Difference between revisions of "Antepartum Record"
Tsoutherland (talk | contribs) |
Tsoutherland (talk | contribs) |
||
| Line 370: | Line 370: | ||
==== Document Specification Form A&B ==== | ==== Document Specification Form A&B ==== | ||
| − | {| cellspacing=0 border=1 align=' | + | {| cellspacing=0 border=1 align='center' |
! style='background-color:#cfcfcf'|Data Element | ! style='background-color:#cfcfcf'|Data Element | ||
! style='background-color:#cfcfcf'|Opt | ! style='background-color:#cfcfcf'|Opt | ||
Revision as of 08:33, 19 March 2008
Introduction
This is a draft of the Antepartum Record Profile (AR) supplement to the PCC Technical Framework. This draft is a work in progress, not the official supplement or profile.
Profile Abstract
The Antepartum Record Profile (AR)
The Antpartum Record continues the description of the content structures for the ACOG Antepartum Record Forms as begun in the Antepartum Summary Profile.
- Forms A&B - The initial assessment and physical
- Forms C&F&G - Update records and progress notes
- Form D - Laboratory Evaluations
- Form E - Education Assessment
The ACOG Form also includes:
- An Obstetric Medical History
- A Postpartum form
A sample may be found at target: http://www.acog.org/acb-custom/aa128.pdf
This profile defines the implementation of HL7 CDA documents to represent the data elements from forms A, B, D, and E, along with the XDS, XDR and XDM bindings. This profile also defines mechanisms to group them into a single logical folder.
Glossary
The following terms are found on Form A of the Antepartum Record:
- AB, Induced
- Number of induced abortions by patient
- AB, Spontaneous
- Number of spontaneous abortions by patient
- Ectopics
- Number of ectopic pregnancies by patient
- Final EDD
- Expected Date of Delivery; a fixed date determined by ultrasound measurements and/or last menstrual period. Also called EDC - Expected Date of Confinement
- Full term
- Number of babies the mother has delivered that were between 37 and 42 weeks gestation.
- Living
- Number of living children of patient
- Multiple births
- Number of deliveries of more than one baby by patient
- Premature
- Definition
- Total Preg
- Definition
Form A - Menstrual History
- Frequency
- Specify in days the duration of the patient's monthly cycle
- hCG+
- Specify the date of the Human Chorionic Gonadotropin pregnancy test
- LMP (last menstrual period)
- Date measured as the first day of the patient's most recent cycle.
- Approximate (month known) - Patient is unsure of exact date but can offer an approximate date
- Definite - Patient can say with certainty the date of her last menstrual period
- Final - Finally agreed upon date of LMP after ultrasound measurements
- Unknown - Patient does not know the date of her last menstrual period
- Menarche
- Age at onset of initial menstrual period
- Menses Monthly
- Yes/No. Specify that the patient has or does not have a monthly period.
- Normal Amount/duration
- Yes/No. Specify that the patient's last menstrual was typical or not in amount and duration
- On BCP at concept
- Yes/No. Specify if the patient was on birth control pills at the time of conception
- Prior Menses
- Date of patient's latest period
Form A - Past Pregnancies
- Anesthesia
- Specify the type of anesthesia used in previous pregnancies.
- ART Treatment
- Autoimmune disorder
- Birth weight
- Specify the weight of patient's previous babies at birth.
- Date
- Month/Year of birth of patient's previous babies.
- D (Rh) sensitized
- GA weeks
- Specify gestational age in weeks at delivery of patient's previous pregnancies.
- Infertility
- Kidney disease/UTI
- Length of labor
- Specify the number of hours patient was in labor for previous pregnancies.
- Place of Delivery
- Specify the location patient delivered for previous pregnancies.
- Preterm labor
- Yes/No. Specify if the patient had preterm labor with previous pregnancies
- Pulmonary (TB, Asthma)
- Sex M/F
- Specify sex of patient's previously delivered babies.
- Type Delivery
- Specify type of delivery for previous pregnancies.
