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Volume 11. Printed Maternal, Neonatal and Child Casenotes.
Volume Editor: Rupert Fawdry and Helga Perry (So far)To see a sample page Click here
If interested in the possibility of editing this volume Click here
Current Master copy is with: RF (Panel11-13RF.pages)
Discussion Links: None specific yet. Use EEPDtalk at www.eepd.org.uk
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“We haven’t thrown away all our radios because television has been invented.
Paper is not obsolete, just because we now also have electronic records”
In acute hospital medicine in most of the world, paper cannot yet (cannot ever?) be abandoned, especially for pregnancy records held by the expectant mother - and this probably also applies to maternity records of continuing clinical care. Indeed, purely Electronic Records have major disadvantages and may sometimes even be dangerous.
If paper is to be complementary to highly complex EPRs, then more attention needs to be given to the quality and content of such paper records.
But the diffusion of information about the design of such case-notes has, until now, been mainly a matter of chance.
The long term aim of this volume will therefore be
a) to facilitate access to as many different designs as possible,
b) to suggest various principles which should be followed in their design,
c) to explore what items may sometimes or always be included in such records
d) to suggest which data items might need to be standardised and which can be left flexible.
In time it may assist in the process of developing a standard national (international?) paper record which matches the specification for a national (international?) maternity EPR set of flow-patterned, chronologically arranged definitions of questions and all allowable answer options. However because of the flexibility of paper compared with electronic data-sets there is far less need for any kind of standardisation, especially since standardisation inevitably handicaps attempts at creative innovation
(18 Nov 2010)
“We haven’t thrown away our shoes because of the invention of the motor car.”“
“We haven’t thrown away all our radios because television has been invented.”
In a similar way electronic records are both different from, and complementary to, paper records.
Despite what some have, in the past assumed, it is becoming more and more obvious that in future,the vast majority of hospitals, even in the developed world, will not be “Paperless“ but “Paper-light. In other words they will need to cope with both “Chips and Paper! (or rather “Chips and Paper; and Sticky Labels”)
Indeed it may well be said that
“A Paperless system is Yesterday’s Fantasy;
but a Less Paper system could be Today’s Reality”
Finally the vital general principle
“If you want to design a good electronic system,
always get your paperwork up to the highest possible standard first!”
To fail to do this is to guarantee a dysfunctional computer system.
Three Main Perspectives
This volume looks at perinatal paper records from three main perspectives.
- First, a look at the difference between type of data items which can be included in a printed paper record as compared with the electronic version, using the Fertility History Problems as an example.
- Secondly, regarding maternity record design:
This section facilitates access to several initiatives and many examples. For a general article on the principles which need to be considered in such designs, see “Antenatal Records carried by Expectant Mothers“
- Thirdly: Although printed items differ from electronic data items, for the sake of efficient, error-free and cost-effective entry of data from paper records to electronic databases, there needs to be a clear relationship between the data items in each format. For this reason, suggestions are made as to what printed items should be included, and in what order, in a printed paper record.
1. The Design of Paper Records
Many of the records illustrated in this section involve copyright; and for this reason it is recommended that the section regarding copyright issues and medical proformas &/or records be read at an early stage when using this section
For the reasons set out in www.fawdry.info/eepd/01_ess/b_eprs/B03_Hybrids.pdf, hospital paper records are unlikely to be totally supplanted by electronic records for many years (if ever); and as long as such paper records continue to exist, the quality of maternity care will to a greater or less extent depend upon the detailed design of such paper records.
a) Overview of the general principles regarding the design of such records.
b) Main U.K. Maternity & Neonatal Initiatives (Past and current)
This section provides easy access to the main U.K. initiatives relevant to the creation of paper maternity records used in more than one district i.e. i) the Green Notes (created in 1985 in Milton Keynes and subsequently used by over a million women in the West Midlands region and elsewhere), ii) the National Pregnancy Record Project, iii) the (West Midlands Perinatal Institute) Pregnancy Notes and iv) the Scottish Pregnancy Record Project
c) Examples of other Paper Maternity Records from the Wealthier Countries
Over the past thirty years the writer has built up a massive and unique collection of paper maternity records, both from Britain and many other parts of the world. In order to facilitate the spread of potentially useful ideas it is intended to provide access to a gradually increasing number of such records on or through this web site.
d) Ideas from the Two-Thirds World.
Starting with the WHO recommended “Family Health Card” (in various languages) it is intended that this section of the EEPD provides access to good design ideas, especially pictorial ideas, from several two-thirds world countries.
e) Birth and Pregnancy Preferences
For something as unpredictable as Birth it seems better to call these “Birth Preferences” rather than the traditional “Birth Plans”.
This part of the paper maternity record involves particular problems and opportunities. For this reason examples of several useful approaches are included here. (Pending)
If you do have access to any local maternity or neonatal records which you feel have unique features which may contribute to the creativity of others, we would be grateful if you could send two copies by post to me, Dr Rupert Fawdry, 31, St.Mary’s Way, Leighton Buzzard, LU7 2RX, U.K. or even better send them as a set of scanned .pdf or .doc files to email@example.com.
