Antepartum Care Summary Profile

Antepartum Summary (APS) summarizes the most critical information to an Obstetrician regarding the status of a patients pregnancy. The APS document is a medical summary and inherits all header constraints from Medical Summaries.

Summary

Although classified in as a type of Medical Summary, the Antepartum Summary is typically used as a 'living document' where the latest information is added to the end of the flowsheet at each visit. This is different than a typical Medical Summary which typically would not share information until the document is complete. Although this pattern of updates is not prohibited by the Medical Summary documentation, it is also not typical. APS documents may be published at the end of each visit, but subsequent updates with a pregnancy shall be represented as a document replacement.

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.

The Antepartum Summary is a content profile that is intended to eventually sit within a larger folder structure that contains documents related to Antepartum care which will be defined in future years called the Antepartum Record

The APS Medical Summary Profile solves the problem of transferring antepartum information between an obstetrician and the clinicians in the Labor & Delivery suite.

Benefits

• Leverage Clinical Documents ontology
  • A common mechanism for transfer of encoded clinical data embedded in documents
• Ameliorates risk in Obstetric care by ensuring that the latest information is available to clinicians during a women’s Labor and Delivery event

Details

• Automates the creation of the manual Forms C&F typically used in the transfer of care of a pregnant woman
• Specifies the content to be extracted from an EMR system used in an obstetrician’s office, how it is to be codified and organized for packing in an electronic “envelope”
• Specifies the meta-data to be used for identifying the APS document in the XDS Registry

Systems Affected

EMR Systems in Obstetrician’s Offices Hospital Information System modules used in the Labor & Delivery suite

Actors

• Content Creator
• Content Consumer

There are two actors in the APS profile, the Content Creator and the Content Consumer. The sharing or transmission of content from one actor to the other is addressed by the appropriate use of IHE profiles described in the section on Content Bindings with XDS, XDM and XDR and is out of scope of this profile. A Document Source or a Portable Media Creator may embody the APS Content Creator Actor. A Document Consumer, a Document Recipient or a Portable Media Importer may embody the APS Content Consumer Actor.

See Also

Profile Status: Trial Implementation

The Patient Care Coordination Framework is the official master document for this Profile.

The Medical Summaries FAQ answers typical questions about what the Profile does.

The Medical Summaries Purchasing describes considerations when purchasing equipment to deploy this Profile.

The Medical Summaries Implementation provides additional information about implementing this Profile in software.

This page is based on the Profile Template