| ARCHETYPE ID | openEHR-EHR-OBSERVATION.pregnancy_assertion.v0 |
|---|---|
| Concept | Pregnancy assertion |
| Description | A clinical determination made by a clinician about whether or not the individual is pregnant at a specific point in time, based on the best available evidence and supporting safe clinical decision making. |
| Use | Use to record a clinician’s determination about whether or not the individual is pregnant, based on the clinician’s best current knowledge. It should be accompanied by the evidence that provides the rationale for the assertion. ‘May be pregnant’ is intentionally omitted as a value for this assertion as it reflects an assumed, rather than recorded, state for any woman of child-bearing age until a pregnancy assertion is made. The assertion that a woman is currently pregnant or not is a critical factor in safe clinical decision-making. For example, the differential diagnosis of abdominal pain can differ significantly between pregnant and non-pregnant women, and may lead to distinct diagnostic and treatment pathways. Any assertion should be considered accurate only at the time it is made. For example, an assertion of ‘Pregnant' may be valid during the process of diagnosing an ectopic pregnancy but becomes invalid following surgical resolution. Similarly, an assertion of 'Not pregnant’ based on history and a negative urine test may need revision if subsequent symptoms, examination findings, or test results have changed. |
| Misuse | Not to be used to record summary information about a single pregnancy. Use the EVALUATION.pregnancy_summary archetype for this purpose. Not to be used to record the status or phase of an active pregnancy, such as preconception, pregnant, or postpartum. At the time of authoring it is not yet determined which archetype should be used for this purpose. Not to be used to record details about procedures performed during a pregnancy, for example terminations or deliveries. Use the ACTION.procedure or other relevant archetypes for this purpose. Not to be used in the context of questionnaire-style representations, such as self-reported data with questions like 'Are you currently pregnant?' At the time of authoring it is not yet determined which archetype should be used for this purpose. Not to be used to record absence of known pregnancy history. At the time of authoring it is not yet determined which archetype should be used for this purpose. Not to be used to record an estimated due date of delivery. Use the EVALUATION.estimated_date_delivery archetype for this purpose. Not to be used to record the gestational age of a fetus at a point in time. Use the OBSERVATION.gestation_assertion archetype for this purpose. |
| Purpose | To record a clinician’s determination about whether the individual is pregnant, considered accurate only at the time of assertion. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Marit Alice Venheim Organisation: Helse Vest IKT AS Email: marit.alice.venheim@helse-vest-ikt-no Date originally authored: 2020-05-05 |
| Other Details Language | Author name: Marit Alice Venheim Organisation: Helse Vest IKT AS Email: marit.alice.venheim@helse-vest-ikt-no Date originally authored: 2020-05-05 |
| Other Details (Language Independent) |
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| Keywords | pregnancy, pregnant, exclusion, confirmation |
| Lifecycle | in_development |
| UID | 752bdebc-9c67-4190-b872-db5361dab992 |
| Language used | en |
| Citeable Identifier | 1246.145.1344 |
| Revision Number | 0.0.1-alpha |
| protocol | |
| Extension | Extension: Additional information required to extend the model with local content or to align with other reference models or formalisms. For example: local information requirements; or additional metadata to align with FHIR. Include: All not explicitly excluded archetypes |
| data | |
| Pregnancy assertion | Pregnancy assertion: A clinical determination made by a clinician about whether or not the individual is pregnant at a specific point in time.
|
| Justification | Justification: Narrative description of the justification or rationale for the assertion. |
| Clinical evidence | Clinical evidence: Structured clinical evidence supporting the assertion. For example: laboratory test results; organ inventory; diagnoses or past procedures. Include: openEHR-EHR-CLUSTER.clinical_ |
| Comment | Comment: Additional narrative about the pregnancy assertion, not captured in other fields. |
| events | |
| Any point in time event | Any point in time event: Default, unspecified point in time event which may be explicitly defined in a template or at run-time. |
| Other contributors | Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor) Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor) SB Bhattacharyya, Bhattacharyyas Clinical Records Research & Informatics LLP, India Michelle Currie, SavantSolutions4HIT, LLC, United States Ciprian Gerstenberger, Helse Nord IKT, Norway (openEHR Editor) Heather Grain, Llewelyn Grain Informatics, Australia Evelyn Hovenga, EJSH Consulting, Australia Henri Huttunen, UNA Oy, Finland June Marie Nepstad Knappskog, Helse Nord IKT AS, Norway (openEHR Editor), Norway (openEHR Editor) Jörgen Kuylenstierna, eWeave AB, Sweden Liv Laugen, Oslo University Hospital, Norway, Norway (openEHR Editor) Darin Leonhardt, PLRI für medizinische Informatik/ Medizinische Hochschule, Germany Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Cecilia Mascia, CRS4, Italy Ian McNicoll, freshEHR Clinical Informatics, United Kingdom Olha Nikolaieva, University Hospital Basel, Switzerland Mikael Nyström, Cambio Healthcare Systems AB, Sweden Jayashree Panickar, India Ana Pascual Segura, Catsalut, Spain Anton Pichugin, GKU IAC at Department of Information Technologies of the city of Moscow (DIT Moscow), Russia Marlene Pérez Colman, Digital Health and Care Wales, United Kingdom Bipinkumar Rathod, NHS, United Kingdom Videha Sharma, University of Manchester, United Kingdom Norwegian Review Summary, Norwegian Public Hospitals, Norway John Tore Valand, Helse Vest IKT, Norway (openEHR Editor) Wouter Zanen, Eurotranplant, Netherlands |
| Translators |
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