antenatal care city and hackney template guide 2016/17 · 2019-11-20 · 2 template control page...

1

Antenatal Care City and

Hackney Template Guide

2016/17

2

Template Control Page Antenatal Care City and Hackney Template Guide

Title Antenatal Care City and Hackney CEG

Author CEG

Version 9

Description This template supports City and Hackney Early Years Service(vr8)

Date December 2016

DOCUMENT MANAGEMENT REVISION HISTORY

Version Date Summary of Changes

1.0 October 2012 The version number starts at 1.0 to reflect rationalisation process.

1.1 16 Oct 2012 Information box corrected to show target group is 28 to 38 weeks.

1.2 April 2013 Added gravida codes and last entry of gestational diabetes.

1.3 Nov 2013 Replaced EDD diary entries with EDD read codes (to support better data collection for pertussis campaign)

1.4 June 2014 Added first presentation page, smoking page, alcohol page and immunisation page. Added Subsequent exams page for any exams done after the 16 week exam. Modified Rhesus Blood grouping picking list, Added Anti D globulin needed prompt (8B81). Added gestational calculator web link. Added A/N care social risks, A/N care Obstetric risks, Parity and Mat B1 signed, modified Pertussis information and added Diary entry for Pertussis. Removed Folic Acid Advice in 1st trimester (67AE), Vitamin D Supplements (8B73) due to Healthy Start.

Vr1 July 2014 Added to Emis Template Library so version numbering reset. Added Enhanced Service checks.

Vr 2 May 2015

Vr 3 August 2015 Replaced Pertussis codes with: 6556. Pertussis vaccination in pregnancy 65560 Pertussis vaccination in pregnancy given by other healthcare provider 8IEc. Pertussis vaccination in pregnancy declined 68NQ0 Pertussis vaccination in pregnancy contraindicated Removed Last entry of Flu jab, old code no longer used (65ED)

3

Vr4 September 2015

Added codes for the referral form. Added Last Haemoglobin value. Created a separate page for Subsequent Appointments. Added the FGM page. Added Gravida codes (after parity): Gravida 1 (1532), Gravida 2 (1533), Gravida 3 (1534) Gravida 4 (1535), Gravida 5 (1536), Gravida 6 (1537), Gravida 7 (1538),

Gravida 8 (1539), Gravida 9 (153A), Gravida 10 (153B), Gravida more than

10 (153C. Modified the ES Check information box to indicate that the Obstetric and social risks are to be done in the 4 months prior to the 16 week exam

Vr5 Nov 2015 Reinstated Boostrix code so that the woman’s Immunisation history is complete. Replaced corresponding Diary entries. Added note indicating the payment code. Added Edinburg Depression Scale page

Vr6 April 2016 Update of Information for Pertussis programme (from NHS Employer)

Vr7 June 2016 Amendments: 1st presentation page made into library item

Additions:

Section headers: Obsetric History; Examination, Antenatal Advice, Consider aspirin and iron supplements, depression

screening **A/N booking apt; A/N obstetric risks/AN Social

risks; refer to antenatal clinic for 1st presentation Prompts:

Gravida NOS (153Z)

Info on Family Nurse Partnership Referral to family nurse partnership Depression screening info Depression screening prompt Edinburgh depression scale MSU sent to lab (4615) Healthy start info to 16 week check Retired: ES Page until further confirmation

Vr8 December 2016 Added Enhanced service label ** to Social Risk assessment for 16th week exam. Updated risk assessment information to indicate that risk exams must be redone at 16 week exam.

V9 Removed referral to antenatal clinic from 16 week exam. Modified Pertussis Vaccination info. Added Flu info. Blood Test Results page added. Added UPP, Child Health Check and 16th Birthday check pages. Added web link for Healthy Start.

AUTHORISATION

Reviewed by Approved by Date Date sent to EMIS

Luis Rivas Dr Kirsten Brown

December 2015

Jo Tissier Kirsten Brown June 2016

December 20016

Library Items, and concepts used by this template

4

Library Items

Antenatal -1st presentation City and Hackney CEG

Lifestyle Intervention CEG 1.0

Female Genital Mutilation (FGM)

Edinburgh Depression Scale CEG

Ethnicity CEG 1.0

5

Prompt Code What does this prompt mean EMIS WEB Consult. Section

1st Presentation

Info CH Payment Indicator: Extended (i.e20mins) GP consultation at pregnancy presentation

**A/N booking examination

62N1 Tick box Text box: 1st Presentation Appt at practice

Info LMP and EDD must be entered. Also record patient pregnant if not recorded.

