Modellbiblioteket openEHR Fork
Name
Pregnancy summary
Description
Overview or summary record of a pregnancy and outcome, including the antenatal period, labour, birth and the immediate postnatal period.
Keywords
pregnancy
fetus
foetus
infant
neonate
delivery
conception
due
date
expected
labor
labour
birth
baby
babies
EDD
EDB
Purpose
To support the recording of an overview or summary record of an identified pregnancy and outcome, including the antenatal period, labor, birth and the immediate postnatal period.
Use
Use to record an overview or summary record of an identified pregnancy and outcome, including the antenatal period, labor, birth and the immediate postnatal period.
During an active pregnancy, this archetype supports the evolution of a persistent pregnancy-related health summary record, with information gradually accumulated or updated, throughout the duration of the pregnancy, labour, birth and the immediate postnatal period. As the data is committed to the persistent health record, the date of the update is also recorded in the 'Last Updated' data element in Protocol, to ensure that if this pregnancy summary is taken out of context of the health record for other purposes, such as data exchange, the date of the latest update is kept with the clinical data.
After birth, this summary record can be used to share essential information with other healthcare providers about the pregnancy, labour, birth and immediate postnatal period.
Each completed pregnancy summary saved to the health record can be re-used to populate the Past Pregnancy History details in subsequent pregnancy records.
In situations where completed pregnancy summaries are not available for each previous pregnancy, this archetype can also be used to record a relevant subset of information that can be used to populate the Past Pregnancy History details with new or active pregnancy records.
During an active pregnancy, this archetype supports the evolution of a persistent pregnancy-related health summary record, with information gradually accumulated or updated, throughout the duration of the pregnancy, labour, birth and the immediate postnatal period. As the data is committed to the persistent health record, the date of the update is also recorded in the 'Last Updated' data element in Protocol, to ensure that if this pregnancy summary is taken out of context of the health record for other purposes, such as data exchange, the date of the latest update is kept with the clinical data.
After birth, this summary record can be used to share essential information with other healthcare providers about the pregnancy, labour, birth and immediate postnatal period.
Each completed pregnancy summary saved to the health record can be re-used to populate the Past Pregnancy History details in subsequent pregnancy records.
In situations where completed pregnancy summaries are not available for each previous pregnancy, this archetype can also be used to record a relevant subset of information that can be used to populate the Past Pregnancy History details with new or active pregnancy records.
Misuse
Not to be used to record event-based information during the pregnancy, labor, birth and immediate postnatal period. These will be recorded using OBSERVATION archetypes - for example, the information related to history & examination during antenatal visits or during labour.
Not to be used to record summary information about a woman's Obstetric history - use EVALUATION.obstetric_summary.
Not to be used to record detailed information about a woman's Menstrual Cycle - use OBSERVATION.menstrual_cycle.
Not to be used to record detailed information about infant feeding - a separate archetype will be used.
Not to be used to record a general menstrual history summary or diary - separate archetypes will be used.
Not to be used to record summary information about a woman's Obstetric history - use EVALUATION.obstetric_summary.
Not to be used to record detailed information about a woman's Menstrual Cycle - use OBSERVATION.menstrual_cycle.
Not to be used to record detailed information about infant feeding - a separate archetype will be used.
Not to be used to record a general menstrual history summary or diary - separate archetypes will be used.
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.
Archetype Id
openEHR-EHR-EVALUATION.pregnancy_summary.v0
Copyright
© openEHR Foundation
Licencing
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/.
Original Author
Heather Leslie
Atomica Informatics
Atomica Informatics
Date Originally Authored
To support the recording of an overview or summary record of an identified pregnancy and outcome, including the antenatal period, labor, birth and the immediate postnatal period.
Language | Details |
---|---|
Norwegian Bokmal |
Marit Alice Venheim
Helse Vest IKT AS
|
Portuguese (Brazil) |
Adriana Kitajima, Gabriela Alves, Maria Angela Scatena, Marivan Abrahäo
Core Consulting
|
Spanish (Colombia) |
Francisco Ramirez ante
SITIS SAS
|
Name | Card | Type | Description |
---|---|---|---|
Pregnancy label
|
0..1 | DV_TEXT |
|
Pregnancy confirmed
|
0..1 |
CHOICE OF
DV_DATE_TIME
DV_URI
DV_BOOLEAN
|
Confirmation of the pregnancy.
Comment
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.
DV_DATE_TIME
DV_URI
|
Pregnancy synopsis
|
0..1 | DV_TEXT |
Narrative description about the entire pregnancy, labour and delivery, including complications.
Comment
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.
|
Assisted reproduction?
|
0..1 | DV_BOOLEAN |
Was the pregnancy a result of assisted reproductive technology?
Comment
True, if assisted reproduction was required to achieve the pregnancy.
Constraint for DV_BOOLEAN
|
Assisted reproduction type
|
0..1 | DV_TEXT |
Type of assisted reproductive technology used to achieve pregnancy.
Comment
Coding with a terminology is preferred, where possible.
|
Early pregnancy outcome
|
0..1 | DV_TEXT |
Outcome of the pregnancy as a whole.
Comment
This data element is only used to record the outcome of a pregnancy, before it is useful to record an outcome on a per foetus 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 foetus use the 'Infant outcome' data element instead. This data element is redundant if 'Infant outcome' has been recorded.
|
Pregnancy duration
|
0..1 | DV_DURATION |
The gestation when the pregnancy has ended.
Comment
Also known as 'Gestation at birth' for pregnancies resulting in viable outcomes.
DV_DURATION
|
Pregnancy end date
|
0..1 | DV_DATE_TIME |
The date and/or time marking the end of the pregnancy.
Comment
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.
DV_DATE_TIME
|
Multiple pregnancy?
|
0..1 |
CHOICE OF
DV_CODED_TEXT
DV_TEXT
DV_BOOLEAN
|
Assertion about whether the pregnancy is cateogrised as 'multiple pregnancy'.
Comment
This categorial data element is commonly required within registries or used in risk assessment, rather than recording the actual 'Number of foetuses'.
Constraint for DV_CODED_TEXT
|
Number of foetuses
|
0..1 | DV_COUNT |
Number of foetuses identified in utero.
Constraint for DV_COUNT
min: >= 0
|
Onset of labour
|
0..1 | DV_CODED_TEXT |
Manner in which labour started.
Constraint for DV_CODED_TEXT
|
Induction method
|
0..* | DV_TEXT |
Method of labour induction.
Comment
Coding of the 'Induction Method' with a terminology is desirable, where possible.
|
Reason for induction
|
0..* | DV_TEXT |
Reason for induction of labour.
|
Augmentation method
|
0..* | DV_TEXT |
Method of labour augmentation.
Comment
Coding of the 'Augmentation Method' with a terminology is desirable, where possible.
|
Total duration of labor
|
0..1 | DV_DURATION |
Total duration of all three stages of labour.
DV_DURATION
|
Perineum
|
0..1 |
CHOICE OF
DV_TEXT
DV_CODED_TEXT
|
Coded or narrative description about the condition of the perineum after birth, including injuries and repairs.
Constraint for DV_CODED_TEXT
|
Episiotomy
|
0..1 | DV_BOOLEAN |
Was an episiotomy performed?
|
Estimated blood loss
|
0..1 | DV_QUANTITY |
Estimation of total maternal blood loss during birth and immediately postpartum.
DV_QUANTITY
|
Place category
|
0..1 | DV_TEXT |
Category of the place where the individual died.
Comment
It is strongly recommended that 'Place category' be coded with an external terminology. For example: hospital; birthing clinic; or home.
|
Place of outcome
|
0..1 | DV_TEXT |
Simple details about the location where the pregnancy was delivered or an alternative outcome of the pregnancy was treated or managed.
Comment
For example: the name of the hospital or clinic.
|
Structured place of outcome
|
0..* | Slot (Cluster) |
Structured details about the location where the pregnancy was delivered or an alternative outcome of the pregnancy was treated or managed.
Comment
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.
Slot
Slot
|
Additional details
|
0..* | Slot (Cluster) |
Structured details about additional information related to the pregnancy summary.
Comment
For example: findings from examination of the placenta.
Slot
Slot
|
|
0..* | CLUSTER |
Details about pregnancy complications or birth complications affecting the mother.
Comment
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.
CLUSTER
|
Complication
|
1..1 | DV_TEXT |
Identification of the complication.
Comment
Coding of the 'Complication' with a terminology is desirable, where possible. For example, post partum haemorrhage or pre-eclampsia.
|
Description
|
0..1 | DV_TEXT |
Narrative description of the maternal complication.
|
Date/Time of onset
|
0..1 | DV_DATE_TIME |
Date of onset of complication, as assessed by a clinician.
Comment
If only a partial date is available, this is acceptable.
DV_DATE_TIME
|
|
0..* | CLUSTER |
Information about a single foetus or newborn infant.
Comment
These data elements may be used to record details about live births or stillborn infants.
CLUSTER
|
Label/name
|
0..1 | DV_TEXT |
Identification of the infant.
Comment
Identification might be by the name of the neonate or a label given to a non-viable foetus.
|
Infant outcome
|
0..1 | DV_TEXT |
Outcome of the pregnancy for the identified infant or foetus.
Comment
This data element is only used to record the outcome of a pregnancy for a single infant or foetus. 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.
|
Date/time of delivery
|
0..1 | DV_DATE_TIME |
Date and time of delivery for the infant.
Comment
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.
DV_DATE_TIME
|
Assigned sex
|
0..1 | DV_CODED_TEXT |
Sex of the infant by direct observation of external genitalia.
Comment
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.
Constraint for DV_CODED_TEXT
|
Birth detail
|
0..* | Slot (Cluster) |
A subset of persistent or summary information about the pregnancy and birth of an infant, selected for utility of use within both the maternal and infant health records.
