Perinatal Data Collection Optimisation

Mandatory fields

A number of Perinatal Data Collection (PDC) data items

are mandatory.

Mandatory items are shaded yellow and must be

entered before moving to another section.

The yellow shading disappears once data is entered in

the mandatory field.

It is only possible to sign and save the data once the

mandatory fields are complete.

Birth order

A key PDC reporting field that is mandatory is Birth

order. For a singleton the birth order is recorded as 1.

In the case of twins, Baby A is recorded in Birth order as

a 1, and Baby B is recorded as a 2.

It is important to record multiple births carefully as

birth order is a key element of the PDC.

Visual identification of PDC data fields

Data fields included in the PDC extract will now appear

on-screen in blue text.

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NB. Blue text is not exclusively associated with PDC

data. Any data field that has reference text associated

with it also appears in blue.

The reference text for a PDC data field indicates “This information is required for Perinatal Data

Collection (PDC) purposes”.

Menu restructure: i-View Labour and Birthing

i) Labour/Birthing Information

Within the Labour and Birthing band there is a new

section called Labour/Birthing Information.

This section replaces Induction, Augmentation, 1st

Stage, 2nd Stage, Assisted Birth and Caesarean sections.

The information from these sections has been moved to

Labour/Birthing Information and conditional logic

applied to group data fields associated with the specific

Method of birth.

Drop down options for Method of birth are:

For example, if Caesarean lower segment is chosen as

the Method of birth, only data related to that type of

caesarean appears on screen for completion.

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Correspondingly, if Vaginal vacuum is chosen, all data

fields related to an assisted birth will appear on screen

and the caesarean data options will not be visible.

ii) Newborn Birthing Information

Within the Labour and Birthing band there is a new

section called Newborn Birthing Information.

This section replaces the Baby Birth and Apgars section.

This information is now included within Newborn

Birthing Information and conditional logic applied to

group data fields associated with Neonate outcome.

Drop down options for Neonate outcomes are:

Onset regular respirations

If any of the neonate outcomes are chosen, an Onset

regular respirations field appears for completion along

with other mandatory fields including Birth order, Sex at

birth and Apgar scores at 1 minute and 5 minute

intervals.

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Additional fields may appear once the Apgar score at 5

minutes is calculated.

The first example below shows data fields for a high

Apgar score (i.e. 7 and over). Apgar score at 5 minutes is

the last data field prior to Baby Vigilance Observations.

The second example shows a low Apgar score (i.e. 6 and

under) in the right column. The low score triggers the

appearance of additional fields so that Apgar score at

10 minutes can be calculated.

Fetal death

If Fetal death is chosen as the Neonate outcome, an

additional field entitled Appearance if stillborn appears.

iii) Fetal Blood Sampling

The number of fields in the Fetal Blood Sampling

section has been compressed.

Conditional logic has been applied to 2 new data fields:

FBS pH taken

FBS lactate taken.

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If the maternity clinician indicates either test was

performed, an additional field will appear to allow entry

of results for the specific test.

In the example below, an FBS lactate sample was taken

and an additional field appears to enter the intrapartum

fetal blood sampling results.

If the results entered are not within the appropriate

range, an error message will appear on screen.

Information on the ranges that apply to fetal blood

sampling is available in the reference text for the data

items.

Bulk data rectification (uncharting)

Uncharting refers to “undoing” a Results Copy that was

associated with an incorrect patient encounter.

It is now possible to unchart multiple data fields at

once, rather than doing individual fields one at a time.

Data copied from a mother’s chart to a baby’s chart via

i-View appears in the baby’s chart in the Neonatal

Copied Results band.

In this example data from the Birth Information section

will be uncharted.

Select the incorrect data by holding down the Ctrl key

whilst clicking on the individual data fields. The fields

will appear shaded once they have been selected.

Once all the required fields have been highlighted, right

click and choose Unchart from the menu options that

appear on screen.

An Unchart window will appear showing the data items

to be uncharted in a table.

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A reason is required (mandatory field) for uncharting

the data. If necessary, an item-specific reason can be

provided for each item within the table. Dropdown

options for Reason are:

If the same reason applies for all data items, it is

possible to auto-populate the Reason column by

choosing an option from the separate Reason field

beneath the table. NB. The dropdown options in this

field are the same as above.

The reason you choose in this field will be entered into

the table for all items.

The process is completed when the user Signs the

Unchart request.

Once the incorrect data is removed from the data field

an In Error message appears instead. This provides a

record of the incorrect data entry for clinical audit

purposes.

It is now possible for the correct data to be transferred

via the Results Copy function.

Notes

1. It is only possible for a maternity clinician to unchart results they have entered. It is not possible to

unchart another user’s entries. It is possible for a

Health Information Manager to unchart results if the

staff member who entered the results is no longer

available.

2. Results must be uncharted in the same place they were documented e.g. results documented in i-View

must be uncharted in i-View; correspondingly results

document in the Results tab in PowerChart must be

uncharted in PowerChart.

** Warning message **

Upon completion of the uncharting process a warning

message will appear on screen.

To clear the message, click OK. Ideally, this message

would appear once per uncharted record.

Unfortunately it currently appears for each data item

that has been uncharted e.g. 10 data items uncharted

will generate 10 warning messages to be cleared.

Please Note: This matter has been raised as a defect

with Cerner. Unfortunately it will most likely not be

rectified prior to go live in October.

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