SNOMED-CT Description 236946009 Macdonald's cervical cerclage (procedure) 46681009 Cerclage of cervix during pregnancy by abdominal approach (procedure) 90442009 Cerclage of cervix during pregnancy by vaginal approach (procedure) 360399007 Marckwald operation on cervix (procedure) 176785004 Non-obstetric encircling suture of cervical os (procedure) 236947000 Shirodkar's cervical cerclage (procedure) BFDR Date of Last Menses Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.69 Value Set Code PHVS_NumberofLiveBirths_NCHS Value Set Description To reflect the Date of Last Menses Vocabulary OID 2.16.840.1.113883.6.1 LOINC Code LOINC Description 3145-0 Menstrual period start.last 33066-2 Estimated last menstrual period 8665-2 Date last menstrual period BFDR Delivery Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.14 Value Set Code PHVS_Delivery_NCHS Value Set Description To Reflect the Delivery Procedure Vocabulary 2.16.840.1.113883.6.96 Birth Defects Implementation Guide APP-11
SNOMED-CT Code SNOMED-CT Description 133905007 Delivery room care (regime/therapy) 177184002 Normal delivery procedure (procedure) 1807002 Failed forceps delivery (procedure) 2321005 Delivery by Ritgen maneuver (procedure) 5556001 Manually assisted spontaneous delivery (procedure) 10745001 Delivery of transverse presentation (procedure) 15413009 High forceps delivery with episiotomy (procedure) 16819009 Delivery of face presentation (procedure) 17744000 Subtotal hysterectomy after cesarean delivery (procedure) 17860005 Low forceps delivery with episiotomy (procedure) 18625004 Low forceps delivery (procedure) 19390001 Partial breech delivery with forceps to aftercoming head (procedure) 22633006 Vaginal delivery, medical personnel present (procedure) 25296001 Delivery by Scanzoni maneuver (procedure) 25828002 Mid forceps delivery with episiotomy (procedure) 26313002 Delivery by vacuum extraction with episiotomy (procedure) 29613008 Delivery by double application of forceps (procedure) 30476003 Barton's forceps delivery (procedure) 38479009 Frank breech delivery (procedure) 40219000 Delivery by Malstrom's extraction with episiotomy (procedure) 45718005 Vaginal delivery with forceps including postpartum care (procedure) 48204000 Spontaneous unassisted delivery, medical personnel present (procedure) 54973000 Total breech delivery with forceps to aftercoming head (procedure) 56620000 Delivery of placenta following delivery of infant outside of hospital (procedure) 57411006 Colpoperineorrhaphy following delivery (procedure) 61586001 Delivery by vacuum extraction (procedure) 62508004 Mid forceps delivery (procedure) 71166009 Forceps delivery with rotation of fetal head (procedure) 72059007 Destructive procedure on fetus to facilitate delivery (procedure) 72492007 Footling breech delivery (procedure) 89346004 Delivery by Kielland rotation (procedure) 89849000 High forceps delivery (procedure) 90438006 Delivery by Malstrom's extraction (procedure) 177128002 Induction and delivery procedures (procedure) 177152009 Breech extraction delivery with version (procedure) 177157003 Spontaneous breech delivery (procedure) 177158008 Assisted breech delivery (procedure) 177161009 Forceps cephalic delivery (procedure) Birth Defects Implementation Guide APP-12
SNOMED-CT Code SNOMED-CT Description 177162002 High forceps cephalic delivery with rotation (procedure) 177164001 Midforceps cephalic delivery with rotation (procedure) 177167008 Barton forceps cephalic delivery with rotation (procedure) 177168003 DeLee forceps cephalic delivery with rotation (procedure) 177170007 Piper forceps delivery (procedure) 177173009 High vacuum delivery (procedure) 177174003 Low vacuum delivery (procedure) 177175002 Vacuum delivery before full dilation of cervix (procedure) 177179008 Cephalic vaginal delivery with abnormal presentation of head at delivery without instrument (procedure) 177180006 Manipulative cephalic vaginal delivery with abnormal presentation of head at delivery without instrument (procedure) 177181005 Non-manipulative cephalic vaginal delivery with abnormal presentation of head at delivery without instrument (procedure) 177184002 Normal delivery procedure (procedure) 177185001 Water birth delivery (procedure) 177212000 Normal delivery of placenta (procedure) 199771001 Piper forceps delivery by application to aftercoming head (procedure) 236973005 Delivery procedure (procedure) 236974004 Instrumental delivery (procedure) 236975003 Nonrotational forceps delivery (procedure) 236976002 Outlet forceps delivery (procedure) 236977006 Forceps delivery, face to pubes (procedure) 236978001 Forceps delivery to the aftercoming head (procedure) 236982004 Delivery of the after coming head (procedure) 236989008 Abdominal delivery for shoulder dystocia (procedure) 236991000 Operation to facilitate delivery (procedure) 236994008 Placental delivery procedure (procedure) 237008007 Maneuvers for delivery in shoulder dystocia (procedure) 237311001 Breech delivery (procedure) 248273008 Aspiration curettage of uterus after delivery (procedure) 265639000 Midforceps delivery without rotation (procedure) 275168001 Neville-Barnes forceps delivery (procedure) 275169009 Simpson's forceps delivery (procedure) 287976008 Breech/instrumental delivery operations (procedure) 287977004 Dilation/incision of cervix - delivery aid (procedure) 288193006 Supervision - normal delivery (procedure) 302383004 Forceps delivery (procedure) 306727001 Breech presentation, delivery, no version (procedure) 315308008 Dilatation of cervix for delivery (procedure) 359943008 Partial breech delivery (procedure) 384729004 Delivery of vertex presentation (procedure) Birth Defects Implementation Guide APP-13
SNOMED-CT Code SNOMED-CT Description 386338001 Intrapartal care: high-risk delivery (regime/therapy) 386622003 Duhrssen's incisions of cervix to assist delivery (procedure) 387711001 Pubiotomy to assist delivery (procedure) 391998006 Dilation and curettage of uterus after delivery (procedure) 397990008 Analgesia for labor/delivery (procedure) 408817009 Amniotomy at delivery (procedure) 408819007 Delivery of placenta by maternal effort (procedure) BFDR Epidural Anesthesia Medication Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.26 Value Set Code PHVS_EpiduralAnesthesiaMedication_NCHS Value Set Description To Reflect an Epidural Anesthesia Medication RxNORM Code Vocabulary 2.16.840.1.113883.6.88 RxNORM Description 403803 bupivacaine 0.0375 % / fentanyl 5 MCG/ML Injectable Solution 578142 bupivacaine 0.05 % / fentanyl 3 MCG/ML Injectable Solution 898637 bupivacaine 0.06 % / hydromorphone hydrochloride 2 MG per 100 ML Injectable Solution 604078 bupivacaine 0.0625 % / fentanyl 2 MCG/ML Injectable Solution 359521 bupivacaine 0.0625 % / fentanyl 5 MCG/ML Injectable Solution 898639 bupivacaine 0.0625 % / hydromorphone hydrochloride 10 MCG/ML Injectable Solution 991609 bupivacaine 0.0625 % / hydromorphone hydrochloride 5 MCG/ML Injectable Solution 403802 bupivacaine 0.1 % / fentanyl 4 MCG/ML Injectable Solution 991439 bupivacaine 0.1 % / hydromorphone hydrochloride 10 MCG/ML Injectable Solution 389167 bupivacaine 0.1 % Injectable Solution 359517 bupivacaine 0.125 % / fentanyl 2 MCG/ML Injectable Solution 898642 bupivacaine 0.125 % / hydromorphone hydrochloride 20 MCG/ML Injectable Solution 359285 bupivacaine 0.125 % Injectable Solution 282472 bupivacaine 0.25 % Injectable Solution 108469 bupivacaine 0.375 % Injectable Solution 308818 bupivacaine 0.5 % / epinephrine 1:200,000 Injectable Solution 282473 bupivacaine 0.5 % Injectable Solution 578135 Bupivacaine 0.625 MG/ML / Fentanyl 0.0025 MG/ML Injectable Solution Birth Defects Implementation Guide APP-14
RxNORM Code RxNORM Description 359520 Bupivacaine 0.625 MG/ML / Fentanyl 0.004 MG/ML Injectable Solution 359284 Bupivacaine 0.625 MG/ML Injectable Solution 359518 Bupivacaine 1 MG/ML / Fentanyl 0.002 MG/ML Injectable Solution 578143 Bupivacaine 1 MG/ML / Fentanyl 0.003 MG/ML Injectable Solution 359523 Bupivacaine 1 MG/ML / Fentanyl 0.005 MG/ML Injectable Solution 403804 Bupivacaine 1 MG/ML / Fentanyl 0.01 MG/ML Injectable Solution 107627 Bupivacaine 1.05 MG/ML Injectable Solution 700625 Bupivacaine 1.25 MG/ML / Fentanyl 0.0025 MG/ML Injectable Solution 578136 Bupivacaine 1.25 MG/ML / Fentanyl 0.003 MG/ML Injectable Solution 700626 Bupivacaine 1.25 MG/ML / Fentanyl 0.004 MG/ML Injectable Solution 359522 Bupivacaine 1.25 MG/ML / Fentanyl 0.005 MG/ML Injectable Solution 727503 bupivacaine 100 MG per 20 ML Prefilled Syringe 727417 bupivacaine 125 MG per 50 ML Prefilled Syringe 700624 Bupivacaine 2 MG/ML Injectable Solution 317067 Bupivacaine 2.5 MG/ML / Epinephrine 0.005 MG/ML Injectable Solution 403805 Bupivacaine 2.5 MG/ML / Fentanyl 0.02 MG/ML Injectable Solution 415205 Bupivacaine 3.75 MG/ML / Lidocaine 10 MG/ML Injectable Solution 308820 Bupivacaine 7.5 MG/ML / Epinephrine 0.005 MG/ML Injectable Solution 308819 Bupivacaine 7.5 MG/ML Injectable Solution 415410 Bupivacaine 8.25 MG/ML Injectable Solution 477303 Bupivacaine Hydrochloride 2 MG/ML Injectable Solution 992805 chloroprocaine 2 % Injectable Solution 992801 Chloroprocaine hydrochloride 10 MG/ML Injectable Solution 992809 Chloroprocaine hydrochloride 30 MG/ML Injectable Solution 415205 Bupivacaine 3.75 MG/ML / Lidocaine 10 MG/ML Injectable Solution 309697 Dexamethasone 4 MG/ML / Lidocaine 10 MG/ML Injectable Solution 245841 Lidocaine 10 MG/ML / Methylprednisolone 40 MG/ML Injectable Solution Birth Defects Implementation Guide APP-15
BFDR Epidural Anesthesia Procedure Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.27 Value Set Code PHVS_EpiduralAnesthesia_NCHS Value Set Description To Reflect an Epidural Anesthesia Procedure SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 18946005 Epidural anesthesia (procedure) 58611004 Epidural injection of anesthetic substance, therapeutic, lumbar, continuous (procedure) 180886007 Local anesthetic sacral epidural block (procedure) 112943005 Epidural injection of anesthetic substance, diagnostic, caudal, continuous (procedure) 67716003 Epidural injection of anesthetic substance, therapeutic, caudal, continuous (procedure) 398044000 Low dose epidural (procedure) 64817005 Anesthesia for vaginal delivery (procedure) BFDR Facility Location OR Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.104 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 2.16.840.1.113883 1096-7 Inpatient operating room/suite 1094-2 Operating and recovery rooms Code Description BFDR Fertility Enhancing Drugs Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.144 Value Set Description To reflect that Fertility Enhancing Drugs were administered as a Risk Factor in Pregnancy Vocabulary OID 2.16.840.1.113883.6.88 Birth Defects Implementation Guide APP-16
RxNorm Code 197523 Clomiphene 50 MG Oral Tablet RxNorm Description 347764 Follicle Stimulating Hormone 150 UNT/ML / Luteinizing Hormone 150 UNT/ML Injectable Solution 314097 Follicle Stimulating Hormone 75 UNT/ML / Luteinizing Hormone 75 UNT/ML Injectable Solution 313561 Urofollitropin 150 UNT/ML Injectable Solution 348522 Urofollitropin 300 UNT/ML Injectable Solution 854749 0.21 ML follitropin beta 833 UNT/ML Prefilled Syringe 854754 0.78 ML follitropin beta 833 UNT/ML Prefilled Syringe 854756 1.17 ML follitropin beta 833 UNT/ML Prefilled Syringe 854752 follitropin beta 350 UNT per 0.42 ML Prefilled Syringe 205320 follitropin beta 75 UNT/ML Injectable Solution 389216 follitropin beta 833 UNT/ML Injectable Solution 310413 Follitropin Alfa 300 UNT/ML Injectable Solution 351125 Follitropin Alfa 600 UNT/ML Injectable Solution 847960 follitropin alfa 75 UNT/ACTUAT Prefilled Pen, 12 ACTUAT 847953 Follitropin Alfa 75 UNT/ACTUAT Prefilled Syringe, 4 ACTUAT 847957 follitropin alfa 75 UNT/ACTUAT Prefilled Syringe, 6 ACTUAT 562724 Follitropin Alfa 75 UNT/ML Injectable Solution 896854 Chorionic Gonadotropin 10000 UNT/ML Injectable Solution 727505 chorionic gonadotropin 0.25 MG per 0.5 ML Prefilled Syringe 562725 Chorionic Gonadotropin 0.25 MG/ML Injectable Solution 403979 Chorionic Gonadotropin 0.5 MG/ML Injectable Solution 896854 Chorionic Gonadotropin 10000 UNT/ML Injectable Solution 562828 Chorionic Gonadotropin 500 UNT/ML Injectable Solution 197411 Bromocriptine 2.5 MG Oral Tablet 197412 bromocriptine 5 MG (bromocriptine mesylate 5.74 MG) Oral Capsule 1043563 24 HR Metformin hydrochloride 1000 MG / saxagliptin 2.5 MG Extended Release Tablet 1043570 24 HR Metformin hydrochloride 1000 MG / saxagliptin 5 MG Extended Release Tablet 1043578 24 HR Metformin hydrochloride 500 MG / saxagliptin 5 MG Extended Release Tablet 861731 Glipizide 2.5 MG / Metformin hydrochloride 250 MG Oral Tablet 861736 Glipizide 2.5 MG / Metformin hydrochloride 500 MG Oral Tablet 861740 Glipizide 5 MG / Metformin hydrochloride 500 MG Oral Tablet 861743 Glyburide 1.25 MG / Metformin hydrochloride 250 MG Oral Tablet Birth Defects Implementation Guide APP-17
RxNorm Code RxNorm Description 861748 Glyburide 2.5 MG / Metformin hydrochloride 500 MG Oral Tablet 861753 Glyburide 5 MG / Metformin hydrochloride 500 MG Oral Tablet 861025 Metformin hydrochloride 100 MG/ML Oral Solution 899989 24 HR Metformin hydrochloride 1000 MG / pioglitazone 15 MG Extended Release Tablet 899994 Metformin hydrochloride 1000 MG / pioglitazone 15 MG Extended Release Tablet 899996 24 HR Metformin hydrochloride 1000 MG / pioglitazone 30 MG Extended Release Tablet 900001 Metformin hydrochloride 1000 MG / pioglitazone 30 MG Extended Release Tablet 861760 Metformin hydrochloride 1000 MG / rosiglitazone 2 MG Oral Tablet 861763 Metformin hydrochloride 1000 MG / rosiglitazone 4 MG Oral Tablet 1043568 Metformin hydrochloride 1000 MG / saxagliptin 2.5 MG Extended Release Tablet 1043575 Metformin hydrochloride 1000 MG / saxagliptin 5 MG Extended Release Tablet 861769 Metformin hydrochloride 1000 MG / sitagliptin 50 MG Oral Tablet 860996 24 HR Metformin hydrochloride 1000 MG Extended Release Tablet 860999 Metformin hydrochloride 1000 MG Extended Release Tablet 861004 Metformin hydrochloride 1000 MG Oral Tablet 861783 Metformin hydrochloride 500 MG / pioglitazone 15 MG Oral Tablet 861787 Metformin hydrochloride 500 MG / repaglinide 1 MG Oral Tablet 861790 Metformin hydrochloride 500 MG / repaglinide 2 MG Oral Tablet 861795 Metformin hydrochloride 500 MG / rosiglitazone 1 MG Oral Tablet 861806 Metformin hydrochloride 500 MG / rosiglitazone 2 MG Oral Tablet 861816 Metformin hydrochloride 500 MG / rosiglitazone 4 MG Oral Tablet 1043583 Metformin hydrochloride 500 MG / saxagliptin 5 MG Extended Release Tablet 861819 Metformin hydrochloride 500 MG / sitagliptin 50 MG Oral Tablet 860975 24 HR Metformin hydrochloride 500 MG Extended Release Tablet 860978 Metformin hydrochloride 500 MG Extended Release Tablet 861007 Metformin hydrochloride 500 MG Oral Tablet Birth Defects Implementation Guide APP-18
RxNorm Code RxNorm Description 861021 Metformin hydrochloride 625 MG Oral Tablet 860981 24 HR Metformin hydrochloride 750 MG Extended Release Tablet 860984 Metformin hydrochloride 750 MG Extended Release Tablet 861822 Metformin hydrochloride 850 MG / pioglitazone 15 MG Oral Tablet 861010 Metformin hydrochloride 850 MG Oral Tablet 378730 Metformin Oral Tablet 374635 Glyburide / Metformin Oral Tablet 899988 Metformin / pioglitazone Extended Release Tablet 577093 Metformin / pioglitazone Oral Tablet 802742 Metformin / repaglinide Oral Tablet 378729 Metformin / rosiglitazone Oral Tablet 1043561 Metformin / saxagliptin Extended Release Tablet 700516 Metformin / sitagliptin Oral Tablet 372804 Metformin Extended Release Tablet 406082 Metformin Oral Solution 372803 Metformin Oral Tablet BFDR Fetal Presentation at Birth - Breech Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.108 Value Set Code PHVS_FetalPresentationAtBirthBreech_NCHS Value Set Description To Reflect the Fetal Presentation at Birth - Breech method of delivery SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 6096002 Breech presentation (finding) SNOMED-CT Description 199354004 Breech presentation - delivered (finding) 199355003 Breech presentation with antenatal problem (finding) 49168004 Complete breech presentation (finding) 249097002 Footling breech presentation (finding) 48906005 Breech presentation, double footling (finding) 58903006 Breech presentation, single footling (finding) 18559007 Frank breech presentation (finding) 38049006 Incomplete breech presentation (finding) Birth Defects Implementation Guide APP-19
SNOMED-CT Code SNOMED-CT Description 163514003 On examination - breech presentation (finding) 271370008 Deliveries by breech extraction (finding) 237325000 Head entrapment during breech delivery (disorder) 271373005 Deliveries by spontaneous breech delivery (finding) 199751005 Obstructed labor due to breech presentation (finding) 364748006 Finding of position of breech presentation (finding) 79888005 Sacroanterior position (finding) 408812003 Direct sacroanterior position (finding) 64433002 Left sacroanterior position (finding) 79643007 Right sacroanterior position (finding) 249103009 Sacrolateral position (finding) 54486001 Left sacrolateral position (finding) 89550007 Right sacrolateral position (finding) 58261003 Sacroposterior position (finding) 249102004 Direct sacroposterior position (finding) 2138000 Left sacroposterior position (finding) 112073004 Right sacroposterior position (finding) BFDR Fetal Presentation at Birth - Cephalic Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.109 Value Set Code PHVS_FetalPresentationAtBirthCephalic_NCHS Value Set Description To Reflect the Fetal Presentation at Birth - Cephalic method of delivery SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 70028003 Vertex presentation (finding) SNOMED-CT Description 163513009 On examination - vertex presentation (finding) 441640001 Vertex presentation with caput succedaneum (finding) 309469004 Spontaneous vertex delivery (finding) 441640001 Vertex presentation with caput succedaneum (finding) 14058000 Asynclitism 46017002 Anterior asynclitism 90731001 Posterior asynclitism 90381008 Occiptoanterior position 408813008 Direct occiptoanterior position 14409005 Left occiptoanterior position 39889007 Right occiptoanterior position Birth Defects Implementation Guide APP-20
