Difference between revisions of "Antepartum Care Summary Profile"

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WORKS-in-PROGRESS
 
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This profile defines the content sections for Antepartum Care summaries. It uses HL7 Clinical Document Architecture (CDA) Release 2 and.....
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The Antepartum Summary (APS) represents a summary of the most critical information to an Obstetrician regarding the status of a patients pregnancy.
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The APS document is a medical summary and inherits all header constraints from Medical Summaries.
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==Summary==
 
==Summary==
  
The ''Cross-Enterprise Sharing of Medical Summaries'' profile provides a mechanism to automate the sharing process between care providers of Medical Summaries, a class of clinical documents that contain the most relevant portions of information about the patient intended for a specific provider or a broad range of potential providers in different settings. Patient transfers and, therefore, the summary documents that accompany these transfers can be categorized into 3 primary types:  Episodic, Collaborative, or Permanent. Medical Summaries are commonly created and consumed by electronic medical record systems at points in time of one of these types of transfers of care.  For example, a referral note is a medical summary used for a collaborative transfer of care whereby a discharge summary is a medical summary reflecting an episodic transfer.
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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 document is complete.  Although this pattern of updates is not prohibited by Medical Summary, it is also not typical. For APS documents may be published at the end of each visit, but subsequent updates with a pregnancy SHALL be represented as document replacement
  
 
[[image:xdsms.png|frame|center|The Cross-Enterprise Sharing of Medical Summaries Integration Profile solves the problem of transferring summary patient information between providers in different clinical settings.
 
[[image:xdsms.png|frame|center|The Cross-Enterprise Sharing of Medical Summaries Integration Profile solves the problem of transferring summary patient information between providers in different clinical settings.

Revision as of 21:22, 17 April 2008

WORKS-in-PROGRESS

The Antepartum Summary (APS) represents a summary of 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

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 document is complete. Although this pattern of updates is not prohibited by Medical Summary, it is also not typical. For APS documents may be published at the end of each visit, but subsequent updates with a pregnancy SHALL be represented as document replacement

The Cross-Enterprise Sharing of Medical Summaries Integration Profile solves the problem of transferring summary patient information between providers in different clinical settings.

Benefits

  • Leverage Clinical Documents ontology
    • A common mechanism for transfer of encoded clinical data embedded in documents
  • Enhances Clinical Documents criteria for key use cases:
    • Inpatient to Primary Care Provider
    • Primary Care Provider to Specialist

Details

The basic process flow supported by XDS-MS mirrors current manual practices: someone gathers the appropriate documents from the patient medical record, copies them, packages them up with a cover letter explaining the reason the information is being sent, and then ships the package to the receiving provider. This is often accompanied by a telephone call from the sending provider to the receiving provider that indicates that such information is forthcoming.

Systems Affected

EHR Systems

Actors

Transactions

See Also

Profile Status: Final Text

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