Difference between revisions of "Labor and Delivery History and Physical"

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''This template is for the one or two page user-oriented overview of an IHE Profile that is in Final Text, Trial Implementation or perhaps Public Comment.  Delete text in italics and replace it with your material.  Don't forget to delete the double quotes too.''
 
  
''Your page name should simply be Full Profile Name with spaces, with capitals, without the acronym. e.g. Scheduled Workflow. so it provides a title to the page. You can redirect the acronym to the full named page if you like for bonus points.''
 
  
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The Labor and Delivery History and Physical (LDHP) profile records data that is often collected during initial admission to a birthing facility. It includes, but is not
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limited to demographics, histories, allergies, physical examinations, vital signs, and care plans.
  
''<IN ONE LINE, tell a user what the profile is about (including the acronym) so they can decide if they're on the right page.  Basically this should be the same sentence that appears on the [[Profiles]] catalog page>''
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also included is Labor Delivery Summary and Maternal Discharge Summary
 
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''e.g. Scheduled Workflow (SWF) integrates ordering, scheduling, imaging acquisition, storage and viewing for Radiology exams.''
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__TOC__
 
__TOC__
  
 
==Summary==
 
==Summary==
''<Describe the profile in about a paragraph using user-oriented language. Focus on what it accomplishes for a user (i.e. the Use Cases). Don't get into how it works, leave that to the Details section.>''
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The information collected during labor, delivery and the immediate postpartum period is very important to follow-up care for both mother and infant, whether the follow-up care is provided in an inpatient or outpatient facility. A physician's recommendation for a follow-up hematocrit test or evaluation of the incision in the office may be noted in the Labor and Delivery Summary or in the Maternal Discharge Summary. These documents must be available in both inpatient and outpatient settings. Pertinent maternal information includes, but is not limited to, delivery type; labor type; anesthesia type; labor, delivery and postpartum complications; and specific maternal information such as medications, laboratory test results, allergies and plans for contraception. Pertinent neonatal information includes, but is not limited to, delivery method, gender, birth time, birth weight, gestational age at delivery, APGAR scores, and medications received in the delivery room including immunizations.
  
''<Insert a simple graphic that, at a glance, visually summarizes what the profile is about.  Do not use an actor/transaction diagram here.  Show your graphic to someone for 5 seconds (literally) and ask them what it's about.  If what they say hits the main points in your summary paragraph, you have succeeded.  E.g. a graphic of a hospital, a clinic, and a lab with patient records moving between them.  .>''
 
 
''<See [[Help:Contents#Tips_.26_Tricks| Help - Tips and Tricks]] for details on inserting an image/graphic.>''
 
  
 
==Benefits==
 
==Benefits==
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<!--
 
''<If the profile can improve Cost, Safety, Quality or Efficiency then list the specific examples of that benefit (e.g. error reduction, increased throughput) and how they come about (e.g. SWF reduces patient errors due to mistyped demographics at the modality by transfering demographics electronically from the Order Filler).  Consider using a bullet list for readability.  Such benefits help users and vendors make the business case for the profile.  If the profile does not improve any aspect of Cost, Safety, Quality or Efficiency feel free to talk about something else here.>''
 
''<If the profile can improve Cost, Safety, Quality or Efficiency then list the specific examples of that benefit (e.g. error reduction, increased throughput) and how they come about (e.g. SWF reduces patient errors due to mistyped demographics at the modality by transfering demographics electronically from the Order Filler).  Consider using a bullet list for readability.  Such benefits help users and vendors make the business case for the profile.  If the profile does not improve any aspect of Cost, Safety, Quality or Efficiency feel free to talk about something else here.>''
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-->
  
 
==Details==
 
==Details==
  
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<!--
 
''<A few paragraphs, if appropriate, providing more details (mostly in user-speak, not tech-speak) on what the profile does and how it works.>''
 
''<A few paragraphs, if appropriate, providing more details (mostly in user-speak, not tech-speak) on what the profile does and how it works.>''
 