SNOMED-CT Code SNOMED-CT Description 249071008 Occipitolateral position 18905000 Left occipitolateral position 37040008 Right occipitolateral position 37235006 Occiptoposterior position 249070009 Direct occiptoposterior position 31477000 Left occiptoposterior position 36547009 Right occiptoposterior position BFDR Fetal Presentation at Birth - Other Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.110 Value Set Code PHVS_FetalPresentationAtBirthCephalic_NCHS Value Set Description To Reflect the Fetal Presentation at Birth - Cephalic method of delivery SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 249079005 Fontanelles presenting (finding) SNOMED-CT Description 249082000 Anterior fontanelle presenting (finding) 249081007 Both fontanelles presenting (finding) 249083005 Posterior fontanelle presenting (finding) 23954006 Acromion presentation (finding) 14058000 Asynclitism (finding) 8014007 Brow presentation (finding) 124736009 Compound presentation (finding) 21882006 Face presentation (finding) 46200004 Funic presentation (finding) 50724007 Longitudinal fetal presentation (finding) 15028002 Abnormal fetal presentation (finding) Birth Defects Implementation Guide APP-21
BFDR Fourth Degree Perineal Laceration Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.101 Value Set Code PHVS_FourthDegreePerinealLaceration_NCHS Value Set Description To reflect Fourth Degree Perineal Laceration as a maternal morbidity SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 399031001 Fourth degree perineal laceration (disorder) 16950007 Fourth degree perineal laceration involving anal mucosa (disorder) 34262005 Fourth degree perineal laceration involving rectal mucosa (disorder) 199934009 Fourth degree perineal tear during delivery - delivered (disorder) 199935005 Fourth degree perineal tear during delivery with postnatal problem (disorder) BFDR Glucocortico Steroids Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.3.21 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.38 Value Set Description To Reflect administration of Glucocortico Steroids RxNORM Code Vocabulary 2.16.840.1.113883.6.88 RxNORM Description 308717 Betamethasone 3 MG/ML Injectable Solution 308718 Betamethasone 4 MG/ML Injectable Solution 578803 Betamethasone 3 MG/ML (as betamethasone sodium phosphate) / Betamethasone acetate 3 MG/ML Injectable Suspension 309697 Dexamethasone 4 MG/ML / Lidocaine 10 MG/ML Injectable Solution 881355 Dexamethasone 0.02 MG/ML Injectable Solution 436510 Dexamethasone 0.133 MG/ML Injectable Solution 309696 Dexamethasone 10 MG/ML Injectable Solution 393267 Dexamethasone 16 MG/ML Injectable Solution 435681 Dexamethasone 2 MG/ML Injectable Solution 315061 Dexamethasone 20 MG/ML Injectable Solution 197584 Dexamethasone 24 MG/ML Injectable Solution Birth Defects Implementation Guide APP-22
RxNORM Code RxNORM Description 880649 Dexamethasone 3 MG/ML Injectable Solution 309698 Dexamethasone 4 MG/ML Injectable Solution 105394 Dexamethasone 5 MG/ML Injectable Solution 387080 Dexamethasone 8 MG/ML Injectable Solution 309687 Dexamethasone 16 MG/ML Injectable Suspension 309688 Dexamethasone 8 MG/ML Injectable Suspension BFDR ICU Care Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.188 Value Set Description To reflect the that the mother was transferred to ICU following the birth SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 305796008 Seen by intensive care - service (finding) 305797004 Seen by adult intensive care - service (finding) 305644002 Seen by intensive care specialist (finding) 305645001 Seen by adult intensive care specialist (finding) 305465003 Under care of intensive care specialist (finding) 305466002 Under care of adult intensive care specialist (finding) BFDR Induction of Labor Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.34 Value Set Code PHVS_InductionOfLabor_NCHS Value Set Description To Reflect that there was an Induction of Labor Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 177135005 Oxytocin induction of labor (procedure) 177136006 Prostaglandin induction of labor (procedure) 180221005 Intravenous induction of labor (procedure) 236958009 Induction of labor (procedure) 236969007 Acupuncture for induction of labor (procedure) 308037008 Syntocinon induction of labor (procedure) Birth Defects Implementation Guide APP-23
SNOMED-CT Code SNOMED-CT Description 31208007 Medical induction of labor (procedure) 408818004 Induction of labor by artificial rupture of membranes (procedure) 315308008 Dilatation of cervix for delivery (procedure) 425861005 Cervical ripening with balloon (procedure) 236965001 Cervical ripening with drug (procedure) 236967009 Cervical ripening with ethinyl estradiol (procedure) 236966000 Cervical ripening with Prostaglandin E2 (procedure) 236968004 Cervical ripening with relaxin (procedure) 236962003 Cervical ripening with Foley catheter (procedure) 236963008 Cervical ripening with tents (procedure) 236964002 Cervical ripening with synthetic tent (procedure) 85179000 Insertion of laminaria into cervix (procedure) 236960006 Sweeping of membrane (procedure) BFDR Infertility Treatment Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.143 Value Set Code PHVS_InfertilityTreatment_NCHS Value Set Description To reflect Risk Factors of Pregnancy Infertility Treatment Vocabulary OID 2.16.840.1.113883.6.96 SNOMED-CT Code 65046005 Infertility therapy (procedure) SNOMED-CT Description 183036001 Female infertility therapy (procedure) 236896006 Artificial insemination by donor (procedure) 236895005 Artificial insemination by husband (procedure) 57233006 Artificial insemination with sperm washing and capacitation (procedure) 46249006 Artificial insemination, heterologous (procedure) 66601000 Artificial insemination, homologous (procedure) 176844003 Intracervical artificial insemination (procedure) 265064001 Intrauterine artificial insemination (procedure) 426250000 Intrauterine insemination using donor sperm (procedure) 426389008 Intrauterine insemination using partner sperm (procedure) 425644009 Intrauterine insemination with controlled ovarian hyperstimulation using donor sperm (procedure) 426968007 Intrauterine insemination with controlled ovarian hyperstimulation using partner sperm (procedure) Birth Defects Implementation Guide APP-24
SNOMED-CT Code SNOMED-CT Description 225250007 Intravaginal artificial insemination (procedure) 225249007 Subzonal insemination (procedure) 176843009 Gamete intrauterine transfer (procedure) 236912008 Gamete intrafallopian transfer (procedure) 176996001 Endoscopic intrafallopian transfer of gamete (procedure) 236913003 Fallopian replacement of egg with delayed insemination (procedure) 225249007 Subzonal insemination 236915005 Tubal embryo transfer 236914009 Zygote intrafallopian transfer 63487001 Assisted fertilization (procedure) BFDR IV Medication Administration Route Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.3.21 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.4 Value Set Description To reflect that IV Medication Administration Route was used to administer a medication Data Element Vocabulary 2.16.840.1.113883.12.162 IV Intravenous HL7 Route of Administration BFDR Mother s Delivery Weight Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.9.15.1 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.120 Value Set Code PHVS_MothersDeliveryWeight_NCHS Value Set Description To Reflect the Mother's Delivery Weight Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 8345-1 Body weight^post partum 69461-2 Body weight^ at delivery Birth Defects Implementation Guide APP-25
BFDR Neonatal Sepsis Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.3.21 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.6 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 2.16.840.1.113883.6.96 SNOMED-CT Description 276669000 Bacterial sepsis of newborn (disorder) 211420008 Neonatal candida septicemia (disorder) 359646002 Neonatal disseminated listeriosis (disorder) 403000003 Neonatal systemic candidosis (disorder) 206380000 Sepsis of newborn due to anaerobes (disorder) 206379003 Sepsis of newborn due to Escherichia coli (disorder) 206378006 Sepsis of newborn due to Staphylococcus aureus (disorder) 206376005 Sepsis of the newborn (disorder) 41229001 Septicemia of newborn (disorder) 43424001 Tetanus neonatorum (disorder) BFDR Newborn Receiving Surfactant Replacement Therapy Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.3.21 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.11 Value Set Description To reflect that the Newborn received Surfactant Replacement Therapy reflecting an abnormal condition of the newborn RXNORM Code Vocabulary 2.16.840.1.113883.6.88 RXNORM Description 259034 Beractant 25 MG/ML Injectable Suspension 379138 Beractant Injectable Suspension 259611 Calfactant 35 MG/ML Inhalant Solution 379477 Calfactant Inhalant Solution 141920 Colfosceril 13.5 MG/ML Injectable Suspension 385921 Colfosceril Injectable Suspension 259216 Poractant alfa 80 MG/ML Injectable Suspension 375227 Poractant alfa Injectable Suspension Birth Defects Implementation Guide APP-26
BFDR NICU Care Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.198 Value Set Description To reflect the that the baby was transferred to NICU following the birth SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 405269005 Neonatal intensive care unit (environment) BFDR Number of Preterm Births Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.187 Value Set Description To reflect the number of preterm births in prior pregnancies Vocabulary OID 2.16.840.1.113883.6.1 LOINC Code LOINC Description 11637-6 Births Preterm (reported) BFDR Obstetric Estimate of Gestation Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.124 Value Set Description To reflect the Obstetric Estimate of Gestation of the newborn. Vocabulary 2.16.840.1.113883.6.1 LOINC Code LOINC Description 11884-4 Gestational age Clinical.estimated 53695-3 Gestational age Clinical.estimated from prior assessment BFDR Premature Rupture Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.129 Value Set Code PHVS_PrematureRupture_NCHS Birth Defects Implementation Guide APP-27
Value Set Description To Reflect Onset of labor with Premature Rupture SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 44223004 Premature rupture of membranes (disorder) 288207006 Membrane rupture with delivery delay (disorder) 199658006 Premature rupture of membranes delivered (disorder) 199659003 Premature rupture of membranes with antenatal problem (disorder) 199662000 Premature rupture of membranes with onset of labor after 24 hours of the rupture (disorder) 199660008 Premature rupture of membranes with onset of labor within 24 hours of the rupture (disorder) 199661007 Premature rupture of membranes, labor delayed by therapy (disorder) 312974005 Preterm premature rupture of membranes (disorder) 237267007 Prolonged premature rupture of membranes (disorder) 12729009 Prolonged rupture of membranes 199670005 Prolonged artificial rupture of membranes 199672002 Prolonged artificial rupture of membranes delivered 199673007 Prolonged artificial rupture of membranes with antenatal problem 237267007 Prolonged premature rupture of membranes 237262008 Prolonged spontaneous rupture of membranes BFDR Route and Method of Delivery Cesarean Delivery Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.114 Value Set Code Value Set Description PHVS_RouteMethodOfDeliveryCesarean_NCHS To Reflect the Route and Method of Delivery as Cesarean Delivery Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code 11466000 Cesarean section (procedure) SNOMED-CT Description 177141003 Elective cesarean section (procedure) 177142005 Elective upper segment cesarean section (procedure) 177143000 Elective lower segment cesarean section (procedure) 17744000 Subtotal hysterectomy after cesarean delivery (procedure) 236985002 Emergency lower segment cesarean section (procedure) Birth Defects Implementation Guide APP-28
SNOMED-CT Code SNOMED-CT Description 236986001 Emergency upper segment cesarean section (procedure) 236987005 Emergency cesarean hysterectomy (procedure) 236988000 Elective cesarean hysterectomy (procedure) 236990004 Postmortem cesarean section (procedure) 24806008 Anesthesia for cesarean hysterectomy (procedure) 274130007 Emergency cesarean section (procedure) 386234001 Cesarean section care (regime/therapy) 398307005 Low cervical cesarean section (procedure) 41059002 Cesarean hysterectomy (procedure) 440073003 Education about vaginal birth after cesarean section (procedure) 4847005 Anesthesia for cesarean section (procedure) 57271003 Extraperitoneal cesarean section (procedure) 84195007 Classical cesarean section (procedure) 89053004 Vaginal cesarean section (procedure) BFDR Route and Method of Delivery Forceps Delivery Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.112 Value Set Code PHVS_ RouteMethodOfDeliveryForceps_NCHS Value Set Description To Reflect the Route and Method of Delivery as Forceps Delivery SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 177167008 Barton forceps cephalic delivery with rotation (procedure) 177168003 DeLee forceps cephalic delivery with rotation (procedure) 177161009 Forceps cephalic delivery (procedure) 1807002 Forceps delivery failed (situation) 236978001 Forceps delivery to the aftercoming head (procedure) 236977006 Forceps delivery, face to pubes (procedure) 172524003 Forceps extraction of lens (procedure) 177162002 High forceps cephalic delivery with rotation (procedure) 15413009 High forceps delivery with episiotomy (procedure) 18625004 Low forceps delivery (procedure) 17860005 Low forceps delivery with episiotomy (procedure) 236975003 Nonrotational forceps delivery (procedure) Birth Defects Implementation Guide APP-29
SNOMED-CT Code SNOMED-CT Description 236976002 Outlet forceps delivery (procedure) 19390001 Partial breech delivery with forceps to aftercoming head (procedure) 177170007 Piper forceps delivery (procedure) 89849000 High forceps delivery (procedure) 71166009 Forceps delivery with rotation of fetal head (procedure) 62508004 Mid forceps delivery (procedure) 54973000 Total breech delivery with forceps to aftercoming head (procedure) 45718005 Vaginal delivery with forceps including postpartum care (procedure) 30476003 Barton's forceps delivery (procedure) 302383004 Forceps delivery (procedure) 29613008 Delivery by double application of forceps (procedure) 275169009 Simpson's forceps delivery (procedure) 275168001 Neville-Barnes forceps delivery (procedure) 25828002 Mid forceps delivery with episiotomy (procedure) BFDR Route and Method of Delivery Scheduled Cesarean Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.116 Value Set Code PHVS_RouteMethodOfDeliveryScheduledCesarean_NCHS Value Set Description To Reflect the Route and Method of Delivery as Scheduled Cesarean SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 177141003 Elective cesarean section (procedure) 177142005 Elective upper segment cesarean section (procedure) 177143000 Elective lower segment cesarean section (procedure) 236988000 Elective cesarean hysterectomy (procedure) BFDR Route and Method of Delivery Spontaneous Delivery Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.111 Value Set Code PHVS_RouteMethodOfDeliverySpontaneous_NCHS Birth Defects Implementation Guide APP-30
Value Set Description To Reflect the Route and Method of Delivery as Spontaneous Delivery SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 309469004 Spontaneous vertex delivery (finding) 199329004 Multiple delivery, all spontaneous (finding) 271373005 Deliveries by spontaneous breech delivery (finding) BFDR Route and Method of Delivery Trial of Labor Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.115 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 2.16.840.1.113883.6.96 90306000 Trial labor (finding) 23332002 Failed trial of labor (disorder) SNOMED-CT Description 413339006 Failed trial of labor - delivered (disorder) BFDR Route and Method of Delivery Vaccum Delivery Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.113 Value Set Code PHVS_RouteMethodOfDeliveryVacuum_NCHS Value Set Description To Reflect the Route and Method of Delivery as Vacuum Delivery SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 177174003 Low vacuum delivery (procedure) 177173009 High vacuum delivery (procedure) 177176001 Trial of vacuum delivery (procedure) 61586001 Delivery by vacuum extraction (procedure) 90438006 Delivery by Malstrom's extraction (procedure) 40219000 Delivery by Malstrom's extraction with episiotomy (procedure) 26313002 Delivery by vacuum extraction with episiotomy (procedure) 177175002 Vacuum delivery before full dilation of cervix (procedure) Birth Defects Implementation Guide APP-31
SNOMED-CT Code SNOMED-CT Description 172524003 Forceps extraction of lens (procedure) 177161009 Forceps cephalic delivery (procedure) 177162002 High forceps cephalic delivery with rotation (procedure) 177167008 Barton forceps cephalic delivery with rotation (procedure) 177168003 DeLee forceps cephalic delivery with rotation (procedure) 177170007 Piper forceps delivery (procedure) 17860005 Low forceps delivery with episiotomy (procedure) 1807002 Failed forceps delivery (procedure) 18625004 Low forceps delivery (procedure) 19390001 Partial breech delivery with forceps to aftercoming head (procedure) 236975003 Nonrotational forceps delivery (procedure) 236976002 Outlet forceps delivery (procedure) 236977006 Forceps delivery, faces to pubes (procedure) 236978001 Forceps delivery to the aftercoming head (procedure) 25828002 Mid forceps delivery with episiotomy (procedure) 275168001 Neville-Barnes forceps delivery (procedure) 275169009 Simpson s forceps delivery (procedure) 29613008 Delivery by double application of forceps (procedure) 302383004 Forceps delivery (procedure) 30476003 Barton s forceps delivery (procedure) 3190002 Epilation by forceps (procedure) 45718005 Vaginal delivery with forceps including postpartum care (procedure) 54926006 Epilation of eyebrow by forceps (procedure) 54973000 Total breech delivery with forceps to aftercoming head (procedure) 62508004 Mid forceps delivery (procedure) 69422002 Trial forceps delivery (procedure) 71166009 Forceps delivery with rotation of fetal head (procedure) 71580008 Correction of trichiasis by epilation with forceps (procedure) 74004007 Epilation of eyelid by forceps (procedure) 89849000 High forceps delivery (procedure) Birth Defects Implementation Guide APP-32
