Maternity Record: Record and Patient Administration
Version | v1.0 - March 2024 |
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Status | Published |
Important Information
Within this requirements catalogue we use the terms woman, women, and pregnant women. However, we recognise that some transgender men, non-binary people and people with variations in sex characteristics (VSC) or who are intersex may also access maternity services. Maternity services and delivery of care must therefore be appropriate, inclusive, and sensitive to the needs of everyone who accesses maternity services, including those who are trans, non-binary or intersex.
Contents
- 1 M1.01.1 - List of Women Allocated to Community Teams
- 2 M1.02.1 - Name of Maternity Health Care Professional on a Woman's Record
- 3 M1.03.1 - Working Offline and Synchronisation
- 4 M1.04.1 - Pregnant Women and Neonatal Flags
- 5 M1.05.1 - Trust Definable Communications (Summary of Care Letters)
- 6 M1.05.2 - Trust Definable Communications (Appointment Letters, and or SMS Messages)
- 7 M1.06.1 - National Health Service (NHS) Number Generation for Neonates
- 8 M1.07.1 - Preventing Duplicate Registrations for Neonates
- 9 M1.08.1 - Maternity Record Closure (Pregnancy Episode)
- 10 M1.08.2 - Maternity Record Closure (Historic Clinical Notes)
- 11 M1.09.1 - Records of Non-Midwife Health Care Professionals
- 12 M1.10.1 - Sharing Maternity Records (Maternity Woman)
- 13 M1.10.2 - Sharing Maternity Records (Health Care Professional)
- 14 M1.11.1 - Cross Border Activities (Clinical History)
- 15 M1.11.2 - Cross Border Activities (Moves In and Out)
- 16 M1.12.1 - Past Pregnancies Data Transfer
- 17 M1.13.1 - Legacy Data Migration
- 18 M1.14.1 - Personalised Shortcuts
- 19 M1.15.1 - National Patient Safety Agency (NPSA) Wristband and Barcode Production
- 20 M1.16.1 - Patient Demographic Service (PDS) Birth Notification
- 21 M1.17.1 - Support for Evolving Clinical Practices
- 22 M1.18.1 - Storing Written Translation
- 23 M1.19.1 - System Integration (United Kingdom)
- 24 M1.19.2 - System Integration (Overseas)
- 25 M1.20.1 - User Interface Personalisation
Capability M1.01
The solution must support a full patient list view of all women who have booked (and are waiting to be booked) which must be able to be displayed at a Community Team level and assigned midwife level together with their named Obstetrician. This must include details of each woman's current gestation and expected date of delivery (EDD).
M1.01.1 - List of Women Allocated to Community Teams |
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DCF Core Capability |
As a Health Care Professional, Hospital Administrator or Manager I want to be able to view a list of pregnant or postnatal women by their Community Team and or named midwife allocation So that I can track appointments and administrative or clinical tasks for the group of women Acceptance criteria:Given that a Health Care Professional, Hospital Administrator or Manager is permitted to view lists of women on the system When the Health Care Professional, Hospital Administrator or Manager logs onto the system Then the Health Care Professional, Hospital Administrator or Manager will be able to see a full list women who have booked (and are waiting to be booked) by their Community Team (i.e. traditional team or Continuity of Carer (CoC) team, or both) And the list of women will include their demographics, displayed at a community team level showing the following details:
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Standards Compliance |
Capability M1.02
The solution must record the name of the maternity health care professional delivering care and acting as the named midwife and where applicable the named consultant for the woman.