Slot
Slot
|
Presenting part
|
0..1 |
CHOICE OF
DV_CODED_TEXT
DV_TEXT
|
Presenting part of the infant at delivery.
Comment
The clinical context for recording this data element is only presentation at delivery, not at any other phase of labour.
Constraint for DV_CODED_TEXT
|
Position
|
0..1 | DV_CODED_TEXT |
Position of the infant at delivery.
Constraint for DV_CODED_TEXT
|
Birthweight
|
0..1 | DV_QUANTITY |
Weight of the infant at delivery.
Comment
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.
DV_QUANTITY
|
Feeding
|
0..1 | DV_TEXT |
Narrative description about feeding of the infant.
|
Neonatal outcome
|
0..1 |
CHOICE OF
DV_TEXT
DV_CODED_TEXT
|
Description of the outcome at the end of the neonatal period per newborn infant.
Constraint for DV_CODED_TEXT
|
Neonatal summary
|
0..1 | DV_TEXT |
Narrative description about issues, concerns about the infant or events occurring during the neonatal period.
|
Date/time of neonatal death
|
0..1 | DV_DATE_TIME |
DV_DATE_TIME
|
Age at neonatal death
|
0..1 | DV_DURATION |
The age of the infant if they died during the neonatal period.
DV_DURATION
|
|
0..* | CLUSTER |
Details about any complications affecting the newborn.
Comment
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.
CLUSTER
|
Complication
|
1..1 | DV_TEXT |
Identification of the complication after birth.
Comment
Coding of the 'Complication' with a terminology is desirable, where possible. For example, neonatal hypoglycaemia or hypothermia.
|
Description
|
0..1 | DV_TEXT |
Narrative description of complication.
|
Date/time of onset
|
0..1 | DV_DATE_TIME |
Date and/or time of onset of the complication.
DV_DATE_TIME
|
Name | Card | Type | Description |
---|---|---|---|
Last updated
|
0..1 | DV_DATE_TIME |
The date/time the pregnancy summary was last updated.
DV_DATE_TIME
|
Extension
|
0..* | Slot (Cluster) |
Additional information required to capture local content or to align with other reference models/formalisms.
Comment
For example: local information requirements or additional metadata to align with FHIR.
Slot
Slot
|
archetype (adl_version=1.4; uid=9122c39a-3817-426e-9ae4-d1f438b1d26b) openEHR-EHR-EVALUATION.pregnancy_summary.v0 concept [at0000] -- Pregnancy summary language original_language = <[ISO_639-1::en]> translations = < ["nb"] = < language = <[ISO_639-1::nb]> author = < ["name"] = <"Marit Alice Venheim"> ["organisation"] = <"Helse Vest IKT AS"> ["email"] = <"marit.alice.venheim@helse-vest-ikt.no"> > > ["pt-br"] = < language = <[ISO_639-1::pt-br]> author = < ["name"] = <"Adriana Kitajima, Gabriela Alves, Maria Angela Scatena, Marivan Abrahäo"> ["organisation"] = <"Core Consulting"> ["email"] = <"contato@coreconsulting.com.br"> > accreditation = <"Hospital Alemão Oswaldo Cruz"> > ["es-co"] = < language = <[ISO_639-1::es-co]> author = < ["name"] = <"Francisco Ramirez ante"> ["organisation"] = <"SITIS SAS"> ["email"] = <"framirez74@gmail.com"> > accreditation = <"Ingeniero de Sistemas"> > > description original_author = < ["name"] = <"Heather Leslie"> ["organisation"] = <"Atomica Informatics"> ["email"] = <"heather.leslie@atomicainformatics.com"> ["date"] = <"2007-02-28"> > details = < ["nb"] = < language = <[ISO_639-1::nb]> purpose = <"For å støtte registreringen av en oversikt eller oppsummering av en bekreftet graviditet og utfall, inkludert svangerskapsperioden, fødselen og den umiddelbare postpartum perioden."> use = <"*Use to record an overview or summary record of an identified pregnancy and outcome, including the antenatal period, labor, birth and the immediate postnatal period. During an active pregnancy, this archetype supports the evolution of a persistent pregnancy-related health summary record, with information gradually accumulated or updated, throughout the duration of the pregnancy, labour, birth and the immediate postnatal period. As the data is committed to the persistent health record, the date of the update is also recorded in the 'Last Updated' data element in Protocol, to ensure that if this pregnancy summary is taken out of context of the health record for other purposes, such as data exchange, the date of the latest update is kept with the clinical data. After birth, this summary record can be used to share essential information with other healthcare providers about the pregnancy, labour, birth and immediate postnatal period. Each completed pregnancy summary saved to the health record can be re-used to populate the Past Pregnancy History details in subsequent pregnancy records. In situations where completed pregnancy summaries are not available for each previous pregnancy, this archetype can also be used to record a relevant subset of information that can be used to populate the Past Pregnancy History details with new or active pregnancy records. (en)"> keywords = <"graviditet", "svangerskap", "foster", "spedbarn", "neonatal", "forløsning", "befruktning", "termin", "termindato", "forventet", "fødsel", "baby", "babyer"> misuse = <"Brukes ikke for å dokumentere event-based informasjon i løpet av graviditeten, fødsel og den umiddelbare postpartum perioden. Disse vil bli dokumentert ved bruk av OBSERVATION arketyper, for eksempel informasjon som er relatert til historikk og undersøkelser ved svangerskapskontroller og under fødselen. Brukes ikke for å dokumentere sammenfattet informasjon om kvinnens obstetriske historie - bruk EVALUATION.obstetric_summary. Brukes ikke for å dokumentere detaljert informasjon om kvinnens menstruasjonssyklus - bruk OBSERVATION.menstrual_cycle. Brukes ikke for å dokumentere detaljert informasjon om spedbarns måltider/mating - en seperat arketype vil bli brukt til dette formålet. Brukes ikke for å dokumentere en generell sammenfattet menstruasjonshistorikk eller menstruasjonsdagbok - seperate arketyper vil bli brukt til dette formålet."> copyright = <"© openEHR Foundation"> > ["pt-br"] = < language = <[ISO_639-1::pt-br]> purpose = <"*To support the recording of an overview or summary record of an identified pregnancy and outcome, including the antenatal period, labor, birth and the immediate postnatal period. (en)"> use = <"*Use to record an overview or summary record of an identified pregnancy and outcome, including the antenatal period, labor, birth and the immediate postnatal period. During an active pregnancy, this archetype supports the evolution of a persistent pregnancy-related health summary record, with information gradually accumulated or updated, throughout the duration of the pregnancy, labour, birth and the immediate postnatal period. As the data is committed to the persistent health record, the date of the update is also recorded in the 'Last Updated' data element in Protocol, to ensure that if this pregnancy summary is taken out of context of the health record for other purposes, such as data exchange, the date of the latest update is kept with the clinical data. After birth, this summary record can be used to share essential information with other healthcare providers about the pregnancy, labour, birth and immediate postnatal period. Each completed pregnancy summary saved to the health record can be re-used to populate the Past Pregnancy History details in subsequent pregnancy records. In situations where completed pregnancy summaries are not available for each previous pregnancy, this archetype can also be used to record a relevant subset of information that can be used to populate the Past Pregnancy History details with new or active pregnancy records. (en)"> keywords = <"gravidez", "feto", "feto", "infantil", "neonato", "parto", "concepção", "aguardado", "data", "esperado", "trabalho de parto", "parto", "nascimento", "bebê", "bebês", "data provável do parto", "data prevista do nascimento"> misuse = <"Não deve ser utilizado para gravar informação baseada em eventos durante a gravidez, parto, nascimento e período pós-natal imediato. Estes serão gravados utilizando arquétipos de OBSERVAÇÃO - por exemplo, a informação relacionada com a história e exame durante consultas pré-natais ou durante o parto. Não deve ser usado para gravar resumo de informações sobre a história obstétrica de uma mulher - usar EVALUATION.obstetric_summary. Não deve ser usado para gravar informações detalhadas sobre o ciclo menstrual de uma mulher - usar OBSERVATION.menstrual_cycle. Não deve ser usado para registrar informações detalhadas sobre a alimentação infantil - um arquétipo separado deverá ser utilizado. Não deve ser usado para registrar um resumo ou um diário da história menstrual (geral ou diária) - um arquétipo separado deverá ser utilizado."> copyright = <"© openEHR Foundation"> > ["en"] = < language = <[ISO_639-1::en]> purpose = <"To support the recording of an overview or summary record of an identified pregnancy and outcome, including the antenatal period, labor, birth and the immediate postnatal period."> use = <"Use to record an overview or summary record of an identified pregnancy and outcome, including the antenatal period, labor, birth and the immediate postnatal period. During an active pregnancy, this archetype supports the evolution of a persistent pregnancy-related health summary record, with information gradually accumulated or updated, throughout the duration of the pregnancy, labour, birth and the immediate postnatal period. As the data is committed to the persistent health record, the date of the update is also recorded in the 'Last Updated' data element in Protocol, to ensure that if this pregnancy summary is taken out of context of the health record for other purposes, such as data exchange, the date of the latest update is kept with the clinical data. After birth, this summary record can be used to share essential information with other healthcare providers about the pregnancy, labour, birth and immediate postnatal period. Each completed pregnancy summary saved to the health record can be re-used to populate the Past Pregnancy History details in subsequent pregnancy records. In situations where completed pregnancy summaries are not available for each previous pregnancy, this archetype can also be used to record a relevant subset of information that can be used to populate the Past Pregnancy History details with new or active pregnancy records."