- Uterine Anomaly/DES
- Varicosities/Phlebitis
The following terms are found on Form B of the Antepartum Record:
- Abdomen
- Adnexa
- BMI
- BP
- Breasts
- Cervix
- Diagonal Conjugate
- Extremities
- Fundi
- Gynecoid pelvic type
- Heart
- HEENT
- Height
- Lungs
- Lymph nodes
- Rectum
- Sacrum
- Skin
- Spines
- Subpubic arch
- Teeth
- Thyroid
- Uterus size
- Vagina
- Vulva
- Weight
The following terms are found on Form D of the Antepartum Record:
- 1st Trimester Aneuploidy risk assessment
- 2nd Trimester serum screening
- Amnio/CVS
- Amniotic Fluid (AFP)
- Antibody screen
- Anti-D Immune Globulin (RHIG)
- Blood type
- Chlamydia
- Cystic Fibrosis
- D (Rh) Antibody screen
- D (Rh) type
- Diabetes screen
- Familial Dysautonomia
- Genetic Screening Test
- Gonorrhea
- Group B Strep
- GTT (if screen abnormal)
- HBsAg
- HCT/HGB/MCV
- Hemoglobin
- Hemoglobin Electrophoresis
- HIV
- HIV Counseling/Testing
- Karotype
- MSAFP/Multiple markers
- Pap test
- PPD
- Rubella
- Tay-Sachs
- Ultrasound
- Urine Culture/Screen
- Varicella
- VDRL
The following terms are found on Form E of the Antepartum Record: First Trimester
- Alcohol
- Anticipated Course of prenatal care
- Childbirth classes/hospital facilities
- Domestic violence
- Environmental/Work hazards
- Exercise
- Illicit/Recreational drugs
- Indications for ultrasounds
- Influenza vaccine
- Nutrition and weight gain counseling, special diet
- Risk factors identified by prenatal history
- Seatbelt use
- Sexual activity
- Smoking counseling
- Tobacco (Ask,advise,assess,assist,and arrange)
- Toxoplasmosis precautions
- Travel
- Use of any medications (including supplements, vitamins, herbs or OTC drugs)
Second Trimester
- Abnormal lab values
- Domestic violence
- Influenza vaccine
- Postpartum family planning/tubal sterilization
- Selecting a newborn care provider
- Signs and symptoms of preterm labor
- Smoking counseling
Third Trimester
- Anesthesia/Analgesia plans
- Breast or bottle feeding
- Circumcision
- Domestic violence
- Family medical leave or disability forms
- Fetal Movement monitoring
- Influenza vaccine
- Labor signs
- Newborn education (Newborn screening, jaundice, SIDS, car seat)
- Postpartum depression
- Postterm counseling
- Signs & Symptoms of Pregnancy-induced hypertension
- Smoking counseling
- VBAC counseling
- History and physical have been sent to hospital
- Tubal sterilization consent signed
Issue Log
Open Issues
- Issue
- Issue
Closed Issues
Volume I
Add the following bullet to the list of profiles
- Antepartum Record - A folder of content profiles that contains the summarization record or the antepartum care delivery including initial patient history and physical, ambulatory checks of mother and fetus, laboratory studies, and patient education.
Dependencies
Add the following row(s) to the list of dependencies
| Integration Profile | Dependency | Dependency Type | Purpose |
|---|---|---|---|
| Antepartum Record A&B | IHE History and Physical | Child | Initial Intake and Assessment for antepartum care |
| Antepartum Summary Form C&F&G | Medical Summary | Child | Update and Progress Note |
| Antepartum Summary Form D | XD-Lab | Child | Obstetric Lab Evaluation |
| Antepartum Summary Form E | Obstetric Education Form |
Profile Name
The Antepartum Record Profile (AR)
There are over 4 million births in the United States each year, including more than 1 million cesarean sections and more than 300,000 preterm or low birth weight babies. Obstetric patients in labor and admitted to Labor and Delivery must have a complete summary of their antepartum ambulatory care available at the time of admission to evaluate and / or ameliorate risk. This same data is required at any visit to Labor and Delivery for any other problems or special needs a patient may require. The antepartum record must be available in its entirety for appropriate care and legal concerns.
Practitioners who would use the aggregated record include: obstetricians, perinatologists, certified nurse midwives, family practice physicians, pediatricians, labor and delivery staff, emergency department staff, anesthesiologists, hospitalists, social workers, other medical specialists and patients.