M1.02.1 - Name of Maternity Health Care Professional on a Woman's Record |
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DCF Core Capability |
As a Health Care Professional, Hospital Administrator or Manager I want to be able to add the name of a Maternity Health Care Professional to a woman's record on the system So that I can know the associated Lead Health Care Professional providing care and is the named midwife or the named consultant Acceptance Criteria 1Given that a Health Care Professional, Hospital Administrator or Manager is permitted to edit a woman's record on the system When the named midwife or named consultant is known Then there will be a provision to add, the associated Lead Health Care Professional acting as the named midwife or the named consultant to the record Acceptance Criteria 2Given that a Health Care Professional is permitted to edit a woman’s record on the system When the Health Care Professional records care delivery Then there will be a provision to add to the record, the associated Lead Health Care Professional delivering care Acceptance Criteria 3Given that a Health Care Professional, Hospital Administrator or Manager is permitted to view a woman’s record on the system When the Health Care Professional opens the woman's record Then the record will display the name of the associated Lead Health Care Professional (if it has been recorded) delivering care and or acting as the named midwife or the named consultant |
Standards Compliance |
STD116 Personalised Care and Support Plan |
Capability M1.03
The solution must have the ability for a user to work offline and have those changes uploaded (or synchronised) to the record when the connection is restored. The merging must be intelligent, date and timestamped to the clinical event and flag any errors. Once merged any workflows that would have been triggered had the user been online must now be triggered. This must function either when a particular user goes offline, or a wider outage like the whole hospital going offline. This must allow for planned and unplanned offline working.
M1.03.1 - Working Offline and Synchronisation |
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DCF Core Capability |
As a Health Care Professional I want to be able to record information offline on the system So that I can enter data contemporaneously even when there is no internet connection and the system will synchronise my work when I am back online Acceptance CriteriaGiven that a Health Care Professional is permitted to add clinical information to a woman's record on the system When the system is offline and the Health Care Professional adds clinical information to the woman's record Then all offline changes will be synchronised with the woman's record when a connection is restored And the synchronisation must be date and time stamped |
Standards Compliance |
Capability M1.04
The solution must allow users to set “flags” (for both woman and neonate) that warn all other users that a woman or neonate has an alert. Where Trust's clinical systems hold additional alerts, the solution should allow these to be visible within the maternity solution for example safeguarding, vulnerable adults, a child or neonate at risk or previous pregnancy loss.
M1.04.1 - Pregnant Women and Neonatal Flags |
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DCF Core Capability |
As a Health Care Professional I want to be able to set flags for both women accessing maternity care and / or neonates on the system So that other Health Care Professionals can be made aware of any risk alerts associated with the woman and / or the neonate Acceptance Criteria 1Given that a Health Care Professional is permitted to add clinical information to a woman's record on the system When a Health Care Professional needs to set a risk flag for a woman accessing maternity care and / or a neonate Then the Health Care Professional will be able to set the appropriate risk flag which will inform other Health Care Professionals that the woman has an alert at every appointment and during any part of the maternity pathway (i.e. high or low risk, safeguarding risk, complex social factors) Acceptance Criteria 2Given that a woman has an alert on their record on the system When the woman is cared for in non maternity care settings Then the system will send an alert to the associated Health Care Professional with the details of the risk And the viewing of the content and the nature of the alert will be limited based on user roles (i.e. restricting the viewing of confidential information) And the Health Care Professional will also be able to view all existing flags in all settings for a woman accessing maternity care and or a neonate Acceptance Criteria 3Given that other Trust clinical systems hold additional alerts for a woman When the Health Care Professional with the right permission opens a woman's record Then these additional alerts will be visible to the Health Care Professional at every appointment and during every part of the maternity pathway And the Health Care Professional will also be able to view all existing flags in all settings for a woman accessing maternity care and or a neonate Additional InformationThe viewing of the content and nature of the alert will be limited based on user roles (i.e. restricting the viewing of confidential information). The solution will alert at every appointment and during any part of the maternity pathway: high or low risk, safeguarding risk, complex social factors. It will also alert staff when the woman is admitted and if the woman has been designated as high risk, providing details of the risk. This will include passing the alert that a woman is pregnant to other systems and services (e.g. if they report to A&E the solution must ensure that the A&E staff know the woman is pregnant). The term all settings refers to all settings where maternity care is delivered such as Acute, Community and Mental Health settings. Sharing information within the Acute setting such as with / between Maternity and Gynaecology services or the Emergency Department is considered a core requirement. Sharing information with Mental Health settings is considered transformational.
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Standards Compliance |
STD001 Accessible Information |
Capability M1.05
The solution must provide the capability to automatically generate Trust definable communications. This must include a variety of forms of communication like emails, SMS messages and letters.
