AIHW 2003. Perinatal National Minimum Data Set: National Health Data Dictionary, Version 12. National Health Data Dictionary. Cat. no. HWI 59. Canberra: AIHW.
Northern Territory Government, Department of Health. Pregnancy Health Record. HM424-12/06.
Queensland Government, Department of Health. Pregnancy Health Record. SW071 - v1.00 - 06/2010.
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2007-02-28
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2007-02-28
- 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
- References: Pregnancy Summary, Draft Archetype [Internet]. nehta, Australia, nehta Clinical Knowledge Manager [cited: 2016-02-21]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1013 AIHW 2003. Perinatal National Minimum Data Set: National Health Data Dictionary, Version 12. National Health Data Dictionary. Cat. no. HWI 59. Canberra: AIHW. Northern Territory Government, Department of Health. Pregnancy Health Record. HM424-12/06. Queensland Government, Department of Health. Pregnancy Health Record. SW071 - v1.00 - 06/2010.
- Current Contact: Heather Leslie, Atomica Informatics
- Original Namespace: openEHR Foundation
- Original Publisher: org.openehr
- Custodian Namespace: org.openehr
- MD5-CAM-1.0.1: 3E03204F1560B046B7EF8A09A61D29A2
- Build Uid: 4ce2bdb4-90d8-44a7-ae4d-8951729a20ac
- Revision: 0.0.1-alpha
For example: local information requirements or additional metadata to align with FHIR.
Include:
All not explicitly excluded archetypes
For example: pre-pregnant, such as intending to get pregnant, not taking contraception, actively undertaking IVF treatment; pregnant; post-partum. This status could be designated as 'pre-pregnant' to initiate care pathways for a woman actively attempting to conceive, to ensure that clinical management carefully avoids treatment that could harm a mother or fetus in an unrecognised pregnancy.
For example: '1', 'Triplet', or 'Sam'."
Choice of:
Text
Count
Confirmation may be documented either by date, boolean selection or a link to a confirmatory test result within the health record. This data element may be used to trigger a 'Current' 'Pregnancy status' within the EVALUATION.pregnancy_status archetype.
Choice of:
Date/Time
URI
Boolean
This data element may be used to populate the 'Pregnancy/birth synopsis' data element within the EVALUATION.birth_details archetype in an infant health record.
True, if assisted reproduction was required to achieve the pregnancy.
Allowed values: {true}
Coding with a terminology is preferred, where possible.
This data element is only used to record the outcome of a pregnancy, before it is useful to record an outcome on a per fetus basis. For example: a 'miscarriage' or a 'missed abortion'. Coding of the 'Early pregnancy outcome' with an external terminology is recommended. If it is necessary to record outcome information per infant or fetus use the 'Infant outcome' data element instead. This data element is redundant if 'Infant outcome' has been recorded.
Also known as 'Gestation at birth' for pregnancies resulting in viable outcomes.
Allowed values: weeks, days
0 days..52 weeks
This data element may be renamed in a template, depending on the pregnancy outcome. For example: date of delivery for a live birth or stillbirth; date of miscarriage; or date of termination.
This categorial data element is commonly required within registries or used in risk assessment, rather than recording the actual 'Number of fetuses'.
Choice of:
Coded Text- Present [The pregnancy has more than one fetus.]
- Absent [The pregnancy has only one fetus.]
- Text
- Boolean
min: >=0
- No labour [No onset of labour.]
- Spontaneous [Onset without intervention.]
- Induced [Onset through intervention.]
Coding of the 'Induction Method' with a terminology is desirable, where possible.
Coding of the 'Augmentation Method' with a terminology is desirable, where possible.
Allowed values: days, hours, minutes
>=0 hours
Choice of:
- Text
- Coded Text
- First degree vaginal tear [Involve just the skin of the vaginal opening and perineum.]
- Second degree vaginal tear [Involve the skin and muscle of the perineum and might extend deep into the vagina.]
- Third degree vaginal tear [Tear in the vaginal tissue, perineal skin, and perineal muscles that extends into the anal sphincter.]
- Fourth degree vaginal tear [Extend through the anal sphincter and into the mucous membrane that lines the rectum.]
Property: Volume
Units: ml
For example: the name of the hospital or clinic.
It is strongly recommended that 'Place category' be coded with an external terminology. For example: hospital; birthing clinic; or home.
For example: this data element will be renamed to 'Place of delivery' for a pregnancy that ends in the delivery of one or more newborns.
Include:
openEHR-EHR-CLUSTER.address.v1 and specialisations
For example: findings from examination of the placenta.
