Antepartum Summary Form C

Introduction

This is a draft of the Antepartum Summary Profile (APS) supplement to the Patient Care Coordination Technical Framework. This draft is a work in progress, not the official supplement or profile.

Profile Abstract

The Antepartum Summary (APS) describes the content structures for the ACOG Antepartum Record Forms.

 It is divided into 4 content profiles:

1. Forms A&B - The initial assessment and physical
2. Form C&F - Update records and progress notes
3. Form D - Laboratory Evaluations
4. Form E - Education Assessment
5. Form G - Progress Notes

The ACOG form also includes:

1. An Obstetric Medical History
2. A Postpartum Form

A sample may be found at [1]

This profile defines the implementation of HL7 CDA documents to represent these Form C, and the XDS, XDR, and XDM bindings. Future profiles will focus on other related forms along with mechanisms to group them into a single logical folder.

Glossary

The following terms are found in Form C of the Antepartum Record.

Antepartum

Period of pregnancy between conception and onset of labor, referring to the mother.

Cervix Exam (Dil/Eff/Sta)

Examination to determine, Dilation, Effacement, and Station of the fetus.

• Dilation refers to the size of the opening in the cervix, usually recorded in centimeters (measured from 0[=closed] to 10 [=fully dialated or open]).
• Effacement refers to the thickness or thinness of the cervix (measured from 0% (or uneffaced, =thick) to 100% (completely thinned out).
• Station refers to the progress of the head (or presenting part) though the pelvis (measured in negative number, 0, and positive numbers, either in cms above or below the ischial spines or in relative distance to the introitus, (i.e., “thirds.”).

EDD

Expected Date of Delivery, a fixed date determined by ultrasound measurements and /or last menstrual period. Also called EDC - Expected Date of Confinement.

Initial EDD

Expected Date of Delivery, assuming 40 weeks or 280 days since last menstrual period.

FHR

Fetal Heart Rate. A measurement of the pulse of the fetus.

Fetal Movement

Maternal perception of movement by the fetus

Fundal Height

Measurement of the size of the uterus from the top of the pubic bone to the top of the uterus in centimeters. This measurement is used to assess fetal growth. This measurement should be done at every prenatal visit.

Fundal Height at Umbilicus

The point in the pregnancy when the uterus is at the umbilicus (belly button), which usually corresponds to 20 weeks gestation (the half-way point of the pregnancy).

LMP

Last Menstrual Period: as measured from the first day of a woman’s last cycle prior to the pregnancy.

Presentation

Refers to the part of the fetus that is presenting first, i.e. breech, vertex, etc.

Preterm Labor Signs/Symptoms

Any sign or symptom suggesting possible labor, that occurs before 37 weeks of gestation. For example: regular or irregular contractions, ruptured membranes, abdominal cramps, low, dull backache, pelvic or abdominal pressure, change in type or increase of vaginal discharge.

Quickening

A woman’s initial awareness of movement of the fetus within the womb/uterus. Usually reported between 18 – 20 weeks gestation with a first pregnancy, often as early as 16 weeks with subsequent pregnancies.

Ultrasound length

Identifying the size and position of the fetus by ultrasound exam to estimate gestational age

Weeks Gestation (Best est.)

The best estimate of the length of time since conception.

The following terms are found in Form A of the Antepartum Record.

AB Induced

Number of induced abortions the mother has had

AB Spontaneous

Number of spontaneous abortions the patient has had

Ectopics

Number of ectopic pregnancies the patient has had

Frequency

Length of duration for patient’s typical monthly period

Full Term

Number of babies the mother has delivered between 37 and 42 weeks gestation

hCG +

Specify date of positive Human Chorionic Gonadotropin pregnancy test.

Living

Number of living children the mother has

LMP (last menstrual period)

measured from the first day of the patient’s cycle

• Definite - Patient is sure of the date of last menstrual period
• Approximate – Patient is unsure of exact date but can offer an approximate date
• Unknown – Patient does not know date of last menstrual period.
• Final – Finally agreed upon date of LMP after U/S measurements.

Menarche (age onset)

Age at onset of initial menstrual period

Menses Monthly

Specify that the patient has a monthly period or not.

