Type | Standard / Implementation Specification | Standards Process Maturity | Implementation Maturity | Adoption Level | Federally required | Cost | Test Tool Availability |
---|---|---|---|---|---|---|---|
Standard for observations
|
Final
|
Production
|
![]() |
No
|
Free
|
No
|
|
Standard for observation values
|
Final
|
Production
|
![]() |
No
|
Free
|
No
|
|
Standard
|
Balloted Draft
|
Feedback requested
|
Feedback Requested |
No
|
Free
|
No
|
Limitations, Dependencies, and Preconditions for Consideration |
Applicable Value Set(s) and Starter Set(s)
|
---|---|
|
|
Comment
Submitted by dvreeman on 2018-09-27
Regenstrief - Comment
We concur with the recommendations on the use of LOINC and SNOMED CT here, and the pattern holds for additional relevant information collected.
Submitted by gdixon on 2018-09-12
Supplemented Pregnancy Status Documentation
Additional information should be collected regarding patient pregnancy status, this IG is being prepared for publication. See Project Summary for HL7 CDA R2 Implementation Guide: C-CDA R2.1 Supplemental Templates for Pregnancy Status, Release 1 - US Realm
Submitted by andersol on 2018-08-08
Error in table of contents
When using the left-hand side-bar, and select Pregnancy Status, the link displayed is incorrect. It is to Representing Health Care Data for Emergency Medical Services, but should be Representing Patient Pregnancy Status. Please see attached documentation for more details.
Submitted by Brett Andriesen
on 2018-08-13
Thanks - we will look into…
Thanks - we will look into this and correct this issue ASAP.
Submitted by aheshmat on 2020-09-21
ACOG Comments RE: Proposed Representing Pregnancy Status
For full formatted version, please see the attached word document.
Pregnancy Status Class
Comment on the class: ACOG supports the comment already made supporting HL7s CCDA “Pregnancy Status” as it is comprehensive in this area and would better support both clinical research and public health use cases. https://www.hl7.org/implement/standards/product_brief.cfm?product_id=494
1. PREGNANCY STATUS
1A. Requirement Level: Must Have
1A. Value set: Yes, No, Unknown, currently pregnant or confirmed pregnant, not currently pregnant or pregnancy refuted, recently pregnant, possibly pregnant.
1A. Comments
ACOG recommends that “recently pregnant” be defined as within the last 12 months to capture pregnancy related complications. Importantly, pregnancy-related deaths may occur well beyond the early postpartum period.
Per the CDC:
“A pregnancy-related death is defined as the death of a woman while pregnant or within 1 year of the end of a pregnancy –regardless of the outcome, duration or site of the pregnancy–from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.”
1A. Use Case: The Use Case for Pregnancy Episode is to ensure that a status of pregnancy is accurate and not reflective of a pregnancy that took place in the past. It is also important to ensure that multiple pregnancies within a given time period are accurately reflected. This is important for clinical care as well as for both research and public health use cases.
1A. ACOG Related Materials: CO736 | Optimizing Postpartum Care (05/2018)
1B. Requirement Level: Nice to Have
1B. Value set: Patient reported, pregnancy test, urine-based pregnancy test, serum-based pregnancy test, ultrasound, clinical impression, history of hysterectomy other.
1B. Comments: ACOG questions the need for these ‘nice to have’ values under pregnancy status as they are duplicative of values that exist elsewhere. Pregnancy tests and ultrasound are already covered in the Laboratory and Procedures Class and thus do not have a need to be restated here. History of hysterectomy more appropriately belongs with a designation of medically unable to conceive. Patient reported is a general health concern. Clinical impression is covered by yes, confirmed pregnant.
2. DATE PREGNANCY STATUS
Requirement Level: Must Have
Value Set: Date
No ACOG comments.
3. ESTIMATED DELIVERY DATE (EDD)
Requirement Level: Must Have if pregnant, preferred
Value Set: Date
Comments
ACOG Related Materials (ReVITALize): Obstetrics Data Definitions: Estimated Due Date (EDD): The best EDD is determined by last menstrual period if confirmed by early ultrasound or no ultrasound performed, early ultrasound if no known last menstrual period or the ultrasound is not consistent with last menstrual period, or known date of fertilization (e.g., assisted reproductive technology).
