Antenatal record held by pregnant mother
As a complete data set of antenatal items that may be recorded in a hand-held record
Not for use with any situation other than pregnancy
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| Archetype Id | openEHR-EHR-COMPOSITION.encounter.v1 |
| Template ID | 8f4039bb-9fba-46b7-815d-31f0d09eae72 |
| NHS CFH Care Record Element | Care Professional Documentation |
| Business Process Level | Inclusive set of patient held information during antenatal care |
| User roles | Obstetricians, Midwives, General Practitioners |
| Owner | CFH NHS England |
| Specialty | Obstetrics |
| Care setting | Primary care, Maternity |
| Client group | Pregnant women |
| Sign off | CFH NHS England |
| Copyright | Crown |
| Acknowledgements | |
| Issues |
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data [1]
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Any event [0..1]
[+/-] data [1]
Preferred name [0..1]
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Ethnic background [0..1]
Maternal ethnicity [0..1]
Paternal ethnicity [0..1]
Other family ethnicity [0..1]
Language spoken at home [0..1]
Second language [0..1]
Need an interpreter [0..1]
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Education [0..1]
Age at starting formal education [0..1]
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Current education [0..1]
Current education level [0..1]
Special education needs [0..1]
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Education milestones achieved [0..1]
Education level achieved [0..*]
Date achieved [0..*]
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Completed education [0..1]
Highest level of education achieved [0..1]
Age at leaving formal education [0..1]
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Employment [0..1]
Current Employment status [0..*]
Current Occupation [0..*]
Current occupational health exposure [0..1]
Previous Occupations [0..*]
Previous occupational health exposure [0..*]
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Social and community network [0..*]
Marital Status [0..1]
Household type [0..1]
Type of accomodation [0..1]
Household composition [0..*]
Interests and Hobbies [0..1]
Spiritual & Religious beliefs [0..1]
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data [1]
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Any event [0..1]
[+/-] data [1]
Substance name [0..1]
Status [0..1]
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Details of Tobacco use [0..1]
Form [0..1]
Regularity of use [0..1]
Date commenced [0..1]
Age commenced [0..1]
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Consumption [0..1]
Average weekly consumption [0..1]
OR ![]()
Average daily consumption [0..1]
OR ![]()
Maximal daily consumption [0..1]
OR ![]()
Total cigarette consumption [0..1]
Date ceased [0..1]
Age ceased [0..1]
Comment [0..1]
[+/-]
Changing smoking status [0..1]
[+/-]
Previous attempts to quit smoking [0..1]
Location [0..1]
Date of attempt [0..1]
Description of attempt [0..1]
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Therapeutic intervention [0..1]
Agent [0..1]
Used optimally [0..1]
Comment [0..1]
Outcome [0..1]
[+/-]
Exposure to tobacco smoke [0..1]
Household members smoke [0..1]
Workplace exposure [0..1]
[+/-] data [1]
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Do you have/have you had: [1..*]
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Asthma or chest problems [1..*]
Condition [1]
Answer [0..1]
A comment on the answer [0..1]
[+/-]
Vaginal bleeding in this pregnancy [1..*]
Condition [1]
Answer [0..1]
A comment on the answer [0..1]
[+/-]
Vaginal bleeding in this pregnancy [1..*]
Condition [1]
Answer [0..1]
A comment on the answer [0..1]
Summary [0..1]
[+/-] data [1]
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Has anyone in your family had: [1..*]
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Diabetes [1..*]
Condition [1]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Other conditions [1..*]
Condition [1]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Other conditions [1..*]
Condition [1]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Thrombosis (blood clots) [1..*]
Condition [1]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Thallassaemia [1..*]
Condition [1]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Sickle Cell Anaemia [1..*]
Condition [1]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Cystic Fibrosis [1..*]
Condition [1]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Muscular Dystrophy [1..*]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
High Blood Pressure [1..*]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Hip problems from birth [1..*]
Condition [1]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Mental illness [1..*]
Condition [1]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Eclampsia [1..*]
Condition [1]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Has anyone in your family or in the family of the baby's father had: [1..*]
[+/-]
Question [1..*]
Condition [1]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Has anyone in your family or in the family of the baby's father had: [1..*]
[+/-]
