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| =Introduction=
| | #redirect [[PCC TF-1/APS]] |
| ''This is a draft of the Antepartum Summary Profile (ACS) supplement to the Patient Care Coordination Technical Framework. This draft is a work in progress, not the official supplement or profile.''
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| __TOC__
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| ==Profile Abstract==
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| The Antepartum Summary Profile (ACS) one-paragraphs-desc
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| ==Glossary==
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| ; Term : Definition
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| ==Issue Log==
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| ===Open Issues===
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| # Issue
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| # Issue
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| ===Closed Issues===
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| =Volume I=
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| <pre>Add the following bullet to the list of profiles</pre>
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| * Antepartum Summary - one-line descr
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| ===Dependencies===
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| <pre>Add the following row(s) to the list of dependencies</pre>
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| {|style='background-color:#7f7f7f;' align='center' border='1' cellspacing='0'
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| !Integration Profile
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| !Dependency
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| !Dependency Type
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| !Purpose
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| |- style='background-color:#ffffff;' align='center'
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| |Antepartum Summary
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| |-
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| |}
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| ==Profile Name==
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| The Antepartum Summary Profile (ACS) one-paragraphs-desc
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| Obstetrical 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.
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| As the patient is seen over a finite period in the office, aggregation of specific relevant data is important to the evaluation of the obstetrical patient upon presentation to Labor and Delivery. During the 40 weeks of a typical pregnancy duration, the patient will have had 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. The original New OB History & Physical, 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 must all be presented and evaluated upon entry to the Labor and Delivery Suite to ensure optimal care for the patient and the fetus.
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| While for labor patients the planned method of delivery may be vaginal (natural), there is a substantive chance the delivery route may be surgical, requiring anesthesia and post-surgical care.
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| Current practice is to copy the (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), often 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.
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| 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 .
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| 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 in this study, only one hospital was involved, 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.
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| 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.
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| ===Use Cases===
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| ====Use Case Name 1====
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| One or more paragraphs describing a clinical scenario.
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| ====Use Case Name 2====
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| One or more paragraphs describing a clinical scenario.
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| ===Actors/Transaction===
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| [[image:at.jpg|frame|center|Antepartum Summary Actor Diagram]] | |
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| {|style='background-color:#7f7f7f;' align='center' border='1' cellspacing='0'
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| !Actor
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| !Transaction
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| !Opt.
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| !Section
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| |+Antepartum Summary Actors and Transactions
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| |- style='background-color:#ffffff;' align='center'
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| |Actor 1
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| |Transaction 1
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| |R
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| |[[#Transaction 1]]
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| |-
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| |}
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| === Options ===
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| {|style='background-color:#7f7f7f;' align='center' border='1' cellspacing='0'
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| !Actor
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| !Option
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| !Section
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| |+Antepartum Summary Options
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| |- style='background-color:#ffffff;' align='center'
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| |Actor 1
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| |Option 1
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| |[[#Option 1]]
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| |-
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| |}
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| ==== Option 1 ====
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| A description of option 1.
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| === Grouping ===
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| === Process Flow ===
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| [[Image:seq.jpg|frame|center|Antepartum Summary Process Flow]]
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| More text about process flow
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| == Actor Definitions ==
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| ; Actor : Definition
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| == Transaction Definitions ==
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| ; Transaction : Definition
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| =Volume II=
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| ==Transaction 1==
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| === Scope ===
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| === Use Case Roles ===
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| [[image:ucr.jpr|frame|center]
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| ; Actor: Actor 1
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| ; Role: Role of Actor 1
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| lather, rise and repeat for each actor
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| === Referenced Standards ===
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| ; [http://link.htm STD] : Description
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| === Interaction Diagram ===
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| [[image:int.jpg|frame|center]]
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| ==== Message 1 of Interaction ====
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| ===== Trigger =====
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| ===== Message Semantics =====
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| ===== Expected Actions =====
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| [[Category:Patient Care Coordination]]
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| [[Category:Draft Profile Supplement]]
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