> keywords = <"pregnancy", "fetus", "foetus", "infant", "neonate", "delivery", "conception", "due", "date", "expected", "labor", "labour", "birth", "baby", "babies", "EDD", "EDB"> misuse = <"Not to be used to record event-based information during the pregnancy, labor, birth and immediate postnatal period. These will be recorded using OBSERVATION archetypes - for example, the information related to history & examination during antenatal visits or during labour. Not to be used to record summary information about a woman's Obstetric history - use EVALUATION.obstetric_summary. Not to be used to record detailed information about a woman's Menstrual Cycle - use OBSERVATION.menstrual_cycle. Not to be used to record detailed information about infant feeding - a separate archetype will be used. Not to be used to record a general menstrual history summary or diary - separate archetypes will be used."> copyright = <"© openEHR Foundation"> > ["es-co"] = < language = <[ISO_639-1::es-co]> purpose = <"*To support the recording of an overview or summary record of an identified pregnancy and outcome, including the antenatal period, labor, birth and the immediate postnatal period. (en)"> use = <"*Use to record an overview or summary record of an identified pregnancy and outcome, including the antenatal period, labor, birth and the immediate postnatal period. During an active pregnancy, this archetype supports the evolution of a persistent pregnancy-related health summary record, with information gradually accumulated or updated, throughout the duration of the pregnancy, labour, birth and the immediate postnatal period. As the data is committed to the persistent health record, the date of the update is also recorded in the 'Last Updated' data element in Protocol, to ensure that if this pregnancy summary is taken out of context of the health record for other purposes, such as data exchange, the date of the latest update is kept with the clinical data. After birth, this summary record can be used to share essential information with other healthcare providers about the pregnancy, labour, birth and immediate postnatal period. Each completed pregnancy summary saved to the health record can be re-used to populate the Past Pregnancy History details in subsequent pregnancy records. In situations where completed pregnancy summaries are not available for each previous pregnancy, this archetype can also be used to record a relevant subset of information that can be used to populate the Past Pregnancy History details with new or active pregnancy records. (en)"> keywords = <"Embarazo", "Feto", "Infantil", "Recién nacido", "Entrega", "Concepción", "Trabajo de parto", "Labor de parto", "Nacimiento", "Bebé", "Neonato", "Fecha probable de parto", "Fecha Última Mestruación", "Fecha de Nacimiento"> misuse = <"No debe utilizarse para registrar información de eventos durante el embarazo, trabajo de parto y el período postnatal inmediato. Estos se registraran utilizando arquetipos de observación - por ejemplo, la información relacionada con la historia y examen durante las visitas prenatales o controles durante el parto. No debe utilizarse para registrar la información de resumen sobre la historia obstétrica de la mujer - utilizar EVALUATION.obstetric_summary. No debe utilizarse para registrar la información detallada sobre el ciclo menstrual de una mujer - OBSERVATION.menstrual_cycle uso. No debe utilizarse para registrar información detallada acerca de la alimentación infantil - se utiliza un arquetipo diferente. No debe utilizarse para registrar un resumen general de la historia menstrual o un diario - se utilizarán arquetipos distintos. "> copyright = <"© openEHR Foundation"> > > lifecycle_state = <"in_development"> other_contributors = <"Sheryl Alexander, NT Department of Health, Australia", "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)"> other_details = < ["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<heather.leslie@atomicainformatics.com>"> ["original_namespace"] = <"openEHR Foundation"> ["original_publisher"] = <"org.openehr"> ["custodian_namespace"] = <"org.openehr"> ["MD5-CAM-1.0.1"] = <"768700943707E9FAAA043B59F904850A"> ["build_uid"] = <"4845f1f1-614b-4ed4-b692-a454c7b33cb9"> ["revision"] = <"0.0.1-alpha"> > definition EVALUATION[at0000] matches { -- Pregnancy summary data matches { ITEM_TREE[at0001] matches { -- Tree items cardinality matches {0..*; unordered} matches { ELEMENT[at0146] occurrences matches {0..1} matches { -- Pregnancy label value matches { DV_TEXT matches {*} } } ELEMENT[at0158] occurrences matches {0..1} matches { -- Pregnancy confirmed value matches { DV_DATE_TIME matches {*} DV_URI matches {*} DV_BOOLEAN matches {*} } } ELEMENT[at0083] occurrences matches {0..1} matches { -- Pregnancy synopsis value matches { DV_TEXT matches {*} } } ELEMENT[at0104] occurrences matches {0..1} matches { -- Assisted reproduction? value matches { DV_BOOLEAN matches { value matches {true} } } } ELEMENT[at0105] occurrences matches {0..1} matches { -- Assisted reproduction type value matches { DV_TEXT matches {*} } } ELEMENT[at0094] occurrences matches {0..1} matches { -- Early pregnancy outcome value matches { DV_TEXT matches {*} } } ELEMENT[at0159] occurrences matches {0..1} matches { -- Pregnancy duration value matches { DV_DURATION matches { value matches {PWD/|P0D..P52W|} } } } ELEMENT[at0174] occurrences matches {0..1} matches { -- Pregnancy end date value matches { DV_DATE_TIME matches {*} } } ELEMENT[at0178] occurrences matches {0..1} matches { -- Multiple pregnancy? value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0179, -- Present at0180] -- Absent } } DV_TEXT matches {*} DV_BOOLEAN matches {*} } } ELEMENT[at0007] occurrences matches {0..1} matches { -- Number of foetuses value matches { DV_COUNT matches { magnitude matches {|>=0|} } } } ELEMENT[at0008] occurrences matches {0..1} matches { -- Onset of labour value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0112, -- No labour at0009, -- Spontaneous at0010] -- Induced } } } } ELEMENT[at0096] occurrences matches {0..*} matches { -- Induction method value matches { DV_TEXT matches {*} } } ELEMENT[at0097] occurrences matches {0..*} matches { -- Reason for induction value matches { DV_TEXT matches {*} } } ELEMENT[at0022] occurrences matches {0..*} matches { -- Augmentation method value matches { DV_TEXT matches {*} } } ELEMENT[at0016] occurrences matches {0..1} matches { -- Total duration of labor value matches { DV_DURATION matches { value matches {PDTHM/|>=PT0H|} } } } ELEMENT[at0118] occurrences matches {0..1} matches { -- Perineum value matches { DV_TEXT matches {*} DV_CODED_TEXT matches { defining_code matches { [local:: at0153, -- First degree vaginal tear at0154, -- Second degree vaginal tear at0155, -- Third degree vaginal tear at0156] -- Fourth degree vaginal tear } } } } ELEMENT[at0157] occurrences matches {0..1} matches { -- Episiotomy value matches { DV_BOOLEAN matches {*} } } ELEMENT[at0119] occurrences matches {0..1} matches { -- Estimated blood loss value matches { C_DV_QUANTITY < property = <[openehr::129]> list = < ["1"] = < units = <"ml"> > > > } } ELEMENT[at0173] occurrences matches {0..1} matches { -- Place category value matches { DV_TEXT matches {*} } } ELEMENT[at0175] occurrences matches {0..1} matches { -- Place of outcome value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0172] occurrences matches {0..*} matches { -- Structured place of outcome include archetype_id/value matches {/openEHR-EHR-CLUSTER\.address(-[a-zA-Z0-9_]+)*\.v1/} } allow_archetype CLUSTER[at0161] occurrences matches {0..*} matches { -- Additional details include archetype_id/value matches {/openEHR-EHR-CLUSTER\.exam-placenta(-[a-zA-Z0-9_]+)*\.v0/} } CLUSTER[at0065] occurrences matches {0..*} matches { -- Maternal complication items cardinality matches {1..*; unordered} matches { ELEMENT[at0066] matches { -- Complication value matches { DV_TEXT matches {*} } } ELEMENT[at0068] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } ELEMENT[at0067] occurrences matches {0..1} matches { -- Date/Time of onset value matches { DV_DATE_TIME matches {*} } } } } CLUSTER[at0028] occurrences matches {0..*} matches { -- Per infant items cardinality matches {1..*; unordered} matches { ELEMENT[at0036] occurrences matches {0..1} matches { -- Label/name value matches { DV_TEXT matches {*} } } ELEMENT[at0163] occurrences matches {0..1} matches { -- Infant outcome value matches { DV_TEXT matches {*} } } ELEMENT[at0029] occurrences matches {0..1} matches { -- Date/time of delivery value matches { DV_DATE_TIME matches {*} } } ELEMENT[at0037] occurrences matches {0..1} matches { -- Assigned sex value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0113, -- Male at0114, -- Female at0115, -- Indeterminate at0176, -- Intersex at0177] -- Unknown } } } } allow_archetype CLUSTER[at0160] occurrences matches {0..*} matches { -- Birth detail include archetype_id/value matches {/openEHR-EHR-CLUSTER\.birth_detail(-[a-zA-Z0-9_]+)*\.v0/} } ELEMENT[at0045] occurrences matches {0..1} matches { -- Presenting part value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0046, -- Vertex at0047, -- Breech at0048, -- Face at0049, -- Brow at0106, -- Foot at0107, -- Arm at0133] -- Shoulder } } DV_TEXT matches {*} } } ELEMENT[at0149] occurrences matches {0..1} matches { -- Position value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0150, -- Left occiput anterior/transverse at0151, -- Right occiput anterior/transverse at0152] -- Unknown } } } } ELEMENT[at0038] occurrences matches {0..1} matches { -- Birthweight value matches { C_DV_QUANTITY < property = <[openehr::124]> list = < ["1"] = < units = <"g"> magnitude = <|0.0..10000.0|> precision = <|0|> > ["2"] = < units = <"kg"> magnitude = <|0.0..10.0|> precision = <|2|> > > > } } ELEMENT[at0109] occurrences matches {0..1} matches { -- Feeding value matches { DV_TEXT matches {*} } } ELEMENT[at0165] occurrences matches {0..1} matches { -- Neonatal outcome value matches { DV_TEXT matches {*} DV_CODED_TEXT matches { defining_code matches { [local:: at0168, -- Live at0169] -- Deceased } } } } ELEMENT[at0170] occurrences matches {0..1} matches { -- Neonatal summary value matches { DV_TEXT matches {*} } } ELEMENT[at0167] occurrences matches {0..1} matches { -- Date/time of neonatal death value matches { DV_DATE_TIME matches {*} } } ELEMENT[at0166] occurrences matches {0..1} matches { -- Age at neonatal death value matches { DV_DURATION matches {*} } } CLUSTER[at0061] occurrences matches {0..