BFDR Ruptured Uterus Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.102 Value Set Code PHVS_RupturedUterus_NCHS Value Set Description To reflect Ruptured Uterus as a maternal morbidity SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 199958008 Ruptured uterus before labor (disorder) 199960005 Rupture of uterus before labor - delivered (disorder) 199961009 Rupture of uterus before labor with antenatal problem (disorder) 69270005 Rupture of uterus during AND/OR after labor (disorder) 199964001 Rupture of uterus during and after labor - delivered (disorder) 199965000 Rupture of uterus during and after labor - delivered with postnatal problem (disorder) 15504009 Rupture of gravid uterus (disorder) 49561003 Rupture of gravid uterus before onset of labor (disorder) 34430009 Rupture of uterus (disorder) BFDR Spinal Anesthesia Medication Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.28 Value Set Code PHVS_SpinalAnesthesiaMedication_NCHS Value Set Description To Reflect a Spinal Anesthesia RxNORM Code Vocabulary 2.16.840.1.113883.6.88 RxNORM Description 403803 bupivacaine 0.0375 % / fentanyl 5 MCG/ML Injectable Solution 578142 bupivacaine 0.05 % / fentanyl 3 MCG/ML Injectable Solution 898637 bupivacaine 0.06 % / hydromorphone hydrochloride 2 MG per 100 ML Injectable Solution 604078 bupivacaine 0.0625 % / fentanyl 2 MCG/ML Injectable Solution 359521 bupivacaine 0.0625 % / fentanyl 5 MCG/ML Injectable Solution 898639 bupivacaine 0.0625 % / hydromorphone hydrochloride 10 MCG/ML Injectable Solution 991609 bupivacaine 0.0625 % / hydromorphone hydrochloride 5 MCG/ML Injectable Solution 403802 bupivacaine 0.1 % / fentanyl 4 MCG/ML Injectable Solution Birth Defects Implementation Guide APP-33
RxNORM Code RxNORM Description 991439 bupivacaine 0.1 % / hydromorphone hydrochloride 10 MCG/ML Injectable Solution 389167 bupivacaine 0.1 % Injectable Solution 359517 bupivacaine 0.125 % / fentanyl 2 MCG/ML Injectable Solution 898642 bupivacaine 0.125 % / hydromorphone hydrochloride 20 MCG/ML Injectable Solution 359285 bupivacaine 0.125 % Injectable Solution 282472 bupivacaine 0.25 % Injectable Solution 108469 bupivacaine 0.375 % Injectable Solution 308818 bupivacaine 0.5 % / epinephrine 1:200,000 Injectable Solution 282473 bupivacaine 0.5 % Injectable Solution 578135 Bupivacaine 0.625 MG/ML / Fentanyl 0.0025 MG/ML Injectable Solution 359520 Bupivacaine 0.625 MG/ML / Fentanyl 0.004 MG/ML Injectable Solution 359284 Bupivacaine 0.625 MG/ML Injectable Solution 359518 Bupivacaine 1 MG/ML / Fentanyl 0.002 MG/ML Injectable Solution 578143 Bupivacaine 1 MG/ML / Fentanyl 0.003 MG/ML Injectable Solution 359523 Bupivacaine 1 MG/ML / Fentanyl 0.005 MG/ML Injectable Solution 403804 Bupivacaine 1 MG/ML / Fentanyl 0.01 MG/ML Injectable Solution 107627 Bupivacaine 1.05 MG/ML Injectable Solution 700625 Bupivacaine 1.25 MG/ML / Fentanyl 0.0025 MG/ML Injectable Solution 578136 Bupivacaine 1.25 MG/ML / Fentanyl 0.003 MG/ML Injectable Solution 700626 Bupivacaine 1.25 MG/ML / Fentanyl 0.004 MG/ML Injectable Solution 359522 Bupivacaine 1.25 MG/ML / Fentanyl 0.005 MG/ML Injectable Solution 727503 bupivacaine 100 MG per 20 ML Prefilled Syringe 727417 bupivacaine 125 MG per 50 ML Prefilled Syringe 700624 Bupivacaine 2 MG/ML Injectable Solution 317067 Bupivacaine 2.5 MG/ML / Epinephrine 0.005 MG/ML Injectable Solution 403805 Bupivacaine 2.5 MG/ML / Fentanyl 0.02 MG/ML Injectable Solution 415205 Bupivacaine 3.75 MG/ML / Lidocaine 10 MG/ML Injectable Solution 308820 Bupivacaine 7.5 MG/ML / Epinephrine 0.005 MG/ML Injectable Solution Birth Defects Implementation Guide APP-34
RxNORM Code RxNORM Description 308819 Bupivacaine 7.5 MG/ML Injectable Solution 415410 Bupivacaine 8.25 MG/ML Injectable Solution 477303 Bupivacaine Hydrochloride 2 MG/ML Injectable Solution 992805 chloroprocaine 2 % Injectable Solution 992801 Chloroprocaine hydrochloride 10 MG/ML Injectable Solution 992809 Chloroprocaine hydrochloride 30 MG/ML Injectable Solution 415205 Bupivacaine 3.75 MG/ML / Lidocaine 10 MG/ML Injectable Solution 309697 Dexamethasone 4 MG/ML / Lidocaine 10 MG/ML Injectable Solution 245841 Lidocaine 10 MG/ML / Methylprednisolone 40 MG/ML Injectable Solution BFDR Spinal Anesthesia Procedure Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.29 Value Set Code PHVS_SpinalAnesthesiaProcedure_NCHS Value Set Description To Reflect an Spinal Anesthesia Procedure SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 108215007 Anesthesia for procedure on spine AND/OR spinal cord (procedure) 15624001 Anesthesia for spinal fluid shunting procedure (procedure) 22048001 Anesthesia for spinal cord procedure (procedure) 40365004 Anesthesia for procedure on lumbosacral spinal cord (procedure) 417724007 Referral to epidural anesthesia for spinal pain (procedure) 434546004 Care of subject following combined spinal-epidural anesthesia (regime/therapy) 57580002 Anesthesia for procedure on thoracic spinal cord (procedure) 86583004 Anesthesia for procedure on cervical spinal cord (procedure) 231255000 Spinal subdural local anesthetic block (procedure) 231043002 Local anesthetic block on spinal nerve root (procedure) 231044008 Local anesthetic block on spinal nerve ganglion (procedure) 231261002 Combined spinal/epidural local anesthetic block (procedure) 303358008 Neurolytic nerve block around spinal cord meninges (procedure) 303356007 Local anesthetic nerve block around spinal cord meninges (procedure) Birth Defects Implementation Guide APP-35
SNOMED-CT Code SNOMED-CT Description 431928000 Local anesthetic block of spinal nerve root using fluoroscopic guidance (procedure) 231253007 Local anesthetic lumbar intrathecal block (procedure) 9166009 Injection of anesthetic substance, diagnostic, subarachnoid, continuous (procedure) 47188007 Injection of anesthetic substance, therapeutic, subarachnoid, continuous (procedure) 20381001 Injection of anesthetic substance, therapeutic, subarachnoid, differential (procedure) BFDR Third Degree Perineal Laceration Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.100 Value Set Code PHVS_ThirdDegreePerinealLaceration_NCHS Value Set Description To reflect Third Degree Perineal Laceration as a maternal morbidity SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 10217006 Third degree perineal laceration (disorder) 199930000 Third degree perineal tear during delivery - delivered (disorder) 199931001 Third degree perineal tear during delivery with postnatal problem (disorder) 199934009 Fourth degree perineal tear during delivery - delivered (disorder) 199935005 Fourth degree perineal tear during delivery with postnatal problem (disorder) BFDR Tocolysis Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.128 Value Set Code PHVS_Tocolysis_NCHS Value Set Description To reflect Obstetric Procedures as Tocolysis Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 103747003 Tocolysis (procedure) 5048009 External cephalic version with tocolysis (procedure) 237003003 Tocolysis for hypertonicity of uterus (procedure) Birth Defects Implementation Guide APP-36
BFDR Total Time on Ventilator Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.91 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 2.16.840.1.113883.6.96 Pending SNOMED-CT Description BFDR Transfusion Whole Blood or Packed Red Blood Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.99 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 2.16.840.1.113883.6.96 SNOMED-CT Description 33389009 Transfusion of whole blood (procedure) 11397000 Autotransfusion of whole blood (procedure) 180206004 Intra-arterial blood transfusion (procedure) 225284006 Transfusing whole blood under pressure (procedure) 116863004 Transfusion of red blood cells (procedure) 425513008 Transfusion of leucoreduced red blood cells (procedure) 71493000 Transfusion of packed red blood cells (procedure) 180207008 Intravenous blood transfusion of packed cells (procedure) 426290002 Transfusion of washed red blood cells (procedure) 12719002 Platelet transfusion (procedure) 180208003 Intravenous blood transfusion of platelets (procedure) 117078000 Transfusion of platelet concentrate (procedure) 116810007 Transfusion of plateletpheresis product (procedure) 116797000 Transfusion of factor IX (procedure) 74287006 Transfusion of coagulation factors (procedure) 274502001 Antihemophilic factor transfusion (procedure) 425524005 Transfusion antithrombin III factor (procedure) 116798005 Transfusion of factor VII (procedure) Birth Defects Implementation Guide APP-37
BFDR Unplanned Hysterectomy Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.103 Value Set Description BFDR Unplanned Hysterectomy Value Set Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 625654015 Emergency cesarean hysterectomy BFDR Unplanned Operation Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.105 Value Set Description To reflect Unplanned Operation as a maternal morbidity SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 259863001 Removal of Shirodkar suture from cervix (procedure) 372456005 Repair of obstetric laceration (procedure) 177217006 Immediate repair of obstetric laceration (procedure) 177221004 Immediate repair of minor obstetric laceration (procedure) 177219009 Immediate repair of obstetric laceration of perineum and sphincter of anus (procedure) 177218001 Immediate repair of obstetric laceration of uterus or cervix uteri (procedure) 177220003 Immediate repair of obstetric laceration of vagina and floor of pelvis (procedure) 9724000 Repair of current obstetric laceration of uterus (procedure) 31939001 Repair of obstetric laceration of cervix (procedure) 315307003 Repair of obstetric laceration of lower urinary tract (procedure) 61353001 Repair of obstetric laceration of bladder (procedure) 42390009 Repair of obstetric laceration of bladder and urethra (procedure) 36248000 Repair of obstetric laceration of urethra (procedure) 48775002 Repair of obstetric laceration of pelvic floor (procedure) 441619002 Repair of obstetric laceration of perineum and anal sphincter and mucosa of rectum (procedure) 112925006 Repair of obstetric laceration of vulva (procedure) 55669006 Repair of obstetrical laceration of perineum (procedure) 367476005 Colpoepisiorrhaphy (procedure) Birth Defects Implementation Guide APP-38
SNOMED-CT Code SNOMED-CT Description 177227000 Secondary repair of obstetric laceration (procedure) 112926007 Suture of obstetric laceration of vagina (procedure) 57411006 Colpoperineorrhaphy following delivery (procedure) C Cause of Death Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 2.16.840.1.114222.4.11.3593 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 2.16.840.1.113883.6.3 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
CDC Detailed Race Value Set Race 2.16.840.1.113883.1.11.14914 DYNAMIC Code System(s) Race and Ethnicity - CDC 2.16.840.1.113883.6.238 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 http://phinvads.cdc.gov/vads/viewcodesystemconcept.action?oid= 2.16.840.1.113883.6.238&code=1000-9 1006-6 Abenaki 1579-2 Absentee Shawnee 1490-2 Acoma 2126-1 Afghanistani 2060-2 African 2058-6 African American 1994-3 Agdaagux 1212-0 Agua Caliente 1045-4 Agua Caliente Cahuilla 1740-0 Ahtna 1654-3 Ak-Chin 1993-5 Akhiok 1897-8 Akiachak 1898-6 Akiak 2007-3 Akutan 1187-4 Alabama Coushatta 1194-0 Alabama Creek 1195-7 Alabama Quassarte 1899-4 Alakanuk 1383-9 Alamo Navajo 1744-2 Alanvik 1737-6 Alaska Indian 1735-0 Alaska Native 1739-2 Alaskan Athabascan 1741-8 Alatna 1900-0 Aleknagik 1966-1 Aleut 2008-1 Aleut Corporation Concept Name Birth Defects Implementation Guide APP-40
Concept Code Concept Name 2009-9 Aleutian 2010-7 Aleutian Islander 1742-6 Alexander 1008-2 Algonquian 1743-4 Allakaket 1671-7 Allen Canyon 1688-1 Alpine 1392-0 Alsea 1968-7 Alutiiq Aleut 1845-7 Ambler 1004-1 American Indian 1002-5 American Indian or Alaska Native 1846-5 Anaktuvuk 1847-3 Anaktuvuk Pass 1901-8 Andreafsky 1814-3 Angoon 1902-6 Aniak 1745-9 Anvik 1010-8 Apache 2129-5 Arab 1021-5 Arapaho 1746-7 Arctic 1849-9 Arctic Slope Corporation 1848-1 Arctic Slope Inupiat 1026-4 Arikara 1491-0 Arizona Tewa 2109-7 Armenian 1366-4 Aroostook 2028-9 Asian 2029-7 Asian Indian 1028-0 Assiniboine 1030-6 Assiniboine Sioux 2119-6 Assyrian 2011-5 Atka 1903-4 Atmautluak 1850-7 Atqasuk 1265-8 Atsina Birth Defects Implementation Guide APP-41
Concept Code 1234-4 Attacapa 1046-2 Augustine 1124-7 Bad River 2067-7 Bahamian 2030-5 Bangladeshi 1033-0 Bannock 2068-5 Barbadian 1712-9 Barrio Libre 1851-5 Barrow 1587-5 Battle Mountain 1125-4 Bay Mills Chippewa 1747-5 Beaver 2012-3 Belkofski 1852-3 Bering Straits Inupiat 1904-2 Bethel 2031-3 Bhutanese 1567-7 Big Cypress 1905-9 Bill Moore's Slough 1235-1 Biloxi 1748-3 Birch Creek 1417-5 Bishop 2056-0 Black 2054-5 Black or African American 1035-5 Blackfeet 1610-5 Blackfoot Sioux 1126-2 Bois Forte 2061-0 Botswanan 1853-1 Brevig Mission 1418-3 Bridgeport 1568-5 Brighton 1972-9 Bristol Bay Aleut 1906-7 Bristol Bay Yupik 1037-1 Brotherton 1611-3 Brule Sioux 1854-9 Buckland 2032-1 Burmese 1419-1 Burns Paiute Concept Name Birth Defects Implementation Guide APP-42
Concept Code Concept Name 1039-7 Burt Lake Band 1127-0 Burt Lake Chippewa 1412-6 Burt Lake Ottawa 1047-0 Cabazon 1041-3 Caddo 1054-6 Cahto 1044-7 Cahuilla 1053-8 California Tribes 1907-5 Calista Yupik 2033-9 Cambodian 1223-7 Campo 1068-6 Canadian and Latin American Indian 1069-4 Canadian Indian 1384-7 Canoncito Navajo 1749-1 Cantwell 1224-5 Capitan Grande 2092-5 Carolinian 1689-9 Carson 1076-9 Catawba 1286-4 Cayuga 1078-5 Cayuse 1420-9 Cedarville 1393-8 Celilo 1070-2 Central American Indian 1815-0 Central Council of Tlingit and Haida Tribes 1465-4 Central Pomo 1750-9 Chalkyitsik 2088-3 Chamorro 1908-3 Chefornak 1080-1 Chehalis 1082-7 Chemakuan 1086-8 Chemehuevi 1985-1 Chenega 1088-4 Cherokee 1089-2 Cherokee Alabama 1100-7 Cherokee Shawnee 1090-0 Cherokees of Northeast Alabama Birth Defects Implementation Guide APP-43
Concept Code Concept Name 1091-8 Cherokees of Southeast Alabama 1909-1 Chevak 1102-3 Cheyenne 1612-1 Cheyenne River Sioux 1106-4 Cheyenne-Arapaho 1108-0 Chickahominy 1751-7 Chickaloon 1112-2 Chickasaw 1973-7 Chignik 2013-1 Chignik Lagoon 1974-5 Chignik Lake 1816-8 Chilkat 1817-6 Chilkoot 1055-3 Chimariko 2034-7 Chinese 1855-6 Chinik 1114-8 Chinook 1123-9 Chippewa 1150-2 Chippewa Cree 1011-6 Chiricahua 1752-5 Chistochina 1153-6 Chitimacha 1753-3 Chitina 1155-1 Choctaw 1910-9 Chuathbaluk 1984-4 Chugach Aleut 1986-9 Chugach Corporation 1718-6 Chukchansi 1162-7 Chumash 2097-4 Chuukese 1754-1 Circle 1479-5 Citizen Band Potawatomi 1911-7 Clark's Point 1115-5 Clatsop 1165-0 Clear Lake 1156-9 Clifton Choctaw 1056-1 Coast Miwok Birth Defects Implementation Guide APP-44
Concept Code Concept Name 1733-5 Coast Yurok 1492-8 Cochiti 1725-1 Cocopah 1167-6 Coeur D'Alene 1169-2 Coharie 1171-8 Colorado River 1394-6 Columbia 1116-3 Columbia River Chinook 1173-4 Colville 1175-9 Comanche 1755-8 Cook Inlet 1180-9 Coos 1178-3 Coos, Lower Umpqua, Siuslaw 1756-6 Copper Center 1757-4 Copper River 1182-5 Coquilles 1184-1 Costanoan 1856-4 Council 1186-6 Coushatta 1668-3 Cow Creek Umpqua 1189-0 Cowlitz 1818-4 Craig 1191-6 Cree 1193-2 Creek 1207-0 Croatan 1912-5 Crooked Creek 1209-6 Crow 1613-9 Crow Creek Sioux 1211-2 Cupeno 1225-2 Cuyapaipe 1614-7 Dakota Sioux 1857-2 Deering 1214-6 Delaware 1222-9 Diegueno 1057-9 Digger 1913-3 Dillingham 2070-1 Dominica Islander Birth Defects Implementation Guide APP-45
Concept Code 2069-3 Dominican 1758-2 Dot Lake 1819-2 Douglas 1759-0 Doyon 1690-7 Dresslerville 1466-2 Dry Creek 1603-0 Duck Valley 1588-3 Duckwater 1519-8 Duwamish 1760-8 Eagle 1092-6 Eastern Cherokee 1109-8 Eastern Chickahominy 1196-5 Eastern Creek 1215-3 Eastern Delaware 1197-3 Eastern Muscogee 1467-0 Eastern Pomo 1580-0 Eastern Shawnee 1233-6 Eastern Tribes 1093-4 Echota Cherokee 1914-1 Eek 1975-2 Egegik 2120-4 Egyptian 1761-6 Eklutna 1915-8 Ekuk 1916-6 Ekwok 1858-0 Elim 1589-1 Elko 1590-9 Ely 1917-4 Emmonak 2110-5 English 1987-7 English Bay 1840-8 Eskimo 1250-0 Esselen 2062-8 Ethiopian 1094-2 Etowah Cherokee 2108-9 European 1762-4 Evansville Concept Name Birth Defects Implementation Guide APP-46
Concept Code Concept Name 1990-1 Eyak 1604-8 Fallon 2015-6 False Pass 2101-4 Fijian 2036-2 Filipino 1615-4 Flandreau Santee 1569-3 Florida Seminole 1128-8 Fond du Lac 1480-3 Forest County 1252-6 Fort Belknap 1254-2 Fort Berthold 1421-7 Fort Bidwell 1258-3 Fort Hall 1422-5 Fort Independence 1605-5 Fort McDermitt 1256-7 Fort Mcdowell 1616-2 Fort Peck 1031-4 Fort Peck Assiniboine Sioux 1012-4 Fort Sill Apache 1763-2 Fort Yukon 2111-3 French 1071-0 French American Indian 1260-9 Gabrieleno 1764-0 Gakona 1765-7 Galena 1892-9 Gambell 1680-8 Gay Head Wampanoag 1236-9 Georgetown (Eastern Tribes) 1962-0 Georgetown (Yupik-Eskimo) 2112-1 German 1655-0 Gila Bend 1457-1 Gila River Pima-Maricopa 1859-8 Golovin 1918-2 Goodnews Bay 1591-7 Goshute 1129-6 Grand Portage 1262-5 Grand Ronde Birth Defects Implementation Guide APP-47
Concept Code Concept Name 1130-4 Grand Traverse Band of Ottawa/Chippewa 1766-5 Grayling 1842-4 Greenland Eskimo 1264-1 Gros Ventres 2087-5 Guamanian 2086-7 Guamanian or Chamorro 1767-3 Gulkana 1820-0 Haida 2071-9 Haitian 1267-4 Haliwa 1481-1 Hannahville 1726-9 Havasupai 1768-1 Healy Lake 1269-0 Hidatsa 2037-0 Hmong 1697-2 Ho-chunk 1083-5 Hoh 1570-1 Hollywood Seminole 1769-9 Holy Cross 1821-8 Hoonah 1271-6 Hoopa 1275-7 Hoopa Extension 1919-0 Hooper Bay 1493-6 Hopi 1277-3 Houma 1727-7 Hualapai 1770-7 Hughes 1482-9 Huron Potawatomi 1771-5 Huslia 1822-6 Hydaburg 1976-0 Igiugig 1772-3 Iliamna 1359-9 Illinois Miami 1279-9 Inaja-Cosmit 1860-6 Inalik Diomede 1442-3 Indian Township 1360-7 Indiana Miami Birth Defects Implementation Guide APP-48