 
''<If the user might be familiar with the mechanisms used by the profile, you can mention them here.  E.g. Evidence Documents is based on DICOM Structured Report (SR) Templates.>''
 
''<If the user might be familiar with the mechanisms used by the profile, you can mention them here.  E.g. Evidence Documents is based on DICOM Structured Report (SR) Templates.>''
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''<If the user might have an appreciation for the problems addressed in the profile, you can mention them here, but keep it short.  E.g. Mapping HL7 Order fields to DICOM Modality Worklist attributes can be inconsistent in the marketplace, so Scheduled Workflow provides vendors with more detailed instructions.>''
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-->
  
''<If the user might have an appreciation for the problems addressed in the profile, you can mention them here, but keep it short.  E.g. Mapping HL7 Order fields to DICOM Modality Worklist attributes can be inconsistent in the marketplace, so Scheduled Workflow provides vendors with more detailed instructions.>''
 
 
 
==Systems Affected==
 
==Systems Affected==
''<List (in user terms) the types of systems they might expect to have implemented actors from this profile, e.g. RIS, PACS, HIS, CAD Workstation, etc. and for each, how it would participate.>''
 
  
<!--
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:* EHR Systems
* ''PACS systems may store, manage, and/or display Evidence Documents.''
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:* Hospital Systems
* ''Display systems may query, retrieve and display Evidence Documents.''
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* ''Reporting workstations may retrieve, process and include details from Evidence Documents in reports
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-->
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'''Actors & Transactions:'''
 
'''Actors & Transactions:'''
 
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:* [[Content Creator]]
''<Insert an actor-transaction diagram, and or list of Content Definitions>''
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:* [[Content Consumer]]
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[[Image: PCC Share Content Diagram.png | 450px]]
  
 
==Specification==
 
==Specification==
  
'''Profile Status:''' [[Comments| Final Text]]   
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'''Profile Status:''' [[Comments| Trial Implementation]]   
''<Replace "Final Text" with "Trial Implementation" or "Public Comment" as appropriate.>''
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'''Documents:'''  
 
'''Documents:'''  
 
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:* [http://ihe.net/uploadedFiles/Documents/PCC/IHE_PCC_Suppl_Labor_and_Delivery_Profiles.pdf Labor and Delivery Profiles]
''<Provide direct links to the specific volumes or supplements, and list the volume sections relevant to this profile.  This is a simple inventory of official normative and informative text.  If you would like to provide a reading guide or walkthrough of what is in each of the different sections for implementers or users, do that in the Profile FAQ or the Profile Implementation Page linked below.  If the profile uses transactions from multiple Tech. Frameworks, repeat the structure below.>''
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:* [http://ihe.net/Technical_Framework/upload/IHE_PCC_Suppl_PW_Rev1-1_TI_2010-08-30.pdf Perinatal Workflow]
 
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<!--
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[http://www.ihe.net/Technical_Framework/index.cfm#radiology IHE Radiology Technical Framework:]
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:* [http://www.ihe.net/Technical_Framework/upload/ihe_tf_rev8.pdf Vol. 1] - Section 5 (SWF Profile)
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:* [http://www.ihe.net/Technical_Framework/upload/ihe_tf_rev8-2.pdf Vol. 2] - Sections 4.8 to 4.10, 4.14 to 4.19, and 4.23
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:* [http://www.ihe.net/Technical_Framework/upload/ihe_tf_rev8-3.pdf Vol. 3] - Appendix E
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-->
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'''Underlying Standards:'''
 
'''Underlying Standards:'''
  
 
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:* HL7 CDA Release 2.0
''<list all the standards on which the profile is based; if possible with links to sources>''
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<!--
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:* [http://dicom.nema.org DICOM]
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:* [http://www.hl7.org HL7]
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:* ...
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-->
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==See Also==
 
==See Also==
 
''<The following sections can be left out if there is nothing to point to.  This is just to show where such information can go.>''
 
 
  
 
'''Related Profiles'''
 
'''Related Profiles'''
  
''<List profiles this one depends on, profiles that depend on this one, profiles that are synergistic with this one.  Start with the name of the other profile as a link and then explain the relationship.>''
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* Cross-Enterprise Document Sharing (XDS)
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* Cross-Enterprise Reliable Document Interchange (XDR)
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* Cross-Enterprise Document Media Interchange (XDM)
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* Request for Clinical Guidance (RCG)
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* Notification of Availability (NAV)
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* Document Digital Signature (DSG)
  
<!--
 
* ''[[Reporting Workflow]] [RWF] may use Evidence Documents as inputs to the reporting process.''
 