*} matches { -- Newborn complication items cardinality matches {1..*; unordered} matches { ELEMENT[at0062] matches { -- Complication value matches { DV_TEXT matches {*} } } ELEMENT[at0064] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } ELEMENT[at0063] occurrences matches {0..1} matches { -- Date/time of onset value matches { DV_DATE_TIME matches {*} } } } } } } } } } protocol matches { ITEM_TREE[at0081] matches { -- Tree items cardinality matches {0..*; unordered} matches { ELEMENT[at0082] occurrences matches {0..1} matches { -- Last updated value matches { DV_DATE_TIME matches {*} } } allow_archetype CLUSTER[at0164] occurrences matches {0..*} matches { -- Extension include archetype_id/value matches {/.*/} } } } } } ontology term_definitions = < ["en"] = < items = < ["at0000"] = < text = <"Pregnancy summary"> description = <"Overview or summary record of a pregnancy and outcome, including the antenatal period, labour, birth and the immediate postnatal period."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0007"] = < text = <"Number of foetuses"> description = <"Number of foetuses identified in utero."> > ["at0008"] = < text = <"Onset of labour"> description = <"Manner in which labour started."> > ["at0009"] = < text = <"Spontaneous"> description = <"Onset without intervention."> > ["at0010"] = < text = <"Induced"> description = <"Onset through intervention."> > ["at0016"] = < text = <"Total duration of labor"> description = <"Total duration of all three stages of labour."> > ["at0022"] = < text = <"Augmentation method"> description = <"Method of labour augmentation."> comment = <"Coding of the 'Augmentation Method' with a terminology is desirable, where possible."> > ["at0028"] = < text = <"Per infant"> description = <"Information about a single foetus or newborn infant."> comment = <"These data elements may be used to record details about live births or stillborn infants."> > ["at0029"] = < text = <"Date/time of delivery"> description = <"Date and time of delivery for the infant."> comment = <"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."> > ["at0036"] = < text = <"Label/name"> description = <"Identification of the infant."> comment = <"Identification might be by the name of the neonate or a label given to a non-viable foetus."> > ["at0037"] = < text = <"Assigned sex"> description = <"Sex of the infant by direct observation of external genitalia."> comment = <"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."> > ["at0038"] = < text = <"Birthweight"> description = <"Weight of the infant at delivery."> comment = <"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."> > ["at0045"] = < text = <"Presenting part"> description = <"Presenting part of the infant at delivery."> comment = <"The clinical context for recording this data element is only presentation at delivery, not at any other phase of labour."> > ["at0046"] = < text = <"Vertex"> description = <"The vertex was the presenting part."> > ["at0047"] = < text = <"Breech"> description = <"The breech was the presenting part."> > ["at0048"] = < text = <"Face"> description = <"The face was the presenting part."> > ["at0049"] = < text = <"Brow"> description = <"The brow was the presenting part."> > ["at0061"] = < text = <"Newborn complication"> description = <"Details about any complications affecting the newborn."> comment = <"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."> > ["at0062"] = < text = <"Complication"> description = <"Identification of the complication after birth."> comment = <"Coding of the 'Complication' with a terminology is desirable, where possible. For example, neonatal hypoglycaemia or hypothermia."> > ["at0063"] = < text = <"Date/time of onset"> description = <"Date and/or time of onset of the complication."> > ["at0064"] = < text = <"Description"> description = <"Narrative description of complication."> > ["at0065"] = < text = <"Maternal complication"> description = <"Details about pregnancy complications or birth complications affecting the mother."> comment = <"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."> > ["at0066"] = < text = <"Complication"> description = <"Identification of the complication."> comment = <"Coding of the 'Complication' with a terminology is desirable, where possible. For example, post partum haemorrhage or pre-eclampsia."> > ["at0067"] = < text = <"Date/Time of onset"> description = <"Date of onset of complication, as assessed by a clinician."> comment = <"If only a partial date is available, this is acceptable."> > ["at0068"] = < text = <"Description"> description = <"Narrative description of the maternal complication."> > ["at0081"] = < text = <"Tree"> description = <"@ internal @"> > ["at0082"] = < text = <"Last updated"> description = <"The date/time the pregnancy summary was last updated."> > ["at0083"] = < text = <"Pregnancy synopsis"> description = <"Narrative description about the entire pregnancy, labour and delivery, including complications."> comment = <"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."> > ["at0094"] = < text = <"Early pregnancy outcome"> description = <"Outcome of the pregnancy as a whole."> comment = <"This data element is only used to record the outcome of a pregnancy, before it is useful to record an outcome on a per foetus 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 foetus use the 'Infant outcome' data element instead. This data element is redundant if 'Infant outcome' has been recorded. "> > ["at0096"] = < text = <"Induction method"> description = <"Method of labour induction."> comment = <"Coding of the 'Induction Method' with a terminology is desirable, where possible."> > ["at0097"] = < text = <"Reason for induction"> description = <"Reason for induction of labour."> > ["at0104"] = < text = <"Assisted reproduction?"> description = <"Was the pregnancy a result of assisted reproductive technology?"> comment = <"True, if assisted reproduction was required to achieve the pregnancy."> > ["at0105"] = < text = <"Assisted reproduction type"> description = <"Type of assisted reproductive technology used to achieve pregnancy."> comment = <"Coding with a terminology is preferred, where possible."> > ["at0106"] = < text = <"Foot"> description = <"A foot was the presenting part."> > ["at0107"] = < text = <"Arm"> description = <"An arm was the presenting part."> > ["at0109"] = < text = <"Feeding"> description = <"Narrative description about feeding of the infant."> > ["at0112"] = < text = <"No labour"> description = <"No onset of labour."> > ["at0113"] = < text = <"Male"> description = <"Baby appears physically male."> > ["at0114"] = < text = <"Female"> description = <"Baby appears physically female."> > ["at0115"] = < text = <"Indeterminate"> description = <"Sex of the baby has not yet been able to be determined from observation of physical characteristics."> > ["at0118"] = < text = <"Perineum"> description = <"Coded or narrative description about the condition of the perineum after birth, including injuries and repairs."> > ["at0119"] = < text = <"Estimated blood loss"> description = <"Estimation of total maternal blood loss during birth and immediately postpartum."> > ["at0133"] = < text = <"Shoulder"> description = <"A shoulder was the presenting part."> > ["at0146"] = < text = <"Pregnancy label"> description = <""> > ["at0149"] = < text = <"Position"> description = <"Position of the infant at delivery."> > ["at0150"] = < text = <"Left occiput anterior/transverse"> description = <"The baby's back was toward the left side of the uterus at onset of labour."> > ["at0151"] = < text = <"Right occiput anterior/transverse"> description = <"The baby's back was toward the right side of the uterus at onset of labour."> > ["at0152"] = < text = <"Unknown"> description = <"It is not known which side the baby's back was positioned by onset of labour."> > ["at0153"] = < text = <"First degree vaginal tear"> description = <"Involve just the skin of the vaginal opening and perineum."> > ["at0154"] = < text = <"Second degree vaginal tear"> description = <"Involve the skin and muscle of the perineum and might extend deep into the vagina."> > ["at0155"] = < text = <"Third degree vaginal tear"> description = <"Tear in the vaginal tissue, perineal skin, and perineal muscles that extends into the anal sphincter."> > ["at0156"] = < text = <"Fourth degree vaginal tear"> description = <"Extend through the anal sphincter and into the mucous membrane that lines the rectum."> > ["at0157"] = < text = <"Episiotomy"> description = <"Was an episiotomy performed?"> > ["at0158"] = < text = <"Pregnancy confirmed"> description = <"Confirmation of the pregnancy."> comment = <"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."> > ["at0159"] = < text = <"Pregnancy duration"> description = <"The gestation when the pregnancy has ended."> comment = <"Also known as 'Gestation at birth' for pregnancies resulting in viable outcomes."> > ["at0160"] = < text = <"Birth detail"> description = <"A subset of persistent or summary information about the pregnancy and birth of an infant, selected for utility of use within both the maternal and infant health records."> > ["at0161"] = < text = <"Additional details"> description = <"Structured details about additional information related to the pregnancy summary."> comment = <"For example: findings from examination of the placenta."> > ["at0163"] = < text = <"Infant outcome"> description = <"Outcome of the pregnancy for the identified infant or foetus."> comment = <"This data element is only used to record the outcome of a pregnancy for a single infant or foetus. 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."> > ["at0164"] = < text = <"Extension"> description = <"Additional information required to capture local content or to align with other reference models/formalisms."> comment = <"For example: local information requirements or additional metadata to align with FHIR. "> > ["at0165"] = < text = <"Neonatal outcome"> description = <"Description of the outcome at the end of the neonatal period per newborn infant."