During the 40 weeks of a typical pregnancy duration, the patient will have an initial History and Physical Examination, followed by repetitive office visits with multiple laboratory studies, imaging (usually ultrasound) studies, and serial physical examinations with recordings of vital signs, fundal height, and the fetal heart rate. As the patient is seen over a finite period in the office, aggregation of specific relevant data important to the evaluation of the obstetric patient upon presentation to Labor and Delivery is captured on paper forms. The antepartum record contains the most critical information needed including the ongoing Medical Diagnoses, the Estimated Due Date, outcomes of any prior pregnancies, serial visit data on the appropriate growth of the uterus and assessments of fetal well being, authorizations, laboratory and imaging studies. This data must all be presented and evaluated upon entry to the Labor and Delivery Suite to ensure optimal care for the patient and the fetus.
Although the patient and her care provider may plan for a vaginal (natural) method of delivery, there is a substantive chance the delivery route may be surgical, requiring anesthesia and post-surgical care.
Current practice is to copy the patient's (paper) chart at various times during the pregnancy (as at 28 weeks and at 36 weeks of completed gestation), and transport the copies of the chart to the hospital the patient intends to use for delivery. Should the patient arrive prior to the chart copy arriving, or if the chart (or information within the chart) is missing on presentation of the patient to Labor and Delivery (a frequent occurrence), the staff or clinicians repeat laboratory or imaging studies. This results in unwarranted and duplicative tests, is wasteful of time and resources, and leads to dissatisfied patients. Further, missing or incomplete information about the patient’s clinical status may create a situation where critical information is unavailable to clinicians, which may ultimately result in an injury, inadequate aftercare or other undesirable outcome.
Significantly, a large portion of patients arrive in L&D without complete documentation. In one recent U.S. study , ~70% of patients (with paper charts) arrived in L&D without their current medical record being available. While only one hospital was involved in this study, one can see the extent of the issue, with pregnant patients possibly going to a different hospital than planned (preterm labor, rapid labor and unable to make it to the planned delivery hospital, or visiting a distant city), moving mid-care, or with a covering physician (rather than the primary obstetrician) on call.
In a Swedish study done in the 1990’s, critical data on paper records were incomplete from 45 to 87.5% of the time. Thus, availability of current medical records remains a significant problem for most hospital Labor and Delivery units; availability of key information electronically will significantly enhance patient safety.
Use Cases
Use Case: Antepartum Care Delivery
Pre-condition
The patient’s obstetrician sees the patient for her pregnancy in the ambulatory (office) setting. During the pregnancy, the patient is noted to have a medical problem requiring consultation with a Maternal-Fetal Medicine specialist (perinatologist). The office obtains pre-authorization from the insurance payer for the consult, and for the intended or anticipated route of delivery, and transmits that information to both the consultant and to the hospital.
Events
The patient is seen in the obstetrician’s office where a complete medical and relevant social history are taken by the nurse and recorded in the office EHR, incorporating data from the perinatologist’s consultation report as appropriate. Laboratory and imaging reports ordered by the perinatologist as well as the perinatologist’s consultation report are displayed electronically to the obstetrician. The obstetrician reviews the consultation report from the perinatologist’s office and imaging studies ordered by the perinatologist along with data recorded by the nurse. Physical exam reveals some abnormalities. The obstetrician orders additional laboratory studies, and sends the patient to the hospital to Labor and Delivery.
When the laboratory results return, the physician completes the admission H&P, Allergies, Medications, includes the data prepared or ordered by the perinatologist, and makes it available to L&D. This data includes an assessment of the patient’s health status, and the requisite data summarized from the antepartum care given. The charge nurse for L&D documents that the complete collection of documents needed is available. The Post-Partum discharge planning is notified and assures that there is a suitable environment with appropriate support for post-delivery after-care.
Post-condition
The Pre-delivery H&P and Antepartum Summary with appropriate relationships to the Perinatologist Consultation, and all the antepartum laboratory and imaging studies are available to the obstetrician and the birthing center personnel for incorporation into their respective EHRs. The H&P is also available to the patient for viewing and incorporation into the patient’s PHR, and into the newborn baby’s PHR. For the APS profile, summary content is available to the obstetrician, with a plan for full content to be added in future years through other content profiles that share this use case.