M1.05.1 - Trust Definable Communications (Summary of Care Letters) |
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DCF Core Capability |
As a Health Care Professional I want the system to automatically generate Trust letters So that I can easily produce summaries of care to share with women and other Health Care Professionals Acceptance CriteriaGiven that a Health Care Professional is permitted to create summary of care letters on the system When the Health Care Professional logs onto the system Then the Health Care Professional will be able to create summary of care letters which will be automatically generated for and sent to women. |
Standards Compliance |
STD076 Secure Email |
M1.05.2 - Trust Definable Communications (Appointment Letters, and or SMS Messages) |
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DCF Core Capability |
As a Hospital Administrator or Manager I want the system to automatically generate Trust letters and / or SMS messages So that I can easily send out appointments and reminders to women Acceptance CriteriaGiven that a Hospital Administrator or Manager is permitted to send letters and / or SMS messages from the system When the Hospital Administrator or Manager logs onto the system Then the Hospital Administrator or Manager will be able to create appointment letters and reminders which will be automatically generated for and sent to women as letters and / or SMS messages |
Standards Compliance |
STD076 Secure Email |
Capability M1.06
The solution must support a link to the live NHS Spine, PDS or any replacement national system to obtain a new NHS number for each neonate in real time.
This must also provide the ability to link to Birth Notification Application (BNA), where the solution can’t obtain an NHS number for the neonate.
The solution must also confirm NHS numbers and synchronise the woman's core demographics.
There should be an option to add an NHS number manually in the event that a woman does not have an NHS number to link to a neonate.
The solution must also be able to capture a local patient identifier (often called a hospital number).
M1.06.1 - National Health Service (NHS) Number Generation for Neonates |
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DCF Core Capability |
As a Health Care Professional I want the system to link to the NHS Spine to obtain the new NHS number for the neonate So that neonates can be given their unique NHS number in real time that can be used for their onward NHS care Acceptance Criteria 1Given that a woman's record has already been created on the system When the woman gives birth and the neonatal record has been created on the system Then the system will obtain a new NHS number for the neonate in real time from the Live NHS Spine, Patient Demographic Service (PDS) or any replacement system And the system must also confirm the NHS number and synchronise the woman's core demographics Acceptance Criteria 2Given that a woman's record has been created on the system When the system cannot obtain a new NHS number for the neonate in real time from Live NHS Spine, PDS or any replacement system Then the system must also provide the ability to link to the Birth Notification Application (BNA) Acceptance Criteria 3Given that a woman's record has been created on the system When the woman does not have an NHS number Then the Health Care Professional will have an option on the system to manually add an NHS number for the woman to link to a neonate |
Standards Compliance |
Capability M1.07
The solution must flag up potential duplicate registrations by prompting the user to indicate whether the registration is for a multiple birth and record both registrable and non-registrable births for multiple births (e.g. twins born at <24 weeks where one stillborn and one is alive).
M1.07.1 - Preventing Duplicate Registrations for Neonates |
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DCF Core Capability |
As a Health Care Professional I want the system to flag if I am registering a multiple birth So that their will be no duplication of registration records on the system, but I can register multiple births Acceptance CriteriaGiven that a Health Care Professional is permitted to register neonates on the system When the Health Care Professional attempts to register more than one neonate Then the system must prompt the Health Care Professional to acknowledge that multiple registrations are required (e.g. for twins, triplets, etc.) |
Standards Compliance |
Capability M1.08
The solution should have the functionality to close the Maternity record when the pregnancy has ended.
Any closed pregnancy should be accessible via an archive facility within the solution.
It should also handle the closure of a pregnancy when the expected date of delivery (EDD) has elapsed and the outcome is unknown.
Closed pregnancies should prevent automatic interface updates or manual updates to be made to the record.
