Add Obstetric Information to an Encounter

Add and update a patient's pregnancy history and active pregnancy in Obstetric Hx. Record the estimated due date (EDD) details, vital signs, initial physical exam information, and daily observations, and print an Antepartum Report Form.

To learn how to enter a patient's obstetric history in the patient chart, refer to Patient Chart: Obstetric Hx.

Notes about EGA

• In Obstetric Hx, estimated gestational age (EGA) is based on the current date.
• In Physical Exam (Obstetric > Observations), EGA is based on the encounter date.
• In EHR, the EGA calculation method shows under Obstetric History (Active Pregnancy) in Encounter Summary Preview and the clinical summary print preview.
• In Patient Portal, the EGA calculation method shows in the Encounter Note (including print preview).

Contents

Add a Past Pregnancy
Add an Active Pregnancy
Enter Vital Signs
Physical Exam
Antepartum Report Form

Navigate to Obstetric Hx

In an encounter, click S on the SOAP menu, select Patient Hx, and then select Obstetric Hx.

Add a Past Pregnancy

Add a past pregnancy in the Pregnancy Hx section.

1. Click Add a Pregnancy.

2. Enter the pregnancy details.
3. Click Save Changes.

Add an Active Pregnancy

1. Click Add an Active Pregnancy.
2. Click Details.

EDD

After you click Details, the EDD tab opens. 

3. Enter the EDD information.
4. Select the EGA Calculation method. 

5. Click Save Changes.

Within the Obstetrics Hx tab, the Active Pregnancy section shows above the Pregnancy Hx section. The selected EGA calculated method is shown next to the gestational age. Our example shows the EGA as based on LMP.

Initial exam, ultrasounds, fundal height at the umbilicus, and quickening rows sort according to the dates entered with the oldest date at the top below LMP. LMP, initial EDD, and final EDD rows do not move.

Newborn & Provider

1. Click the Newborn & Provider tab.
2. Enter the information within the Newborn and Providers sections.
3. Click Save Changes.

Enter Vital Signs

1. Click O on the SOAP menu and select Vital Signs.
2. Click Enter Vitals.
3. Enter the vital signs information.
4. Click Save.

Information saved here, including blood pressure, pain level, and height and weight will prepopulate within Observations in Physical Exam.

Custom lab urine tests are available within the LABS - URINE tab.

5. Click a urine test.
6. Enter the values.
7. Click Save.

Information saved here will prepopulate within Observations in Physical Exam .

Physical Exam

Initial Physical

1. Click O on the SOAP menu and select Physical Exam.
2. Click the Obstetric tab.
3. Click Initial Physical.
4. Click Initial Exam.
5. Enter the initial physical exam information. 
6. Click Save.

This information will prepopulate within Observations.

Observations

1. Click Observations.
2. Enter/select observations.

Example comment: The EGA calculation method has changed to ULTRASOUND 1.

3. To create a follow-up reminder, click the button below Next Appointment. 
4. Click Save Changes.

You are notified when observations meet the space limit for the Antepartum Report Form.

Create a Follow-up Reminder

1. Click the button below Next Appointment. 
2. Make your selections.
3. Click Save.

Scheduled follow-ups appear in Recall List in PM (Schedule > Recall List).

Antepartum Report Form

Print the Antepartum Report Form

1. Within the Active Pregnancy section, click Print.

Your print request is queued and will be available in Administrative in the patient's chart. The print request message notifies you that when you export the Antepartum Report, your observation notes may be truncated.

The Antepartum Report Form is available in the Documents section in Administrative.

2. ​To download the form, click the file or select the row and then click Download.

 

See Also:
Patient Chart: Obstetric Hx