OB Postpartum Visit Summary Detailed Proposal

1. Proposed Profile: OB Postpartum Visit Summary Detailed Proposal

• Proposal Editor: Tone Southerland and Anne Diamond
• Profile Editor: Tone Southerland
• Date: N/A (Wiki keeps history)
• Version: N/A (Wiki keeps history)
• Domain: Patient Care Coordination (PCC)

Summary

There is a need to ensure adequate follow-up care for women and to maintain the educational activities traditionally provided to the mother/family during postpartum hospitalization. The Postpartum Visit documents the ongoing assessment of the physical and psycho-social status of the new mother. Practitioners who would use the information contained in the Postpartum Visit Summary are: obstetrician-gynecologist, family physician, and other medical specialists. This information may also be incorporated into a patient's PHR.

2. The Problem

Careful postpartum follow-up is necessary to ensure prompt diagnosis and treatment of any maternal complications which addresses issues such as:

• To review risk factors: domestic violence, depression
• Interventions: smoking cessation
• Problem management: wound care
• Education: preconception counseling, family planning, folic acid supplementation

Patients may be referred to other care providers for treatment of specific issues, ie depression, diabetes, etc before the end of the postpartum period.

3. Key Use Case

Case 1

Patient sees obstetrician (or other care provider) for a follow up visit after delivery. The patient reports alternating feelings of happiness and extreme sadness. The patient is referred for specialized care. Postpartum Visit Summary is shared with consultant/specialist or other care provider to whom the patient is referred.

Case 2

Patient sees obstetrician (or other care provider) for a follow up visit after delivery with an abnormal outcome that requires continued care. Patient returns to primary care physician for continuing management of diabetes. Patient continues to be seen by obstetrician and primary care provider. Postpartum Visit Summary is update by PCP and sent back to obstetrician.

4. Standards & Systems

• CCD ASTM/HL7 Continuity of Care Document
• CDAR2 HL7 CDA Release 2.0
• ACOG D/PP American College of Obstetricians and Gynecologists Discharge/Postpartum form
• 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 Postpartum Visit Summary 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 information contained in the Postpartum Visit Summary Profile completes the record of pregnancy.

6. Support & Resources

A copy of a Discharge/Postpartum form can be accessed from the American College of Obstetricians and Gynecologists at: http://www.acog.org/acb-custom/aa197.pdf

Editor: Tone Southerland with Mike McCoy Reviewer: Jean Millar, Dianne, Anne Diamond, Keith W. Boone, Mike Jolley

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