Concept Code Concept Name 2038-8 Indonesian 1861-4 Inupiaq 1844-0 Inupiat Eskimo 1281-5 Iowa 1282-3 Iowa of Kansas-Nebraska 1283-1 Iowa of Oklahoma 1552-9 Iowa Sac and Fox 1920-8 Iqurmuit (Russian Mission) 2121-2 Iranian 2122-0 Iraqi 2113-9 Irish 1285-6 Iroquois 1494-4 Isleta 2127-9 Israeili 2114-7 Italian 1977-8 Ivanof Bay 2048-7 Iwo Jiman 2072-7 Jamaican 1313-6 Jamestown 2039-6 Japanese 1495-1 Jemez 1157-7 Jena Choctaw 1013-2 Jicarilla Apache 1297-1 Juaneno 1423-3 Kaibab 1823-4 Kake 1862-2 Kaktovik 1395-3 Kalapuya 1299-7 Kalispel 1921-6 Kalskag 1773-1 Kaltag 1995-0 Karluk 1301-1 Karuk 1824-2 Kasaan 1468-8 Kashia 1922-4 Kasigluk 1117-1 Kathlamet Birth Defects Implementation Guide APP-49
Concept Code 1303-7 Kaw 1058-7 Kawaiisu 1863-0 Kawerak 1825-9 Kenaitze 1496-9 Keres 1059-5 Kern River 1826-7 Ketchikan 1131-2 Keweenaw 1198-1 Kialegee 1864-8 Kiana 1305-2 Kickapoo 1520-6 Kikiallus 2014-9 King Cove 1978-6 King Salmon 1309-4 Kiowa 1923-2 Kipnuk 2096-6 Kiribati 1865-5 Kivalina 1312-8 Klallam 1317-7 Klamath 1827-5 Klawock 1774-9 Kluti Kaah 1775-6 Knik 1866-3 Kobuk 1996-8 Kodiak 1979-4 Kokhanok 1924-0 Koliganek 1925-7 Kongiganak 1992-7 Koniag Aleut 1319-3 Konkow 1321-9 Kootenai 2040-4 Korean 2093-3 Kosraean 1926-5 Kotlik 1867-1 Kotzebue 1868-9 Koyuk 1776-4 Koyukuk Concept Name Birth Defects Implementation Guide APP-50
Concept Code Concept Name 1927-3 Kwethluk 1928-1 Kwigillingok 1869-7 Kwiguk 1332-6 La Jolla 1226-0 La Posta 1132-0 Lac Courte Oreilles 1133-8 Lac du Flambeau 1134-6 Lac Vieux Desert Chippewa 1497-7 Laguna 1777-2 Lake Minchumina 1135-3 Lake Superior 1617-0 Lake Traverse Sioux 2041-2 Laotian 1997-6 Larsen Bay 1424-1 Las Vegas 1323-5 Lassik 2123-8 Lebanese 1136-1 Leech Lake 1216-1 Lenni-Lenape 1929-9 Levelock 2063-6 Liberian 1778-0 Lime 1014-0 Lipan Apache 1137-9 Little Shell Chippewa 1425-8 Lone Pine 1325-0 Long Island 1048-8 Los Coyotes 1426-6 Lovelock 1618-8 Lower Brule Sioux 1314-4 Lower Elwha 1930-7 Lower Kalskag 1199-9 Lower Muscogee 1619-6 Lower Sioux 1521-4 Lower Skagit 1331-8 Luiseno 1340-9 Lumbee 1342-5 Lummi Birth Defects Implementation Guide APP-51
Concept Code Concept Name 1200-5 Machis Lower Creek Indian 2052-9 Madagascar 1344-1 Maidu 1348-2 Makah 2042-0 Malaysian 2049-5 Maldivian 1427-4 Malheur Paiute 1350-8 Maliseet 1352-4 Mandan 1780-6 Manley Hot Springs 1931-5 Manokotak 1227-8 Manzanita 2089-1 Mariana Islander 1728-5 Maricopa 1932-3 Marshall 2090-9 Marshallese 1454-8 Marshantucket Pequot 1889-5 Mary's Igloo 1681-6 Mashpee Wampanoag 1326-8 Matinecock 1354-0 Mattaponi 1060-3 Mattole 1870-5 Mauneluk Inupiat 1779-8 Mcgrath 1620-4 Mdewakanton Sioux 1933-1 Mekoryuk 2100-6 Melanesian 1356-5 Menominee 1781-4 Mentasta Lake 1228-6 Mesa Grande 1015-7 Mescalero Apache 1838-2 Metlakatla 1072-8 Mexican American Indian 1358-1 Miami 1363-1 Miccosukee 1413-4 Michigan Ottawa 1365-6 Micmac Birth Defects Implementation Guide APP-52
Concept Code Concept Name 2085-9 Micronesian 2118-8 Middle Eastern or North African 1138-7 Mille Lacs 1621-2 Miniconjou 1139-5 Minnesota Chippewa 1782-2 Minto 1368-0 Mission Indians 1158-5 Mississippi Choctaw 1553-7 Missouri Sac and Fox 1370-6 Miwok 1428-2 Moapa 1372-2 Modoc 1729-3 Mohave 1287-2 Mohawk 1374-8 Mohegan 1396-1 Molala 1376-3 Mono 1327-6 Montauk 1237-7 Moor 1049-6 Morongo 1345-8 Mountain Maidu 1934-9 Mountain Village 1159-3 Mowa Band of Choctaw 1522-2 Muckleshoot 1217-9 Munsee 1935-6 Naknek 1498-5 Nambe 2064-4 Namibian 1871-3 Nana Inupiat 1238-5 Nansemond 1378-9 Nanticoke 1937-2 Napakiak 1938-0 Napaskiak 1936-4 Napaumute 1380-5 Narragansett 1239-3 Natchez 2079-2 Native Hawaiian Birth Defects Implementation Guide APP-53
Concept Code Concept Name 2076-8 Native Hawaiian or Other Pacific Islander 1240-1 Nausu Waiwash 1382-1 Navajo 1475-3 Nebraska Ponca 1698-0 Nebraska Winnebago 2016-4 Nelson Lagoon 1783-0 Nenana 2050-3 Nepalese 2104-8 New Hebrides 1940-6 New Stuyahok 1939-8 Newhalen 1941-4 Newtok 1387-0 Nez Perce 2065-1 Nigerian 1942-2 Nightmute 1784-8 Nikolai 2017-2 Nikolski 1785-5 Ninilchik 1241-9 Nipmuc 1346-6 Nishinam 1523-0 Nisqually 1872-1 Noatak 1389-6 Nomalaki 1873-9 Nome 1786-3 Nondalton 1524-8 Nooksack 1874-7 Noorvik 1022-3 Northern Arapaho 1095-9 Northern Cherokee 1103-1 Northern Cheyenne 1429-0 Northern Paiute 1469-6 Northern Pomo 1787-1 Northway 1391-2 Northwest Tribes 1875-4 Nuiqsut 1788-9 Nulato 1943-0 Nunapitchukv Birth Defects Implementation Guide APP-54
Concept Code 1622-0 Oglala Sioux 2043-8 Okinawan 1016-5 Oklahoma Apache 1042-1 Oklahoma Cado 1160-1 Oklahoma Choctaw 1176-7 Oklahoma Comanche 1218-7 Oklahoma Delaware 1306-0 Oklahoma Kickapoo 1310-2 Oklahoma Kiowa 1361-5 Oklahoma Miami 1414-2 Oklahoma Ottawa 1446-4 Oklahoma Pawnee 1451-4 Oklahoma Peoria 1476-1 Oklahoma Ponca 1554-5 Oklahoma Sac and Fox 1571-9 Oklahoma Seminole 1998-4 Old Harbor 1403-5 Omaha 1288-0 Oneida 1289-8 Onondaga 1140-3 Ontonagon 1405-0 Oregon Athabaskan 1407-6 Osage 1944-8 Oscarville 2500-7 Other Pacific Islander 2131-1 Other Race 1409-2 Otoe-Missouria 1411-8 Ottawa 1999-2 Ouzinkie 1430-8 Owens Valley 1416-7 Paiute 2044-6 Pakistani 1333-4 Pala 2091-7 Palauan 2124-6 Palestinian 1439-9 Pamunkey 1592-5 Panamint Concept Name Birth Defects Implementation Guide APP-55
Concept Code Concept Name 2102-2 Papua New Guinean 1713-7 Pascua Yaqui 1441-5 Passamaquoddy 1242-7 Paugussett 2018-0 Pauloff Harbor 1334-2 Pauma 1445-6 Pawnee 1017-3 Payson Apache 1335-9 Pechanga 1789-7 Pedro Bay 1828-3 Pelican 1448-0 Penobscot 1450-6 Peoria 1453-0 Pequot 1980-2 Perryville 1829-1 Petersburg 1499-3 Picuris 1981-0 Pilot Point 1945-5 Pilot Station 1456-3 Pima 1623-8 Pine Ridge Sioux 1624-6 Pipestone Sioux 1500-8 Piro 1460-5 Piscataway 1462-1 Pit River 1946-3 Pitkas Point 1947-1 Platinum 1443-1 Pleasant Point Passamaquoddy 1201-3 Poarch Band 1243-5 Pocomoke Acohonock 2094-1 Pohnpeian 1876-2 Point Hope 1877-0 Point Lay 1501-6 Pojoaque 1483-7 Pokagon Potawatomi 2115-4 Polish 2078-4 Polynesian Birth Defects Implementation Guide APP-56
Concept Code Concept Name 1464-7 Pomo 1474-6 Ponca 1328-4 Poospatuck 1315-1 Port Gamble Klallam 1988-5 Port Graham 1982-8 Port Heiden 2000-8 Port Lions 1525-5 Port Madison 1948-9 Portage Creek 1478-7 Potawatomi 1487-8 Powhatan 1484-5 Prairie Band 1625-3 Prairie Island Sioux 1202-1 Principal Creek Indian Nation 1626-1 Prior Lake Sioux 1489-4 Pueblo 1518-0 Puget Sound Salish 1526-3 Puyallup 1431-6 Pyramid Lake 2019-8 Qagan Toyagungin 2020-6 Qawalangin 1541-2 Quapaw 1730-1 Quechan 1084-3 Quileute 1543-8 Quinault 1949-7 Quinhagak 1385-4 Ramah Navajo 1790-5 Rampart 1219-5 Rampough Mountain 1545-3 Rappahannock 1141-1 Red Cliff Chippewa 1950-5 Red Devil 1142-9 Red Lake Chippewa 1061-1 Red Wood 1547-9 Reno-Sparks 1151-0 Rocky Boy's Chippewa Cree 1627-9 Rosebud Sioux Birth Defects Implementation Guide APP-57
Concept Code Concept Name 1549-5 Round Valley 1791-3 Ruby 1593-3 Ruby Valley 1551-1 Sac and Fox 1143-7 Saginaw Chippewa 2095-8 Saipanese 1792-1 Salamatof 1556-0 Salinan 1558-6 Salish 1560-2 Salish and Kootenai 1458-9 Salt River Pima-Maricopa 1527-1 Samish 2080-0 Samoan 1018-1 San Carlos Apache 1502-4 San Felipe 1503-2 San Ildefonso 1506-5 San Juan 1505-7 San Juan De 1504-0 San Juan Pueblo 1432-4 San Juan Southern Paiute 1574-3 San Manual 1229-4 San Pasqual 1656-8 San Xavier 1220-3 Sand Hill 2023-0 Sand Point 1507-3 Sandia 1628-7 Sans Arc Sioux 1508-1 Santa Ana 1509-9 Santa Clara 1062-9 Santa Rosa 1050-4 Santa Rosa Cahuilla 1163-5 Santa Ynez 1230-2 Santa Ysabel 1629-5 Santee Sioux 1510-7 Santo Domingo 1528-9 Sauk-Suiattle 1145-2 Sault Ste. Marie Chippewa Birth Defects Implementation Guide APP-58
Concept Code 1893-7 Savoonga 1830-9 Saxman 1952-1 Scammon Bay 1562-8 Schaghticoke 1564-4 Scott Valley 2116-2 Scottish 1470-4 Scotts Valley 1878-8 Selawik 1793-9 Seldovia 1657-6 Sells 1566-9 Seminole 1290-6 Seneca 1291-4 Seneca Nation 1292-2 Seneca-Cayuga 1573-5 Serrano 1329-2 Setauket 1795-4 Shageluk 1879-6 Shaktoolik 1576-8 Shasta 1578-4 Shawnee 1953-9 Sheldon's Point 1582-6 Shinnecock 1880-4 Shishmaref 1584-2 Shoalwater Bay 1586-7 Shoshone 1602-2 Shoshone Paiute 1881-2 Shungnak 1891-1 Siberian Eskimo 1894-5 Siberian Yupik 1607-1 Siletz 2051-1 Singaporean 1609-7 Sioux 1631-1 Sisseton Sioux 1630-3 Sisseton-Wahpeton 1831-7 Sitka 1643-6 Siuslaw 1529-7 Skokomish Concept Name Birth Defects Implementation Guide APP-59
Concept Code Concept Name 1594-1 Skull Valley 1530-5 Skykomish 1794-7 Slana 1954-7 Sleetmute 1531-3 Snohomish 1532-1 Snoqualmie 1336-7 Soboba 1146-0 Sokoagon Chippewa 1882-0 Solomon 2103-0 Solomon Islander 1073-6 South American Indian 1595-8 South Fork Shoshone 2024-8 South Naknek 1811-9 Southeast Alaska 1244-3 Southeastern Indians 1023-1 Southern Arapaho 1104-9 Southern Cheyenne 1433-2 Southern Paiute 1074-4 Spanish American Indian 1632-9 Spirit Lake Sioux 1645-1 Spokane 1533-9 Squaxin Island 2045-3 Sri Lankan 1144-5 St. Croix Chippewa 2021-4 St. George 1963-8 St. Mary's 1951-3 St. Michael 2022-2 St. Paul 1633-7 Standing Rock Sioux 1203-9 Star Clan of Muscogee Creeks 1955-4 Stebbins 1534-7 Steilacoom 1796-2 Stevens 1647-7 Stewart 1535-4 Stillaguamish 1649-3 Stockbridge 1797-0 Stony River Birth Defects Implementation Guide APP-60
Concept Code Concept Name 1471-2 Stonyford 2002-4 Sugpiaq 1472-0 Sulphur Bank 1434-0 Summit Lake 2004-0 Suqpigaq 1536-2 Suquamish 1651-9 Susanville 1245-0 Susquehanock 1537-0 Swinomish 1231-0 Sycuan 2125-3 Syrian 1705-3 Table Bluff 1719-4 Tachi 2081-8 Tahitian 2035-4 Taiwanese 1063-7 Takelma 1798-8 Takotna 1397-9 Talakamish 1799-6 Tanacross 1800-2 Tanaina 1801-0 Tanana 1802-8 Tanana Chiefs 1511-5 Taos 1969-5 Tatitlek 1803-6 Tazlina 1804-4 Telida 1883-8 Teller 1338-3 Temecula 1596-6 Te-Moak Western Shoshone 1832-5 Tenakee Springs 1398-7 Tenino 1512-3 Tesuque 1805-1 Tetlin 1634-5 Teton Sioux 1513-1 Tewa 1307-8 Texas Kickapoo 2046-1 Thai Birth Defects Implementation Guide APP-61
Concept Code 1204-7 Thlopthlocco 1514-9 Tigua 1399-5 Tillamook 1597-4 Timbi-Sha Shoshone 1833-3 Tlingit 1813-5 Tlingit-Haida 2073-5 Tobagoan 1956-2 Togiak 1653-5 Tohono O'Odham 1806-9 Tok 2083-4 Tokelauan 1957-0 Toksook 1659-2 Tolowa 1293-0 Tonawanda Seneca 2082-6 Tongan 1661-8 Tonkawa 1051-2 Torres-Martinez 2074-3 Trinidadian 1272-4 Trinity 1837-4 Tsimshian 1205-4 Tuckabachee 1538-8 Tulalip 1720-2 Tule River 1958-8 Tulukskak 1246-8 Tunica Biloxi 1959-6 Tuntutuliak 1960-4 Tununak 1147-8 Turtle Mountain 1294-8 Tuscarora 1096-7 Tuscola 1337-5 Twenty-Nine Palms 1961-2 Twin Hills 1635-2 Two Kettle Sioux 1663-4 Tygh 1807-7 Tyonek 1970-3 Ugashik 1672-5 Uintah Ute Concept Name Birth Defects Implementation Guide APP-62
Concept Code Concept Name 1665-9 Umatilla 1964-6 Umkumiate 1667-5 Umpqua 1884-6 Unalakleet 2025-5 Unalaska 2006-5 Unangan Aleut 2026-3 Unga 1097-5 United Keetowah Band of Cherokee 1118-9 Upper Chinook 1636-0 Upper Sioux 1539-6 Upper Skagit 1670-9 Ute 1673-3 Ute Mountain Ute 1435-7 Utu Utu Gwaitu Paiute 1808-5 Venetie 2047-9 Vietnamese 1247-6 Waccamaw-Siousan 1637-8 Wahpekute Sioux 1638-6 Wahpeton Sioux 1675-8 Wailaki 1885-3 Wainwright 1119-7 Wakiakum Chinook 1886-1 Wales 1436-5 Walker River 1677-4 Walla-Walla 1679-0 Wampanoag 1064-5 Wappo 1683-2 Warm Springs 1685-7 Wascopum 1598-2 Washakie 1687-3 Washoe 1639-4 Wazhaza Sioux 1400-1 Wenatchee 2075-0 West Indian 1098-3 Western Cherokee 1110-6 Western Chickahominy 1273-2 Whilkut Birth Defects Implementation Guide APP-63
Concept Code 2106-3 White 1148-6 White Earth 1887-9 White Mountain 1019-9 White Mountain Apache 1888-7 White Mountain Inupiat 1692-3 Wichita 1248-4 Wicomico 1120-5 Willapa Chinook 1694-9 Wind River 1024-9 Wind River Arapaho 1599-0 Wind River Shoshone 1696-4 Winnebago 1700-4 Winnemucca 1702-0 Wintun 1485-2 Wisconsin Potawatomi 1809-3 Wiseman 1121-3 Wishram 1704-6 Wiyot 1834-1 Wrangell 1295-5 Wyandotte 1401-9 Yahooskin 1707-9 Yakama 1709-5 Yakama Cowlitz 1835-8 Yakutat 1065-2 Yana 1640-2 Yankton Sioux 1641-0 Yanktonai Sioux 2098-2 Yapese 1711-1 Yaqui 1731-9 Yavapai 1715-2 Yavapai Apache 1437-3 Yerington Paiute 1717-8 Yokuts 1600-6 Yomba 1722-8 Yuchi 1066-0 Yuki 1724-4 Yuman Concept Name Birth Defects Implementation Guide APP-64
Concept Code 1896-0 Yupik Eskimo 1732-7 Yurok 2066-9 Zairean 1515-6 Zia 1516-4 Zuni Concept Name D No applicable value sets. E Ethnicity Value Set 2.16.840.1.114222.4.11.837 DYNAMIC Code System(s) Race and Ethnicity - CDC 2.16.840.1.113883.6.238 Code Code System Print Name 2135-2 Race and Ethnicity Code Sets Hispanic or Latino 2186-5 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 2.16.840.1.114222.4.11.830 Concept Code Concept Name 01 Alabama 02 Alaska 60 American Samoa 04 Arizona 05 Arkansas 81 Baker Island Birth Defects Implementation Guide APP-65
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
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
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 3166-1 Value Set Country Value Set 2.16.840.1.113883.3.88.12.80.63 DYNAMIC Code System(s) ISO 3166-1 Country Codes: 1.0.3166.1 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 3166-1 code elements available in the alpha-2 code of ISO's country code standard http://www.iso.org/iso/country_codes/iso_3166_code_lists.htm Concept Code Concept Name AFG AFGHANISTAN ALA ÅLAND ISLANDS ALB ALBANIA DZA ALGERIA Birth Defects Implementation Guide APP-68
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
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
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
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
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
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
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
J No applicable value sets. K No applicable value sets. L No applicable value sets. M Marital Status Value Set HL7 Marital Status ID 2.16.840.1.113883.1.11.12212 Marital Status 2.16.840.1.113883.5.2 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
Maternal Risk Factors Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 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
SNOMED-CT Code 99 Unknown SNOMED-CT Description MCH HBS 5 Min Apgar Score Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.9.16 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.12 Value Set Code PHVS_ApgarScore5Min_NCHS Value Set Description To reflect the 5 Min Apgar Score Vocabulary OID 2.16.840.1.113883.6.1 LOINC Code LOINC Description 9274-2 Score^5M post birth MCH HBS 10 Min Apgar Score Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.9.16 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.13 Value Set Code PHVS_ApgarScore10Min_NCHS Value Set Description To Reflect the 10 Min Apgar Score Vocabulary OID 2.16.840.1.113883.6.1 LOINC Code LOINC Description 9271-8 Score^10M post birth MCH HBS Antibiotic Administration Procedure Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.178 Value Set Code PHVS_AntibioticAdministrationProcedure_NCHS Value Set Description To Reflect Antibiotic Administration Procedure during labor and delivery SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 281790008 Intravenous antibiotic therapy (procedure) 307520009 Intramuscular antibiotic therapy (procedure) Birth Defects Implementation Guide APP-78
MCH HBS Assisted Ventilation Immediately Following Delivery Value Set Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.7 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 2.16.840.1.113883.6.96 Pending Pending SNOMED-CT Description MCH HBS Birth Height Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 Value Set TBD OID Value Set Description To Reflect the Birth Height Vocabulary 2.16.840.1.113883.6.1 LOINC Code LOINC Description TBD Birth Height MCH HBS Birth Weight Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.20 Value Set Description To Reflect the Birth Weight Vocabulary 2.16.840.1.113883.6.1 LOINC Code LOINC Description 3141-9 Birth Weight Birth Defects Implementation Guide APP-79
MCH HBS Date of Last Live Birth Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.67 Value Set Description To Reflect the Date of Last Live Birth Vocabulary 2.16.840.1.113883.6.1 LOINC Code LOINC Description 68499-3 Date last live birth MCH HBS Date of Last Other Pregnancy Outcome Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.70 Value Set Description To Reflect the Date of Last Other Pregnancy Outcome Vocabulary OID 2.16.840.1.113883.6.1 LOINC Code LOINC Description Pending Pending MCH HBS First Prenatal Care Visit Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.133 Value Set Code PHVS_FirstPrenatalCareVisit_NCHS Value Set Description To Reflect the First Prenatal Care Visit Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 424441002 Prenatal initial visit (regime/therapy) MCH HBS Intramuscular Medication Administration Route Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.3.21 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.5 Value Set Description To reflect that Intramuscular Medication Administration Route was used to administer a medication Birth Defects Implementation Guide APP-80
Vocabulary 2.16.840.1.113883.12.162 Data Element HL7 Route of Administration IM Intramuscular MCH HBS Karyotype Determination Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.154 Value Set Code PHVS_KaryotypeDetermination_NCHS Value Set Description To Reflect Fetal Autopsy was performed Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 312948004 Karyotype determination (procedure) 444309000 Determination of karyotype from blood specimen (procedure) MCH HBS Last Prenatal Care Visit Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.134 Value Set Description To Reflect the Last Prenatal Care Visit Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description Pending Pending MCH HBS Number of Live Births Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.68 Value Set Code PHVS_NumberofLiveBirths_NCHS Value Set Description To Reflect the Number of Live Births Vocabulary OID 2.16.840.1.113883.6.1 LOINC Code LOINC Description 11636-8 Births.live Birth Defects Implementation Guide APP-81
