Brief Profile Proposal Page 2

Integrating the Healthcare Enterprise Obstetric Postpartum Visit Summary Profile Proposal

Obstetric Postpartum Discharge Summary Proposed Profile Proposed Editor Tone Southerland, Anne Diamond Date October 6, 2008 Version .2 Domain Patient Care Coordination

Careful postpartum follow-up is necessary to ensure prompt diagnosis and treatment of any maternal or neonatal 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

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. Practitioners who would use the information contained in the Postpartum Visit Summary are: obstetrician- gynecologist, family physician, specialist and other medical specialists. This information may also be incorporated into a patient's PHR. 1. Patient sees obstetrician (or other care provider) for a follow up visit after delivery and the Postpartum Visit Summary is created. 2. Postpartum Visit Summary is shared with consultant/specialist or other care provider the patient is referred to. 3. Postpartum Visit Summary is update by specialist and sent back to obstetrician??

Template v2.01 – June07 Printed: 9-Apr-18 [Brief] Profile Proposal Page 2

CCD ASTM/ HL7 Continuity of Care Document CDAR2 HL7 CDA Release 2.0 ACOG D/PP American College of Obstetricians and Gynecologists (ACOG) Discharge/Postpartum Form LOINC Logical Observation Identifiers, Names and Codes SNOMED Systemized Nomenclature for Medicine DSG Document Digital Signature NAV Notification of Document Availability

The information contained in the Obstetric Postpartum Visit Summary is important for the continuing care of the mother. Practitioners who would use the information contained in the Postpartum Discharge Summary are: obstetrician-gynecologist, family physician, social worker, covering physician, and other medical specialists. This is a very important document. At present the delivery portion of this record is generally not available in the office to even fill out the top 3 sections of the form. Having this available electronically will certainly go a long way in improving continuity of care. Since it is rare that this Postpartum Visit Summary is shared with a consultant/specialist what is the real use case? 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

Template v2.01 – June07 Printed: 9-Apr-18