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OpenMatData Perinatal Data Resource Document (original EEPD Volume 4)

This document aims to be useful in the design of an internationally standardised, chronologically-arranged, flow-pattered perinatal electronic patient record dataset by merging as many as possible of the multitude of datasets relevant to Perinatal Medicine into a single data resource document and providing an analysis of each item as described in http://fawdry.info/eepd/01_ess/b_eprs/B06_Analysis.pdf


  •  % = % needing that question
  • Underline = Default Answer
  • † = Must be removed when data is anonymised.
  • PAM = Programmed Assistant for Maternity care. The PAM App questions are indicated in blue text


Contents

Cost/Workload Assumption throughout this Resource Document

  • UK Birthrate 580,000 per year.
  • Data Entry by Midwives if Wages and Overheads cost £10+£10/hour
  • Data Entry Work: 4 secs. if “Known” or “Quick Look Up” ; 10 secs. if “Time consuming” or “Need to ask Maternent”


Electronic Data Entry Workload & Cost Categories

See also Rupert Fawdry's 2008 workload and cost estimates (PDF file)

The category assigned will depend on the degree of complexity of the IT system in any particular departmental E.P.R. and the number of electronic linkages with other separate departmental E.P.R. systems


A. INDIVIDUAL PATIENT CARE (Esp. PATIENT ENCOUNTER ASSISTANCE = LOGICAL PRIORITY ITEMS)

A1 “Downloaded from Patient Administration Systems (PAS)”
“Downloaded from PAS” or Cost Neutral
“Downloaded from PAS” or Impractical
“Downloaded from PAS” or Retrospective only (nn%)
Should be already compulsory on PAS and should then be automatically downloaded electronically.
A2 “Cost Neutral”
“Cost Neutral” (or Individual Care Quality?) Automatically Recommended
A3 “Individual Care Quality”
Increased WORKLOAD & COST but will probably facilitate improved Individual Care Quality
Bias towards Recommendation
A4 “Electronic Transfer to or from other Computer Systems”
A5 “Computer Generated - based on A1-A4 data”
Automatically recommended whenever appropriate data is available

B. PURELY FOR MANAGEMENT, AUDIT and GOVERNANCE etc. (Potential for “Paralysis by Analysis”)

B1 “Retrospective Analysis only”
Bias against Recommendation. Actual National Cost/Workload depends on the percentage of pregnancies where this question needs to be answered (even if answer is nearly always negative)
B2 “Managerial Workload Forecasting”
B3 “Computer Generated - based on B1-B2 data”
Automatically recommended whenever appropriate data is available

C. OTHER

C1 “Separate E.P.R. data entry probably not cost effective or not necessary”
More cost effective, at least at this phase, if entered as a free text entry under a more general E.P.R. heading
C2 “Paper Record enough”
“Paper Record enough” - Too late for EPR at this stage
“Paper Record enough” - EPR entry impractical at this stage
“Paper Record enough” - EPR entry probably never justified
“Paper Record enough” - EPR entry pointless extra work

D1 “Requires data unlikely to be available on any Paper Record”
D2 “Not on National Pregnancy Record” - EPR entry probably impractical at this stage
D3 “Not for Paper or EPR” - unless computer generated
e.g. Confirmed to be below 5th or below 10th Centile or Social Group based on Occupation
D4 “Not for Paper or EPR” - probably unethical to collect
e.g. Ethnic Group of actual father of baby. While it may be possible to know this and to take account of the information in the personal care of an individual expectant mother it would seem wrong for such a sensitive piece of information to be documented either on paper or electronically
D5 “Other”
e.g. NHS Number of Previous Baby: Either already part of this mother‘s E.P.R. or rarely required



Contents of the Resource Document

Table of Contents arranged in flow-patterned "Logical Priority" order

Demographic & Support Definitions

D. Demographic & Support Staff Data. Start of a new Maternity EPR
D1. Mother's Demographic Data
D2. Professional Support Staff Data (at Birth)