Patient currently pregnant

621 Tick box History

Last menstrual period -1st day

1513 Tick box Date prompt

History

Gestational calculator - http://www.patient.co.uk/doctor/Obstetric-Calculator.htm

Estimated date of delivery from last period

15140 Tick box Date prompt Text box: Enter number of weeks

History

Length of Gestation 62X Tick box Enter number of weeks

History

Risk Assessment Info

Info Conduct a risk assessment to ensure all social and medical issues are discussed with the pregnant woman

**A/N care obstetric risks

A/N care: H/O poor obstetric history (6236) A/N Care: No obstetric risk factors identified (EMISNQAN31) Text box for details

History

**A/N care social risks

A/N care: social risk NOS (625Z) A/N Care: No social risk factors identified (EMISNQAN30) Text box for details

History

Parity Nulliparous (1521) Para 1 (1522) Para 2 (1523) Para 3 (1524) Para 4 (1525) Para 5 (1526) Para 6 (1527) Para 7 (1528)

History

Antenatal Care City and Hackney Template Guide

http://www.patient.co.uk/doctor/Obstetric-Calculator.htm





6

Gravida Gravida 1 (1532) Gravida 2 (1533) Gravida 3 (1534) Gravida 4 (1535) Gravida 5 (1536) Gravida 6 (1537) Gravida 7 (1538) Gravida 8 (1539)

History

Gravida 9 (153A) Gravida 10 (153B) Gravida more than 10 (153C) Gravida NOS (153Z)

Obstetric History

H/O Obstetric problem

H/O: Eclampsia (15A3) H/O: Pre-Eclampsia (15AB) H/O: Caesarean Section (15A2) H/O: Perinatal Fetal Loss (15A8) H/O: Manual Removal of Placenta (15A5) H/O: Previous Forceps Delivery (15AA) H/O: Obstetric Problems NOS (15AZ) Select more than one Text Line: Give detail

Examination

BP 246 Value Examination

O/E – height 229 Tick box Examination

O/E - weight 22A Tick box Examination

BMI 22K BMI Widget, click to obtain BMI score Assessment

Info Use Lifestyle Intervention Page to record smoking, alcohol, exercise and diet advice

Family Nurse Partnership Visibility rule: Age less than 20 CEG

Info Family Nurse Partnership is a support programme for first time young mothers (and fathers) aged 19 or under. Find referral form in documents tab.

**Referral to family nurse partnership

8T0a Tick box

Info AND refer to antenatal clinic

Referral to Antenatal Clinic

**Referral to antenatal clinic

8HT9 Tick box

Antenatal Advice

Pregnancy 67A Tick box Additional

7

advice

Info Every expectant mother is entitled to free Healthy Start vitamins from her booking visit until her child reaches 1 year. Women who receive benefits may also be entitled to vouchers for fruit, vegetables and milk. For more information see Healthy Start leaflets

Healthy Start guidance

Hyperlink http://www.blizard.qmul.ac.uk/~ceg01?opt=general&alias=ch-guidance-for-health-and-care-professionals

Healthy Start Program

6B7 Tick box Additional

Advice about Antenatal screening

EMISNQ AD49

Tick box

Additional

Click here for diet and lifestyle advice during pregnancy leaflet

http://www.patient.co.uk/health/diet-and-lifestyleduring-pregnancy

Click here for pregnancy screening tests

http://www.patient.co.uk/health/pregnancy-screeningtests

Folic Acid and Aspirin Advice

Info Folic acid 400mcg or folic acid 5mg if diabetic, BMI>30, on anti-epileptic medication, history or family history of neural tube defects. Check that aspirin has been prescribed to high risk women.

Click here for Folic Acid Advice and Vitamin D Advice

Hyperlink http://blizard.qmul.ac.uk/~ceg01?opt=Antenatal&alias= folic-acid-and-vitamin-d-guidelines-may-2016

Click here for aspirin advice

Hyperlink http://blizard.qmul.ac.uk/~ceg01?opt=Antenatal&alias= aspirin-in-pregnancy

Info Use medication module to code medication review done.