MCH HBS Number Prenatal Care Visits Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.135 Value Set Description To reflect the Number Prenatal Care Visits Vocabulary 2.16.840.1.113883.6.1 LOINC Code LOINC Description 68493-6 Prenatal visits for this pregnancy MCH HBS Number of Previous Live Births Now Dead Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.122 Value Set Description To Reflect the Previous Other Pregnancy Outcomes Vocabulary 2.16.840.1.113883.6.1 LOINC Code LOINC Description 68496-9 Live births.now dead MCH HBS Number of Previous Live Births Now Living Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.123 Value Set Code PHVS_NoOfPreviousLiveBirthsNowLiving_NCHS Value Set Description To Reflect the Previous Other Pregnancy Outcomes Vocabulary 2.16.840.1.113883.6.1 LOINC Code LOINC Description 11638-4 Births.still living MCH HBS Number of Prior Pregnancies Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.3.28 Value Set OID 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.71 Value Set Code PHVS_NumberOfPriorPregnancies_NCHS Value Set Description To Reflect the Number of Prior Pregnancies Birth Defects Implementation Guide APP-82
Vocabulary OID 2.16.840.1.113883.6.1 Code System Name LOINC LOINC Code LOINC Description 11996-6 Pregnancies 11977-6 Parity MCH HBS Poor Pregnancy Outcome History Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.142 Value Set Code PHVS_PoorPregnancyOutcomeHistory_NCHS Value Set Description To reflect Risk Factors of Pregnancy Outcome of Perinatal Death History SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 169583006 Antenatal care: history of perinatal death (situation) 169582001 Antenatal care: history of stillbirth (situation) 169585004 Antenatal care: history of trophoblastic disease (situation) 169584000 Antenatal care: poor obstetric history (situation) 161744009 History of Miscarriage 161747002 History of 1 Miscarriage 161748007 History of 2 Miscarriage 161749004 History of 3 Miscarriage 161750004 History of 4 Miscarriages 161751000 History of 5 Miscarriages 161752007 History of 6 Miscarriages 161804005 History of - antepartum hemorrhage (situation) 275569003 History of - delivery no details (situation) 275569003 History of - delivery no details (situation) 161806007 History of - eclampsia (situation) 161763005 History of - ectopic pregnancy (situation) 161803004 History of - obstetric problem (situation) 161809000 History of - postpartum hemorrhage (situation) 161765003 History of - premature delivery (situation) 161810005 History of - prolonged labor (situation) 161807003 History of - severe pre-eclampsia (situation) 161743003 History of - stillbirth (situation) Birth Defects Implementation Guide APP-83
SNOMED-CT Code SNOMED-CT Description 428978004 History of choriocarcinoma of placenta (situation) 441493008 History of premature labor (situation) MCH HBS Pre-Pregnancy Weight Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.19376.1.5.3.1.4.13.5 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.118 Value Set Code PHVS_PrePregnancyWeight_NCHS Value Set Description To Reflect the mother s Pre-Pregnancy Weight Vocabulary 2.16.840.1.113883.6.1 LOINC Code LOINC Description 56077-1 Body weight^pre current pregnancy 8348-5 Body weight^pre pregnancy MCH HBS Seizure or Serious Neurologic Dysfunction Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.3.6 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.10 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 2.16.840.1.113883.6.96 SNOMED-CT Code 91175000 Seizure (finding) 444229001 Afebrile seizure (finding) SNOMED-CT Description 41119002 Akinetic seizure without atonia (finding) 41510006 Anoxic seizure (finding) 438156004 Anoxic epileptic seizure (finding) 440443001 Reflex anoxic seizure (finding) 59754009 Brief atonic seizure (finding) 58895005 Central convulsion (finding) 313307000 Epileptic seizure (finding) 192982004 Epileptic seizures - akinetic (finding) 192981006 Epileptic seizures - atonic (finding) Birth Defects Implementation Guide APP-84
SNOMED-CT Code SNOMED-CT Description 192991000 Epileptic seizures - clonic (finding) 192993002 Epileptic seizures - tonic (finding) 433083002 Complex febrile seizure (finding) 246545002 Generalized seizure (finding) 6208003 Clonic seizure (finding) 2665008 Coordinate convulsion (finding) 54200006 Tonic-clonic seizure (finding) 65155005 Grand mal seizure (finding) 163590008 On examination - grand mal fit (finding) 20544001 Secondarily generalized seizures (finding) 87185006 Long atonic seizure (finding) 19593003 Movement partial seizure (finding) 371129000 Paralysis from birth trauma (disorder) 40980002 Spastic paralysis due to birth injury (disorder) 28534004 Spastic paralysis due to intracranial birth injury (disorder) 79591004 Spastic paralysis due to spinal birth injury (disorder) 95628005 Neonatal encephalopathy (disorder) 277480002 Neonatal asphyxial encephalopathy (disorder) 277479000 Postnatal hypoxic encephalopathy (disorder) MCH HBS Significant Birth Injury Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.9 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 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 56110009 Birth trauma of fetus (disorder) 206253009 Birth injury to face (disorder) 37384000 Birth injury to scalp (disorder) 82729001 Caput succedaneum (disorder) 302962000 Chignon (disorder) 206201001 Vacuum extraction chignon (disorder) Birth Defects Implementation Guide APP-85
SNOMED-CT Code SNOMED-CT Description 268822004 Fetal monitoring scalp injury (disorder) 276704001 Electrode injury to scalp during birth (disorder) 276705000 Sampling injury to scalp during birth (disorder) 206199003 Scalp injuries due to birth trauma (disorder) 206200000 Cephalhematoma due to birth trauma (disorder) 206203003 Scalp abrasions due to birth trauma (disorder) 403849006 Scalp injury due to vacuum extraction (disorder) 129631008 Birth trauma deafness (disorder) 206251006 Birth trauma due to amniocentesis (disorder) 240312009 Cerebral injury due to birth trauma (disorder) 206196005 Cerebral hemorrhage due to birth injury (disorder) 206195009 Extradural hemorrhage in fetus or newborn (disorder) 206188000 Subdural and cerebral hemorrhage due to birth trauma (disorder) 206192007 Tentorial tear due to birth trauma (disorder) 206234004 Cranial nerve injury due to birth trauma (disorder) 55712002 Facial nerve injury as birth trauma (disorder) 84947004 Facial palsy as birth trauma (disorder) 111465000 Erb-Duchenne palsy as birth trauma (disorder) 50263004 Hematoma of vulva of fetus or newborn as birth trauma (disorder) 16581008 Injury of spine AND/OR spinal cord as birth trauma (disorder) 53785005 Injury to brachial plexus as birth trauma (disorder) 206226005 Brachial plexus palsy due to birth trauma (disorder) 81774005 Klumpke-Déjerine paralysis as birth trauma (disorder) 240317003 Kidney injury due to birth trauma (disorder) 240316007 Laryngeal injury due to birth trauma (disorder) 206245001 Liver rupture due to birth trauma (disorder) 371129000 Paralysis from birth trauma (disorder) 40980002 Spastic paralysis due to birth injury (disorder) 28534004 Spastic paralysis due to intracranial birth injury (disorder) 79591004 Spastic paralysis due to spinal birth injury (disorder) 403848003 Perinatal forceps injury (disorder) 403847008 Perinatal skin trauma due to obstetric injury (disorder) 206235003 Peripheral nerve injury due to birth trauma (disorder) 206233005 Birth injury to phrenic nerve (disorder) 28778005 Phrenic nerve paralysis as birth trauma (disorder) 206228006 Birth plexus injury - whole plexus (disorder) Birth Defects Implementation Guide APP-86
SNOMED-CT Code SNOMED-CT Description 206247009 Scalpel wound due to birth trauma (disorder) 240314005 Skeletal injury due to birth trauma (disorder) 206216003 Birth dislocation of the shoulder (disorder) 20596003 Fracture of long bone, as birth trauma (disorder) 275365008 Birth fracture of radius (disorder) 275366009 Birth fracture of ulna (disorder) 206209004 Fracture of clavicle due to birth trauma (disorder) 206213006 Fracture of femur due to birth trauma (disorder) 206211008 Fracture of humerus due to birth trauma (disorder) 240315006 Fracture of nose due to birth trauma (disorder) 268824003 Fracture of radius and/or ulna due to birth trauma (disorder) 64728002 Fracture of spine due to birth trauma (disorder) 206214000 Fracture of tibia and/or fibula due to birth trauma (disorder) 206221000 Spine dislocation due to birth trauma (disorder) 206220004 Spine or spinal cord injury due to birth trauma (disorder) 206223002 Spinal cord laceration due to birth trauma (disorder) 206224008 Spinal cord rupture due to birth trauma (disorder) 268826001 Spleen rupture due to birth trauma (disorder) 206252004 Sternomastoid injury due to birth injury (disorder) 30671001 Tentorial tear as birth trauma (disorder) Meconium Staining Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.36 Value Set Code PHVS_MeconiumStaining_NCHS Value Set Description To Reflect that there was moderate or heavy Meconium staining SNOMED-CT Code Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Description 408793000 Meconium stained liquor - grade II (finding) 408794006 Meconium stained liquor - grade III (finding) 289294000 Thick meconium stained liquor (finding) 249136005 Fresh meconium staining liquor (finding) 249137001 Old meconium staining liquor (finding) Birth Defects Implementation Guide APP-87
N No applicable value sets. O No applicable value sets. P Personal Relationship Role Type Value Set Personal Relationship Role Type 2.16.840.1.113883.1.11.19563 DYNAMIC Code System(s) RoleCode 2.16.840.1.113883.5.111 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. http://www.hl7.org/memonly/downloads/v3edition.cfm#v320 08 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
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
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
Precipitous Labor Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.130 Value Set Code PHVS_PrecipitousLabor_NCHS Value Set Description To Reflect Onset of labor with Precipitous Labor Vocabulary 2.16.840.1.113883.6.96 SNOMED-CT Code SNOMED-CT Description 51920004 Precipitate labor (disorder) 199833004 Precipitate labor - delivered (disorder) 199834005 Precipitate labor with antenatal problem (disorder) Pregnancy Outcomes Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 Entry Template 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 Value Set OID 2.16.840.1.114222.4.11.3071 Value Set Code PHVS_PregnancyOutcome_FDD Value Set Description Outcome of pregnancy answer list Concept Code Concept Name 289257009 Mother not delivered (finding) OTH Other 282020008 Premature delivery (finding) 17369002 Spontaneous abortion (disorder) 237364002 Stillbirth (finding) 21243004 Term birth of newborn (finding) UNK Unknown Prolonged Labor Section Template 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 Entry Template 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 Value Set 1.3.6.1.4.1.19376.1.7.3.1.1.13.8.131 Value Set Code PHVS_ProlongedLabor_NCHS Value Set Description To Reflect Onset of labor with Prolonged Labor Vocabulary 2.16.840.1.113883.6.96 Birth Defects Implementation Guide APP-91
SNOMED-CT Code SNOMED-CT Description 53443007 Prolonged labor (disorder) 35347003 Delayed delivery after artificial rupture of membranes (disorder) 21987001 Delayed delivery of second of multiple births (disorder) 237321009 Delayed delivery of triplet (disorder) 275429002 Delayed delivery of second twin (disorder) 199860006 Delayed delivery of second twin, triplet etc. (disorder) 199862003 Delayed delivery second twin delivered (disorder) 199863008 Delayed delivery second twin with antenatal problem (disorder) 33627001 Prolonged first stage of labor (disorder) 199847000 Prolonged first stage - delivered (disorder) 199848005 Prolonged first stage with antenatal problem (disorder) 387700009 Prolonged latent phase of labor (disorder) 77259008 Prolonged second stage of labor (disorder) 199857004 Prolonged second stage - delivered (disorder) 199858009 Prolonged second stage with antenatal problem (disorder) Q No applicable value sets. R Race Value Set Race 2.16.840.1.113883.1.11.14914 DYNAMIC Code System(s) Race and Ethnicity - CDC 2.16.840.1.113883.6.238 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 http://phinvads.cdc.gov/vads/viewcodesystemconcept.acti on?oid=2.16.840.1.113883.6.238&code=1000-9 Birth Defects Implementation Guide APP-92
Concept Code Concept Name 1006-6 Abenaki 1579-2 Absentee Shawnee 1490-2 Acoma 2126-1 Afghanistani 2060-2 African 2058-6 African American 1994-3 Agdaagux 1212-0 Agua Caliente 1045-4 Agua Caliente Cahuilla 1740-0 Ahtna 1654-3 Ak-Chin 1993-5 Akhiok 1897-8 Akiachak 1898-6 Akiak 2007-3 Akutan 1187-4 Alabama Coushatta 1194-0 Alabama Creek 1195-7 Alabama Quassarte 1899-4 Alakanuk 1383-9 Alamo Navajo 1744-2 Alanvik 1737-6 Alaska Indian 1735-0 Alaska Native 1739-2 Alaskan Athabascan 1741-8 Alatna 1900-0 Aleknagik 1966-1 Aleut 2008-1 Aleut Corporation 2009-9 Aleutian 2010-7 Aleutian Islander 1742-6 Alexander 1008-2 Algonquian 1743-4 Allakaket 1671-7 Allen Canyon 1688-1 Alpine 1392-0 Alsea 1968-7 Alutiiq Aleut 1845-7 Ambler 1004-1 American Indian 1002-5 American Indian or Alaska Native 1846-5 Anaktuvuk 1847-3 Anaktuvuk Pass 1901-8 Andreafsky 1814-3 Angoon 1902-6 Aniak 1745-9 Anvik Birth Defects Implementation Guide APP-93
Concept Code Concept Name 1010-8 Apache 2129-5 Arab 1021-5 Arapaho 1746-7 Arctic 1849-9 Arctic Slope Corporation 1848-1 Arctic Slope Inupiat 1026-4 Arikara 1491-0 Arizona Tewa 2109-7 Armenian 1366-4 Aroostook 2028-9 Asian 2029-7 Asian Indian 1028-0 Assiniboine 1030-6 Assiniboine Sioux 2119-6 Assyrian 2011-5 Atka 1903-4 Atmautluak 1850-7 Atqasuk 1265-8 Atsina 1234-4 Attacapa 1046-2 Augustine 1124-7 Bad River 2067-7 Bahamian 2030-5 Bangladeshi 1033-0 Bannock 2068-5 Barbadian 1712-9 Barrio Libre 1851-5 Barrow 1587-5 Battle Mountain 1125-4 Bay Mills Chippewa 1747-5 Beaver 2012-3 Belkofski 1852-3 Bering Straits Inupiat 1904-2 Bethel 2031-3 Bhutanese 1567-7 Big Cypress 1905-9 Bill Moore's Slough 1235-1 Biloxi 1748-3 Birch Creek 1417-5 Bishop 2056-0 Black 2054-5 Black or African American 1035-5 Blackfeet 1610-5 Blackfoot Sioux 1126-2 Bois Forte 2061-0 Botswanan 1853-1 Brevig Mission Birth Defects Implementation Guide APP-94
Concept Code Concept Name 1418-3 Bridgeport 1568-5 Brighton 1972-9 Bristol Bay Aleut 1906-7 Bristol Bay Yupik 1037-1 Brotherton 1611-3 Brule Sioux 1854-9 Buckland 2032-1 Burmese 1419-1 Burns Paiute 1039-7 Burt Lake Band 1127-0 Burt Lake Chippewa 1412-6 Burt Lake Ottawa 1047-0 Cabazon 1041-3 Caddo 1054-6 Cahto 1044-7 Cahuilla 1053-8 California Tribes 1907-5 Calista Yupik 2033-9 Cambodian 1223-7 Campo 1068-6 Canadian and Latin American Indian 1069-4 Canadian Indian 1384-7 Canoncito Navajo 1749-1 Cantwell 1224-5 Capitan Grande 2092-5 Carolinian 1689-9 Carson 1076-9 Catawba 1286-4 Cayuga 1078-5 Cayuse 1420-9 Cedarville 1393-8 Celilo 1070-2 Central American Indian 1815-0 Central Council of Tlingit and Haida Tribes 1465-4 Central Pomo 1750-9 Chalkyitsik 2088-3 Chamorro 1908-3 Chefornak 1080-1 Chehalis 1082-7 Chemakuan 1086-8 Chemehuevi 1985-1 Chenega 1088-4 Cherokee 1089-2 Cherokee Alabama 1100-7 Cherokee Shawnee 1090-0 Cherokees of Northeast Alabama 1091-8 Cherokees of Southeast Alabama Birth Defects Implementation Guide APP-95
Concept Code Concept Name 1909-1 Chevak 1102-3 Cheyenne 1612-1 Cheyenne River Sioux 1106-4 Cheyenne-Arapaho 1108-0 Chickahominy 1751-7 Chickaloon 1112-2 Chickasaw 1973-7 Chignik 2013-1 Chignik Lagoon 1974-5 Chignik Lake 1816-8 Chilkat 1817-6 Chilkoot 1055-3 Chimariko 2034-7 Chinese 1855-6 Chinik 1114-8 Chinook 1123-9 Chippewa 1150-2 Chippewa Cree 1011-6 Chiricahua 1752-5 Chistochina 1153-6 Chitimacha 1753-3 Chitina 1155-1 Choctaw 1910-9 Chuathbaluk 1984-4 Chugach Aleut 1986-9 Chugach Corporation 1718-6 Chukchansi 1162-7 Chumash 2097-4 Chuukese 1754-1 Circle 1479-5 Citizen Band Potawatomi 1911-7 Clark's Point 1115-5 Clatsop 1165-0 Clear Lake 1156-9 Clifton Choctaw 1056-1 Coast Miwok 1733-5 Coast Yurok 1492-8 Cochiti 1725-1 Cocopah 1167-6 Coeur D'Alene 1169-2 Coharie 1171-8 Colorado River 1394-6 Columbia 1116-3 Columbia River Chinook 1173-4 Colville 1175-9 Comanche 1755-8 Cook Inlet Birth Defects Implementation Guide APP-96
Concept Code Concept Name 1180-9 Coos 1178-3 Coos, Lower Umpqua, Siuslaw 1756-6 Copper Center 1757-4 Copper River 1182-5 Coquilles 1184-1 Costanoan 1856-4 Council 1186-6 Coushatta 1668-3 Cow Creek Umpqua 1189-0 Cowlitz 1818-4 Craig 1191-6 Cree 1193-2 Creek 1207-0 Croatan 1912-5 Crooked Creek 1209-6 Crow 1613-9 Crow Creek Sioux 1211-2 Cupeno 1225-2 Cuyapaipe 1614-7 Dakota Sioux 1857-2 Deering 1214-6 Delaware 1222-9 Diegueno 1057-9 Digger 1913-3 Dillingham 2070-1 Dominica Islander 2069-3 Dominican 1758-2 Dot Lake 1819-2 Douglas 1759-0 Doyon 1690-7 Dresslerville 1466-2 Dry Creek 1603-0 Duck Valley 1588-3 Duckwater 1519-8 Duwamish 1760-8 Eagle 1092-6 Eastern Cherokee 1109-8 Eastern Chickahominy 1196-5 Eastern Creek 1215-3 Eastern Delaware 1197-3 Eastern Muscogee 1467-0 Eastern Pomo 1580-0 Eastern Shawnee 1233-6 Eastern Tribes 1093-4 Echota Cherokee 1914-1 Eek 1975-2 Egegik Birth Defects Implementation Guide APP-97
Concept Code Concept Name 2120-4 Egyptian 1761-6 Eklutna 1915-8 Ekuk 1916-6 Ekwok 1858-0 Elim 1589-1 Elko 1590-9 Ely 1917-4 Emmonak 2110-5 English 1987-7 English Bay 1840-8 Eskimo 1250-0 Esselen 2062-8 Ethiopian 1094-2 Etowah Cherokee 2108-9 European 1762-4 Evansville 1990-1 Eyak 1604-8 Fallon 2015-6 False Pass 2101-4 Fijian 2036-2 Filipino 1615-4 Flandreau Santee 1569-3 Florida Seminole 1128-8 Fond du Lac 1480-3 Forest County 1252-6 Fort Belknap 1254-2 Fort Berthold 1421-7 Fort Bidwell 1258-3 Fort Hall 1422-5 Fort Independence 1605-5 Fort McDermitt 1256-7 Fort Mcdowell 1616-2 Fort Peck 1031-4 Fort Peck Assiniboine Sioux 1012-4 Fort Sill Apache 1763-2 Fort Yukon 2111-3 French 1071-0 French American Indian 1260-9 Gabrieleno 1764-0 Gakona 1765-7 Galena 1892-9 Gambell 1680-8 Gay Head Wampanoag 1236-9 Georgetown (Eastern Tribes) 1962-0 Georgetown (Yupik-Eskimo) 2112-1 German 1655-0 Gila Bend Birth Defects Implementation Guide APP-98