Include:
openEHR-EHR-CLUSTER.exam-placenta.v0 and specialisations
Maternal complications recorded within this maternal 'Pregnancy summary' archetype may be used to populate EVALUATION.problem_diagnosis or ACTION.procedure archetypes as part of a maternal Problem list, or similar. Alternatively these complications may be derived from relevant entries previously documented in the maternal health record using EVALUATION.problem_diagnosis or ACTION.procedure archetypes.
Coding of the 'Complication' with a terminology is desirable, where possible. For example, post partum haemorrhage or pre-eclampsia.
If only a partial date is available, this is acceptable.
These data elements may be used to record details about live births or stillborn infants.
Identification might be by the name of the neonate or a label given to a non-viable fetus.
This data element is only used to record the outcome of a pregnancy for a single infant or fetus. For example: 'Live birth'; or 'Stillbirth'. Coding of the 'Infant outcome' with an external terminology is recommended. If it is necessary to record outcome information for the pregnancy as a whole use the 'Early pregnancy outcome' data element instead. This data element is redundant if 'Early pregnancy outcome' has been recorded.
This data element may be used to populate the newborn's health record using the 'Date of birth' data element within the EVALUATION.birth_details archetype.
Coding with a terminology is preferred, where possible. For example: Male; female; intersex; indeterminate. Indeterminate is to be used in the situation where the infant has ambiguous external genitalia. This data element may be used to populate the newborn health record using the 'Sex assigned at birth' data element within the EVALUATION.gender archetype.
- Male [Baby appears physically male.]
- Female [Baby appears physically female.]
- Indeterminate [Sex of the baby has not yet been able to be determined from observation of physical characteristics.]
- Intersex
- Unknown
Include:
openEHR-EHR-CLUSTER.birth_
The clinical context for recording this data element is only presentation at delivery, not at any other phase of labour.
Choice of:
- Coded Text
- Vertex [The vertex was the presenting part.]
- Breech [The breech was the presenting part.]
- Face [The face was the presenting part.]
- Brow [The brow was the presenting part.]
- Foot [A foot was the presenting part.]
- Arm [An arm was the presenting part.]
- Shoulder [A shoulder was the presenting part.]
- Text
- Left occiput anterior/transverse [The baby's back was toward the left side of the uterus at onset of labour.]
- Right occiput anterior/transverse [The baby's back was toward the right side of the uterus at onset of labour.]
- Unknown [It is not known which side the baby's back was positioned by onset of labour.]
This data element may be used to populate the newborn health record using both the 'Weight' data element and 'Birth' EVENT within the OBSERVATION.body_weight archetype.
Property: Mass
Units:
- 0.0..10000.0 g
Limit decimal places: 0 - 0.0..10.0 kg
Limit decimal places: 2
Choice of:
- Text
- Coded Text
- Live [The infant survived the neonatal period.]
- Deceased [The infant did not survive the neonatal period.]
Newborn complications recorded within this maternal 'Pregnancy summary' archetype may be used to populate EVALUATION.problem_diagnosis or ACTION.procedure archetypes to initiate a Problem list, or similar, within a newborn health record.
Coding of the 'Complication' with a terminology is desirable, where possible. For example, neonatal hypoglycaemia or hypothermia.
Rita Apelt, Department of Health,NT, Australia
Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor)
Stephen Chu, NEHTA, Australia
Margaret Cotter, AMSANT, Australia
Michelle Dowden, Miwatj Health Ngalkanbuy Health, Australia
Tim Garden, NTG Department of Health, Australia
Tanya Gardner, CAAC, Australia
Sam Heard, Ocean Informatics, Australia (Editor)
Bernadette Lack, Department of Health, Australia
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Hugh Leslie, Ocean Informatics, Australia
Chunlan Ma, Ocean Informatics, Australia
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Jeremy Oats, NT Health, Australia
Steven Schatz, Department of Health (Northern Territory), Australia
Rosalie Schultz, Anyinginyi Health Aboriginal Corporation, Australia
Gary Sinclair, NT DoH, Australia
Cherie Whitbread, Royal Darwin Hospital, Australia
Jo Wright, NT Dept of Health, Australia (Editor)
- Norwegian Bokmål: Marit Alice Venheim, Helse Vest IKT AS, marit.alice.venheim@helse-vest-ikt.no
- Portuguese (Brazil): Adriana Kitajima, Gabriela Alves, Maria Angela Scatena, Marivan Abrahäo, Core Consulting, contato@coreconsulting.com.br, Hospital Alemão Oswaldo Cruz
- Catalan: Clara Calleja Vega, CatSalut. Servei Català de la Salut., ccalleja@catsalut.cat
- Spanish (Spain): Laura Moral Lopez, Sistema de Salut de Catalunya, lauramoral@catsalut.cat
- Spanish (Colombia): Francisco Ramirez ante, SITIS SAS, framirez74@gmail.com, Ingeniero de Sistemas