Use Case Name 2
A pregnant diabetic patient is seen by her obstetrician in the office for a prenatal care. An ultrasound is performed to determine gestational age. The patient is sent for perinatology consult as a high-risk patient. Her obstetrician transmits preauthorization insurance information, labs and anticipated route of delivery to perinatologist and hospital.
The patient returns to her perinatologist biweekly for blood testing and ultrasounds when necessary in addition to regular ob visits. The perinatologist reports back to the obstetrician after each visit. Complete History and Physical, imaging and additional labs are performed during patient’s regular visit with her obstetrician.
The patient arrives at labor and delivery at the hospital. Obstetrician completes the admission H&P, Allergies, Medications, and includes the data prepared or ordered by the perinatologist, and makes it available to L&D. This data includes an assessment of the patient’s health status, and the requisite data summarized from the antepartum care given. The charge nurse for L&D documents that the complete collection of documents needed is available.
The patient’s obstetrician delivers by Cesarean Section after anesthesia. The post-partum discharge planning is notified and assures that there is a suitable environment with appropriate support for post-delivery after-care. Delivery information, i.e. birth weight, APGAR scores, type of delivery, etc is available for pediatrician. The patient can then incorporate H&P into her own and her newborn’s PHR.
Actors/Transaction
There are two actors in this profile, the Content Creator and the Content Consumer. Content is created by a Content Creator and is to be consumed by a Content Consumer. The sharing or transmission of content from one actor to the other is addressed by the appropriate use of IHE profiles described below, and is out of scope of this profile. A Document Source or a Portable Media Creator may embody the Content Creator Actor. A Document Consumer, a Document Recipient or a Portable Media Importer may embody the Content Consumer Actor. The sharing or transmission of content or updates from one actor to the other is addressed by the use of appropriate IHE profiles described by section 3.7 Content Bindings with XDS, XDM and XDR found in the Patient Care Coordination Technical Framework
Options
| Actor | Option | Section |
|---|---|---|
| Content Consumer | View Option (1) Document Import Option (1) |
PCC TF-1: 2.13.1 PCC TF-1: 2.13.2 |
| Content Creator | Referral Option (1) Discharge Summary Option (1) |
PCC TF-1: 2.13.5 PCC TF-1: 2.13.6 |
Note 1: The Actor shall support at least one of these options.
Grouping
Content Bindings with XDS, XDM and XDR
It is expected that the transfers of care will occur in an environment where the physician offices and hospitals have a coordinated infrastructure that serves the information sharing needs of this community of care. Several mechanisms are supported by IHE profiles:
- A registry/repository-based infrastructure is defined by the IHE Cross Enterprise Document Sharing (XDS) and other IHE Integration Profiles such as patient identification (PIX & PDQ), and notification of availability of documents (NAV).
- A media-based infrastructure is defined by the IHE Cross Enterprise Document Media Interchange (XDM) profile.
- A reliable messaging-based infrastructure is defined by the IHE Cross Enterprise Document Reliable Interchange (XDR) profile.
- All of these infrastructures support Security and privacy through the use of the Consistent Time (CT) and Audit Trail and Node Authentication (ATNA) profiles.
For more details on these profiles, see the IHE IT Infrastructure Technical Framework.
Content profiles may impose additional requirements on the transactions used when grouped with actors from other IHE Profiles.
Cross Enterprise Document Sharing, Media Interchange and Reliable Messages
Actors from the ITI XDS, XDM and XDR profiles embody the Content Creator and Content Consumer sharing function of this profile. A Content Creator or Content Consumer must be grouped with appropriate actors from the XDS, XDM or XDR profiles, and the metadata sent in the document sharing or interchange messages has specific relationships to the content of the clinical document described in the content profile.
Notification of Document Availability (NAV)
A Document Source should provide the capability to issue a Send Notification Transaction per the ITI Notification of Document Availability (NAV) Integration Profile in order to notify one or more Document Consumer(s) of the availability of one or more documents for retrieval. One of the Acknowledgement Request options may be used to request from a Document Consumer that an acknowledgement should be returned when it has received and processed the notification. A Document Consumer should provide the capability to receive a Receive Notification Transaction per the NAV Integration Profile in order to be notified by Document Sources of the availability of one or more documents for retrieval. The Send Acknowledgement option may be used to issue a Send Acknowledgement to a Document Source that the notification was received and processed.