> > ["at0166"] = < text = <"Age at neonatal death"> description = <"The age of the infant if they died during the neonatal period."> > ["at0167"] = < text = <"Date/time of neonatal death"> description = <""> > ["at0168"] = < text = <"Live"> description = <"The infant survived the neonatal period."> > ["at0169"] = < text = <"Deceased"> description = <"The infant did not survive the neonatal period."> > ["at0170"] = < text = <"Neonatal summary"> description = <"Narrative description about issues, concerns about the infant or events occurring during the neonatal period."> > ["at0172"] = < text = <"Structured place of outcome"> description = <"Structured details about the location where the pregnancy was delivered or an alternative outcome of the pregnancy was treated or managed."> comment = <"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."> > ["at0173"] = < text = <"Place category"> description = <"Category of the place where the individual died."> comment = <"It is strongly recommended that 'Place category' be coded with an external terminology. For example: hospital; birthing clinic; or home."> > ["at0174"] = < text = <"Pregnancy end date"> description = <"The date and/or time marking the end of the pregnancy."> comment = <"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."> > ["at0175"] = < text = <"Place of outcome"> description = <"Simple details about the location where the pregnancy was delivered or an alternative outcome of the pregnancy was treated or managed."> comment = <"For example: the name of the hospital or clinic."> > ["at0176"] = < text = <"Intersex"> description = <""> > ["at0177"] = < text = <"Unknown"> description = <""> > ["at0178"] = < text = <"Multiple pregnancy?"> description = <"Assertion about whether the pregnancy is cateogrised as 'multiple pregnancy'."> comment = <"This categorial data element is commonly required within registries or used in risk assessment, rather than recording the actual 'Number of foetuses'."> > ["at0179"] = < text = <"Present"> description = <"The pregnancy has more than one foetus."> > ["at0180"] = < text = <"Absent"> description = <"The pregnancy has only one foetus."> > > > ["pt-br"] = < items = < ["at0000"] = < text = <"*Pregnancy summary(en)"> description = <"*Overview or summary record of a pregnancy and outcome, including the antenatal period, labour, birth and the immediate postnatal period. (en)"> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0007"] = < text = <"*Number of foetuses (en)"> description = <"*Quantidade de fetos identificados no útero."> > ["at0008"] = < text = <"*Onset of labour(en)"> description = <"*Maneira em que o trabalho de parto começou."> > ["at0009"] = < text = <"Espontâneo"> description = <"Início sem intervenção."> > ["at0010"] = < text = <"Induzido"> description = <"Início através da indução."> > ["at0016"] = < text = <"*Total duration of labor(en)"> description = <"*Duração total dos três estágios do trabalho de parto."> > ["at0022"] = < text = <"*Augmentation method(en)"> description = <"*Condução do trabalho de parto."> comment = <"Codificação do \"Condução do trabalho de parto\" com uma terminologia é desejável, sempre que possível."> > ["at0028"] = < text = <"*Per infant (en)"> description = <"*Information about a single foetus or newborn infant. (en)"> comment = <"*These data elements may be used to record details about live births or stillborn infants. (en)"> > ["at0029"] = < text = <"*Date/time of delivery (en)"> description = <"*Date and time of delivery for the infant. (en)"> comment = <"*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. (en)"> > ["at0036"] = < text = <"*Label/name (en)"> description = <"*Identification of the infant. (en)"> comment = <"*Identification might be by the name of the neonate or a label given to a non-viable foetus. (en)"> > ["at0037"] = < text = <"*Assigned sex (en)"> description = <"*Sex of the infant by direct observation of external genitalia. (en)"> comment = <"*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. (en)"> > ["at0038"] = < text = <"*Birthweight (en)"> description = <"*Weight of the infant at delivery. (en)"> comment = <"*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. (en)"> > ["at0045"] = < text = <"*Presenting part(en)"> description = <"*Presenting part of the infant at delivery. (en)"> comment = <"*The clinical context for recording this data element is only presentation at delivery, not at any other phase of labour. (en)"> > ["at0046"] = < text = <"Vértice"> description = <"*The vertex was the presenting part. (en)"> > ["at0047"] = < text = <"Nádegas"> description = <"*The breech was the presenting part. (en)"> > ["at0048"] = < text = <"Face"> description = <"*The face was the presenting part. (en)"> > ["at0049"] = < text = <"Testa"> description = <"*The brow was the presenting part. (en)"> > ["at0061"] = < text = <"*Newborn complication (en)"> description = <"*Details about any complications affecting the newborn. (en)"> comment = <"*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. (en)"> > ["at0062"] = < text = <"*Complication(en)"> description = <"*Identificação da complicação após o nascimento ."> comment = <"Codificação das \"complicação\" com uma terminologia é desejável , sempre que possível . Por exemplo, hipoglicemia neonatal ou hipotermia ."> > ["at0063"] = < text = <"*Date/time of onset (en)"> description = <"*Data/Hora do início da complicação."> > ["at0064"] = < text = <"Descrição"> description = <"Descrição narrativa da complicação."> > ["at0065"] = < text = <"*Maternal complication(en)"> description = <"*Detalhes sobre complicações na gravidez ou complicações no parto que afetam a mãe."> comment = <"*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. (en)"> > ["at0066"] = < text = <"Complicação"> description = <"Identificação da complicação."> comment = <"A codificação de \"complicação\" com uma terminologia é desejável , sempre que possível . Por exemplo, hemorragia pós-parto ou pré -eclampsia."> > ["at0067"] = < text = <"*Date/Time of onset(en)"> description = <"*Data de início da complicação, como avaliada por um clínico."> comment = <"Se apenas uma data parcial estiver disponível, isto é aceitável."> > ["at0068"] = < text = <"Descrição"> description = <"Descrição narrativa da complicação materna."> > ["at0081"] = < text = <"Tree"> description = <"@ internal @"> > ["at0082"] = < text = <"*Last updated(en)"> description = <"*The date/time the pregnancy summary was last updated. (en)"> > ["at0083"] = < text = <"*Pregnancy synopsis(en)"> description = <"*Narrative description about the entire pregnancy, labour and delivery, including complications. (en)"> comment = <"*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. (en)"> > ["at0094"] = < text = <"*Early pregnancy outcome (en)"> description = <"*Outcome of the pregnancy as a whole. (en)"> comment = <"*This data element is only used to record the outcome of a pregnancy, before it is useful to record an outcome on a per foetus 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 foetus use the 'Infant outcome' data element instead. This data element is redundant if 'Infant outcome' has been recorded. (en)"> > ["at0096"] = < text = <"*Induction method(en)"> description = <"*Método de indução do trabalho de parto."> comment = <"A codificação do \"método de indução\" com uma terminologia é desejável , sempre que possível ."> > ["at0097"] = < text = <"*Reason for induction(en)"> description = <"*Motivo para a indução do parto."> > ["at0104"] = < text = <"*Assisted reproduction?(en)"> description = <"*A gravidez foi resultado do uso de tecnologia de reprodução assistida?"> comment = <"Verdade, se para alcançar a gravidez foi necessário reprodução assistida."> > ["at0105"] = < text = <"*Assisted reproduction type(en)"> description = <"*Tipo de tecnologia de reprodução assistida utilizada para conseguir a gravidez."> comment = <"Codificação com uma terminologia é preferível, quando possível."> > ["at0106"] = < text = <"Pé"> description = <"*A foot was the presenting part. (en)"> > ["at0107"] = < text = <"Braço"> description = <"*An arm was the presenting part. (en)"> > ["at0109"] = < text = <"Alimentação"> description = <"*Narrative description about feeding of the infant. (en)"> > ["at0112"] = < text = <"Não há trabalho de parto"> description = <"Trabalho de parto não iniciado."> > ["at0113"] = < text = <"Masculino"> description = <"Aparencia do recém-nascido parece fisicamente masculina."> > ["at0114"] = < text = <"Feminina"> description = <"Aparência do recém-nascido parece fisicamente feminina."> > ["at0115"] = < text = <"Indeterminada"> description = <"Não possível ainda determinar o sexo do recém-nascido a partir da observação das características físicas."> > ["at0118"] = < text = <"Períneo"> description = <"*Coded or narrative description about the condition of the perineum after birth, including injuries and repairs. (en)"> > ["at0119"] = < text = <"*Estimated blood loss (en)"> description = <"*Estimation of total maternal blood loss during birth and immediately postpartum. (en)"> > ["at0133"] = < text = <"Ombro"> description = <"*A shoulder was the presenting part. (en)"> > ["at0146"] = < text = <"*Pregnancy label (en)"> description = <""> > ["at0149"] = < text = <"*Position (en)"> description = <"*Position of the infant at delivery. (en)"> > ["at0150"] = < text = <"*Left occiput anterior/transverse (en)"> description = <"*The baby's back was toward the left side of the uterus at onset of labour. (en)"> > ["at0151"] = < text = <"*Right occiput anterior/transverse (en)"> description = <"*The baby's back was toward the right side of the uterus at onset of labour. (en)"> > ["at0152"] = < text = <"*Unknown (en)"> description = <"*It is not known which side the baby's back was positioned by onset of labour. (en)"> > ["at0153"] = < text = <"*First degree vaginal tear (en)"> description = <"*Involve just the skin of the vaginal opening and perineum. (en)"> > ["at0154"] = < text = <"*Second degree vaginal tear (en)"> description = <"*Involve the skin and muscle of the perineum and might extend deep into the vagina. (en)"> > ["at0155"] = < text = <"*Third degree vaginal tear (en)"> description = <"*Tear in the vaginal tissue, perineal skin, and perineal muscles that extends into the anal sphincter. (en)"> > ["at0156"] = < text = <"*Fourth degree vaginal tear (en)"> description = <"*Extend through the anal sphincter and into the mucous membrane that lines the rectum. (en)"> > ["at0157"] = < text = <"*Episiotomy (en)"> description = <"*Was an episiotomy performed? (en)"> > ["at0158"] = < text = <"*Pregnancy confirmed (en)"> description = <"*Confirmation of the pregnancy. (en)"> comment = <"*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. (en)"> > ["at0159"] = < text = <"*Pregnancy duration (en)"> description = <"*The gestation when the pregnancy has ended. (en)"> comment = <"*Also known as 'Gestation at birth' for pregnancies resulting in viable outcomes. (en)"> > ["at0160"] = < text = <"*Birth detail (en)"> description = <"*A subset of persistent or summary information about the pregnancy and birth of an infant, selected for utility of use within both the maternal and infant health records. (en)"> > ["at0161"] = < text = <"*Additional details (en)"> description = <"*Structured details about additional information related to the pregnancy summary. (en)"> comment = <"*For example: findings from examination of the placenta. (en)"> > ["at0163"] = < text = <"*Infant outcome (en)"> description = <"*Outcome of the pregnancy for the identified infant or foetus. (en)"> comment = <"*This data element is only used to record the outcome of a pregnancy for a single infant or foetus. 