Labor and Delivery History and Physical

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.

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.

Systems Affected

• EHR Systems
• Hospital Systems

Actors & Transactions:

• Content Creator
• Content Consumer

Specification

Profile Status: Trial Implementation

Documents:

• Labor and Delivery Profiles
• Perinatal Workflow

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

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