Initial Assessment

I. Initial Assessment
I1. Initial Pregnancy Assessment History (Booking)
I1-A. DATES
I1-B. WHO and WHERE
I1-C. PERSONAL - EXPECTANT MOTHER
I1-D. ETHNIC ORIGIN, LANGUAGE & RELIGION
I1-E. HUSBAND / PARTNER (PUTATIVE FATHER) - I1-F. TRUE FATHER OF CHILD
I1-G. NEXT OF KIN - I1-H. EMERGENCY CONTACT PERSON
I1-I. EDUCATION / HOUSING / SUPPORT
I1-J. RELEVANT MEDICAL PROBLEMS
I1-K. PAST INVESTIGATIONS, SURGERY OR OTHER TREATMENT
I1-L. HABITS AND RECREATIONS
I1-M. GENETIC HISTORY
I1-N. MENSTRUAL AND CONTRACEPTIVE HISTORY
I1-O PAST OBSTETRIC HISTORY see P. Past Obstetric History (= Summary of This Pregnancy)
I2. Once-only Clinical Observations at Initial Assessment
I3. Decisions and Actions at Initial Assessment

Pregnancy History (POH: Past Obstetric History)

P. Past Obstetric History (= Summary of This Pregnancy)
P1. Total Number of Previous Pregnancies
P2. Each Individual Past Pregnancy
P3. For Each Baby in this Pregnancy
P4. Regarding Any Previous Pregnancy
P5. Obstetric Numbers

Hospital Sourced Antenatal Data

H. Hospital Sourced Antenatal Data
H1. Antenatal Data - Maternal
H2. Antenatal Data - Fetal

Retrospective

R. Retrospective of this Pregnancy
R1. End of Pregnancy without a “20 week or more Gestation” Birth in this District
R2. Once only later Investigations, Treatments and Decisions
R3. Retrospective Data about the whole of the Present Pregnancy

(Birth) Event of Giving Birth

E. (Birth) Event of Giving Birth - Mother
E1. Labour
E2. Pain Relief in Labour (see also O2. Anaesthetic Involvement in Labour Pain Relief)
E3. Most Significant Route of Birth
E4. Caesarean Section
E5. Retrospective of the Whole of this Birth Event
E6. Analgesia/Anaesthesia for Birth Event See O3. Anaesthesia / Analgesia for Birth Event
E7. Analgesia/Anaesthesia Post-Delivery see O4. Anaesthesia / Analgesia Post-Delivery
E8. Anaesthesia / Analgesia Retrospective see O5. Anaesthesia / Analgesia Retrospective
E9. Before Leaving Labour Ward - Mother

Motherhood

M. Motherhood (Postnatal)
M1. On Arrival in Postnatal Ward - Mother
M2. Events from Birth to Postnatal Discharge - Mother
M3. At the Time of Postnatal Discharge - Mother
M4. After Postnatal Discharge - Mother

Obstetric Anaesthesia

O. Obstetric Anaesthesia
O1. Anaesthetic and Antenatal Care
O2. Anaesthetic Involvement in Labour Pain Relief (see also E2. Pain Relief in Labour)
O3. Anaesthesia / Analgesia for Birth Event
O4. Anaesthesia / Analgesia Post-Delivery
O5. Anaesthesia / Analgesia Retrospective
O6. Anaesthesia / Analgesia Quality and Follow-Up

Birth and Baby

B. Birth and Baby
B1. Birth
B2. Method of Birth
B3. Labour
B4. Birth Intervention
B5. Membranes and Liquor
B6. Birth Anaesthesia / Analgesia see also O3. Anaesthesia / Analgesia for Birth Event
B7. Professional Staff at Birth
B8. Resuscitation
B9. Baby Care and Observations
B10. Before Leaving Labour Ward - Baby

Newborn Baby

N. Newborn Baby
N1. On Arrival in Postnatal Ward - Baby
N2. Events from Birth to Postnatal Discharge - Baby
N3. At the Time of Postnatal Discharge - Baby
N4. After Postnatal Discharge - Baby

Neonatal Special Care

C. Neonatal Special Care
C1. On Admission to Neonatal Care Facility
C2. Neonatal Care Events from Admission to Discharge
C3. At Time of Death / Discharge from Neonatal Care Facility

Stillbirths and Deaths

S. Stillbirths and Deaths
S1 Stillbirth or Neonatal Death
S2 Maternal Death

Health Care Workers

X. Health Care Workers


GENERIC

Generic Maternity and Neonatal

G1. Antenatal - Mother
G2. Pregnancy Scans
G3. Antenatal - Fetus
G4. Labour
G5. Postnatal - Mother
G6. Baby

Generic Values

V1. General Demographic
V2. Patient / (Expectant) Mother Care
V3. Admissions & Discharges
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