| ARCHETYPE ID | openEHR-EHR-OBSERVATION.pregnancy_finding.v0 |
| Concept | Pregnancy assertion |
| Description | A statement or declaration about the pregnancy status of the individual at a specific point in time. |
| Use | Use to record a statement or declaration about the pregnancy status of the individual at a specific point in time. A clinical assertion about whether a pregnancy is present, excluded or possible is clinically important in some clinical scenarios, such as guiding management decisions which may cause harm to a pregnant woman or the fetus in an unrecognised pregnancy. While the presence of a known pregnancy can often be safely assumed or inferred from other routinely recorded data in the health record, clinical practice typically presumes that a woman of child-bearing age may be pregnant until proven otherwise and the ability to record uncertainty regarding the possibility of the individual being pregnant. In some clinical scenarios, excluding the presence of a pregnancy is necessary and carries significant clinical safety and medicolegal implications. Absolute exclusion of pregnancy is possible only in limited cases, such as after the confirmed surgical removal of both ovaries and the uterus. In most other situations, clinicians are required to assert a pregnancy exclusion based on a combination of current clinical assessments and judgment. This exclusion should include the clinician’s rationale or justification, which may reference contemporaneous test results, an organ inventory or a past history of diagnoses and procedures. It is crucial to note that any assertion of pregnancy exclusion in the health record is usually relevant only at the time it is documented. |
| 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 phase of an active pregnancy, such as preconception, pregnant, or postpartum. Use the EVALUATION.pregnancy_phase archetype 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. |
| Purpose | To record a statement or declaration about the pregnancy status of the individual, which is to be considered accurate only at the date and 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 |
| OtherDetails Language Independent | {licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=openEHR Foundation, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=19428E604E0128B613D7A9CBC8D62FAB, build_uid=61991cdb-002b-461c-8c0d-4755abedc1da, ip_acknowledgements=This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org., revision=0.0.1-alpha} |
| Keywords | pregnancy, pregnant, exclusion, |
| Lifecycle | in_development |
| UID | 20f5182a-b3e4-4da1-bdaa-6951241c558d |
| Language used | en |
| Citeable Identifier | 1246.145.1344 |
| Revision Number | 0.0.1-alpha |
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