ARCHETYPE GDM Registry Dataset (openEHR-EHR-CLUSTER.gdm_registry.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.gdm_registry.v1
ConceptGDM Registry Dataset
DescriptionInitial dataset for internal discussion
UseFor baseline
Misuseany other
PurposeFor the GDM Registry dataset development
References
Copyright© openEHR Foundation
AuthorsAuthor name: Koray Atalag
Organisation: NIHI
Email: k.atalag@nihi.auckland.ac.nz
Date originally authored: 2013-11-25
Other Details LanguageAuthor name: Koray Atalag
Organisation: NIHI
Email: k.atalag@nihi.auckland.ac.nz
Date originally authored: 2013-11-25
Other Details (Language Independent)
  • MD5-CAM-1.0.1: 422F4A62C26F26F4448881C2E08BD9C5
Keywords
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.1593
items
DEMOGRAPHICDEMOGRAPHIC: Demographic details of the woman.
NHINHI: NZ NHI number
Date of birthDate of birth: DoB
EthnicityEthnicity: NZ Ethicities, can be multiple. Using Stats NZ level-2 list
  • European nfd [10]
  • New Zealand European [11]
  • Other European [12]
  • Māori [21]
  • Pacific Peoples nfd [30]
  • Samoan [31]
  • Cook Islands Maori [32]
  • Tongan [33]
  • Niuean [34]
  • Tokelauan [35]
  • Fijian [36]
  • Other Pacific Peoples [37]
  • Asian nfd [40]
  • Southeast Asian [41]
  • Chinese [42]
  • Indian [43]
  • Other Asian [44]
  • Middle Eastern [51]
  • Latin American [52]
  • African [53]
  • Other Ethnicity [61]
  • Don't Know [94]
  • Refused to Answer [95]
  • Repeated Value [96]
  • Response Unidentifiable [97]
  • Response Outside Scope [98]
  • Not Stated [99]
NameName: Full name
CONTACT DETAILSCONTACT DETAILS: Contact info, should be the most recent one
AddressAddress: Address - can be multiple (e.g. physical, postal etc.)
TelecomTelecom: Telephone, fax etc. can be multiple
EmailEmail: Email(s)
Preferred?Preferred?: Whether this is the preferred contact; e.g. others will be used if this fails
CONTACT PEOPLECONTACT PEOPLE: People who can be contacted - can be multiple
NameName: Full name
RelationshipRelationship: Relationship to woman
  • emergency [Contact for use in case of emergency]
  • family [Family]
  • guardian [Guardian]
  • friend [Friend]
  • partner [Partner]
  • work [Contact for matters related to the patients occupation/employment]
  • caregiver [(Non)professional caregiver]
  • agent [Contact that acts on behalf of the patient]
  • guarantor [Contact for financial matters]
  • parent [Parent of the patient]
AddressAddress: Address - can be multiple (e.g. physical, postal etc.)
TelecomTelecom: Telephone, fax etc. can be multiple
EmailEmail: Email(s)
PROVIDERPROVIDER: Woman's healthcare provider (e.g. GP practice, DHB etc). Can be multiple
HPIHPI: Health Provider Index
Designated GPDesignated GP: Woman's GP
PracticePractice: Woman's GP Practice
AddressAddress: Address - can be multiple (e.g. physical, postal etc.)
TelecomTelecom: Telephone, fax etc. can be multiple
EmailEmail: Email(s)
PERSISTENT SUMMARYPERSISTENT SUMMARY: *
Date of first Diabetes Clinic appointmentDate of first Diabetes Clinic appointment: *
Gravida/ParityGravida/Parity: No of pregnancies and deliveries survived to a gestational age of 24 weeks
History of GDMHistory of GDM: Any known Hx of GDM. This information will come from individual pregnancy based entries; collated from existing data.
History of prior GDMHistory of prior GDM: Any known history present or not
Date of last GDM DiagnosisDate of last GDM Diagnosis: Date of GDM Diagnosis
Treatment of GDMTreatment of GDM: Tx of GDM episode
  • Diet [Diet treatment]
  • Tablets [Treatment with tablets]
  • Insulin [Treatment with insulin injection]
Insulin required?Insulin required?: Insulin required during GDM episode
  • Basal [Basal type]
  • Bolus [Bolus injection]
  • Both (basal + bolus) [Both (basal + bolus)]
ComorbiditiesComorbidities: Any comorbidities
  • Hypertension [Hypertension]
  • COS [COS]
  • Dyslipidaemia [Dyslipidaemia]
  • Microalbuminuria [Microalbuminuria]
  • Renal impairment [Renal impairment]
  • Obstructive sleep apnoea [Obstructive sleep apnoea]
Family history of diabetesFamily history of diabetes: Known family history?
  • None [No family Hx]
  • Parent [Hx of DM in parent(s)]
  • Brother [Hx of DM in brother(s)]
  • Sister [Hx of DM in sister(s)]
  • Child [Hx of DM in child(ren)]
Smoking statusSmoking status: SNOMED smoking status valueset AND two ex-smoker added
  • Current every day smoker [449868002]
  • Current some day smoker [428041000124106]
  • Former smoker [8517006]
  • Never smoker (Never Smoked) [266919005]
  • Smoker, current status unknown [77176002]
  • Unknown if ever smoked [266927001]
  • Ex-smoker (stopped in last 12 months) [Ex-smoker (stopped in last 12 months)]
  • Ex-smoker (stopped longer than 12 months) [Ex-smoker (stopped longer than 12 months)]
Attended group educational sessions?Attended group educational sessions?: Whether they attended group educational session that we run.