Concept Code Concept Name 1457-1 Gila River Pima-Maricopa 1859-8 Golovin 1918-2 Goodnews Bay 1591-7 Goshute 1129-6 Grand Portage 1262-5 Grand Ronde 1130-4 Grand Traverse Band of Ottawa/Chippewa 1766-5 Grayling 1842-4 Greenland Eskimo 1264-1 Gros Ventres 2087-5 Guamanian 2086-7 Guamanian or Chamorro 1767-3 Gulkana 1820-0 Haida 2071-9 Haitian 1267-4 Haliwa 1481-1 Hannahville 1726-9 Havasupai 1768-1 Healy Lake 1269-0 Hidatsa 2037-0 Hmong 1697-2 Ho-chunk 1083-5 Hoh 1570-1 Hollywood Seminole 1769-9 Holy Cross 1821-8 Hoonah 1271-6 Hoopa 1275-7 Hoopa Extension 1919-0 Hooper Bay 1493-6 Hopi 1277-3 Houma 1727-7 Hualapai 1770-7 Hughes 1482-9 Huron Potawatomi 1771-5 Huslia 1822-6 Hydaburg 1976-0 Igiugig 1772-3 Iliamna 1359-9 Illinois Miami 1279-9 Inaja-Cosmit 1860-6 Inalik Diomede 1442-3 Indian Township 1360-7 Indiana Miami 2038-8 Indonesian 1861-4 Inupiaq 1844-0 Inupiat Eskimo 1281-5 Iowa Birth Defects Implementation Guide APP-99
Concept Code Concept Name 1282-3 Iowa of Kansas-Nebraska 1283-1 Iowa of Oklahoma 1552-9 Iowa Sac and Fox 1920-8 Iqurmuit (Russian Mission) 2121-2 Iranian 2122-0 Iraqi 2113-9 Irish 1285-6 Iroquois 1494-4 Isleta 2127-9 Israeili 2114-7 Italian 1977-8 Ivanof Bay 2048-7 Iwo Jiman 2072-7 Jamaican 1313-6 Jamestown 2039-6 Japanese 1495-1 Jemez 1157-7 Jena Choctaw 1013-2 Jicarilla Apache 1297-1 Juaneno 1423-3 Kaibab 1823-4 Kake 1862-2 Kaktovik 1395-3 Kalapuya 1299-7 Kalispel 1921-6 Kalskag 1773-1 Kaltag 1995-0 Karluk 1301-1 Karuk 1824-2 Kasaan 1468-8 Kashia 1922-4 Kasigluk 1117-1 Kathlamet 1303-7 Kaw 1058-7 Kawaiisu 1863-0 Kawerak 1825-9 Kenaitze 1496-9 Keres 1059-5 Kern River 1826-7 Ketchikan 1131-2 Keweenaw 1198-1 Kialegee 1864-8 Kiana 1305-2 Kickapoo 1520-6 Kikiallus 2014-9 King Cove 1978-6 King Salmon Birth Defects Implementation Guide APP-100
Concept Code Concept Name 1309-4 Kiowa 1923-2 Kipnuk 2096-6 Kiribati 1865-5 Kivalina 1312-8 Klallam 1317-7 Klamath 1827-5 Klawock 1774-9 Kluti Kaah 1775-6 Knik 1866-3 Kobuk 1996-8 Kodiak 1979-4 Kokhanok 1924-0 Koliganek 1925-7 Kongiganak 1992-7 Koniag Aleut 1319-3 Konkow 1321-9 Kootenai 2040-4 Korean 2093-3 Kosraean 1926-5 Kotlik 1867-1 Kotzebue 1868-9 Koyuk 1776-4 Koyukuk 1927-3 Kwethluk 1928-1 Kwigillingok 1869-7 Kwiguk 1332-6 La Jolla 1226-0 La Posta 1132-0 Lac Courte Oreilles 1133-8 Lac du Flambeau 1134-6 Lac Vieux Desert Chippewa 1497-7 Laguna 1777-2 Lake Minchumina 1135-3 Lake Superior 1617-0 Lake Traverse Sioux 2041-2 Laotian 1997-6 Larsen Bay 1424-1 Las Vegas 1323-5 Lassik 2123-8 Lebanese 1136-1 Leech Lake 1216-1 Lenni-Lenape 1929-9 Levelock 2063-6 Liberian 1778-0 Lime 1014-0 Lipan Apache 1137-9 Little Shell Chippewa Birth Defects Implementation Guide APP-101
Concept Code Concept Name 1425-8 Lone Pine 1325-0 Long Island 1048-8 Los Coyotes 1426-6 Lovelock 1618-8 Lower Brule Sioux 1314-4 Lower Elwha 1930-7 Lower Kalskag 1199-9 Lower Muscogee 1619-6 Lower Sioux 1521-4 Lower Skagit 1331-8 Luiseno 1340-9 Lumbee 1342-5 Lummi 1200-5 Machis Lower Creek Indian 2052-9 Madagascar 1344-1 Maidu 1348-2 Makah 2042-0 Malaysian 2049-5 Maldivian 1427-4 Malheur Paiute 1350-8 Maliseet 1352-4 Mandan 1780-6 Manley Hot Springs 1931-5 Manokotak 1227-8 Manzanita 2089-1 Mariana Islander 1728-5 Maricopa 1932-3 Marshall 2090-9 Marshallese 1454-8 Marshantucket Pequot 1889-5 Mary's Igloo 1681-6 Mashpee Wampanoag 1326-8 Matinecock 1354-0 Mattaponi 1060-3 Mattole 1870-5 Mauneluk Inupiat 1779-8 Mcgrath 1620-4 Mdewakanton Sioux 1933-1 Mekoryuk 2100-6 Melanesian 1356-5 Menominee 1781-4 Mentasta Lake 1228-6 Mesa Grande 1015-7 Mescalero Apache 1838-2 Metlakatla 1072-8 Mexican American Indian 1358-1 Miami Birth Defects Implementation Guide APP-102
Concept Code Concept Name 1363-1 Miccosukee 1413-4 Michigan Ottawa 1365-6 Micmac 2085-9 Micronesian 2118-8 Middle Eastern or North African 1138-7 Mille Lacs 1621-2 Miniconjou 1139-5 Minnesota Chippewa 1782-2 Minto 1368-0 Mission Indians 1158-5 Mississippi Choctaw 1553-7 Missouri Sac and Fox 1370-6 Miwok 1428-2 Moapa 1372-2 Modoc 1729-3 Mohave 1287-2 Mohawk 1374-8 Mohegan 1396-1 Molala 1376-3 Mono 1327-6 Montauk 1237-7 Moor 1049-6 Morongo 1345-8 Mountain Maidu 1934-9 Mountain Village 1159-3 Mowa Band of Choctaw 1522-2 Muckleshoot 1217-9 Munsee 1935-6 Naknek 1498-5 Nambe 2064-4 Namibian 1871-3 Nana Inupiat 1238-5 Nansemond 1378-9 Nanticoke 1937-2 Napakiak 1938-0 Napaskiak 1936-4 Napaumute 1380-5 Narragansett 1239-3 Natchez 2079-2 Native Hawaiian 2076-8 Native Hawaiian or Other Pacific Islander 1240-1 Nausu Waiwash 1382-1 Navajo 1475-3 Nebraska Ponca 1698-0 Nebraska Winnebago 2016-4 Nelson Lagoon 1783-0 Nenana Birth Defects Implementation Guide APP-103
Concept Code Concept Name 2050-3 Nepalese 2104-8 New Hebrides 1940-6 New Stuyahok 1939-8 Newhalen 1941-4 Newtok 1387-0 Nez Perce 2065-1 Nigerian 1942-2 Nightmute 1784-8 Nikolai 2017-2 Nikolski 1785-5 Ninilchik 1241-9 Nipmuc 1346-6 Nishinam 1523-0 Nisqually 1872-1 Noatak 1389-6 Nomalaki 1873-9 Nome 1786-3 Nondalton 1524-8 Nooksack 1874-7 Noorvik 1022-3 Northern Arapaho 1095-9 Northern Cherokee 1103-1 Northern Cheyenne 1429-0 Northern Paiute 1469-6 Northern Pomo 1787-1 Northway 1391-2 Northwest Tribes 1875-4 Nuiqsut 1788-9 Nulato 1943-0 Nunapitchukv 1622-0 Oglala Sioux 2043-8 Okinawan 1016-5 Oklahoma Apache 1042-1 Oklahoma Cado 1160-1 Oklahoma Choctaw 1176-7 Oklahoma Comanche 1218-7 Oklahoma Delaware 1306-0 Oklahoma Kickapoo 1310-2 Oklahoma Kiowa 1361-5 Oklahoma Miami 1414-2 Oklahoma Ottawa 1446-4 Oklahoma Pawnee 1451-4 Oklahoma Peoria 1476-1 Oklahoma Ponca 1554-5 Oklahoma Sac and Fox 1571-9 Oklahoma Seminole 1998-4 Old Harbor Birth Defects Implementation Guide APP-104
Concept Code Concept Name 1403-5 Omaha 1288-0 Oneida 1289-8 Onondaga 1140-3 Ontonagon 1405-0 Oregon Athabaskan 1407-6 Osage 1944-8 Oscarville 2500-7 Other Pacific Islander 2131-1 Other Race 1409-2 Otoe-Missouria 1411-8 Ottawa 1999-2 Ouzinkie 1430-8 Owens Valley 1416-7 Paiute 2044-6 Pakistani 1333-4 Pala 2091-7 Palauan 2124-6 Palestinian 1439-9 Pamunkey 1592-5 Panamint 2102-2 Papua New Guinean 1713-7 Pascua Yaqui 1441-5 Passamaquoddy 1242-7 Paugussett 2018-0 Pauloff Harbor 1334-2 Pauma 1445-6 Pawnee 1017-3 Payson Apache 1335-9 Pechanga 1789-7 Pedro Bay 1828-3 Pelican 1448-0 Penobscot 1450-6 Peoria 1453-0 Pequot 1980-2 Perryville 1829-1 Petersburg 1499-3 Picuris 1981-0 Pilot Point 1945-5 Pilot Station 1456-3 Pima 1623-8 Pine Ridge Sioux 1624-6 Pipestone Sioux 1500-8 Piro 1460-5 Piscataway 1462-1 Pit River 1946-3 Pitkas Point 1947-1 Platinum Birth Defects Implementation Guide APP-105
Concept Code Concept Name 1443-1 Pleasant Point Passamaquoddy 1201-3 Poarch Band 1243-5 Pocomoke Acohonock 2094-1 Pohnpeian 1876-2 Point Hope 1877-0 Point Lay 1501-6 Pojoaque 1483-7 Pokagon Potawatomi 2115-4 Polish 2078-4 Polynesian 1464-7 Pomo 1474-6 Ponca 1328-4 Poospatuck 1315-1 Port Gamble Klallam 1988-5 Port Graham 1982-8 Port Heiden 2000-8 Port Lions 1525-5 Port Madison 1948-9 Portage Creek 1478-7 Potawatomi 1487-8 Powhatan 1484-5 Prairie Band 1625-3 Prairie Island Sioux 1202-1 Principal Creek Indian Nation 1626-1 Prior Lake Sioux 1489-4 Pueblo 1518-0 Puget Sound Salish 1526-3 Puyallup 1431-6 Pyramid Lake 2019-8 Qagan Toyagungin 2020-6 Qawalangin 1541-2 Quapaw 1730-1 Quechan 1084-3 Quileute 1543-8 Quinault 1949-7 Quinhagak 1385-4 Ramah Navajo 1790-5 Rampart 1219-5 Rampough Mountain 1545-3 Rappahannock 1141-1 Red Cliff Chippewa 1950-5 Red Devil 1142-9 Red Lake Chippewa 1061-1 Red Wood 1547-9 Reno-Sparks 1151-0 Rocky Boy's Chippewa Cree 1627-9 Rosebud Sioux Birth Defects Implementation Guide APP-106
Concept Code Concept Name 1549-5 Round Valley 1791-3 Ruby 1593-3 Ruby Valley 1551-1 Sac and Fox 1143-7 Saginaw Chippewa 2095-8 Saipanese 1792-1 Salamatof 1556-0 Salinan 1558-6 Salish 1560-2 Salish and Kootenai 1458-9 Salt River Pima-Maricopa 1527-1 Samish 2080-0 Samoan 1018-1 San Carlos Apache 1502-4 San Felipe 1503-2 San Ildefonso 1506-5 San Juan 1505-7 San Juan De 1504-0 San Juan Pueblo 1432-4 San Juan Southern Paiute 1574-3 San Manual 1229-4 San Pasqual 1656-8 San Xavier 1220-3 Sand Hill 2023-0 Sand Point 1507-3 Sandia 1628-7 Sans Arc Sioux 1508-1 Santa Ana 1509-9 Santa Clara 1062-9 Santa Rosa 1050-4 Santa Rosa Cahuilla 1163-5 Santa Ynez 1230-2 Santa Ysabel 1629-5 Santee Sioux 1510-7 Santo Domingo 1528-9 Sauk-Suiattle 1145-2 Sault Ste. Marie Chippewa 1893-7 Savoonga 1830-9 Saxman 1952-1 Scammon Bay 1562-8 Schaghticoke 1564-4 Scott Valley 2116-2 Scottish 1470-4 Scotts Valley 1878-8 Selawik 1793-9 Seldovia 1657-6 Sells Birth Defects Implementation Guide APP-107
Concept Code Concept Name 1566-9 Seminole 1290-6 Seneca 1291-4 Seneca Nation 1292-2 Seneca-Cayuga 1573-5 Serrano 1329-2 Setauket 1795-4 Shageluk 1879-6 Shaktoolik 1576-8 Shasta 1578-4 Shawnee 1953-9 Sheldon's Point 1582-6 Shinnecock 1880-4 Shishmaref 1584-2 Shoalwater Bay 1586-7 Shoshone 1602-2 Shoshone Paiute 1881-2 Shungnak 1891-1 Siberian Eskimo 1894-5 Siberian Yupik 1607-1 Siletz 2051-1 Singaporean 1609-7 Sioux 1631-1 Sisseton Sioux 1630-3 Sisseton-Wahpeton 1831-7 Sitka 1643-6 Siuslaw 1529-7 Skokomish 1594-1 Skull Valley 1530-5 Skykomish 1794-7 Slana 1954-7 Sleetmute 1531-3 Snohomish 1532-1 Snoqualmie 1336-7 Soboba 1146-0 Sokoagon Chippewa 1882-0 Solomon 2103-0 Solomon Islander 1073-6 South American Indian 1595-8 South Fork Shoshone 2024-8 South Naknek 1811-9 Southeast Alaska 1244-3 Southeastern Indians 1023-1 Southern Arapaho 1104-9 Southern Cheyenne 1433-2 Southern Paiute 1074-4 Spanish American Indian 1632-9 Spirit Lake Sioux Birth Defects Implementation Guide APP-108
Concept Code Concept Name 1645-1 Spokane 1533-9 Squaxin Island 2045-3 Sri Lankan 1144-5 St. Croix Chippewa 2021-4 St. George 1963-8 St. Mary's 1951-3 St. Michael 2022-2 St. Paul 1633-7 Standing Rock Sioux 1203-9 Star Clan of Muscogee Creeks 1955-4 Stebbins 1534-7 Steilacoom 1796-2 Stevens 1647-7 Stewart 1535-4 Stillaguamish 1649-3 Stockbridge 1797-0 Stony River 1471-2 Stonyford 2002-4 Sugpiaq 1472-0 Sulphur Bank 1434-0 Summit Lake 2004-0 Suqpigaq 1536-2 Suquamish 1651-9 Susanville 1245-0 Susquehanock 1537-0 Swinomish 1231-0 Sycuan 2125-3 Syrian 1705-3 Table Bluff 1719-4 Tachi 2081-8 Tahitian 2035-4 Taiwanese 1063-7 Takelma 1798-8 Takotna 1397-9 Talakamish 1799-6 Tanacross 1800-2 Tanaina 1801-0 Tanana 1802-8 Tanana Chiefs 1511-5 Taos 1969-5 Tatitlek 1803-6 Tazlina 1804-4 Telida 1883-8 Teller 1338-3 Temecula 1596-6 Te-Moak Western Shoshone 1832-5 Tenakee Springs Birth Defects Implementation Guide APP-109
Concept Code 1398-7 Tenino 1512-3 Tesuque 1805-1 Tetlin 1634-5 Teton Sioux 1513-1 Tewa 1307-8 Texas Kickapoo 2046-1 Thai 1204-7 Thlopthlocco 1514-9 Tigua 1399-5 Tillamook 1597-4 Timbi-Sha Shoshone 1833-3 Tlingit 1813-5 Tlingit-Haida 2073-5 Tobagoan 1956-2 Togiak 1653-5 Tohono O'Odham 1806-9 Tok 2083-4 Tokelauan 1957-0 Toksook 1659-2 Tolowa 1293-0 Tonawanda Seneca 2082-6 Tongan 1661-8 Tonkawa 1051-2 Torres-Martinez 2074-3 Trinidadian 1272-4 Trinity 1837-4 Tsimshian 1205-4 Tuckabachee 1538-8 Tulalip 1720-2 Tule River 1958-8 Tulukskak 1246-8 Tunica Biloxi 1959-6 Tuntutuliak 1960-4 Tununak 1147-8 Turtle Mountain 1294-8 Tuscarora 1096-7 Tuscola 1337-5 Twenty-Nine Palms 1961-2 Twin Hills 1635-2 Two Kettle Sioux 1663-4 Tygh 1807-7 Tyonek 1970-3 Ugashik 1672-5 Uintah Ute 1665-9 Umatilla 1964-6 Umkumiate 1667-5 Umpqua Concept Name Birth Defects Implementation Guide APP-110
Concept Code Concept Name 1884-6 Unalakleet 2025-5 Unalaska 2006-5 Unangan Aleut 2026-3 Unga 1097-5 United Keetowah Band of Cherokee 1118-9 Upper Chinook 1636-0 Upper Sioux 1539-6 Upper Skagit 1670-9 Ute 1673-3 Ute Mountain Ute 1435-7 Utu Utu Gwaitu Paiute 1808-5 Venetie 2047-9 Vietnamese 1247-6 Waccamaw-Siousan 1637-8 Wahpekute Sioux 1638-6 Wahpeton Sioux 1675-8 Wailaki 1885-3 Wainwright 1119-7 Wakiakum Chinook 1886-1 Wales 1436-5 Walker River 1677-4 Walla-Walla 1679-0 Wampanoag 1064-5 Wappo 1683-2 Warm Springs 1685-7 Wascopum 1598-2 Washakie 1687-3 Washoe 1639-4 Wazhaza Sioux 1400-1 Wenatchee 2075-0 West Indian 1098-3 Western Cherokee 1110-6 Western Chickahominy 1273-2 Whilkut 2106-3 White 1148-6 White Earth 1887-9 White Mountain 1019-9 White Mountain Apache 1888-7 White Mountain Inupiat 1692-3 Wichita 1248-4 Wicomico 1120-5 Willapa Chinook 1694-9 Wind River 1024-9 Wind River Arapaho 1599-0 Wind River Shoshone 1696-4 Winnebago 1700-4 Winnemucca Birth Defects Implementation Guide APP-111
Concept Code Concept Name 1702-0 Wintun 1485-2 Wisconsin Potawatomi 1809-3 Wiseman 1121-3 Wishram 1704-6 Wiyot 1834-1 Wrangell 1295-5 Wyandotte 1401-9 Yahooskin 1707-9 Yakama 1709-5 Yakama Cowlitz 1835-8 Yakutat 1065-2 Yana 1640-2 Yankton Sioux 1641-0 Yanktonai Sioux 2098-2 Yapese 1711-1 Yaqui 1731-9 Yavapai 1715-2 Yavapai Apache 1437-3 Yerington Paiute 1717-8 Yokuts 1600-6 Yomba 1722-8 Yuchi 1066-0 Yuki 1724-4 Yuman 1896-0 Yupik Eskimo 1732-7 Yurok 2066-9 Zairean 1515-6 Zia 1516-4 Zuni Religious Affiliation Value Set HL7 2.16.840.1.113883.1.11.19185 DYNAMIC Code System ID 2.16.840.1.113883.5.1076 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
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
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
Code 1082 United Church of Christ Display Definition Role Codes Value Set OID 2.16.840.1.113883.11.20.12.1 Code System Name RoleCode Code System Code PH_RoleCode_HL7_V3 Code System OID 2.16.840.1.113883.5.111 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
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
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
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 2.16.840.1.114222.4.11.973 Value Set Description US Geological Survey Geographic Names Information System - location codes http://phinvads.cdc.gov/vads/viewvalueset.action?id=19d 34BBC-617F-DD11-B38D-00188B398520 Birth Defects Implementation Guide APP-118
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 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] Report Type SHALL 2.16.840.1.113883.10.20.3 [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 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] SHALL 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] SHOULD 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] SHALL 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] SHALL 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] SHOULD 2.16.840.1.113883.10.20.3 [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
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 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] SHALL 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] SHALL 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] Address Use SHOULD 2.16.840.1.113883.10.20.3 [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 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] SHALL 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] SHALL 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] SHALL 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] SHALL 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] Child s Race SHALL 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] sdtc:race (racecode extension) MAY 2.16.840.1.113883.10.20.22.1.1 [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= '2.16.840.1.113883.4.1')]/@ extension ClinicalDocument/recordTa rget/patientrole/id[@root=' 2.16.840.1.113883.4.1']/@ extension ClinicalDocument/recordTa rget/patientrole/patient/rac ecode/@* ClinicalDocument/recordTa rget/patientrole/patient/sdt c:racecode Birth Defects Implementation Guide APP-120
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 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] SHALL 1.3.6.1.4.1.19376.1.7. 3.1.1.14.1 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 Email Type of Physician Provider Organization ID SHALL SHALL SHALL 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] SHALL 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] SHOULD 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] SHOULD 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] SHALL 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] SHALL 2.16.840.1.113883.10.20.3 [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='2.16.840.1.113883.4.6'] /@extension ClinicalDocument/documen tationof/serviceevent/perfo rmer/assignedentity/addr/* ClinicalDocument/documen tationof/serviceevent/perfo rmer/assignedentity/teleco m ClinicalDocument/documen tationof/serviceevent/perfo rmer/assignedentity/code/ @* ClinicalDocument/documen tationof/serviceevent/perfo rmer/assignedentity/repres entedorganization/* Birth Defects Implementation Guide APP-121
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 2.16.840.1.1138 83.1.11.14914 (CDC) SHALL 2.16.840.1.113883.10.20.3 [General Header Constraints for CDA R2] SHOULD 1.3.6.1.4.1.19376.1.4. 1.3.1 [Encompassing Encounter] SHOULD 1.3.6.1.4.1.19376.1.4. 1.3.1 [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='2.16. 840.1.113883.4.6']/@exten sion section/subject[typecode=' SBJ']/relatedSubject[/code @code='mth']/subject/id[1] section/subject[typecode=' SBJ']/relatedSubject[/code @code='mth']/addr section/subject[typecode=' SBJ']/relatedSubject[/code @code='mth']/addr section/subject[typecode=' SBJ']/relatedSubject[/code @code='mth']/subject/nam e/given section/subject[typecode=' SBJ']/relatedSubject[/code @code='mth']/subject/nam e/family section/subject[typecode=' SBJ']/relatedSubject[/code @code='mth']/subject/birth Time section/subject[typecode=' SBJ']/relatedSubject[/code @code='mth']/subject/birth place/place section/subject[typecode=' SBJ']/relatedSubject[/code @code='mth']/ sdtc: racecode/@code Birth Defects Implementation Guide APP-122