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. (en)"> > ["at0164"] = < text = <"*Extension (en)"> description = <"*Additional information required to capture local content or to align with other reference models/formalisms. (en)"> comment = <"*For example: local information requirements or additional metadata to align with FHIR. (en)"> > ["at0165"] = < text = <"*Neonatal outcome (en)"> description = <"*Description of the outcome at the end of the neonatal period per newborn infant. (en)"> > ["at0166"] = < text = <"*Age at neonatal death (en)"> description = <"*The age of the infant if they died during the neonatal period. (en)"> > ["at0167"] = < text = <"*Date/time of neonatal death (en)"> description = <""> > ["at0168"] = < text = <"*Live (en)"> description = <"*The infant survived the neonatal period. (en)"> > ["at0169"] = < text = <"*Deceased (en)"> description = <"*The infant did not survive the neonatal period. (en)"> > ["at0170"] = < text = <"*Neonatal summary (en)"> description = <"*Narrative description about issues, concerns about the infant or events occurring during the neonatal period. (en)"> > ["at0172"] = < text = <"*Structured place of outcome (en)"> description = <"*Structured details about the location where the pregnancy was delivered or an alternative outcome of the pregnancy was treated or managed. (en)"> comment = <"*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. (en)"> > ["at0173"] = < text = <"*Place category (en)"> description = <"*Category of the place where the individual died. (en)"> comment = <"*It is strongly recommended that 'Place category' be coded with an external terminology. For example: hospital; birthing clinic; or home. (en)"> > ["at0174"] = < text = <"*Pregnancy end date (en)"> description = <"*The date and/or time marking the end of the pregnancy. (en)"> comment = <"*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. (en)"> > ["at0175"] = < text = <"*Place of outcome (en)"> description = <"*Simple details about the location where the pregnancy was delivered or an alternative outcome of the pregnancy was treated or managed. (en)"> comment = <"*For example: the name of the hospital or clinic. (en)"> > ["at0176"] = < text = <"*Intersex (en)"> description = <""> > ["at0177"] = < text = <"*Unknown (en)"> description = <""> > ["at0178"] = < text = <"*Multiple pregnancy? (en)"> description = <"*Assertion about whether the pregnancy is cateogrised as 'multiple pregnancy'. (en)"> comment = <"*This categorial data element is commonly required within registries or used in risk assessment, rather than recording the actual 'Number of foetuses'. (en)"> > ["at0179"] = < text = <"*Present (en)"> description = <"*The pregnancy has more than one foetus. (en)"> > ["at0180"] = < text = <"*Absent (en)"> description = <"*The pregnancy has only one foetus. (en)"> > > > ["es-co"] = < items = < ["at0000"] = < text = <"*Pregnancy summary(en)"> description = <"*Overview or summary record of a pregnancy and outcome, including the antenatal period, labour, birth and the immediate postnatal period. (en)"> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0007"] = < text = <"*Number of foetuses (en)"> description = <"*Número de fetos o productos identificados en el útero"> > ["at0008"] = < text = <"*Onset of labour(en)"> description = <"*Se refiere al inicio del trabajo de parto, este podria ser Espontáneo o Inducido."> > ["at0009"] = < text = <"Espontáneo"> description = <"Cuando el trabajo de Parto inicia de manera Espontánea sin intervencion o uso de Medicamentos."> > ["at0010"] = < text = <"Inducido"> description = <"Cuando el trabajo de parto se empeza de manera artificial."> > ["at0016"] = < text = <"*Total duration of labor(en)"> description = <"*Duracion total de todas las fases del trabajo de parto"> > ["at0022"] = < text = <"*Augmentation method(en)"> description = <"*Método de aumentol trabajo de parto"> comment = <"Siempre que sea posible, Se recomienda el uso de una terminología para codificar el Método de aumento del parto ."> > ["at0028"] = < text = <"*Per infant (en)"> description = <"*Information about a single foetus or newborn infant. (en)"> comment = <"*These data elements may be used to record details about live births or stillborn infants. (en)"> > ["at0029"] = < text = <"*Date/time of delivery (en)"> description = <"*Date and time of delivery for the infant. (en)"> comment = <"*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. (en)"> > ["at0036"] = < text = <"*Label/name (en)"> description = <"*Identification of the infant. (en)"> comment = <"*Identification might be by the name of the neonate or a label given to a non-viable foetus. (en)"> > ["at0037"] = < text = <"*Assigned sex (en)"> description = <"*Sex of the infant by direct observation of external genitalia. (en)"> comment = <"*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. (en)"> > ["at0038"] = < text = <"*Birthweight (en)"> description = <"*Weight of the infant at delivery. (en)"> comment = <"*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. (en)"> > ["at0045"] = < text = <"*Presenting part(en)"> description = <"*Presenting part of the infant at delivery. (en)"> comment = <"*The clinical context for recording this data element is only presentation at delivery, not at any other phase of labour. (en)"> > ["at0046"] = < text = <"Vertical"> description = <"*The vertex was the presenting part. (en)"> > ["at0047"] = < text = <"Nalgas"> description = <"*The breech was the presenting part. (en)"> > ["at0048"] = < text = <"Cara"> description = <"*The face was the presenting part. (en)"> > ["at0049"] = < text = <"Frente"> description = <"*The brow was the presenting part. (en)"> > ["at0061"] = < text = <"*Newborn complication (en)"> description = <"*Details about any complications affecting the newborn. (en)"> comment = <"*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. (en)"> > ["at0062"] = < text = <"*Complication(en)"> description = <"*Identifica las complicación después del nacimiento"> comment = <"Se recomienda el uso de una terminología para codificar la complicación, por ejemplo Hipoglicemia neonatal o hipotermia"> > ["at0063"] = < text = <"*Date/time of onset (en)"> description = <"*Fecha y hora de la compliación"> > ["at0064"] = < text = <"Descripción"> description = <"Naración descriptiva de la complicación"> > ["at0065"] = < text = <"*Maternal complication(en)"> description = <"*Los detalles acerca de las complicaciones del embarazo o complicaciones en el parto afectan a la madre"> comment = <"*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. (en)"> > ["at0066"] = < text = <"Complicación"> description = <"Identificación de la Complicación"> comment = <"codigo de la complicación, es deseable el uso de una terminología . Por ejemplo , hemorragia puerperal o pre- eclampsia."> > ["at0067"] = < text = <"*Date/Time of onset(en)"> description = <"*Fecha de inicio de la complicación, según lo evaluado por un médico."> comment = <"Si sólo se tiene una fecha parcial disponible, es aceptable ."> > ["at0068"] = < text = <"Descripción"> description = <"Descripción narrativa de las complicaciones maternas"> > ["at0081"] = < text = <"Tree"> description = <"@ internal @"> > ["at0082"] = < text = <"*Last updated(en)"> description = <"*The date/time the pregnancy summary was last updated. (en)"> > ["at0083"] = < text = <"*Pregnancy synopsis(en)"> description = <"*Narrative description about the entire pregnancy, labour and delivery, including complications. (en)"> comment = <"*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. (en)"> > ["at0094"] = < text = <"*Early pregnancy outcome (en)"> description = <"*Outcome of the pregnancy as a whole. (en)"> comment = <"*This data element is only used to record the outcome of a pregnancy, before it is useful to record an outcome on a per foetus 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 foetus use the 'Infant outcome' data element instead. This data element is redundant if 'Infant outcome' has been recorded. (en)"> > ["at0096"] = < text = <"*Induction method(en)"> description = <"*Metodo empleado para la inducción del trabajo de parto, por ejemplo empleando Medicamentos (administración de oxitocina) o La amniotomía"> comment = <"Siempre que sea posible, Se recomienda el uso de una terminología para codificar el metodo de Induccion del parto."> > ["at0097"] = < text = <"*Reason for induction(en)"> description = <"*se registra la causa o causas por la cuales se realiza la inducción del trabajo de parto"> > ["at0104"] = < text = <"*Assisted reproduction?(en)"> description = <"*El embarazo fue resultado de emplear técnicas de reproducción asistida o fecundación artificial?"> comment = <"Verdadero, si fue requerida la reproducción asistida para lograr el embarazo."