4. EDD DETERMINATION METHOD
Requirement Level: Nice to have if EDD used
Value Set: LMP, ultrasound first trimester, ultrasound second trimester, ultrasound third trimester, ultrasound, Ovulation date, Embryo transfer, Other.
Comments
Value set comments:
ACOG Related Materials
5. GESTATIONAL AGE
Requirement Level: Must Have if Pregnant alternative to EDD
Value Set: Number with units = weeks or days
Comments: Should be weeks AND days, not weeks OR days
ACOG Related Materials (ReVITALize): Obstetrics Data Definitions: Gestational age (written with both weeks and days; e.g., 39 weeks and 0 days) is calculated using the best obstetrical EDD based on the following formula: gestational age = (280 - (EDD - Reference Date))/ 7
6. DATE GESTATIONAL AGE DETERMINED
Requirement Level: Must have if GA is used
Value Set: Date
No ACOG comments.
7. GESTATIONAL AGE DETERMINATION METHOD
Requirement Level: Must have if GA is used
Value Set: Ultrasound, EDD, ovulation date, OTHERS?
Comments: Dates should be supplied with the determination method as done with EDD determination method. The same value set may be used as EDD determination method: Embryo transfer, Ovulation date, ultrasound, ultrasound third trimester, ultrasound second trimester, ultrasound first trimester, LMP, Other, with the same comment above with dates added (embryo transfer date, ultrasound dates). Intrauterine Insemination needs to be added to the value set.
8. PREGNANCY OUTCOME
Requirement Level: Nice to have if postpartum status is yes
Value Set: Molar pregnancy, elective termination, spontaneous termination <20 weeks gestation, still birth, ectopic/tubal, live birth, unknown, other, not a live birth
Comments
ACOG Related Materials
[1] The term ‘early’ second trimester loss is being used to reflect the time period of 13 weeks to 19 6/7 weeks during the second trimester. Prior to 13 weeks ‘early loss’ should be used and after 20 weeks ‘stillbirth/fetal death’ applies.
9. PREGNANCY OUTCOME DATE
Requirement Level: Must have if postpartum status is yes
Value Set: Date
Comments
10. ANT PREGNANCY OUTCOME WITHIN THE LAST 42 DAYS?
Requirement Level: Must have if not pregnant
Value Set: Yes, no, unknown
Comments
Use Case: Support of clinical decision support (CDS) for medication prescribing; necessary data elements to support research which may require confirmation of protection against pregnancy.
LOINC Details: Pregnancy prevention intention – Reported has existing LOINC codes.
LOINC Term Description: A patient’s current intentions to prevent pregnancy. This includes a male patient’s intentions to prevent pregnancy with a female partner. This term was created for, but not limited in use to, the Office of Population Affair’s (OPA’s) clinical performance measures for contraceptive provision endorsed by the National Quality Forum (NQF). https://loinc.org/91144-6/
Pregnancy Intention is a component of the LOINC Pregnancy and Contraception Panel 86642-6 (FPAR) Family Planning Annual Report. LOINC Term Description: A patient's intention or desire in the next year to either become pregnant or prevent a future pregnancy. This includes male patients seeking pregnancy with a female partner. Pregnancy intention may be used to help improve preconception health screenings and decisions, such as determining an appropriate contraceptive method, taking folic acid, or avoiding toxic exposures such as alcohol, tobacco and certain medications. This term was based on, but is not limited in use to, Power to Decide's One Key Question®, used by the Office of Population Affair's (OPA's) Family Planning Annual Report (FPAR). https://loinc.org/86645-9/
11. LMP (Last Menstrual Period)
Requirement Level: Nice to have alternate to EDD/GA not dependent on pregnant
Value Set: Date
Comments
ACOG Related Materials
12. MULTIPLICITY OF BIRTH/PREGNANCY
Requirement Level: Nice to have
Value Set: Numeric
Comments
ACOG Related Materials
20200921_USCDI ACOG.docx