부산대학교 도서관

The Obstetric Inpatient Discharge Summary is a document considered essential in the complex care network for health care continuity. AIMS: The study proposes a model for the transmission of clinical information contained in the discharge summary with the aim of exchanging the information between electronic systems and defining standards, allowing the testing of obstetric records interoperability, referring, in particular, to births. METHODS: Information was modeled using the methodology for developing archetypes proposed in the International Standardization Organization 13606 standard. RESULTS: The electronic document was implemented in a university hospital, and the information was divided into two sections, one containing maternal data and the other neonate(s) information. An Electronic Health Record extract in eXtensible Markup Language, containing structured clinical data, will constitute the vector of transmission system from hospital information to primary care units. CONCLUSION: The model proposed is expected to subsidize information semantic persistence, contributing to health care quality.