> > ["at0105"] = < text = <"*Assisted reproduction type(en)"> description = <"*Tipo de tecnología de reproducción asistida empleada para lograr el embarazo"> comment = <"Siempre que sea posible, Se recomienda el uso de una terminología para codificar."> > ["at0106"] = < text = <"Pies"> description = <"*A foot was the presenting part. (en)"> > ["at0107"] = < text = <"Brazos"> description = <"*An arm was the presenting part. (en)"> > ["at0109"] = < text = <"Alimentación"> description = <"*Narrative description about feeding of the infant. (en)"> > ["at0112"] = < text = <"No trabajo de PArto"> description = <"Sin inicio del parto"> > ["at0113"] = < text = <"Hombre"> description = <"Bebé con apariencia físicamente masculina"> > ["at0114"] = < text = <"Femenino"> description = <"Bebé con apariencia físicamente femenina"> > ["at0115"] = < text = <"Indeterminado"> description = <"el sexo del bebe no puede ser determinado inicialmente por la observacion de sus características fisicas"> > ["at0118"] = < text = <"perineo"> description = <"*Coded or narrative description about the condition of the perineum after birth, including injuries and repairs. (en)"> > ["at0119"] = < text = <"*Estimated blood loss (en)"> description = <"*Estimation of total maternal blood loss during birth and immediately postpartum. (en)"> > ["at0133"] = < text = <"Hombro"> description = <"*A shoulder was the presenting part. (en)"> > ["at0146"] = < text = <"*Pregnancy label (en)"> description = <""> > ["at0149"] = < text = <"*Position (en)"> description = <"*Position of the infant at delivery. (en)"> > ["at0150"] = < text = <"*Left occiput anterior/transverse (en)"> description = <"*The baby's back was toward the left side of the uterus at onset of labour. (en)"> > ["at0151"] = < text = <"*Right occiput anterior/transverse (en)"> description = <"*The baby's back was toward the right side of the uterus at onset of labour. (en)"> > ["at0152"] = < text = <"*Unknown (en)"> description = <"*It is not known which side the baby's back was positioned by onset of labour. (en)"> > ["at0153"] = < text = <"*First degree vaginal tear (en)"> description = <"*Involve just the skin of the vaginal opening and perineum. (en)"> > ["at0154"] = < text = <"*Second degree vaginal tear (en)"> description = <"*Involve the skin and muscle of the perineum and might extend deep into the vagina. (en)"> > ["at0155"] = < text = <"*Third degree vaginal tear (en)"> description = <"*Tear in the vaginal tissue, perineal skin, and perineal muscles that extends into the anal sphincter. (en)"> > ["at0156"] = < text = <"*Fourth degree vaginal tear (en)"> description = <"*Extend through the anal sphincter and into the mucous membrane that lines the rectum. (en)"> > ["at0157"] = < text = <"*Episiotomy (en)"> description = <"*Was an episiotomy performed? (en)"> > ["at0158"] = < text = <"*Pregnancy confirmed (en)"> description = <"*Confirmation of the pregnancy. (en)"> comment = <"*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. (en)"> > ["at0159"] = < text = <"*Pregnancy duration (en)"> description = <"*The gestation when the pregnancy has ended. (en)"> comment = <"*Also known as 'Gestation at birth' for pregnancies resulting in viable outcomes. (en)"> > ["at0160"] = < text = <"*Birth detail (en)"> description = <"*A subset of persistent or summary information about the pregnancy and birth of an infant, selected for utility of use within both the maternal and infant health records. (en)"> > ["at0161"] = < text = <"*Additional details (en)"> description = <"*Structured details about additional information related to the pregnancy summary. (en)"> comment = <"*For example: findings from examination of the placenta. (en)"> > ["at0163"] = < text = <"*Infant outcome (en)"> description = <"*Outcome of the pregnancy for the identified infant or foetus. (en)"> comment = <"*This data element is only used to record the outcome of a pregnancy for a single infant or foetus. 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. (en)"> > ["at0164"] = < text = <"*Extension (en)"> description = <"*Additional information required to capture local content or to align with other reference models/formalisms. (en)"> comment = <"*For example: local information requirements or additional metadata to align with FHIR. (en)"> > ["at0165"] = < text = <"*Neonatal outcome (en)"> description = <"*Description of the outcome at the end of the neonatal period per newborn infant. (en)"> > ["at0166"] = < text = <"*Age at neonatal death (en)"> description = <"*The age of the infant if they died during the neonatal period. (en)"> > ["at0167"] = < text = <"*Date/time of neonatal death (en)"> description = <""> > ["at0168"] = < text = <"*Live (en)"> description = <"*The infant survived the neonatal period. (en)"> > ["at0169"] = < text = <"*Deceased (en)"> description = <"*The infant did not survive the neonatal period. (en)"> > ["at0170"] = < text = <"*Neonatal summary (en)"> description = <"*Narrative description about issues, concerns about the infant or events occurring during the neonatal period. (en)"> > ["at0172"] = < text = <"*Structured place of outcome (en)"> description = <"*Structured details about the location where the pregnancy was delivered or an alternative outcome of the pregnancy was treated or managed. (en)"> comment = <"*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. (en)"> > ["at0173"] = < text = <"*Place category (en)"> description = <"*Category of the place where the individual died. (en)"> comment = <"*It is strongly recommended that 'Place category' be coded with an external terminology. For example: hospital; birthing clinic; or home. (en)"> > ["at0174"] = < text = <"*Pregnancy end date (en)"> description = <"*The date and/or time marking the end of the pregnancy. (en)"> comment = <"*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. (en)"> > ["at0175"] = < text = <"*Place of outcome (en)"> description = <"*Simple details about the location where the pregnancy was delivered or an alternative outcome of the pregnancy was treated or managed. (en)"> comment = <"*For example: the name of the hospital or clinic. (en)"> > ["at0176"] = < text = <"*Intersex (en)"> description = <""> > ["at0177"] = < text = <"*Unknown (en)"> description = <""> > ["at0178"] = < text = <"*Multiple pregnancy? (en)"> description = <"*Assertion about whether the pregnancy is cateogrised as 'multiple pregnancy'. (en)"> comment = <"*This categorial data element is commonly required within registries or used in risk assessment, rather than recording the actual 'Number of foetuses'. (en)"> > ["at0179"] = < text = <"*Present (en)"> description = <"*The pregnancy has more than one foetus. (en)"> > ["at0180"] = < text = <"*Absent (en)"> description = <"*The pregnancy has only one foetus. (en)"> > > > ["nb"] = < items = < ["at0000"] = < text = <"Graviditetssammenfatning"> description = <"En oversikt eller oppsummering av en bekreftet graviditet og utfall, inkludert svangerskapsperioden, fødselen og den umiddelbare postpartum perioden."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0007"] = < text = <"*Number of foetuses (en)"> description = <"Antall foster identifisert i livmoren."> > ["at0008"] = < text = <"Fødselsstart"> description = <"Måten fødselen startet på."> > ["at0009"] = < text = <"Spontant"> description = <"Spontan fødselssart, uten intervensjon."> > ["at0010"] = < text = <"Indusert"> description = <"Indusert fødsel(start)."> > ["at0016"] = < text = <"Fødselens totale varighet"> description = <"Den totale varigheten av fødselens alle tre stadier."> > ["at0022"] = < text = <"Riestimmulerende metode"> description = <"Metoden brukt for stimulering av rier etter fødselsstart."> comment = <"Koding av \"Riestimmulerende metode\" med en ønsket terminologi, hvor det er mulig."> > ["at0028"] = < text = <"*Per infant (en)"> description = <"*Information about a single foetus or newborn infant. (en)"> comment = <"Disse dataelementene kan brukes til å registrere detaljer om levedefødte eller dødfødte barn."> > ["at0029"] = < text = <"Fødselstidspunkt"> description = <"*Date and time of delivery for the infant. (en)"> comment = <"Dette dataelementet kan bli brukt til å befolke den nyfødtes helsejournal ved å bruke dataelementet \"Fødselsdato\" i arketypen EVALUATION.birth_details (Fødselsdetaljer)."> > ["at0036"] = < text = <"Navn (label)"> description = <"*Identification of the infant. (en)"> comment = <"Identifikasjonen kan være navnet til det nyfødte barnet, eller en type identifikasjon gitt til ikke levedyktige foster."> > ["at0037"] = < text = <"Tilordnet kjønn"> description = <"*Sex of the infant by direct observation of external genitalia. (en)"> comment = <"Kodet med en terminologi er foretrukket, om det er mulig. For eksemplel: Gutt, Jente, Uavklart kjønn. Uavklart kjønn brukes når det ikke er mulig å avgjøre om det er en gutt eller en jente ved å undersøke de ytre kjønnsorganene. Dette dataelementet kan bli brukt til å befolke den nyfødtes helsejournal ved å bruke dataelementet \"Tilordnet kjønn ved fødsel\" i arketypen EVALUATION.gender (Kjønn)."> > ["at0038"] = < text = <"*Birthweight (en)"> description = <"*Weight of the infant at delivery. (en)"> comment = <"Dette dataelementet kan bli brukt til å befolke den nyfødtes helsejournal ved å bruke dataelementet \"Vekt\" og \"Fødsel\" Hendelse i arketypen EVALUATION.body_weight (Kroppsvekt)."> > ["at0045"] = < text = <"Ledende del"> description = <"*Presenting part of the infant at delivery. (en)"> comment = <"Den kliniske konteksten for å registrere dette dataelementet er kun ved forløsning, ikke ved andre tidspunkt i fødselsforløpet."> > ["at0046"] = < text = <"Hodet"> description = <"*The vertex was the presenting part. (en)"> > ["at0047"] = < text = <"Sete"> description = <"*The breech was the presenting part. (en)"> > ["at0048"] = < text = <"Ansikt"> description = <"*The face was the presenting part. (en)"> > ["at0049"] = < text = <"Pannen"> description = <"*The brow was the presenting part. (en)"> > ["at0061"] = < text = <"Nyfødt komplikasjon"> description = <"Detaljer om enhver komplikasjon som angår det nyfødte barnet."