Multiple Births

Number of multiple deliveries the mother has had.

Normal Amount/Duration

Specify that the last menstrual period was typical or not in amount and duration for this patient.

On BCP Concept

Specify if the patient was on birth control pills at conception

Premature

Number of premature babies the mother has delivered

Prior Menses

Date of patient’s prior period.

Total Pregnancy

Total number of times the patient has been pregnant

'Prior Pregnancies' Section:

Anesthesia

Specify the type of anesthesia used for previous pregnancy, i.e., epidural, etc.

Birth Weight

Weight of baby at birth for previous pregnancies

Date

(Day)/Month/Year of delivery of previous pregnancies (day may be optionally recorded)

GA Weeks

Gestational age in weeks at delivery for previous pregnancies

Length of Labor

Number of hours in labor for previous pregnancies

Place of Delivery

Specify where the previous babies were delivered.

Preterm Labor

Specify if the patient had preterm labor with the previous pregnancies.

Sex

Sex of babies for previous pregnancies

Type Delivery

Specify type of delivery for previous pregnancy, i.e. vaginal, cesarean

ART Treatment

Assisted Reproductive Technology Treatment

Volume I

Add the following bullet to the list of profiles

• Antepartum Summary - 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 Summary Form 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

Because many document sections are shared with other Medical Summary document types, an Antepartum Ambulatory Prenatal Care Summary document would fit in nicely with the IHE collection of Medical Summary Documents. The ability for the IHE Medical Summary documents to incorporate the sections required for an Antepartum Summary as well as the inclusion or reference of imaging and laboratory reports and other clinical documents is an important consideration.

Specifically, this proposal is to publish content profiles for additional sections within the new Section Content Profile Framework being developed and then publish a medical summary document content profile for the full Antepartum Ambulatory Prenatal Care Summary document. The section unique to an Antepartum Ambulatory Prenatal Care Summary is the cumulative aggregation of office visits over the defined prenatal period, coupled with the similar requirements of the Pre-Procedure H&P documentation.

Profile Name

The Antepartum Summary Profile (APS)

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.

As the patient is seen over a finite period in the office, aggregation of specific relevant data is important to the evaluation of the obstetric patient upon presentation to Labor and Delivery. 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. 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.

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), 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.

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 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.

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.

Technical Approach

The Antepartum Summary is a folder in XDS that defines a collection of documents. Several content profiles must be completed for the various kinds of documents that might be found in the Pre-Procedure Folder. These content profiles would include (existing and new):

• Pre-procedure patient questionnaire
• Pre-procedure H&P (including surgical and relevant social history)
• Summary of OB-specific Ambulatory Visit Data
• Laboratory Reports
• Imaging Reports
• Consultation Reports
• Diagnostic Imaging (Ultrasound) Images
• Non Stress Test (NST) Reports
• NST Waveforms (may be covered by DICOM)
• Patient Consent Forms for Performance of Procedures
• Payer Authorization Forms

Although the scope of this content profile is limited to the Antepartum Ambulatory Prenatal Care, this discussion illustrates the need to view the aggregation of documents for L&D as the center of multiple related documents and to include in the content profile the mechanisms for specifically referencing these document types.

Stakeholders

The stakeholders who use this document for decision making in the course of patient care include:

• Obstetrician
• Perinatologist
• Certified Nurse Midwives
• Anesthesiologist
• Labor and Delivery and Peri-operative personnel (L&D staff, surgical coordinator, scheduling, surgical nursing)
• Post-op and Post-Partum Nursing
• Social Work (discharge planning)
• Obstetrician (after discharge)

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.

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

{{{1}}} Actor Diagram

Options

{{{1}}} Options

Actor	Option	Section
Content Consumer	View Option (1) Document Import Option (1) Section Import Option (1) Discrete Data Import Option (1)	PCC TF-1: 2.13.1 PCC TF-1: 2.13.2 PCC TF-1: 2.13.3 PCC TF-1: 2.13.4
Content Creator	None Defined	N/A

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.

Volume II

Antepartum Summary Volume 2

Antepartum Summary Example