There is no greater healthcare challenge than that of clinical information and documentation.  It is in gathering and making accessible information about the patient, about care provided and outcomes that we will be able to measure and improve efficacy. A Perinatal Informatics System is intended to provide all members of the healthcare team with comprehensive, accurate and timely information.  DUHS continues to be a leader in the implementation of the Perinatal Electronic Medical Record (EMR).

With the evolution of the Perinatal EMR in our setting, we have been able to customize within our system to enable the documentation of medication reconciliation across the continuum of care.  Comprehensive obstetrical care is documented in OB TraceVue (OBTV) to cover the entire span of obstetrical care, across pregnancies, multiple care providers, prenatal sites and newborn well-baby admission

Medication Reconciliation as defined in the 2007 JCAHO National Safety Goals requires accurate and complete reconciliation of patient medications upon admission, transfer and discharge from the hospital.  This is a mandatory goal for 100% of the patients served at Duke University Hospital.

OBTV provides the medical team a unique opportunity to view the patient’s ongoing medication list.  This list can be accessed at any visit and validated with the patient by all members of the care team.  OBTV is used by multiple disciplines, including pharmacy who documents the medication reconciliation in the progress section of the record.  This provides easy communication with the medical team.