2. Printed Paper Data Sets NOT the same as Electronic Data Sets
Although there have been attempts to create paper records which try to mimic computer data sets (e.g. the 1980-90 Leeds Maternity Records) or computer screens which have tried to mimic the appearance of paper records (as partially attempted by Protos and other computer companies) experience has shown that the best version of the two kinds of record demand a very different design. A vivid example is provided by the question(s) regarding a past history of fertility problems. Note particularly the importance in the electronic version of asking the right questions in the right order to avoid having to enter the same data twice.
A. PRINTED PAPER VERSION
The best Paper Versions, in the Past Medical Problems Section, will normally include the following:
“Fertility Problems?” No / Yes (If Yes, give Details)
Followed by adequate space for free hand-written text for example:
B FLOW-PATTERNED ELECTRONIC EQUIVALENT VERSION
Based on the Qs & A options subsequently used by Protos / iSoft Evolution.
The order of the questions is important, e.g. asking about tubal surgery in the past needs to come before asking about any medication which led to the present pregnancy etc.
IG10. Fertility Problem ever? No / Yes / Unknown / Other (free text)
Help: Answer ‘Yes’ if the expectant mother has ever had any infertility problem I
If this expectant mother has not had any infertility problems - enter “No”
and you will skip the next two questions.
If IG10 = “No” or “Unknown” or “Other”, then jump to IH10
IG15 Infertility Investigations ever? No / Yes / Unknown / Other (free text)
Ever had any investigations for infertility?
Help: Answer “Yes” if this expectant mother and/or her partner
have ever had sufficient worries about infertility as to have had any investigations,
even if, in the end she and her partner did not need any treatment.
If IG15 = “No” or “Unknown” or “Other”, then jump to IH10
IG20 Any Infertility Treatment ever? No / Yes / Unknown / Other (free text)
Help: Answer Yes if this expectant mother has ever had any infertility treatment,
whether it resulted in this pregnancy or not.
The order of the questions is very important here if ambiguity is to be avoided.
For example someone may have had tubal surgery a few months ago,
as well as Clomid in this present pregnancy etc.
If IG20 = “No” or “Unknown” or “Other”, then jump to IH10
IG25 Previous Tubal Surgery No / Yes
Help: Has the expectant mother ever had surgical treatment for infertility.
Sterilisation_Reversal No / Yes
Repair of P.I.D damage No / Yes
Ectopic No / Yes
Unknown or Other reason Allow 1 line
IG30 “Other“ Infertility Treatment ever No / Yes / Unknown /
Help: This question allows it to be recorded that this mother had Clomid two months ago
even if this actual pregnancy did not result directly from the Clomid treatment
If the mother has had surgery, then naturally this pregnancy would be considered
to be a result of that surgery even if the surgery had taken place several years ago.
Hence the very specific wording and order of questions used here.
If IG30= “No” or “Unknown” or “Other”, then jump to IH10
IG40 This pregnancy from prescribed medical or other non surgical treatment No / Yes
Help: Answer Yes only if this pregnancy was the immediate result of a specific treatment
(i.e. Not including past treatment such as tubal or similar surgery)
Clomiphene No / Yes
Tamoxifen No / Yes
Pergonyl No / Yes
HCG No / Yes
Insemination No / Yes
IVF No / Yes
GIFT No / Yes
Other (free text) Allow 1 line
IG45 Previous drug, AID or IVF treatment No / Yes
Answer Yes if this expectant mother has previously had any treatment for infertility
(Not including tubal or similar surgery) even if this did not result in this pregnancy
Clonidine (Clomid) No / Yes
Tamoxifen No / Yes
Pergonyl No / Yes
HCG No / Yes
Artificial Insemination by Donor No / Yes
Artificial Insemination by Husband No / Yes
In Vitro Fertilisation No / Yes
GIFT No / Yes
Other (free text) Allow 2 lines
Unknown No / Yes
Need here to have a further set of questions and answer options regarding the Fertility Centre or hospital which provided any of the treatment so that the outcome of the pregnancy can be automatically fed back to them - electronically or on paper
IH10 Jump to IJ10
i.e. End of this section of a flow-patterned electronic data entry concerning infertility, and jump to next topic.
Attempts to mimic on paper the flow-patterning of an electronic version results in so many pages of printed and hand-written material, that the risk of medical errors almost certainly increases, since important answers get lost in tightly packed pages of text.
Attempts to mimic the simplicity of the paper record on computer leads to a mass of free text which cannot be used as the basis for an electronic data set.
In the light of such fundamental differences it is amazing that so much effort has been wasted so many times on attempting to do this.
c) Suggested Minimum Set of Items to be included in all Printed Records.
As a result of my involvement first in the 1984 Milton Keynes/West Midlands “Green Notes” initiative, then as a member of the working party for the National Maternity Record Project, and most recently the creation of the (West Midlands) Perinatal Unit “Pregnancy Notes” it is recommended that whatever detailed design is used for a paper maternity record the data items in EEPD Volume 5 Logical Priority Core Data-set should be included as nearly as practical in the logical order suggested.
Only when such a standard order has become as uniform as practical will it be possible to create computer systems of the degree of complexity which will in future be required.
Until then each hospital and district will continue to build simple maternity computer systems which fit with their own local paper record but which are incompatible with every other electronic record anywhere else in the world.
Rupert Fawdry (Updated 18 Nov 2010)