Advance directives contains data defining the patient’s direction of care and any reference to supporting documentation. The most recent and up-to-date directives are required, if known, and should be listed in as much detail as possible. Advance directives contains data such as the existence of living wills, healthcare proxies, and CPR and resuscitation status.

Antepartum Summary is a content profile that defines the structure for the aggregation of significant events, diagnoses, and plans of care derived from the visits over the course of an antepartum episode. It is represented in part by Estimated Due Dates and a Visit Summary Flowsheet, in which the aggregated data from the ambulatory office visits is recorded, as well as allergies, advance directives, care plans, and selected histories are provided. The Antepartum Summary represents a summary of the most critical information to an antepartum care provider regarding the status of a patient’s pregnancy.

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Total number of children still living at time this record is generated.

Total number of children whose birth occurred after the beginning of the first day (259th day) of the 38th week following onset of the last menstrual period.

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Increased chance of harm during the period supporting the expulsion of an offspring/child.

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A History of Employment Status Observation is a clinical statement about a person’s relationship to working for pay, family earnings, or training (e.g. having one or more jobs, searching for work, etc.). A person’s ODH Employment Status is independent of Job characteristics, e.g., not “full-time work,” “part-time work,” “self-employed,” because many people have more than one job.

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The age of the conceptus, beginning from the time of fertilization. In clinical obstetrics, the gestational age is often estimated as the time from the last day of the last menstruation which is about 2 weeks before ovulation and fertilization.

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Gestational age in weeks.

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Increased chance of harm during the period supporting the bringing forth of an offspring/child.

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MenstrualStatus Reported.

To document multiple pregnancy.

Other pregnancy outcomes # Includes perinatal death, small for gestational age/intrauterine growth restricted birth. History of pregnancies continuing into the 20th week of gestation and resulting in any of the listed outcomes. Perinatal death includes fetal and neonatal deaths.

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Number of pregnancies terminated before 20 weeks of gestation calculated from the date of onset of last menses [or equivalent date estimated from ultrasound or other measurement or from data derived from assisted fertilization procedure].

Number of intentional medical or surgical terminations of pregnancies before 20 weeks of gestation. [Includes elective and therapeutic terminations.

Number of unintentional terminations of pregnancies before 20 weeks of gestation. [Excludes induced terminations].

Number of Ectopic Pregnancies

Total number of live births. [Complete expulsion or extraction from the mother if a product of human conception, irrespective of duration of pregnancy, which, after expulsion or extraction, breathes or shows any other evidence of life such as heart beat.

Total number of times the patient has been pregnant including the present pregnancy.

Total number of children whose birth occurred through the end of the last day of the 37th week (259th day) following onset of the last menstrual period.

Number of Stillborn Births

Total number of births including abortions, stillbirths and live births. [Note: Because of multiple gestation this number may be greater than the number of abortions plus parity, the number of times the uterus is emptied of a viable pregnancy.

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The pregnancy history collects observations relevant to a single pregnancy within the patient’s history. The organizer for a pregnancy event shall either contain subordinate birth event organizers for each birth event associated with the pregnancy or shall conform to the birth event organizer template, but not both.

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Alcoholic drinks per day

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The Example instance for the AdvanceDirectivesObservation

The Example instance for the AlcoholUseFrequency observation

The Example instance for the BodyWeightMeasuredPrePregnancy observation

The Example instance for the DateOfFirstPrenatalVisit observation

The Example instance for the DateOfLastLiveBirth observation

The Example instance for the DateOfLastMenstralPeriod observation

The Example instance for the DateOfLastOtherPregnancyOutcome observation

The Example instance for the DeliveryDateClinicalEstimate observation

The Example instance for the DeliveryDateEstimatedFromLMP observation

The Example instance for the DeliveryDateEstimatedFromOvulationDate observation

The Example instance for the DeliveryRisk observation

The Example instance for the Diet observation

The Example instance for the DomesticViolenceRisk observation

The Example instance for the DrugUse observation

The Example instance for the DurationOfMenstrualFlow observation

The Example instance for the EmploymentStatus observation

The Example instance for the Exercise observation

The Example instance for the FetusGestationalAge observation

The Example instance for the FetusGestationalAgeClinicalEstimate observation

The Example instance for the FetusGestationalAgeEstimatedFromLMP observation

The Example instance for the FetusGestationalAgeEstimatedFromOvulationDate observation

The Example instance for the FrequencyOfMenstrualCycles observation

The Example instance for the GestationalAge observation

The Example instance for the HCGPlus observation

The Example instance for the Homelessness observation

The Example instance for the LaborRisk observation

The Example instance for the Menarche observation

The Example instance for the MensesMonthly observation

The Example instance for the MenstrualStatus observation

The Example instance for the MultiplePregnancy observation

The Example instance for the NumberOfAbortions observation

The Example instance for the NumberOfAbortionsInduced observation

The Example instance for the NumberOfAbortionsSpontanious observation

The Example instance for the NumberOfBirthsStillLiving observation

The Example instance for the NumberOfBirthsToTerm observation

The Example instance for the NumberOfEctopicPregnancies observation

The Example instance for the NumberOfLiveBirths observation

The Example instance for the NumberOfOtherPregnancyOutcomes observation

The Example instance for the NumberOfPregnancies observation

The Example instance for the NumberOfPrenatalVisitsForThisPregnancy observation

The Example instance for the NumberOfPretermBirths observation

The Example instance for the NumberOfPreviousCesareanDeliveries observation

The Example instance for the NumberOfPreviousLiveBirthsNowDead observation

The Example instance for the NumberOfStillbornBirths observation

The Example instance for the NumberOfTotalBirths observation

The Example instance for the PregnancyEducationObservation

The Example instance for the PregnancyHistory observation

The Example instance for the PriorMensesDate observation

The Example instance for the SmokingTobaccoUseFrequency observation

The Example instance for the ToxicExposure observation