Depression Screening

Info During the past month have you often been bothered by:

1. Little interest or pleasure in doing things?

2. Feeling down, depressed or hopeless?

3. Is this something you would like help with?

http://www.blizard.qmul.ac.uk/~ceg01?opt=general&alias=ch-guidance-for-health-and-care-professionals


http://www.patient.co.uk/health/diet-and-lifestyle-during-pregnancy










8

Depression screening using questions

6896 Tick box Additional

Info Use Edinburgh Page to assess depression

Diary Dates

Info Use Immunisations Page to record diary entry for Pertussis vaccine

A/N 16 week examination due

62N3 Diary entry Additional

**16 week examination Page

**16 week examination **indicates locality payment

Info CH Payment Indicator: Extended consultation to women for the 16 week antenatal review.

**AN 16 week exam

62N3 Tick box Tool tip: CH Payment Indicator: Extended (i.e20mins) GP consultation at 16 weeks

Examination

Estimated date of delivery from scan


History


Length of Gestation 62X Tick box Text: Enter number of weeks

History

Risk Assessment Info

Info Conduct a risk assessment to ensure all social and medical issues are discussed with the pregnant woman, if not already done. This is additional to the risk assessments done at presentation.

Recheck social risk and consider if any further action needs to be taken (including safeguarding issues)

**A/N care obstetric risks

A/N care: H/O poor obstetric history (6236) A/N Care: No obstetric risk factors identified (EMISNQAN31) Text box

History

**A/N care social risks

A/N care: social risk NOS (625Z) A/N Care: No social risk factors identified (EMISNQAN30) Text box

History

**Discussed Screening results.

41C3 Text box Additional

Examination






9

**Blood Pressure

246 Value Examination

Urine Protein Test

Urine protein test not done (4671) Urine protein test negative(4672) Urine protein test = trace(4673) Urine protein test = +(4674) Urine protein test = ++(4675) Urine protein test = +++(4676) Urine protein test = ++++(4677)

Result

Urine test for glucose

Urine glucose test not done (4661) Urine glucose test negative (4662) Urine glucose test = trace (4663) Urine glucose test = + (4664) Urine glucose test = ++ (4665) Urine glucose test = +++ (4666) Urine glucose test = ++++ (4667)

Result

MSU sent to lab

4615 Tick box Test result


Antenatal Advice

Pregnancy advice

67A Tick box

Click here for diet and lifestyle during pregnancy leaflet





Healthy start programme

6B7 Tick box

Aspirin and Iron advice

Info Check that aspirin has been prescribed to high risk women

Click here for aspirin advice

http://blizard.qmul.ac.uk/~ceg01?opt=Antenatal&alias= aspirin-in-pregnancy

Info Investigate a haemoglobin level of less than 11g/dL and consider iron supplementation if indicated

Haemoglobin 423 Last entry of code Include child codes

Info Give information on anomaly scan



10

Info Use medication module to code medication review done

Family Nurse Partnership Visibility rule: Age less than 20 CEG

Family Nurse Partnership is a support programme for first time young mothers (and fathers) aged 19 or under. If not already referred find referral form in documents tab.

Referral to Family Nurse Partnership team

8T0a Tick box

Info OR refer to antenatal clinic







3896 Tick box

Info Use Edinburgh Page to assess depression

Diary Dates

Info Use Immunisations Page to record flu and pertussis vaccine

F/up antenatal examination due

62N Diary entry

Subsequent Appointments Page

Subsequent appointments

Antenatal examination

62N Tick box Examination

Estimated date of delivery from scan


History


Length of Gestation 62X Tick box History Enter number of weeks

Examination

O/E BP 246 Value Examination






11

Urine Protein Test Urine protein test not done (4671) Urine protein test negative(4672) Urine protein test = trace(4673) Urine protein test = +(4674) Urine protein test = ++(4675) Urine protein test = +++(4676)

Result

Urine protein test = ++++(4677)

Urine test for glucose

Urine glucose test not done (4661) Urine glucose test negative (4662) Urine glucose test = trace (4663) Urine glucose test = + (4664) Urine glucose test = ++ (4665) Urine glucose test = +++ (4666) Urine glucose test = ++++ (4667)