M1.08.1 - Maternity Record Closure (Pregnancy Episode) |
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DCF Core Capability |
As a Hospital Administrator or Manager I want to be able to close the maternity record when the pregnancy episode has ended or when the expected date of delivery has elapsed and the woman is lost to follow up So that the pregnancy episode can be closed and the record can no longer be changed Acceptance CriteriaGiven that a maternity record has been created on the system When the pregnancy episode has ended Then the Hospital Administrator or Manager will be able to close the associated maternity record on the system And the closed maternity record will be accessible when needed by any authorised Health Care Professional Acceptance Criteria 2Given that a woman is lost to follow up or does not birth at the booked maternity unit When the Expected Date of Delivery (including additional time) has elapsed, and attempts have been made to locate the woman Then the Hospital Administrator or Manager should still be able to close the associated maternity record on the system And the system will prompt for a reason for closing the associated maternity record on the system And the closed maternity record will be accessible when needed by any authorised Health Care Professional Acceptance Criteria 3Given that a maternity record has been closed on the system When an automatic interface update or manual update is made on the maternity record Then the system must prevent such updates from happening to the closed maternity record |
Standards Compliance |
M1.08.2 - Maternity Record Closure (Historic Clinical Notes) |
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DCF Core Capability |
As a Health Care Professional, I want to be able to view clinical notes from a woman's previous pregnancy and birth in a "read-only" capacity So that I can provide personalised care and advice in any future pregnancies Acceptance CriteriaGiven that a Health Care Professional is permitted to view a maternity record on the system When a Health Care Professional is logged onto the system Then the Health Care Professional will be able to view clinical notes from a woman's previous pregnancy(ies) and birth(s) |
Capability M1.09
The solution should record all relevant non-midwife Health Care Professionals (HCP) who are involved in a woman’s maternity care (including GP, Health Visitor, mental health, social services etc)
Changes to Health Care Professional (HCP) should be identified and a reason given.
The solution should cater for an out of area caregiver and an out of hours HCP, including their details and any additions to the maternity record.
M1.09.1 - Records of Non-Midwife Health Care Professionals |
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DCF Transformation Capability |
As a Health Care Professional I want to be able to record on the system the name of all non-midwife Health Care Professionals So that I can provide relevant information and care summaries to all the associated non-midwife Health Care Professionals (i.e. General Practitioner (GP), Health Visitor, mental health staff, social services staff etc) caring for the woman Acceptance Criteria 1Given that a woman's record is already created on the system When the authorised Health Care Professional opens the woman's record Then the Health Care Professional will be able to add to and update the woman's record with the associated non-midwife Health Care Professionals caring for the woman And the Health Care Professional will also be able to add the reason for updating the woman's record Acceptance Criteria 2Given that a Health Care Professional is permitted to view a woman’s record on the system When the Health Care Professional opens a new form in the record Then the associated non-midwife Health Care Professionals caring for the woman can be viewed Acceptance Criteria 3Given that a woman's record is already created on the system When the authorised Health Care Professional opens the woman's record Then the Health Care Professional will be able to add to the woman's record, the associated out of area caregivers and out of hours Health Care Professionals caring for the woman |
Standards Compliance |
STD057 National Workforce Data Set |
Capability M1.10
The solution should allow the woman to share their maternity record with any clinician, including those out of area. Out of area caregivers should be able to access the notes over an internet connection. The solution should allow these third party contributions to be written back into the record.
M1.10.1 - Sharing Maternity Records (Maternity Woman) |
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DCF Transformation Capability |
As a woman receiving maternity care I want to be able to share my maternity record with any clinician including those outside my Trust or Integrated Care System (ICS) So that they can have a complete knowledge of my clinical history to provide safe and effective, personalised care And I don't have to keep repeating my details Acceptance CriteriaGiven that a woman has access to their own digital maternity record on the system When the woman requires care outside their booked Trust Then the woman should be able to share their maternity record with any Health Care Professional including those out of their area Acceptance Criteria 2Given that the woman has received care at another Trust with a digital maternity care record When the permitted out of area caregiver accesses the woman's maternity record Then the permitted out of area caregiver should be able to access the woman's maternity record over an internet connection And the out of area caregiver should be able to add to the woman's maternity record which can be saved with a date and time stamp |
Standards Compliance |
STD029 Dictionary of Medicines and Devices |
M1.10.2 - Sharing Maternity Records (Health Care Professional) |
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DCF Transformation Capability |
As a Health Care Professional outside the woman's Trust I want to be fully informed of a woman's maternity history and care So that I can offer safe and effective, personalised care. Acceptance CriteriaGiven that the woman has received care at another Trust with a digital maternity care record When the permitted out of area Health Care Professional accesses the woman's maternity record Then the permitted out of area Health Care Professional should be able to access the woman's maternity record over an internet connection And the out of area Health Care Professional should be able to add to the woman's maternity record notes which can be saved with a date and time stamp |
Standards Compliance |
STD029 Dictionary of Medicines and Devices |
Capability M1.11
The solution should be able to handle cross border activity including capturing moves in and out of the Trust's services. This includes capturing when finances would move. The solution should also be able to handle where the woman moves their care outside the trust without cancelling their primary care location (e.g. going to A&E while on holiday).
