Recommendations for the use of the Pregnancy Health Record by wgv13363

VIEWS: 34 PAGES: 2

									                           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
       1 st visit to GP        GP                         Confirm ongoing pregnancy                Commence PHR                                 As desired      N/A
                                                          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 1 st 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)
  nd
 2 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
                                                                                                                                                hospital and
                                                                                                   in her PHR folder
                                                                                                                                                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 - Reco mmendations 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 - Reco mmendations for Use                                                                                 Page 2 of 2

								
To top