OB Postpartum Discharge Summary Detailed Proposal

1. Proposed Profile: OB Postpartum Discharge Summary

• Proposal Editor: Anne Diamond
• Profile Editor: tbd, merge with L&D
• Date: November 2008
• Version: N/A (Wiki keeps history)
• Domain: Patient Care Coordination (PCC)

Summary

The length of stay in birthing facilities after delivery varies according to location and also depends on the characteristics of mothers, newborns, and birthing facility practices. There is a need to ensure adequate follow-up care for patients and to ensure the availability of the discharge information should problems arise during the postpartum period.

2. The Problem

The obstetric postpartum discharge summary communicates information necessary for continuing patient care of the mother after delivery. The patient receives a comprehensive assessment which provides the follow-up care provider with a “snap-shot” of the patient's condition at discharge.

Necessary information includes:

• Delivery type, labor type and anesthesia type
• Postpartum complications
• Neonatal information, ie, name, sex, birth weight, etc of the newborn
• Specific maternal information such as medications, contraceptive method, labs, immunizations, etc.
• Contact information

3. Key Use Case

Necessary information includes:

• Delivery type, labor type and anesthesia type
• Postpartum complications
• Neonatal information, ie, name, sex, birth weight, etc of the newborn
• Specific maternal information such as medications, contraceptive method, labs, immunizations, etc.
• Contact information

Case 1

Inpatient care for patient (mother) is completed and patient is ready to return home with her newborn. Postpartum Discharge Summary is created and shared with the patient’s obstetrician or other care provider. The patient has unusual bleeding and calls her obstetrician's office with questions. The delivery obstetrician is out of town and the covering provider is unfamiliar with the patient's delivery. The covering provider is able to provide appropriate care for the patient based on assessments and interventions documented during the inpatient stay for the delivery.

Case 2

The patient delivered at a facility in another state while on vacation. She is released from the birthing facility, but on the way home, she experiences severe pain. She is seen at a hospital along the way. The discharge summary has been incorporated into the patient's PHR. Care providers can provide appropriate care based on information in the discharge summary.

4. Standards & Systems

• CCD ASTM/HL7 Continuity of Care Document
• CDAR2 HL7 CDA Release 2.0
• ACOG PP/D American College of Obstetricians and Gynecologists (ACOG) Postpartum/Discharge Record
• 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.

Impact on existing integration profiles

The Postpartum Discharge Summary Profile contains information to be shared as part of a Medical summary created as the patient is ready for discharge from the birthing facility. The Postpartum Discharge Profile is a content profile that is intended to eventually sit within a larger folder structure that contains documents related to Antepartum care which will be defined in future years called the Antepartum Record.

6. Support & Resources

A copy of a Discharge/Postpartum record is available at: http://www.acog.org/acb-custom/aa197.pdf

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