PREGNANCYPREGNANCY: *
Clinical InformationClinical Information: Clinical information
Date of GDM diagnosisDate of GDM diagnosis: Date of GDM Dx for a particular pregnancy
Gestation at diagnosisGestation at diagnosis: Duration in weeks
Gravida/ParityGravida/Parity: No of pregnancies and deliveries survived to a gestational age of 24 weeks
ComorbiditiesComorbidities: Any comorbidities
  • Hypertension [Hypertension]
  • COS [COS]
  • Dyslipidaemia [Dyslipidaemia]
  • Microalbuminuria [Microalbuminuria]
  • Renal impairment [Renal impairment]
  • Obstructive sleep apnoea [Obstructive sleep apnoea]
Weight at presentationWeight at presentation: Body weight
Property: Mass
Units:
  • kg
  • g
Height at presentationHeight at presentation: Height
Property: Length
Units:
  • m
  • cm
BMI at presentationBMI at presentation: BMI
Property: Mass per area
Units: kg/m²
First antenatal blood date of requestFirst antenatal blood date of request: First antenatal blood date of request
LaboratoryLaboratory: Lab results
OGTT result (fasting)OGTT result (fasting): fasting OGTT result
Property: Concentration
Units: mmol/l
OGTT result (2 hour)OGTT result (2 hour): 2 hr OGTT result
Property: Concentration
Units: mmol/l
Polycose resultPolycose result: *
Property: Concentration
Units: mmol/l
HbA1c at diagnosisHbA1c at diagnosis: Routinely done - using International Federation of Clinical Chemistry (IFCC) unit (mmol/mol)
Property: Amount (mole)
Units: mmol/mol
Urine microalbuminUrine microalbumin: amount of albumin in urine
Property: Concentration
Units: mg/l
Protein creatinine ratioProtein creatinine ratio: urine protein/creatinine ratio - mg/mmol
Property: Proportion
Serum creatinineSerum creatinine: Routine once referred to clinic. 14682-9 LOINC
Property: Concentration
Units:
  • umol/l
  • mg/dl
ManagementManagement: Management of GDM
Treatment of GDMTreatment of GDM: Tx of GDM episode
  • Diet [Diet treatment]
  • Tablets [Treatment with tablets]
  • Insulin [Treatment with insulin injection]
Insulin required?Insulin required?: Insulin required during GDM episode
  • Basal [Basal type]
  • Bolus [Bolus injection]
  • Both (basal + bolus) [Both (basal + bolus)]
DescriptionDescription: Description of management details of GDM episode
End of pregnancyEnd of pregnancy: End of pregnancy data
Gestation at deliveryGestation at delivery: gestation at delivery - in weeks
Delivery outcomeDelivery outcome: Outcome of delivery
  • TOP [TOP.]
  • Miscarriage [Miscarriage.]
  • IUD [IUD.]
Pre-eclampsiaPre-eclampsia: Pre-eclampsia present?
Mode of deliveryMode of delivery: Mode of delivery
  • NVD [NVD.]
  • C-Section [C-Section.]
  • Ventouse [Ventouse.]
Neonatal weight at deliveryNeonatal weight at delivery: Neonatal weight at delivery
Property: Mass
Units: g
6 week OGTT result6 week OGTT result: 6 week OGTT result
Property: Concentration
Units:
  • mmol/l
  • mg/dl
HbA1c within 3 months of deliveryHbA1c within 3 months of delivery: HbA1c within 3 months of delivery
Property: Amount (mole)
Units: mmol/mol
Newborn(s)Newborn(s): Information about the baby
NHINHI: NZ NHI number
Post-natal deathPost-natal death: Death after birth?
Neonate ICU admissionNeonate ICU admission: kids frequently get admitted for hypoglycaemia due to maternal hyperinsulinemia
Death dateDeath date: Date of death
Death reasonDeath reason: Reason for death
FollowupFollowup: Any follow-up info
AdministrativeAdministrative: Admin info
ICD Codes at dischargeICD Codes at discharge: ICD Codes at discharge - can be multiple
ONGOINGONGOING: Data to be collected on an ongoing basis
Annual HbA1c resultAnnual HbA1c result: Annual HbA1c result
Property: Amount (mole)
Units: mmol/mol
CASE MANAGEMENTCASE MANAGEMENT: Case management functionality information
ContactContact: For each contact data will be captured longitudinally
Contact info usedContact info used: *
AddressAddress: Address - can be multiple (e.g. physical, postal etc.)
TelecomTelecom: Telephone, fax etc. can be multiple
EmailEmail: Email(s)
Person contactedPerson contacted: Person contacted, woman or other
Contact reasonContact reason: Reason of contact
Contact dateContact date: Contact date
Contact typeContact type: Type of contact
  • 6 weekly OGTT reminder [*]
  • 1 year post delivery HbA1c reminder [*]
  • Abnormal result [*]
  • Data update [*]
  • Ad hoc contact [*]
Case statusCase status: Whether case is open (e.g. patient did not respond etc.) or closed
  • Open [Case open]
  • Closed [Case closed]
Case priorityCase priority: Case priority
  • High [Need urgent attention]
  • Normal [Usual cases]
  • Low [Stable cases]
OutcomeOutcome: Description of correspondence and outcome
Follow-upFollow-up: flag for future consideration / important
Contacting personnelContacting personnel: Personnel who made contact - from list of Registry users
Follow-up notesFollow-up notes: Free text notes - can be multiple
INTERVENTIONINTERVENTION: Details of interventions and outcome
Date of interventionDate of intervention: Date intervention was made
Type of interventionType of intervention: Type of intervention
Mode of deliveryMode of delivery: How intervention was delivered; e.g. TXT, mail etc.
Intervention detailsIntervention details: Free text details of intervention
Other contributorsGDM Registry development team
Translators