Result

MSU sent to lab

4615 Tick box Test Request


Fetal Presentation

O/E - fetal movements

O/E - no fetal movements (2751) O/E - fetal movements seen (2752) O/E - fetal movements felt (2753) O/E - fetus very active (2754) O/E - fetal movemnt.diminished (2755) O/E - fetal movements NOS (275Z)

Examination

O/E - Fetal Heart Heard

O/E - fetal heart not heard (2761) O/E - fetal heart 80-100 (2764) O/E - fetal heart 100-120 (2765) O/E - fetal heart 120-160 (2766) O/E - fetal heart 160-180 (2767) O/E - fetal heart 180-200 (2768)

Examination

Fundal height 27D Tick box Examination

Info Fetal presentation to be checked from 36 weeks gestation

O/E - Fetal Presentation

O/E - vertex presentation (2721) O/E - breech presentation (2722) O/E - oblique lie (2723) O/E - transverse lie (2724) O/E - multiple presentation (2725) O/E -fetal presentation unsure (2726) O/E - fetal presentation NOS (272Z)

Examination

O/E - presenting part station

O/E - presenting part free-5/5 (2741) O/E - presenting part free-4/5 (2742) O/E - partial engagement - 3/5 (2743) O/E - partial engagement - 2/5 (2744) O/E - presentation engaged-1/5 (2745) O/E - fetal station NOS (274Z)

Examination

Antenatal Advice

Pregnancy advice

67A Tick box

12

Click here for diet and lifestyle during pregnancy leaflet





Healthy start programme

6B7 Tick box

Additional

Anti D globulin needed

8B81 Tick box Text box Result

Place of delivery booked

Home delivery (62B2) Consultant unit (62B4) Midwife unit (62B8) No place booked (62B1)

Additional

Mat B1 signed

9542 Tick box Additional

Breastfeeding Education

8C1H Tick box Additional

Antenatal Education

679E Tick box Additional







3896 Tick box

Edinburgh postnatal depression scale

3885 Assessment

Diary Dates

F/up antenatal examinations

62N Diary Entry

Blood Test Results Page



13

Haemoglobin Estimation 423 Value Date prompt

Result

Serum Ferritin 42R4 Value Result

ABO Blood Group Blood Group A (4312) Blood Group B (4313) Blood Group AB (4314) Blood group O (4315) Date prompt

Result

Rhesus Blood Grouping Rhesus negative (4321) Rhesus positive (4322) Rhesus blood group phenotyping (4324) Rhesus and Kell blood group phenotyping (4325)

Result

Rhesus Antibody Rhesus antibody absent(4361) Rhesus antibody present (4362) Date prompt

Result

Hep B Antigen SH Antigen negative (43B3) Hepatitis B surface antig +ve (43B4) Date prompt

Result

HIV Status HIV negative (43C2) HIV positive (43C3) Date prompt

Result

Syphilis Syphilis titre test negative (4381) Syphilis titre test positive (4382) Date prompt

Result

HbA1c (IFCC) 42W5 Value Result

Glucose Level Plasma glucose level (44g) Serum glucose level (44f) Date

prompt

Result

Glucometer Blood Sugar 44T9 Tick box Result

Glucose Tolerance Test Glucose tolerance test normal (44V1) Glucose tolerance test impaired (44V2) Glucose tolerance test diabetic (44V3)

Result

Immunisations Page

Administration

Influenza vaccination invitation letter sent

9OX6 Tick box Additional

14

Influenza vaccination telephone invite

9OX7 Tick box Additional

Seasonal Influenza

Info Flu vaccination to be given at any time during pregnancy

*Seasonal Influenza vaccination

65ED Tick box Procedure

* Seasonal Influenza vaccination by other healthcare provider

Seasonal Influenza vaccination by other healthcare provider (65E20) Seasonal Influenza vaccination by pharmacist (65ED0) Text box

Procedure

Flu Vaccine Exceptions

Seasonal influenza vaccination declined (9OX51) Seasonal influenza vaccination contraindicated (8I2F0) Seasonal influenza vaccination not indicated (8I6D0) H/O: influenza vaccine allergy (14LJ)

Additional

Seasonal influenza vac due

65ED Diary Entry Date prompt

Pertussis

Info Pertussis vaccine as part of Booxtrix-IPV should be offered to all pregnant women, including those immunised in childhood, as early as possible, after 16 weeks gestation and by week 40 of pregnancy. It can be offered at the same time as the flu vaccine, but in a different site. Vaccination against influenza should not be delayed to be given alongside pertussis vaccine. There’s a New Homerton Antenatal Vaccination Service, they will notify practices of patients who do not get vaccinated or decline at their anomaly scan. Vaccination may also be offered beyond week 38 40, including new mothers who have missed the opportunity to be vaccinated during pregnancy and who have not previously been vaccinated to provide protection against pertussis, up to when their child receives their first vaccination.