Document Digital Signature (DSG)
When a Content Creator Actor needs to digitally sign a document in a submission set, it may support the Digital Signature (DSG) Content Profile as a Document Source. When a Content Consumer Actor needs to verify a Digital Signature, it may retrieve the digital signature document and may perform the verification against the signed document content.
Content Modules
Content modules describe the content of a payload found in an IHE transaction. Content profiles are transaction neutral. They do not have dependencies upon the transaction that they appear in.
Content Module 1
Process Flow
More text about process flow
Actor Definitions
- Actor
- Definition
Transaction Definitions
- Transaction
- Definition
Volume II
Antepartum Record Content
Standards
- CDAR2
- Clinical Document Architecture, Release 2, 2005 HL7
- CRS
- Implementation Guide for CDA Release 2 – Level 1 and 2 – Care Record Summary (US realm), 2006, HL7.
- CCD
- ASTM/HL7 Continuity of Care Document (Draft)
Data Element Index Form A&B
| Data Elements | CDA Section | Comments |
|---|---|---|
| Husband/Domestic Partner | CDA H&P Header | |
| Father of Baby | CDA H&P Header | |
| Pregnancy History | Pregnancy History Section | will need to extend this observation to include other data elements - how is that done? |
| Gynecological/Menstrual History | ||
| Medical History | CDA H&P Past Medical History | |
| Symptoms Since LMP | History of Present Illness Section | CDA H&P spec references IHE spec - so use IHE |
| Genetic Screening | Review of Systems Section | CDA H&P spec references IHE spec - so use IHE |
| Infection History | ||
| Initial Physical Exam | CDA H&P Physical Examination |
Document Specification Form A&B
| Data Element | Opt | Section | Template ID |
|---|---|---|---|
| CDA H&P Header A document conforming to the general header constraints SHALL indicate so by including the following template id in the header of the document or by including a template id in the header for a template that requires use of the general header constraint template: <templateId root='2.16.840.1.113883.10.20.3'/> | R | ||
| Pregnancy History Section | R | 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 | |
| CDA H&P Past Medical History 11348-0 | R | ||
| History of Present Illness Section | R | 1.3.6.1.4.1.19376.1.5.3.1.3.4 | |
| Review of Systems Section | R | 1.3.6.1.4.1.19376.1.5.3.1.3.18 | |
| CDA H&P Physical Examination 29545-1 | R |
Data Element Index Form D
| Data Elements | Other Reference | LOINC Section or CDA Element |
|---|---|---|
| Initial Labs | ||
| Optional Labs | ||
| 8-20 Week Labs | ||
| 24-48 Week Labs | ||
| 32-36 Week Labs |
Document Specification Form D
| Data Element | Opt | Section | Template ID |
|---|---|---|---|
| Data Element 1 | R | 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.X | |
| Data Element 2 | R | 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.Y | |
| Data Element 3 | R | 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.Z |
Data Element Index Form E
| Data Elements | Other Reference | LOINC Section or CDA Element |
|---|---|---|
| First Trimester | ||
| Second Trimester | ||
| Third Trimester |
Document Specification Form E
| Data Element | Opt | Section | Template ID |
|---|---|---|---|
| Data Element 1 | R | 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.X | |
| Data Element 2 | R | 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.Y | |
| Data Element 3 | R | 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.Z |
Section Template 1
| TemplateID | 1.3.6.1.4.1.19376.1.5.3.1.3.X | |
|---|---|---|
| Parent Template | 1.3.6.1.4.1.19376.1.5.3.1.3.Y | |
| General Description | This section shall ... | |
| LOINC Code | Opt | Description |
| #####-# | R | Description |
| Entries | Opt | Description |
| 1.3.6.1.4.1.19376.1.5.3.1.4.A | O | Description |
| Sub-sections | Opt | Description |
| 1.3.6.1.4.1.19376.1.5.3.1.3.D | R | Description |
Header Template 1
<entry>An XML Example</entry>
entry
Description of the entry element.
Entry Template 1
<entry>An XML Example</entry>
entry
Description of the entry element.