> comment = <"Nyfødt komplikasjoner registrert i denne maternelle \"Graviditets sammenfatning\" arketypen, kan brukes til å befolke EVALUATION.problem_diagnosis (Problem/diagnose) eller ACTION.procedure (Prosedyre) arketypene som en del av en problemliste eller lignende i den nyfødtes helsejournal."> > ["at0062"] = < text = <"Komplikasjon"> description = <"Identifisering av komplikasjonen etter fødsel."> comment = <"Koding av \"Komplikasjon\" med en ønsket terminologi, der det er mulig. For eksempel neonatal hypoglykemi eller hypotermi."> > ["at0063"] = < text = <"Startidspunkt/dato"> description = <"Startidspunkt og/eller dato for komplikasjonen."> > ["at0064"] = < text = <"Beskrivelse"> description = <"Fritekstbeskrivelse av komplikasjonen."> > ["at0065"] = < text = <"Maternell komplikasjon"> description = <"Detaljer angående graviditetskomplikasjoner eller fødselskomplikasjoner som påvirker moren."> comment = <"Maternelle komplikasjoner registrert i denne maternelle \"Graviditets sammenfatning\" arketypen, kan brukes til å befolke EVALUATION.problem_diagnosis (Problem/diagnose) eller ACTION.procedure (Prosedyre) arketypene som en del av en maternell problemliste eller lignende. Alternativt, kan disse komplikasjonene hentes fra relevante registreringer fra tidligere dokumentert i den maternelle helsejournalen ved bruk av EVALUATION.problem_diagnosis (Problem/diagnose) or ACTION.procedure (Prosedyre) arketypene."> > ["at0066"] = < text = <"Komplikasjon"> description = <"Identifisering av komplikasjon."> comment = <"Koding av \"Komplikasjon\" med en ønsket terminologi, hvor det er mulig. For eksempel postpartum blødning eller pre-eklampsi."> > ["at0067"] = < text = <"Starttidspunkt/dato"> description = <"Start tidspunkt/dato angående komplikasjonen, satt etter en vurdering gjort av en kliniker."> comment = <"Finnes det bare et delvis/ufullstendig tidspunkt, så aksepteres det."> > ["at0068"] = < text = <"Beskrivelse"> description = <"Fritekstbeskrivelse av den maternelle komplikasjonen."> > ["at0081"] = < text = <"Tree"> description = <"@ internal @"> > ["at0082"] = < text = <"Sist oppdatert"> description = <"Dato/tidspunktet graviditets sammenfatningen sist ble oppdatert."> > ["at0083"] = < text = <"Graviditetssammenfattning"> description = <"Fritekst beskrivelse som omhandler hele svangerskapet og fødsel, inkludert komplikasjoner."> comment = <"Dette dataelementet kan brukes til å befolke dataelementet \"Svangerskap/fødsel sammendrag\" i arketypen EVALUATION.birth_detalis i barnets helsejournal."> > ["at0094"] = < text = <"*Early pregnancy outcome (en)"> description = <"*Outcome of the pregnancy as a whole. (en)"> comment = <"*This data element is only used to record the outcome of a pregnancy, before it is useful to record an outcome on a per foetus 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 foetus use the 'Infant outcome' data element instead. This data element is redundant if 'Infant outcome' has been recorded. (en)"> > ["at0096"] = < text = <"Induksjonsmetode"> description = <"Induksjonsmetoden som er brukt."> comment = <"Koding av \"Induksjonsmetode\" med en ønsket teminologi, hvor dette er mulig."> > ["at0097"] = < text = <"Induksjonsindikasjon"> description = <"Årsaken/indikasjonen til at fødselen blir indusert."> > ["at0104"] = < text = <"Assistert reproduksjon?"> description = <"Var graviditeten et resultat av assistert befuktningsteknologi?"> comment = <"Sant, dersom assistert befruktning var avgjørende for å bli gravid."> > ["at0105"] = < text = <"Assistert reproduksjon type"> description = <"Hvilken type assistert befruktning ble brukt for å oppnå graviditeten."> comment = <"Kodet med terminologi er foretrukket, dersom det er mulig."> > ["at0106"] = < text = <"Fot"> description = <"*A foot was the presenting part. (en)"> > ["at0107"] = < text = <"Arm"> description = <"*An arm was the presenting part. (en)"> > ["at0109"] = < text = <"Ernæring"> description = <"*Narrative description about feeding of the infant. (en)"> > ["at0112"] = < text = <"Ingen fødsel"> description = <"Ingen fødselsstart."> > ["at0113"] = < text = <"Gutt"> description = <"Barnet er tilsynelatende fysisk en gutt."> > ["at0114"] = < text = <"Jente"> description = <"Barnet er tilsynelatende fysisk en gutt."> > ["at0115"] = < text = <"Uavklart kjønn"> description = <"Barnets kjønn er uavklart, da det ikke er mulig å avgjøre ved observasjon av fysiske karakteristika."> > ["at0118"] = < text = <"Perineum"> description = <"Kodet eller fritekst beskrivelse av perineums tilstand etter fødsel, inkludert skader og reparasjoner."> > ["at0119"] = < text = <"Estimert blødning"> description = <"Estimert total blødningmengde iløpet av fødselen og postpartum (første 24 timene)."> > ["at0133"] = < text = <"Skulder"> description = <"*A shoulder was the presenting part. (en)"> > ["at0146"] = < text = <"Graviditet (label)"> description = <""> > ["at0149"] = < text = <"Leie"> description = <"*Position of the infant at delivery. (en)"> > ["at0150"] = < text = <"Venstre occiput anterior/transvers"> description = <"Barnets rygg var mot venstre side av uterus ved fødselsstart. Førsteleie."> > ["at0151"] = < text = <"Høyre occiput anterior/transverse"> description = <"Barnets rygg var mot hørye side av uterus ved fødselsstart. Andre leie."> > ["at0152"] = < text = <"Ukjent"> description = <"Det er ikke kjent hvilken side barnets rygg lå til ved fødselssart."> > ["at0153"] = < text = <"Perinealruptur grad 1"> description = <"Overfladisk skade av hud i perineum eller vaginalslimhinne."> > ["at0154"] = < text = <"Perinealruptur grad 2"> description = <"Dyp perinealskade med affeksjon av muskulatur i perineum, men uten affeksjon av m. sphincter ani eksternus (EAS) (eksterne sfinkter)."> > ["at0155"] = < text = <"Perinealruptur grad 3"> description = <"Skade av perineum som involverer analsfinkter 3a: Ruptur av <50 % av EAS 3b: Ruptur av ≥50 % av EAS 3c: Ruptur av EAS og m. sphincter ani internus (IAS) (interne sfinkter)."> > ["at0156"] = < text = <"Perinealruptur grad 4"> description = <"Skade av perineum som involverer analsfinkter og anal/rektumslimhinne."> > ["at0157"] = < text = <"Episiotomi"> description = <"Ble det utført en episiotomi?"> > ["at0158"] = < text = <"Graviditet bekreftet"> description = <"Bekreftelse på graviditet."> comment = <"Bekreftelsen kan dokumenteres i form av en dato, en avkryssingsrute eller ved å linke til et bekreftende testresultat i den elektroniske journalen. Dataelementet kan brukes til å trigge \"Nåværende gravid\" status i arketypen EVALUATION.pregnancy_status (Graviditet status)."> > ["at0159"] = < text = <"Graviditetens varighet"> description = <"*The gestation when the pregnancy has ended. (en)"> comment = <"Også kjent som \"Gestasjonsalder ved fødsel\" for svangerskap som ender i fødsel."> > ["at0160"] = < text = <"*Birth detail (en)"> description = <"En valgt undergruppe av vedvarende eller oppsummerende informasjon om svangerskapet og fødselen til et spedbarn for bruk i både den maternelle og spedbarnets helsejournal."> > ["at0161"] = < text = <"Ytterligere detaljer"> description = <"Strukturerte detaljer relatert til graviditets sammenfatningen."> comment = <"For eksempel: funn fra undersøkelse av placenta."> > ["at0163"] = < text = <"*Infant outcome (en)"> description = <"*Outcome of the pregnancy for the identified infant or foetus. (en)"> comment = <"*This data element is only used to record the outcome of a pregnancy for a single infant or foetus. 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. (en)"> > ["at0164"] = < text = <"Tilleggsinformasjon"> description = <"Ytterligere informasjon som trengs for å kunne registrere lokalt definert innhold eller for å tilpasse til andre referansemodeller/formalismer."> comment = <"For eksempel lokale informasjonsbehov eller ytterligere metadata for å kunne tilpasse til tilsvarende konsepter i FHIR."> > ["at0165"] = < text = <"*Neonatal outcome (en)"> description = <"*Description of the outcome at the end of the neonatal period per newborn infant. (en)"> > ["at0166"] = < text = <"*Age at neonatal death (en)"> description = <"*The age of the infant if they died during the neonatal period. (en)"> > ["at0167"] = < text = <"*Date/time of neonatal death (en)"> description = <""> > ["at0168"] = < text = <"*Live (en)"> description = <"*The infant survived the neonatal period. (en)"> > ["at0169"] = < text = <"*Deceased (en)"> description = <"*The infant did not survive the neonatal period. (en)"> > ["at0170"] = < text = <"*Neonatal summary (en)"> description = <"*Narrative description about issues, concerns about the infant or events occurring during the neonatal period. (en)"> > ["at0172"] = < text = <"*Structured place of outcome (en)"> description = <"*Structured details about the location where the pregnancy was delivered or an alternative outcome of the pregnancy was treated or managed. (en)"> comment = <"*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. (en)"> > ["at0173"] = < text = <"*Place category (en)"> description = <"*Category of the place where the individual died. (en)"> comment = <"*It is strongly recommended that 'Place category' be coded with an external terminology. For example: hospital; birthing clinic; or home. (en)"> > ["at0174"] = < text = <"*Pregnancy end date (en)"> description = <"*The date and/or time marking the end of the pregnancy. (en)"> comment = <"*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. (en)"> > ["at0175"] = < text = <"*Place of outcome (en)"> description = <"*Simple details about the location where the pregnancy was delivered or an alternative outcome of the pregnancy was treated or managed. (en)"> comment = <"*For example: the name of the hospital or clinic. (en)"> > ["at0176"] = < text = <"*Intersex (en)"> description = <""> > ["at0177"] = < text = <"*Unknown (en)"> description = <""> > ["at0178"] = < text = <"*Multiple pregnancy? (en)"> description = <"*Assertion about whether the pregnancy is cateogrised as 'multiple pregnancy'. (en)"> comment = <"*This categorial data element is commonly required within registries or used in risk assessment, rather than recording the actual 'Number of foetuses'. (en)"> > ["at0179"] = < text = <"*Present (en)"> description = <"*The pregnancy has more than one foetus. (en)"> > ["at0180"] = < text = <"*Absent (en)"> description = <"*The pregnancy has only one foetus. (en)"> > > > >