ACOG ANTEPARTUM RECORD PDF
Fill Acog Antepartum Record, download blank or editable online. Sign, fax and printable from PC, iPad, tablet or mobile with PDFfiller ✓ Instantly ✓ No software. VARICOSITIES/PHLEBITIS. THYROID DYSFUNCTION. 24, ANESTHETIC COMPLICATIONS. TRAUMA/VIOLENCE. ACOG ANTEPARTUM RECORD. Additionally, the prenatal record both guides and documents the delivery of good American College of Obstetricians and Gynecologists (ACOG) antepartum.
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There are over 4 million births in the United States each year. Obstetric patients must have a complete summary of antepartum care recor for all care providers and for labor and delivery staff.
Antepartum Summary Extension – All ACOG Forms
Incomplete information can be a danger to the mother and child and result in injury, inadequate treatment or undesirable outcomes. One study estimates that one-third of all adverse outcomes is a result of poor communication among obstetric providers.
The aggregated information contained in a patient’s antenatal record should be available across multiple care settings. The current practice is to copy the paper chart at various times during the pregnancy and transport the copies to the hospital the patient intends to use for delivery.
Expansion of the Antepartum Summary would provide the capability to electronically communicate pertinent patient history, treatment, lab and imaging information collected over the course of a 40 week pregnancy to care providers and institutions ambulatory, hospital, specialists, etc.
There does not now exist in the industry a standardized integration profile to allow for the exchange of antepartum record information specifically the data elements from ACOG Forms A, B, D and E between healthcare professionals.
Current practice is to copy the paper chart at various times during the pregnancy as at 28 weeks and at 36 weeks of completed gestationand transport the copies of the chart to the hospital the patient intends to use for delivery.
Should the patient arrive prior to the chart copy arriving, or if the chart or information within the chart is antepratum on presentation of the patient to Labor and Delivery a frequent occurrenceoften the staff or clinicians repeat laboratory or imaging studies.
This results in unwarranted and duplicative tests, is wasteful of time and resources, and leads to dissatisfied patients.
The existing IHE antepartum summary profile requires minimal coding associated with the structure data that limits the ability antepaartum aggregate this data and analyze clinical trends. It is preferable by hospitals to utilize more coded data e. This same data is required at any visit to Labor and Delivery for any other problems or special needs a patient may require. During the 40 weeks of a typical pregnancy duration, the patient will have an initial History and Physical Examination, followed antepadtum repetitive office visits with multiple laboratory studies, imaging usually ultrasound studies, and serial physical examinations with avog of vital signs, fundal height, and the fetal heart rate.
As the patient is seen over a finite period in the office, aggregation of specific relevant data important to the evaluation of the obstetric patient upon presentation to Labor and Delivery is caputured on paper forms.
Women’s Health Care Physicians
The antepartum record contains the most critical information needed including the ongoing Medical Diagnoses, the Estimated Due Date, outcomes of any prior pregnancies, serial visit data on the appropriate growth of the uterus and assessments of fetal well being, authorizations, laboratory and imaging studies.
This data must all be presented and evaluated upon entry to the Labor and Delivery Suite to ensure optimal care for the patient and the fetus. Although the patient and her care provider may plan for a vaginal natural method of delivery, there is a substantive chance the delivery route may be surgical, requiring anesthesia and post-surgical care.
Current practice is to copy the patient’s paper chart at various times during the pregnancy as at 28 weeks and at 36 weeks of completed gestationand transport the copies of the chart to the hospital the patient intends to use for delivery.
ACOG ANTEPARTUM RECORD (FORM A)
Should the patient arrive prior to the chart copy arriving, or if the chart or information within the chart is missing on presentation of the patient to Labor and Delivery a frequent occurrencethe staff or clinicians repeat laboratory or imaging studies. In one recent U. While only one hospital was involved in this study, one can see the extent of the issue, with pregnant patients possibly going anhepartum a different hospital than planned preterm labor, rapid labor and unable to make it to the planned delivery hospital, or visiting a distant citymoving mid-care, or with a covering physician rather than the primary obstetrician on call.
Thus, availability of current medical records remains a significant problem for most hospital Labor and Delivery units; availability of key information electronically will significantly enhance patient safety.
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