Information Sharing for Direct Care
- Gavin Start
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 M2.01.1 - Data Capture for All Women (Health Care Professional)
- 2 M2.01.2 - Data Capture for All Women (Health Care Professional working outside of index Trust)
- 3 M2.01.3 - Data Capture for All Women (Caldicott Guardian)
- 4 M2.02.1 - Transfer of Pregnant Person to Theatre
- 5 M2.03.1 - Transfer of Woman and or Neonate to Other Units or Wards
- 6 M2.04.1 - Early Pregnancy Assessments
- 7 M2.05.1 - Transfer of Care Identification
Capability M2.01
The solution must capture the following data for all women:
Capture antenatal and postnatal discharges, transfers and in-utero transfers
It must have the ability to capture induction process (both outpatient and inpatient induction) and any reasons for when care has been delayed.
It must electronically notify GPs of antenatal and postnatal discharges.
It must have the ability to send the booking notification and discharge electronically to other Health Care Professionals including the community midwife, GP and health visitor.
This must appropriately support the scenario where a neonate is being fostered or adopted and include the ability to send appropriate information to other maternity units.
When a neonate is separated (e.g. for adoption or fostering) the neonates details must not show on the woman's record - the link must be obscured to ensure that a non-custodial person cannot acquire data they are not entitled to.
M2.01.1 - Data Capture for All Women (Health Care Professional) |
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DCF Core Capability |
As a Health Care Professional I want the system to prompt me to enter all the necessary data I need to capture for antenatal and postnatal discharges, transfers (including in-utero transfers) and induction of labour So that I can ensure that I have a complete record of care Acceptance CriteriaGiven that a Health Care Professional is permitted to add clinical information to a woman's record on the system When the Health Care Professional needs to record all the necessary data needed for antenatal and postnatal discharges, transfers (including in-utero transfers) and induction of labour Then the Health Care Professional will be prompted by the system to record all the above-mentioned data |
Standards Compliance |
STD029 Dictionary of Medicines and Devices |
M2.01.2 - Data Capture for All Women (Health Care Professional working outside of index Trust) |
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DCF Core Capability |
As a Health Care Professional I want to receive the booking notification and all discharge summaries electronically when I am providing health care outside of the Trust (including GP, and Health Visitor) So that I have up to date (real time) information about the woman so that I can provide safe and personalised care. Acceptance CriteriaGiven that a Health Care Professional needs to receive booking notification and all discharge summaries electronically When the Health Care Professional is providing health care to a woman outside of their Trust (including GP, and Health Visitor) Then the Health Care Professional will have access to up to date information about the maternity care the woman has received And this will be in real time when information is recorded online or transferred immediately as soon as synchronisation occurs when information is recorded offline |
Standards Compliance |
STD029 Dictionary of Medicines and Devices |
M2.01.3 - Data Capture for All Women (Caldicott Guardian) |
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DCF Core Capability |
As a Caldicott Guardian I want to ensure that the neonate's details and health record are not visible to the birth parents when a neonate has been fostered or adopted So that I can follow data protection laws and safeguarding guidance and prevent a non-custodial parent from acquiring data that they are not entitled to Acceptance CriteriaGiven that a neonate has been separated from its parent either through fostering or adoption When a non-custodial parent attempts to access or acquire the neonate's details and or health records Then the neonate's details and or health records will not show on the parent's record on the system And the non-custodial parent will not have access to or be able to acquire the neonate's details and or health records And the system will have ability to send appropriate health care information regarding the neonate to other maternity units |
Standards Compliance |
STD009 Birth notifications |
Capability M2.02
The solution must support the transfer of a woman to theatre and provide the facility to record indications for and outcomes of all operative procedures. Anaesthetic procedures and monitoring must also be recorded. (See also Capability M1.29 Anaesthesia)
M2.02.1 - Transfer of Pregnant Person to Theatre |
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DCF Core Capability |
As a Health Care Professional I want to be able to capture on the system information relating to a woman's transfer to theatre So that the maternity record is a complete record of all care that the woman has received. Acceptance CriteriaGiven that a Health Care Professional is permitted to add clinical information to a woman's record on the system When a woman is being transferred to theatre Then the Health Care Professional will be able to record on the system all information related to the woman's transfer to theatre including the following:
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Standards Compliance |
STD029 Dictionary of Medicines and Devices |
Capability M2.03
The solution must provide facilities to record the transfer of a women and neonate(s) to other units or wards within The Trust (e.g. intensive care, critical care and coronary care) and the reason for transfer. It must also be able to export information with details of the Transfer of Care for another organisation if required.
M2.03.1 - Transfer of Woman and or Neonate to Other Units or Wards |
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DCF Core Capability |
As a Health Care Professional I want to be able to capture on the system all data relating to the transfer of a woman and/or their neonate to non-maternity units or wards within the Trust (such as intensive care, critical care, and coronary care) So that I can ensure the woman receives seamless care Acceptance CriteriaGiven that a Health Care Professional is permitted to add clinical information to a woman's and neonates records on the system When the woman and/or their neonate are transferred to non-maternity units or wards within the Trust Then the Health Care Professional will be able to record on the system the reason for the transfer And the Health Care Professional will be able to share this information with external healthcare organisations if required from the system |
Standards Compliance |
STD029 Dictionary of Medicines and Devices |
Capability M2.04
The solution should link to early pregnancy assessments undertaken for the current pregnancy in Gynaecology services. There should be a manual verification that the assessment is relevant (e.g. not for a previous pregnancy)
M2.04.1 - Early Pregnancy Assessments |
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DCF Transformation Capability |
As a Health Care Professional in maternity I want to be able to view early pregnancy assessments for the current pregnancy that were performed by Gynaecology services So that I can have full information about all care delivered during the pregnancy Acceptance CriteriaGiven that a Health Care Professional is permitted to view a woman's record on the system When a woman has had early assessments undertaken for their current pregnancy by Gynaecology services Then the Health Care Professional will be able to view all the details of the early pregnancy assessments for the current pregnancy on the system And the Health Care Professional will be able to check that the information is relevant (i.e. not for a previous pregnancy) where two or more systems are integrated |
Capability M2.05
The solution should be able to easily identify a transfer of care and the reason for change, and automatically capture the financial pathway within reporting capabilities.
This should include flagging if a woman has double booked services at two or more providers for the same phase of pregnancy where that data is accessible to the solution.
If it appears that a duplicate booking is happening the solution should prompt questions about if this is a transfer of care or if a previous pregnancy has miscarried and thus that episode of care needs ending and a new episode or pregnancy starting.
M2.05.1 - Transfer of Care Identification |
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DCF Transformation Capability |
As a Hospital Administrator or Manager I want the system to identify the transfer of care of a woman from another maternity provider So that
Acceptance CriteriaGiven that there is a need to identify the transfer of care of a woman from another Trust When a woman books at the Trust Then the system would flag if the woman has double booked services at more than one provider for the same pregnancy And the system will prompt the Health Care Professional if it detects a duplicate booking is happening in order to check if this is a transfer of care or if a previous pregnancy has miscarried and thus that episode of care needs ending and a new episode or pregnancy starting And the Health Care Professional will be able to record the reason for the change on the system And the data provided in the system will be matched to the appropriate pregnancy And the Health Care Professional will be able to record on the system the transfers of into the service and out to another service And the system will automatically capture the appropriate financial pathway |
Standards Compliance |
STD039 Health and Social Care Organisation Reference Data |