M1.11.1 - Cross Border Activities (Clinical History) |
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DCF Transformation Capability |
As a Health Care Professional I want the system to capture all cross border care within the United Kingdom So that I can have a complete and seamless knowledge of the woman's clinical history and promote safe, effective and personalised care Acceptance CriteriaGiven that a woman has an existing digital maternity record in their booked Trust When the woman requires care in a different Trust Then the Health Care Professional in the different Trust will be able to see on the system all the woman's digital maternity records from their booked Trust And the Health Care Professional in the different Trust will be able to see on the system all moves in and out of the Trust's services |
Standards Compliance |
STD029 Dictionary of Medicines and Devices |
M1.11.2 - Cross Border Activities (Moves In and Out) |
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DCF Transformation Capability |
As a Hospital Administrator or Manager I want the system to capture moves in and out of Trust services So that I can ensure that the Trust earns the correct tariff for each woman's care Acceptance CriteriaGiven that a woman has an existing record on the maternity system and is receiving care in a Trust When the woman receives care or moves out of their original Trust to another Trust Then the system should capture the woman's move out of their original Trust to another Trust And the system should also capture the finance implication of moves for the woman which would be accessible by the Hospital Administrator or Manager And the system should not automatically cancel the woman's original Trust as their primary care location |
Standards Compliance |
STD018 Commissioning Data Sets (CDS) |
Capability M1.12
The solution should be able to transfer data that is known to be true or constant from previous pregnancies if recorded within the solution during a previous pregnancy event to avoid duplication of data entry.
M1.12.1 - Past Pregnancies Data Transfer |
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DCF Transformation Capability |
As a Health Care Professional I want the system to be able to transfer data that is known to be true and constant, from past pregnancies to the current pregnancy So that I do not have to type it again into the new pregnancy record to save time, avoid duplication of data and reduce errors Acceptance CriteriaGiven that a woman has received maternity care in a Trust When a Health Care Professional is adding a new pregnancy record to the system for the woman Then the system should be able to transfer data that is known to be true and constant, from past pregnancies to the new pregnancy record including:
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Standards Compliance |
Capability M1.13 - Under Review 03/24
There should be the option to migrate legacy maternity records into any new solution.
M1.13.1 - Legacy Data Migration |
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DCF Transformation Capability |
Important Information This capability is under review and further information will follow. |
Standards Compliance |
Capability M1.14
The solution could allow users to configure personalised shortcuts to complete common text entries in free text boxes and notes
M1.14.1 - Personalised Shortcuts |
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DCF Transformation Capability |
As a Health Care Professional I want to be able to use personalised shortcuts on the system So that it will be easy to complete common text entries in free text fields to save time and ensure consistency in recording clinical information Acceptance CriteriaGiven that a Health Care Professional is authorised to log onto the system When the Health Care Professional needs to enter data in textual format into a record Then the Health Care Professional will have the option to use personalised shortcuts to enter texts onto the record And the personalised shortcuts will be user configurable |
Capability M1.15
The solution should support the production of NPSA compliant wristbands once the neonate has been allocated an NHS number. It should allow the production of compliant barcode labels for the neonatal blood spot screening test.