NBDPN ID Data Element Opt Template ID XPATH Mapping FATHER Mother s Ethnicity Ethnicity Value Set 2.16.840.1.1138 83.1.11.15836 (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 2.16.840.1.1138 83.1.11.14914 (CDC) Father s Ethnicity Ethnicity Value Set 2.16.840.1.1138 83.1.11.15836 (CDC) Newborn Delivery Information Section Place of Birth (type or birthing place) SHOULD SHOULD MAY MAY MAY MAY MAY SHALL 1.3.6.1.4.1.19376.1.5. 3.1.1.21.2.4 SHOULD 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] section/subject[typecode=' SBJ']/relatedSubject[/cod@ code='mth']/ sdtc: ethnicgroupcode/@code section/subject[typecode=' SBJ']/relatedSubject[/code @code='mth']/sdtc:id[2] section/subject[typecode=' SBJ']/relatedSubject[/code @code='fth']/subject/nam e /given /middle /birthname /suffix section/subject[typecode=' SBJ']/relatedSubject[/code @code='fth']/subject/birth Time section/subject[typecode=' SBJ']/relatedSubject[/code @code='fth']/sdtc:id[2] section/subject[typecode=' SBJ']/relatedSubject[/code @code='fth']/sdtc: racecode/@code section/subject[typecode=' SBJ']/relatedSubject[/code @code='fth']/ sdtc: ethnicgroupcode/@code ClinicalDocument/compo nent/structuredbody/com ponent/section[templatei d[@root='1.3.6.1.4.1.1937 6.1.5.3.1.1.21.2.4']] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 ]]/entry/act/entryrelationshi p/observation[templateid[ro ot= 1.3.6.1.4.1.19376.1.5.3. 1.4.13']] and [code/@code= 21842-0 ]/value/@value Birth Defects Implementation Guide APP-123
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 1.3.6.1.4.1.19376.1.5. 3.1.1.9.15.1 [Coded Detailed Physical Examination] 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.2 [Coded Vital Signs Section] SHALL 1.3.6.1.4.1.19376.1.5. 3.1.1.9.15.1 [Coded Detailed Physical Examination] 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.2 [Coded Vital Signs Section] SHALL 1.3.6.1.4.1.19376.1.5. 3.1.1.9.15.1 [Coded Detailed Physical Examination] 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.2 [Coded Vital Signs Section] SHALL 1.3.6.1.4.1.19376.1.5. 3.1.1.9.15.1 [Coded Detailed Physical Examination] 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.2 [Coded Vital Signs Section] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.9.15. 1 ]]/entry/act/entryrelations hip/observation[templateid[ root= 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.2']] and [code/@code= 3141-9 ]/value/@value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.9.15. 1 ]]/entry/act/entryrelations hip/observation[templateid[ root= 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.2']] and [code/@code= 8306-3 ]/value/@value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.9.15. 1 ]]/entry/act/entryrelations hip/observation[templateid[ root= 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.2']] and [code/@code= 8306-3 ]/value/@unit ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.9.15. 1 ]]/entry/act/entryrelations hip/observation[templateid[ root= 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.2']] and [code/@code= 8290-9 ]/value/@value Birth Defects Implementation Guide APP-124
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 1.3.6.1.4.1.19376.1.5. 3.1.1.9.15.1 [Coded Detailed Physical Examination] 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.2 [Coded Vital Signs Section] SHALL 1.3.6.1.4.1.19376.1.5. 3.1.1.9.15.1 [Coded Detailed Physical Examination] 1.3.6.1.4.1.19376.1.5. 3.1.1.9.16 [General Appearance] SHALL 1.3.6.1.4.1.19376.1.5. 3.1.1.9.15.1 [Coded Detailed Physical Examination] 1.3.6.1.4.1.19376.1.5. 3.1.1.9.16 [General Appearance] SHALL 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.9.15. 1 ]]/entry/act/entryrelations hip/observation[templateid[ root= 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.2']] and [code/@code= 8290-9 ]/value/@unit ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.9.15. 1 ]]/ component/section [templateid[root= 1.3.6.1.4. 1.19376.1.5.3.1.1.9.16 ]]/en try/act/entryrelationship/ob servation/[code/@code= 82 90-9 ]/value/ ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.9.15. 1 ]]/ component/section [templateid[root= 1.3.6.1.4. 1.19376.1.5.3.1.1.9.16 ]]/en try/act/entryrelationship/ob servation/[code/@code= 92 71-8 ]/value/ ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 ]]/entry/act/entryrelationshi p/observation[templateid[ro ot= 2.16.840.1.113883.10.2 0.1.31']] and [code/@code= 268477000 ] /value/ Birth Defects Implementation Guide APP-125
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 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] SHALL 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] SHALL 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] Infant Expired SHOULD 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 ]]/entry/act/entryrelationshi p/observation[templateid[ro ot= 2.16.840.1.113883.10.2 0.1.31']] and [code/@code= 73771-8 ]/value/@value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 ]]/entry/act/entryrelationshi p/observation[templateid[ro ot= 2.16.840.1.113883.10.2 0.1.31']] and [code/@code= 364587008 ] /value/@value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 ]]/entry/act/entryrelationshi p/observation/code ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 ]]/entry/act/entryrelationshi p/observation[templateid[ro ot= 2.16.840.1.113883.10.2 0.1.31']] and [code/@code= TBD ]/value/ @value Birth Defects Implementation Guide APP-126
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 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] SHOULD 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] SHALL 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.13.2.11 [Procedures and Interventions] 1.3.6.1.4.1.19376.1.5. 3.1.4.19 [Procedures] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.13.2.11 [Procedures and Interventions] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 ]]/entry/act/entryrelationshi p/observation[templateid[ro ot= 2.16.840.1.113883.10.2 0.1.31']] and [code/@code= 152527006 ] /value/@value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 ]]/entry/act/entryrelationshi p/observation[templateid[ro ot= 2.16.840.1.113883.10.2 0.1.31']] and [code/@code= 58332-8 ]/value/@value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4]]/component/sectio n[templateid[@root=1.3.6.1.4.1.19376.1.7.3.1.1.13.7]]/ entry/act/entryrelationship/ observation/ ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.13.2. 11 ]]/entry/procedure [templateid[root= 1.3.6.1.4. 1.19376.1.5.3.1.4.19']]/cod e ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.13.2. 11 ]]/entry/procedure/code Birth Defects Implementation Guide APP-127
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 1.3.6.1.4.1.19376.1.5. 3.1.1.13.2.11 [Procedures and Interventions] 1.3.6.1.4.1.19376.1.5. 3.1.4.19 [Procedures] SHALL 1.3.6.1.4.1.19376.1.5. 3.1.1.13.2.11 [Procedures and Interventions] 1.3.6.1.4.1.19376.1.5. 3.1.4.19 [Procedures] SHALL 1.3.6.1.4.1.19376.1.5. 3.1.3.21 [Medication Administration Section] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.3.21 [Medication Administration Section] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.3.21 [Medication Administration Section] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.13.2. 11 ]]/entry/procedure [templateid[root= 1.3.6.1.4. 1.19376.1.5.3.1.4.19']]/cod e ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.13.2. 11 ]]/entry/procedure [templateid[root= 1.3.6.1.4. 1.19376.1.5.3.1.4.19']]/cod e ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.3.21 ]]/ substanceadministration/co de ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.3.21 ]]/ substanceadministration/ro utecode ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.3.21 ]]/ substanceadministration/ro utecode Birth Defects Implementation Guide APP-128
NBDPN ID Data Element Opt Template ID XPATH Mapping Neonatal Sepsis Seizure or Serious Neurologic Dysfunction SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.3.21 [Medication Administration Section] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.3.6 [Active Problems] Labor and Delivery Section SHALL 1.3.6.1.4.1.19376.1.5. 3.1.1.21.2.3 Plurality (The number of babies resulting from a single pregnancy) SHOULD 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] Births Live SHOULD 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.3.21 ]]/ substanceadministration/en tryrelationship[@typecode ='RSON']/observation[temp lateid/@root= 2.16.840.1.1 13883.10.20.1.28 ]/code ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.4]]/ component/section[templat eid[@root=1.3.6.1.4.1.1937 6.1.5.3.1.3.6]]/entry/act/entr yrelationship/observation/c ode ClinicalDocument/compo nent/structuredbody/com ponent/section[templatei d[@root='1.3.6.1.4.1.1937 6.1.5.3.1.1.21.2.3']] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.3']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 ]]/entry/act/entryrelationshi p/observation[templateid[ro ot='1.3.6.1.4.1.19376.1.5.3. 1.4.13']] and [code/@code= 57722-1 ]/value/@value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.3']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 ]]/entry/act/entryrelationshi p/observation[templateid[ro ot='1.3.6.1.4.1.19376.1.5.3. 1.4.13']] and [code/@code= 11636-8 ]/value Birth Defects Implementation Guide APP-129
NBDPN ID Data Element Opt Template ID XPATH Mapping Pregnancy Outcome Presentation Type Admission to Intensive Care [unit] Perineal Laceration Ruptured Uterus SHOULD 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] SHALL 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] SHALL 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] SHALL 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] SHALL 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.21.2.3']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.7.3.1.1.13.7 ]]/entry/act/entryrelationshi p/observation[templateid[ro ot='1.3.6.1.4.1.19376.1.5.3. 1.4.13']]/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.7.3.1.1.13.7]]/entry/act/entr yrelationship/observation/c ode ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.7.3.1.1.13.7]]/entry/act/entr yrelationship/observation/c ode CodeClinicalDocument/rec ordtarget/component/struct uredbody/component/secti on[templateid[@root=1.3.6. 1.4.1.19376.1.5.3.1.1.21.2. 3]]/component/section[temp lateid[@root=1.3.6.1.4.1.19 376.1.7.3.1.1.13.7]]/entry/a ct/entryrelationship/observ ation/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.7.3.1.1.13.7]]/entry/act/entr yrelationship/observation/c ode Birth Defects Implementation Guide APP-130
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 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] SHALL 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] SHALL 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] SHALL 1.3.6.1.4.1.19376.1.7. 3.1.1.13.7 [Coded Event Outcomes Section] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.13.2.11 [Procedures and Interventions] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.13.2.11 [Procedures and Interventions] ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.7.3.1.1.13.7]]/entry/act/entr yrelationship/observation/c ode ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.7.3.1.1.13.7]]/entry/act/entr yrelationship/observation/c ode ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.7.3.1.1.13.7]]/entry/act/entr yrelationship/observation/c ode ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.7.3.1.1.13.7]]/entry/act/entr yrelationship/observation/c ode ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11]]/entry/proc edure/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11]]/entry/proc edure/code Birth Defects Implementation Guide APP-131
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 1.3.6.1.4.1.19376.1.5. 3.1.1.13.2.11 [Procedures and Interventions] SHALL 1.3.6.1.4.1.19376.1.5. 3.1.1.13.2.11 [Procedures and Interventions] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.13.2.11 [Procedures and Interventions] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.13.2.11 [Procedures and Interventions] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.13.2.11 [Procedures and Interventions] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.13.2.11 [Procedures and Interventions] ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11]]/entry/proc edure/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11]]/entry/proc edure/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11]]/entry/proc edure/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11]]/entry/proc edure/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11]]/entry/proc edure/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11]]/entry/proc edure/code Birth Defects Implementation Guide APP-132
NBDPN ID Data Element Opt Template ID XPATH Mapping Cervical Cerclage SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.13.2.11 [Procedures and Interventions] Tocolysis SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.13.2.11 [Procedures and Interventions] Antibiotics SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.3.21 [Medications Administered] Steroids SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.3.21 [Medications Administered] Augmentation of Labor - Medication SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.3.21 [Medications Administered] Anesthesia SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.3.21 [Medications Administered] ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11]]/entry/proc edure/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11]]/entry/proc edure/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.5.3.1.3.21]]/substanceadm inistration/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.5.3.1.3.21]]/substanceadm inistration/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.5.3.1.3.21]]/substanceadm inistration/code ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.5.3.1.3.21]]/substanceadm inistration/code Birth Defects Implementation Guide APP-133
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 1.3.6.1.4.1.19376.1.5. 3.1.1.9.15.1 [Code Detailed Physical Examination] 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.2 [Coded Vital Signs Section] SHALL 3.6.1.4.1.19376.1.5.3. 1.1.21.1.1 SHALL Can add nullfactor SHALL Can add nullfactor SHALL Can add nullfactor 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.4 [Pregnancy History Section] 1.3.6.1.4.1.19376.1.5. 3.1.4.13.5 [Pregnancy Observation] 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.4 [Pregnancy History Section] 1.3.6.1.4.1.19376.1.5. 3.1.4.13.5 [Pregnancy Observation] 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.4 [Pregnancy History Section] 1.3.6.1.4.1.19376.1.5. 3.1.4.13.5 [Pregnancy Observation] ClinicalDocument/recordTa rget/component/structured Body/component/section[te mplateid[@root=1.3.6.1.4.1.19376.1.5.3.1.1.9.15.1]]/co mponent/section[templateid [@root=1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2]]/entry/act/ent ryrelationship/observation/ [methodcode= 11636-8 ]/value ClinicalDocument/compo nent/structuredbody/com ponent/section[templatei d[@root= 3.6.1.4.1.19376. 1.5.3.1.1.21.1.1 ]] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root = 1.3.6.1.4.1.19376.1.5.3.1. 1.21.1.1']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 ]]/entry/act/entryrelationsh ip/observation[templateid[r oot='1.3.6.1.4.1.19376.1.5. 3.1.4.13.5']] and [code/@code= 69044-6 ]/effectivetime ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root = 1.3.6.1.4.1.19376.1.5.3.1. 1.21.1.1']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 ]]/entry/act/entryrelationsh ip/observation[templateid[r oot='1.3.6.1.4.1.19376.1.5. 3.1.4.13.5']] and [code/@code= 68492-8 ]/ effectivetime ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root = 1.3.6.1.4.1.19376.1.5.3.1. 1.21.1.1']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 ]]/entry/act/entryrelationsh ip/observation[templateid[r oot='1.3.6.1.4.1.19376.1.5. 3.1.4.13.5']] and [code/@code= 68493-6 ]/value Birth Defects Implementation Guide APP-134
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 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.4 [Pregnancy History Section] 1.3.6.1.4.1.19376.1.5. 3.1.4.13.5 [Pregnancy Observation] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.4 [Pregnancy History Section] 1.3.6.1.4.1.19376.1.5. 3.1.4.13.5 [Pregnancy Observation] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.4 [Pregnancy History Section] 1.3.6.1.4.1.19376.1.5. 3.1.4.13.5 [Pregnancy Observation] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.4 [Pregnancy History Section] 1.3.6.1.4.1.19376.1.5. 3.1.4.13.5 [Pregnancy Observation] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root = 1.3.6.1.4.1.19376.1.5.3.1. 1.21.1.1']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 ]]/entry/act/entryrelationsh ip/observation[templateid[r oot='1.3.6.1.4.1.19376.1.5. 3.1.4.13.5']] and [code/@code= 8348-5 ]/value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root = 1.3.6.1.4.1.19376.1.5.3.1. 1.21.1.1']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 ]]/entry/act/entryrelationsh ip/observation[templateid[r oot='1.3.6.1.4.1.19376.1.5. 3.1.4.13.5']] and [code/@code= 32399-8 ]/value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root = 1.3.6.1.4.1.19376.1.5.3.1. 1.21.1.1']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 ]]/entry/act/entryrelationsh ip/observation[templateid[r oot='1.3.6.1.4.1.19376.1.5. 3.1.4.13.5']] and [code/@code= 11638-4 ]/value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root = 1.3.6.1.4.1.19376.1.5.3.1. 1.21.1.1']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 ]]/entry/act/entryrelationsh ip/observation[templateid[r oot='1.3.6.1.4.1.19376.1.5. 3.1.4.13.5']] and [code/@code= 68496-9 ]/value Birth Defects Implementation Guide APP-135