Low dose diphth, tet, acellular pert and inactiv polio vacc

65I8 Diary entry: pertussis Date Prompt

Low dose diphth, tet, acellular pert and inactiv polio vacc

65I8 Tick box and enter vaccine details Procedure

Info Box For payment purposes also tick Pertussis vaccination in pregnancy

15

**Pertussis vaccination in pregnancy

6556 Tick box Procedure

Pertussis vaccination given in pregnancy by other HCP

65560 Tick box Procedure

Declined/contraind icated

8IEc. Pertussis vaccination in pregnancy declined 68NQ0 Pertussis vaccination in pregnancy contraindicated

Additional

Edinburg Depression Scale Page (Library Item)

Edinburg Scale Instructions

Ask the patient how they have felt in the PAST 7 DAYS Questions are scored differently as follows: QUESTIONS 1, 2, & 4 Are scored 0, 1, 2 or 3 with top box scored as 0 and the bottom box scored as 3 QUESTIONS 3, 5-10 Are reverse scored, with the top box scored as a 3 and the bottom box scored as 0 Press 'Calculate' button to record their score (each question must be answered)

EPND score question 1

EMISHG T021

Q1. I have been able to laugh and see the funny side of things Enter Score: 0 - As much as I always could 1 - Not quite so much now 2 - Definitely not so much now 3 - Not at all

EPND score question 2 - enjoyment

EMISHG T022

Q2. I have looked forward with enjoyment to things Enter score: 0 - As much as I ever did 1 - rather less than I used to 2 - Definitely less than I used to 3 - Hardly at all

EPNDS question 3 - blame

EMISHG T023

Q3. I have blamed myself unnecessarily when things went wrong Enter score: 3 - Yes, most of the time 2 - Yes, some of the time 1 - Not very often 0 - No, never

EPNDS question 4 - anxiety

EMISHG T024

Q4. I have been anxious or worried for no good reason Enter score: 0 - No, not at all 1 - Hardly ever 2 - Yes, sometimes 3 - Yes, very often

EPNDS question 5 - panic

EMISHG T025

Q5. I have felt scared or panicky for no very good reason Enter score: 3 - Yes, quite a lot 2 - Yes, sometimes 1 - No, not much 0 - No, not at all

16

EPNDS question 6 - overcome

EMISHG T026

Q6. Things have been getting on top of me Enter score: 3 - Yes, most of the time I haven't been able to cope at all 2 - Yes, sometimes I haven't been coping as well as usual 1 - No, most of the time I have coped quite well 0 - No, I have been coping as well as ever

EPNDS question 7 EMISHG T027

Q7. I have been so unhappy that I've had difficulty sleeping Enter score: 3 - Yes, most of the time 2 - Yes, sometimes 1 - Not very often 0 - No, not at all

EPNDS question 8 - sadness

EMISHG T028

Q8. I have felt sad or miserable Enter score: 3 - Yes, most of the time 2 - Yes, quite often 1 - Not very often 0 - No, not at all

EPNDS question 9 - crying

EMISHG T029

Q9. I have been so unhappy that I have been crying Enter score: 3 - Yes, most of the time 2 - Yes, quite often 1 - Only occasionally 0 - No, never

EPNDS question 10 - selfharm

EMISHG T030

Q10. The thought of harming myself has occurred to me Enter score: 3 - Yes, quite often 2 - Sometimes 1 - Hardly ever 0 - Never

Score EMIS Customs Calculati on

Add up scores of each of the above questions: Score = q1+q2+q3blame+q4anxiety+q5panic+q6overcome+q7sleep+ q8Sadness+q9crying+q10selfharm

Interpretation Maximum score is 30 Possible Depression is 10 or greater Note: Always look at item 10

antenatal care city and hackney template guide 2016/17 · 2019-11-20 · 2 template control page...

Documents