OB Labor and Delivery Summary Detailed Proposal

1. Proposed Profile: OB Labord and Delivery Summary Detailed Proposal

• Proposal Editor: Keith W. Boone and Tone Southerland
• Profile Editor:
• Date: November 2008
• Version: N/A (Wiki keeps history)
• Domain: Patient Care Coordination (PCC)

Summary

The labor and delivery summary is important for care of the mother and newborn in both the inpatient and outpatient settings after delivery. Information that can affect the care of the mother and/or the newborn should be available to all care providers.

2. The Problem

After a patient delivers, the labor and delivery summary is typically used by the postpartum and nursery/NICU units to get an overview of the delivery. For example, in postpartum, the rounding obstetrician may or may not have been present at the birth. The delivery summary would provide the provider with pertinent delivery information, such as complications, that may need to be reassessed or require follow-up. For the newborn, the pediatrician would also refer to a delivery summary for details, such as trauma from birth, which might be pertinent for the infant’s plan of care.

After the mother and baby are discharged, follow-up care is received in an outpatient setting. As in the inpatient setting, the obstetrician and pediatrician need to have the pertinent information from the delivery in order to properly plan for the follow-up care for the mother or newborn. For example, a mother might need a follow-up vaccine in the office, and this information might be noted on the delivery summary.

3. Key Use Case

Practitioners who would use the information contained in the Labor and Delivery Summary could be: attending physicians and staff (during post-partum care in the hospital), obstetrician-gynecologist, family physician, pediatrician, social worker, covering physician, and other medical specialists. This information may also be incorporated into a patient's PHR.

1. Patient Delivers in the Hospital
2. Delivery Summary is produced
3. Attending Physician and Nursing are able to access delivery summary for care planning post delivery
4. Delivery Summary could be shared to the pediatrician or other care provider

4. Standards & Systems

• CCD ASTM/HL7 Continuity of Care Document
• CDAR2 HL7 CDA Release 2.0
• LOINC Logical Observation Identifiers, Names and Codes
• SNOMED Systemized Nomenclature for Medicine
• DSG Document Digital Signature
• NAV Notification of Document Availability

5. Technical Approach

Existing actors

There are two actors in the APS profile, the Content Creator and the Content Consumer. Content is created by a Content Creator and is to be consumed by a Content Consumer.

6. Support & Resources

Editor: Keith W. Boone, Dr. Charles Rica, Ana Estrelich?

Reviewer: Tone Southerland, Diane Kessler, Jean Millar

7. Risks

1. Overlap with QRPH Maternal/Child Health profile and coordination with Public Health

9. Tech Committee Evaluation

Effort Evaluation (as a % of Tech Cmte Bandwidth):

• 35% for ...

Responses to Issues:

See italics in Risk and Open Issue sections

Candidate Editor:

TBA