* ''[[Simple Image & Numeric Reports]] [SINR] may include data copied from Evidence Documents.''
 
* ''[[Cross-enterprise Document Sharing for Imaging]] [XDS-I] can be used to share Evidence Documents between sites over a network.''
 
* ''[[Portable Data for Imaging]] [PDI] can store Evidence Documents on media such as CDs.''
 
* ''[[Import Reconciliation Workflow]] [IRWF] can fix patient ids, etc. of Evidence Documents when importing.''
 
-->
 
 
'''Consumer Information'''
 
 
The [[Profile FAQ Template]] answers typical questions about what the Profile does.  ''<Replace the link with a link to the actual FAQ page for the Profile>''
 
 
The [[Profile Purchasing Template]] describes considerations when purchasing equipment to deploy this Profile.  ''<Replace the link with a link to the actual Purchasing page for the Profile>''
 
 
'''Implementer Information'''
 
 
The [[Profile Implementation Template]] provides additional information about implementing this Profile in software.  ''<Replace the link with a link to the actual Implementation page for the Profile>''
 
  
 
'''Reference Articles'''
 
'''Reference Articles'''
 
''<List References (good and bad) (with link if possible) to Journal Articles that mention IHE's work (and hopefully include some analysis).  Go ahead, Google: IHE <Profile Name> abstract  or Google: IHE <Profile Name> and under the "more" select "Scholar".  You might be surprised. >''
 
  
  
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This page is based on the [[Profile Overview Template]]
 
This page is based on the [[Profile Overview Template]]
  
[[Category:Template]]
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[[Category:Profiles]][[Category:Patient Care Coordination]][[Category:CDA]][[Category:DocShare]]

Latest revision as of 11:02, 4 November 2019


The Labor and Delivery History and Physical (LDHP) profile records data that is often collected during initial admission to a birthing facility. It includes, but is not limited to demographics, histories, allergies, physical examinations, vital signs, and care plans.

also included is Labor Delivery Summary and Maternal Discharge Summary

Summary

The information collected during labor, delivery and the immediate postpartum period is very important to follow-up care for both mother and infant, whether the follow-up care is provided in an inpatient or outpatient facility. A physician's recommendation for a follow-up hematocrit test or evaluation of the incision in the office may be noted in the Labor and Delivery Summary or in the Maternal Discharge Summary. These documents must be available in both inpatient and outpatient settings. Pertinent maternal information includes, but is not limited to, delivery type; labor type; anesthesia type; labor, delivery and postpartum complications; and specific maternal information such as medications, laboratory test results, allergies and plans for contraception. Pertinent neonatal information includes, but is not limited to, delivery method, gender, birth time, birth weight, gestational age at delivery, APGAR scores, and medications received in the delivery room including immunizations.


Benefits

Details

Systems Affected

  • EHR Systems
  • Hospital Systems

Actors & Transactions:

PCC Share Content Diagram.png

Specification

Profile Status: Trial Implementation

Documents:

Underlying Standards:

  • HL7 CDA Release 2.0

See Also

Related Profiles

  • Cross-Enterprise Document Sharing (XDS)
  • Cross-Enterprise Reliable Document Interchange (XDR)
  • Cross-Enterprise Document Media Interchange (XDM)
  • Request for Clinical Guidance (RCG)
  • Notification of Availability (NAV)
  • Document Digital Signature (DSG)


Reference Articles


This page is based on the Profile Overview Template