NPSA - National Patient Safety Agency
M1.15.1 - National Patient Safety Agency (NPSA) Wristband and Barcode Production |
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DCF Transformation Capability |
As a Health Care Professional I want the system to have the ability to support the production of NPSA compliant wristbands and barcode labels for the newborn blood spot screening test So that neonates can receive any necessary care in hospital and access the day 5 newborn blood spot test Acceptance CriteriaGiven that a neonate has been delivered in a Trust When the neonate has been allocated an NHS number Then the system must support the production of NPSA compliant wristbands and barcode labels to be used for the day 5 newborn blood spot screening test. |
Standards Compliance |
STD070 Patient Identifiers for Identity Bands |
Capability M1.16
The solution should automatically produce the PDS birth notification which should automatically be sent electronically to the Child Health Information Services (CHIS) once an NHS number has been allocated
M1.16.1 - Patient Demographic Service (PDS) Birth Notification |
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DCF Innovation Capability |
As a Health Care Professional I want the system to send a PDS notification to the Child Health Information Services (CHIS) So that the details of the woman, details of the neonate and some supporting information around the birth are documented and I can meet my legal requirements for birth notification Acceptance CriteriaGiven that a neonate has been delivered in the Trust When the neonate has been allocated an NHS number Then the system should automatically produce the PDS birth notification which should be sent electronically to the Child Health Information Services (CHIS) |
Standards Compliance |
STD009 Birth notifications |
Capability M1.17
The solution could allow changes to be implemented as needed to allow for evolving clinical practices at a local level. Suppliers should outline any limits or additional charges involved in making changes to data or workflows at a local level.
M1.17.1 - Support for Evolving Clinical Practices |
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DCF Innovation Capability |
As a health care professional, I want to be able to access configuration specialists on or off site to support the adaption of workflows, So that I can support evolving clinical practices at a local level Acceptance CriteriaGiven that the system has been installed When essential changes are required Then the system should be flexible to allow the required changes to be implemented accordingly at a local level And suppliers should outline any limits or additional charges involved in making changes to data or workflows at a local level |
Capability M1.18
Where Trust's are using digital tools for translation rather than interpreters during appointments, the solution should store a record of any written translation material in addition to the Health Care Professional's notes. This would assist in communication with a woman who might have issues with communication in English.
The selections of languages to translate could reflect local demographics of the trust. The solution could read aloud the translations for women who have literacy issues.
M1.18.1 - Storing Written Translation |
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DCF Innovation Capability |
As a Health Care Professional I want to be able to store a record of any written translation material(s) within the maternity record So that I can ensure that I have an accurate record of every consultation and ensure that the woman will be fully informed and have equity in their care Acceptance CriteriaGiven that a woman does not understand English When a Health Care Professional has used the digital language translation tool (which may be from a third party system) to discuss health matters with a woman Then the system should store a record of any written translation material in addition to the Health Care Professional's notes And there will be provision on the system to upgrade with additional languages in the future as the demographics changes |
Standards Compliance |
STD160 Tag content with international language codes |
Capability M1.19
The solution should capture and/or integrate with other systems holding overseas visitor status data and data for those receiving care from other maternity providers such as the Ministry of Defence (MOD), and private or independent maternity care providers.
M1.19.1 - System Integration (United Kingdom) |
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DCF Innovation Capability |
As a Health Care Professional I want the system to be able to integrate with other maternity systems So that I can get health data for external women (i.e. women receiving care from other maternity providers such as the Ministry of Defence, private or independent maternity care providers) to enable me to provide safe, effective, personalised and equitable care Acceptance CriteriaGiven that a woman has received care with an external maternity provider When the woman subsequently engages with NHS maternity care Then the Health Care Professional will be able to view on the system details of the care provided by external maternity providers (i.e. the Ministry of Defence, private or independent maternity care providers) |
Standards Compliance |
M1.19.2 - System Integration (Overseas) |
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DCF Innovation Capability |
As a Hospital Administrator or Manager I want to be able to capture overseas visitor status from other systems So that I can charge non-NHS women for their care Acceptance CriteriaGiven the Trust's obligation to establish overseas visitor's status When the Overseas Visitor Charging Category (OVCC) has been recorded in accordance with information standard DCB3017 Then this information must be shared across all NHS systems |
Standards Compliance |
Capability M1.20
The solution could allow users to personalise their user interface (UI) such as screen layout, column order, filtering options, display as graph etc.
M1.20.1 - User Interface Personalisation |
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DCF Innovation Capability |
As a Health Care Professional I want to be able to personalise the user interface of the system So that I can access the features that I use more often and increase accessibility and efficiency Acceptance CriteriaGiven that a Health Care Professional is permitted to access the system When the Health Care Professional logs onto the system Then the Health Care Professional will be able to personalise the user interface based on their preferences e.g. choose the screen layout or arrange and display elements in a way that makes sense to them |