Recommendations for the Use of the Pregnancy Health Record (PHR) to Ensure Appropriate

Recommendations for the Use of the Pregnancy Health Record (PHR) to ensure appropriate communication and documentation without duplication

Which Antenatal Who What Documentation Visit PHR GP/Obst Birth records records 1st GP Confirm ongoing pregnancy Commence PHR As desired N/A visit to GP Discuss pregnancy care options Notify choice on Referral Form Pg 1 As desired N/A Perform physical assessment Page 4/5 Photocopy N/A pages if desired Perform 1st pregnancy health Page 6 As desired N/A assessment Order investigations requesting 3 Page 8/9 As desired N/A copies of reports (GP record, Birth record, PHR) Decide preferred birth place Complete and send Referral Form Pg 1/2 As desired N/A Woman Agree to participate in use and Receive PHR N/A N/A maintenance of PHR Between visits at Home Woman Read PHR including comments by Complete: N/A N/A carer, consent and other information  Personal Information (Pg 4/5)  Birth Plan (Pg 14)  Smoking assess form (Pg 16) Photocopy PHR at any time during  EPDS score (Pg 18) pregnancy  Consent for Vit K (Pg 19)  Consent for Hep B Imm (Pg 20) 2nd and subsequent Woman Brings PHR N/A N/A visits GP / Obstetrician / Review Investigation results Page 5 Send one Receive, review and file Antenatal Clinic / Other Provide 1 copy of results to woman to keep copy to birth copy of results in her PHR folder hospital and Keep copy of results Assess smoking quit status if required Page 16 N/A N/A Pregnancy health assessment Page 6 - 13 As desired N/A

September 2005 Woman Held Pregnancy Record - Recommendations for Use Page 1 of 2 Recommendations for the Use of the Pregnancy Health Record (PHR) to ensure appropriate communication and documentation without duplication

Booking visit at Birth Woman Brings PHR Health Service Midwife / Medical Officer Assess smoking quit status if required Page 16 N/A N/A Pregnancy health assessment Pages 6 - 13 N/A As desired Complete medical obstetric history if Pages 4/5 N/A KEMH: Photocopy Pages required 4/5 on yellow A3 paper and file or “as desired” Review investigations and results Page 5 Review Vit K and Hep B consent forms Pages 19/20 N/A N/A and ensure they are signed/discussed as appropriate Review EPDS Score and followup as Page 18 N/A As desired appropriate Commence pregnancy education and Page 15 N/A N/A discharge planning Antenatal Admission to Woman Bring PHR and keep with you at all Hospital, Service or times until baby is born Centre Midwife / Medical Officer Note antenatal admission in PHR Note date, reason and place of admission N/A N/A on Page 6 – 13 Usual care and investigations Receive As usual & ensure GP discharge receives D/C summary summary Labour and Birth Woman Bring PHR Give to health carer for filing in permanent N/A As desired admission to Hospital, record Service or Centre Midwife / Medical Officer Usual care Copy of PHR can be provided to woman if Receive As usual and ensure GP desired discharge receives D/C summary, file summary PHR & signed consent forms in medical record

September 2005 Woman Held Pregnancy Record - Recommendations for Use Page 2 of 2