A disease that runs in families [1..*]
Condition [1]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Learning difficulties [1..*]
Condition [1]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Multiple miscarriages [1..*]
Condition [1]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Need for genetic counselling [1..*]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Sudden infant death [1..*]
Condition [1]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Hearing loss from childhood [1..*]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Heart problems from birth [1..*]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Stillbirths [1..*]
Condition [1]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
[+/-]
Abnormalities present from birth [1..*]
Condition [1]
Presence [1]
Answer [0..1]
[+/-]
Affected party [0..*]
Name [0..1]
Relationship [0..1]
A comment on the answer [0..1]
Summary [0..1]
[+/-]
data [1]
[+/-]
Any event [0..1]
[+/-] data [1]
Is partner a blood relative [0..1]
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Mental health [0..1]
Currently having counselling? [0..1]
Previous stress, anxiety or depression? [0..1]
Admitted to hospital with mental health related issue? [0..1]
Diagnosed with bipolar disorder/psychotic illness/schizophrenia? [0..1]
History of severe postnatal illness (psychosis) or needed admission? [0..1]
Any history of repeat (>3 episodes) of self harming behaviour? [0..1]
Feelings of being down, depressed or hopeless in last month? [0..1]
Little interest/pleasure in doing things in last month? [0..1]
Any family member given birth to abnormal baby? [0..1]
Requires assistance with housing [0..1]
Requires assistance re DHSS benefits and grants [0..1]
Interest in Parenthood education [0..1]
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Current pregnancy [0..1]
Type of antenatal care requested [0..1]
Preference for place of delivery [0..1]
Planning for this pregnancy [0..1]
Response when found out about pregnancy [0..1]
Partner's response when found out about pregnancy [0..1]
Length of time trying to get pregnant [0..1]
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Safety [0..1]
Has been subject to physical, sexual or emotional threat in relationship [0..1]
Form of threat [0..1]
Status of threat [0..1]
[+/-] data [1]
Maternity states [0..1]
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Conception [0..1]
Date of last menstrual period [0..1]
Sure of dates [0..1]
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Menstrual details [0..1]
Date of conception [0..1]
Details of assisted conception [0..1]
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Previous pregnancies [0..1]
Any prior pregnancy [0..1]
Number of prior pregnancies [0..1]
Parity [0..1]
Miscarriages [0..1]
Terminations of pregnancy [0..1]
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Current pregnancy [0..1]
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Due Date [0..*]
Expected date of birth [0..1]
Basis for estimated date of birth [0..1]
Agreed due date [0..1]
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Number of fetuses [0..*]
Number of fetuses [1]
Gestation [0..1]
Planned model of care [0..1]
Model of care at delivery [0..1]
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Labour or delivery [0..*]
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Onset of labour [0..1]
Type [0..1]
Time of onset [0..1]
Establishment of labour [0..1]
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Rupture of membranes [0..1]
Type [0..1]
Rupture comments [0..1]
Time of rupture [0..1]
Duration of ruptured membranes [0..1]
Decription of liquor [0..1]
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Augmentation [0..*]
Type [0..1]
Onset of augmentation [0..1]
Duration of augmentation [0..1]
Fetal monitoring [0..*]
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Labour milestones [0..1]
Cervix fully dilated [0..1]
Placenta expelled [0..1]
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Duration [0..1]
Total duration of labour [0..1]
Duration of first stage [0..1]
Duration of third stage [0..1]
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Overview [0..1]
Description of labour [0..1]
Comments [0..1]
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Offspring [0..*]
Outcome [0..1]
Name [0..1]
Date/Time of delivery [0..1]
Gender [0..1]
Birth weight [0..1]
Duration of second stage [0..1]
Place of birth [0..1]
Mode of birth [0..1]
Presenting part at birth [0..1]
Position at birth [0..1]
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Interventions [0..1]
[+/-]
Intervention [0..*]
Type [0..1]
Status [0..1]
Successful [0..1]
Indication [0..1]
Description [0..1]
Description of birth [0..1]
Estimated gestational age [0..1]
[+/-]
Feeding [0..1]
Description of feeding [0..1]
Breast fed [0..1]
Date ceased breast feeding [0..1]
Age ceased breast feeding [0..1]
Age of onset of breast feeding [0..1]
Details of the offspring [0..1]
[+/-]
Fetal or Neonatal complications [0..1]
[+/-]
Fetal or Neonatal complication [0..*]
Date of onset [0..1]
Clinical description [1]
[+/-]
Complications [0..1]
[+/-]
Complication [0..*]
Date of onset [0..1]
Clinical description [0..1]