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 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.4 [Pregnancy History Section] 1.3.6.1.4.1.19376.1.5. 3.1.4.13.5 [Pregnancy Observation] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.4 [Pregnancy History Section] 1.3.6.1.4.1.19376.1.5. 3.1.4.13.5 [Pregnancy Observation] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.4 [Pregnancy History Section] 1.3.6.1.4.1.19376.1.5. 3.1.4.13.5 [Pregnancy Observation] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.4 [Pregnancy History Section] 1.3.6.1.4.1.19376.1.5. 3.1.4.13.5 [Pregnancy Observation] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root = 1.3.6.1.4.1.19376.1.5.3.1. 1.21.1.1']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 ]]/entry/act/entryrelationsh ip/observation[templateid[r oot='1.3.6.1.4.1.19376.1.5. 3.1.4.13.5']] and [code/@code= 68499-3 ]/value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root = 1.3.6.1.4.1.19376.1.5.3.1. 1.21.1.1']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 ]]/entry/act/entryrelationsh ip/observation[templateid[r oot='1.3.6.1.4.1.19376.1.5. 3.1.4.13.5']] and [code/@code= 68500-8 ]/value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root = 1.3.6.1.4.1.19376.1.5.3.1. 1.21.1.1']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 ]]/entry/act/entryrelationsh ip/observation[templateid[r oot='1.3.6.1.4.1.19376.1.5. 3.1.4.13.5']] and [code/@code= TBD ]/value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root = 1.3.6.1.4.1.19376.1.5.3.1. 1.21.1.1']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 ]]/entry/act/entryrelationsh ip/observation[templateid[r oot='1.3.6.1.4.1.19376.1.5. 3.1.4.13.5']] and [code/@code= 11637-6 ]/value Birth Defects Implementation Guide APP-136
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 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.4 [Pregnancy History Section] 1.3.6.1.4.1.19376.1.5. 3.1.4.13.5 [Pregnancy Observation] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.4 [Pregnancy History Section] 1.3.6.1.4.1.19376.1.5. 3.1.4.13.5 [Pregnancy Observation] SHALL 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.4 [Pregnancy History Section] 1.3.6.1.4.1.19376.1.5. 3.1.4.13.5 [Pregnancy Observation] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.4 [Pregnancy History Section] 1.3.6.1.4.1.19376.1.5. 3.1.4.13.5 [Pregnancy Observation] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.4 [Pregnancy History Section] 1.3.6.1.4.1.19376.1.5. 3.1.4.13.5 [Pregnancy Observation] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root = 1.3.6.1.4.1.19376.1.5.3.1. 1.21.1.1']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 ]]/entry/act/entryrelationsh ip/observation[templateid[r oot='1.3.6.1.4.1.19376.1.5. 3.1.4.13.5']]/code@code= ] /effectivetime/low ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root = 1.3.6.1.4.1.19376.1.5.3.1. 1.21.1.1']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 ]]/entry/act/entryrelationsh ip/observation[templateid[r oot='1.3.6.1.4.1.19376.1.5. 3.1.4.13.5']]/code ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root = 1.3.6.1.4.1.19376.1.5.3.1. 1.21.1.1']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 ]]/entry/act/entryrelationsh ip/observation[templateid[r oot='1.3.6.1.4.1.19376.1.5. 3.1.4.13.5']]/code ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root = 1.3.6.1.4.1.19376.1.5.3.1. 1.21.1.1']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 ]]/entry/act/entryrelationsh ip/observation[templateid[r oot='1.3.6.1.4.1.19376.1.5. 3.1.4.13.5']]/code ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root = 1.3.6.1.4.1.19376.1.5.3.1. 1.21.1.1']]/component/secti on[templateid[@root= 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 ]]/entry/act/entryrelationsh ip/observation[templateid[r oot='1.3.6.1.4.1.19376.1.5. 3.1.4.13.5']]/code Birth Defects Implementation Guide APP-137
NBDPN ID Data Element Opt Template ID XPATH Mapping Obstetric Estimate of Gestation Alcohol Intake (Glasses/Week) SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.4 [Pregnancy History Section] 1.3.6.1.4.1.19376.1.5. 3.1.4.13.5 [Pregnancy Observation] SHALL Can add nullfactor 1.3.6.1.4.1.19376.1.5. 3.1.3.16.1 [Coded Social History] 1..3.6.1.4.1.19376.1.5.3.1.4.13.4 [Social History Observation] Payers Section SHALL 1.3.6.1.4.1.19376.1.5. 3.1.1.5.3.7 Payer Type SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.4.17 [Coverage Entry] Medicaid ID Number Name of Insured SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.17 [Coverage Entry] SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.17 [Coverage Entry] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =1.3.6.1.4.1.19376.1.5.3.1. 1.5.3.4]]/component/section [templateid[@root=1.3.6.1. 4.1.19376.1.5.3.1.4.13.5]]/e ntry/act/entryrelationship/o bservation/code ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root =1.3.6.1.4.1.19376.1.5.3.1. 1.5.3.4]]/component/section [templateid[@root= 1.3.6.1. 4.1.19376.1.5.3.1.3.16.1 ]]/ component/section[templat eid[@root= 1..3.6.1.4.1.193 76.1.5.3.1.4.13.4 ]]/entry/ob servation[code/@code= 13 7952002 ]/value ClinicalDocument/compo nent/structuredbody/com ponent/section[templatei d[@root='1.3.6.1.4.1.1937 6.1.5.3.1.1.5.3.7']] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.5.3.7']]/entry/act[template Id[@root='1.3.6.1.4.1.1937 6.1.5.3.1.4.17']]/entryRelati onship/act/code/@* ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 1.5.3.7']]/entry/act[template Id[@root='1.3.6.1.4.1.1937 6.1.5.3.1.4.17']]/entryRelati onship/act/code/act/particip ant[@typecode= COV ]/par ticipantrole[@classcode= PAT ]/id/@extension ClinicalDocument/compone nt/structurebody/componen t/section[templateid[@root= '1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7']]/entry/act[templateI d[@root='1.3.6.1.4.1.19376.1.5.3.1.4.17']] and code[@code='35525-4']]/entryrelationship/act[te mplateid[@root='1.3.6.1.4. 1.19376.1.5.3.1.4.18']]/parti cipant[@typecode='hld']/ participantrole[@classcod e='ind']/playaingentity/nam e/* Birth Defects Implementation Guide APP-138
NBDPN ID Data Element Opt Template ID XPATH Mapping Insurance Company [Payor Source] BxDefects Diagnosis Section BxDefect Diagnosis Entry BxDefect Diagnosis Code SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.17 [Coverage Entry] ClinicalDocument/compone nt/structurebody/componen t/section[templateid[@root= '1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7']]/entry/act[templateI d[@root='1.3.6.1.4.1.19376.1.5.3.1.4.17']] and code[@code='35525-4']]/entryrelationship/act[te mplateid[@root='1.3.6.1.4. 1.19376.1.5.3.1.4.18']]/perf ormer[@typecode='prf']/a ssignedentity[@classcode ='PAT']/representedOrgani zation/name/* SHALL SECTION OID ClinicalDocument/compo nent/structuredbody/com ponent/section[templatei d[@root= SECTION OID TBD ']] SHALL Entry OID TBD ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='SECTION OID TBD ]]/entry/act/entryrelati onship/observation[templat eid[@root='entry 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 nt/section[templateid[@root ='SECTION OID TBD ]]/entry/act/entryrelati onship/observation[templat eid[@root='entry OID TBD']]/value/@* ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='SECTION OID TBD']]/entry/act/entryRelati onship/observation[templat eid[@root= Entry OID TBD']]/effectiveTime/low/@ value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='SECTION OID TBD']]/entry/act/entryRelati onship/observation[templat eid[@root='entry OID TBD']]/value/qualifier[name[ @code="tbd"]]/value/@* Birth Defects Implementation Guide APP-139
NBDPN ID Data Element Opt Template ID XPATH Mapping Primary Site SHOULD Entry OID TBD [BxDefect Diagnosis Entry] Active Problems Section SHALL 1.3.6.1.4.1.19376.1.5. 3.1.3.6 Start and Stop Date of Problem SHALL 1.3.6.1.4.1.19376.1.5. 3.1.3.6 Problem Code SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.5.2 [Problem Concern Entry] Coded Results Section SHALL 1.3.6.1.4.1.19376.1.5. 3.1.3.28 Procedure Entry Procedure Type Procedure Date Time SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.19 SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.19 SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.19 Result Value SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.13 [Simple Observation] Result Text SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.13 [Simple Observation] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='SECTION OID TBD']]/entry/act/entryRelati onship/observation[templat eid[@root='entry OID TBD']]/targetSiteCode/@* 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 d[@root='1.3.6.1.4.1.1937 6.1.5.3.1.3.28']] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.28']]/entry/procedure ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.28']]/entry/procedure/cod e/@* ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.28']]/entry/procedure/effe ctivetime/* ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.28']]/entry/observation/co de/@* ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.28']]/entry/observation/tex t Birth Defects Implementation Guide APP-140
NBDPN ID Data Element Opt Template ID XPATH Mapping Result Date Time SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.13 [Simple Observation] Facility SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.13 [Simple Observation] Facility ID SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.13 [Simple Observation] Procedures Section SHALL 2.16.840.1.113883.10.20.1.12 Procedure Activity Entry Procedure Type Body Site of Procedure Procedure Date Time SHALL 2.16.840.1.113883.10.20.1.29 SHOULD 2.16.840.1.113883.10.20.1.29 SHALL 2.16.840.1.113883.10.20.1.29 SHALL 2.16.840.1.113883.10.20.1.29 Medications Section SHALL 1.3.6.1.4.1.19376.1.5. 3.1.3.19 Medications Entry SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.7 [Medications] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.28']]/entry/observation/eff ectivetime/@value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.28']]/entry/observation/au thor/assignedauthor/repres entedorganization/name ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.28']]/entry/observation/au thor/assignedauthor/repres entedorganization/id ClinicalDocument/compo nent/structuredbody/com ponent/section[templatei d[@root='2.16.840.1.1138 83.10.20.1.12']] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='2.16.840.1.113883.10.20. 1.12']]/entry/procedure ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='2.16.840.1.113883.10.20. 1.12']]/entry/procedure/cod e/@* ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='2.16.840.1.113883.10.20. 1.12']]/entry/procedure/targ etsitecode/@* ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='2.16.840.1.113883.10.20. 1.12']]/entry/procedure/effe ctivetime/* ClinicalDocument/compo nent/structuredbody/com ponent/section[templatei d[@root='1.3.6.1.4.1.1937 6.1.5.3.1.3.19']] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.19']]/entry/substanceAdm inistration Birth Defects Implementation Guide APP-141
NBDPN ID Data Element Opt Template ID XPATH Mapping Start Date SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.4.7 [Medications] Stop Date SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.4.7 [Medications] Frequency SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.7 [Medications] Route SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.4.7 [Medications] Dose SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.4.7 [Medications] Site MAY 1.3.6.1.4.1.19376.1.5. 3.1.4.7 [Medications] Rate SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.4.7 [Medications] Consumable SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.7 Product Entry SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.7.2 ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.19']]/entry/substanceAdm inistration/effectivetime[1]/l ow ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.19']]/entry/substanceAdm inistration/effectivetime[1]/ high ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.19']]/entry/substanceAdm inistration/effectivetime[2]/ period/@* ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.19']]/entry/substanceAdm inistration/routecode/@* ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.19']]/entry/substanceAdm inistration/dosequantity/@* ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.19']]/entry/substanceAdm inistration/approachsitecod e ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.19']]/entry/substanceAdm inistration/ratequantity ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.19']]/entry/substanceAdm inistration/consumable ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.19']]/entry/substanceAdm inistration/consumable/man ufacturedproduct Birth Defects Implementation Guide APP-142
NBDPN ID Data Element Opt Template ID XPATH Mapping Medication Brand Name SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.7.2 [Product Entry] Strength SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.4.7.2 [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 1.3.6.1.4.1.19376.1.5. 3.1.4.7.2 [Product Entry] SHALL 1.3.6.1.4.1.19376.1.5. 3.1.3.21 SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.7 [Medications] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.4.7 [Medications] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.4.7 [Medications] SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.4.7 [Medications] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.19']]/entry/substanceAdm inistration/consumable/man ufacturedproduct/manufact uredmaterial/name ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.19']]/entry/substanceAdm inistration/consumable/man ufacturedproduct/manufact uredmaterial/code/originalt ext ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.19']]/entry/substanceAdm inistration/consumable/man ufacturedproduct/manufact uredmaterial/code/@* ClinicalDocument/compo nent/structuredbody/com ponent/section[templatei d[@root='1.3.6.1.4.1.1937 6.1.5.3.1.3.21']] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.21']]/entry/substanceAdm inistration ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.21']]/entry/substanceAdm inistration/effectivetime[1]/l ow ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.21']]/entry/substanceAdm inistration/effectivetime[1]/ high ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.21']]/entry/substanceAdm inistration/effectivetime[2]/ period/@* Birth Defects Implementation Guide APP-143
NBDPN ID Data Element Opt Template ID XPATH Mapping Route SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.4.7 [Medications] Dose SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.4.7 [Medications] Site of Medication Administration MAY 1.3.6.1.4.1.19376.1.5. 3.1.4.7 [Medications] Rate SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.4.7 [Medications] Consumable SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.7 Product Entry SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.7.2 Product SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.7.2 [Medications] Strength SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.4.7.2 [Product Entry] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.21']]/entry/substanceAdm inistration/routecode/@* ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.21']]/entry/substanceAdm inistration/dosequantity/@* ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.21']]/entry/substanceAdm inistration/approachsitecod e ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.21']]/entry/substanceAdm inistration/ratequantity ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.21']]/entry/substanceAdm inistration/consumable ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.21']]/entry/substanceAdm inistration/consumable/man ufacturedproduct ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.21']]/entry/substanceAdm inistration/consumable/man ufacturedproduct/manufact uredmaterial/name ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.21']]/entry/substanceAdm inistration/consumable/man ufacturedproduct/manufact uredmaterial/code/originalt ext Birth Defects Implementation Guide APP-144
NBDPN ID Data Element Opt Template ID XPATH Mapping Code SHOULD 1.3.6.1.4.1.19376.1.5. 3.1.4.7.2 [Product Entry] Cytogenetics Section SHALL 2.16.840.1.113883.10.20.20.1.4 [GTR Cytogenetics Section] Cytogenetic Analysis Cytogenetic Techniques Specimen Type SHALL SHALL SHALL ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.21']]/entry/substanceAdm inistration/consumable/man ufacturedproduct/manufact uredmaterial/code/@* ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='2.16.840.1.113883.10.20. 20.1.4']] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='2.16.840.1.113883.10.20. 20.1.4']]/entry/observation[t emplateid[@root= 2.16.840.1.113883.10.20.20.2.2 ]] and [code@code= 62356-1 ]/value ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='2.16.840.1.113883.10.20. 20.1.4']]/entry/observation[t emplateid[@root= 2.16.840.1.113883.10.20.20.2.2 ]]/m ethodcode/@* ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='2.16.840.1.113883.10.20. 20.1.4']]/entry/observation[t emplateid[@root= 2.16.840.1.113883.10.20.20.2.2 ]]/s pecimen[templateid[@root ="2.16.840.1.113883.10.20.20.3.1 ]]/ specimenrole/specimenpl ayingentity/code/* Karyotype SHALL ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='2.16.840.1.113883.10.20. 20.1.4']]/entry/observation[t emplateid[@root= 2.16.840.1.113883.10.20.20.2.2 ]]/ entryrelationship/observati on/[templateid[@root= 2.16.840.1.113883.10.20.20.2.2.3 ]] and [code@code= 55199-4 ] /@value Birth Defects Implementation Guide APP-145
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 ='2.16.840.1.113883.10.20. 20.1.4']]/entry/observation[t emplateid[@root= 2.16.840.1.113883.10.20.20.2.2 ]]/e ntryrelationship/observatio n/[code@code= TBD ] /@value Care Plan Section SHALL 1.3.6.1.4.1.19376.1.5. 3.1.3.31 Provider Referred To SHALL 1.3.6.1.4.1.19376.1.5. 3.1.4.14 [Encounters] ClinicalDocument/compo nent/structuredbody/com ponent/section[templatei d[@root='1.3.6.1.4.1.1937 6.1.5.3.1.3.31']] ClinicalDocument/compone nt/structuredbody/compone nt/section[templateid[@root ='1.3.6.1.4.1.19376.1.5.3.1. 3.31']]/entry/encounter/perf ormer/assignedentity/assig nedperson/name/* Birth Defects Implementation Guide APP-146
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
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
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
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