Introduction

This training material is a review on how to enter pregnancy history in the pregnancy outcome template. 


Topics Covered

  • Accessing template
  • Quick Entry/Edit
  • Detailed Entry/Edit

Accessing Template

1. After opening the patient chart and performing the 4-point the check, click on the OBGYN Details sub-link in the patient information bar.

2. The OBGYN synopsis window will open, under Pregnancy History, click the 'Add/Update Detail' button to open the Pregnancy Outcome template.


Quick Entry/Edit

In this panel, a quick entry can be manually be entered. Note: Users would need to document in the Detailed Entry/Edit panel first before doing any editing in this field. 

1. Click in the desired boxes.

2. A number pad will prompt for selection.

3. After entry, click the 'Save and Close' button.



Detailed Entry/Edit


1. Enter the following:

a. Pregnancy entry type (required field)

b. Pregnancy number

c. If the patient had twins or more enter then would have to enter each one.

d. Select sex of the baby

e. Enter provider that performed delivery

f. Enter the place of delivery

2. Enter the following:

a. Enter the delivery date

b. Enter the time of baby delivered

c. Enter the hours the patient was in labor (if the information is obtained)

d. Enter baby’s name

e. Enter supporting person(s) of the delivery

3. Enter the following:

a. Enter the gestational age of delivery

b. Enter the baby’s birth weight

c. Enter APGAR score (appearance, pulse, grimace, activity, and respiration) if the information is obtained

d. Select radio buttons from the following Lacerations and Episiotomy.

e. Other comment boxes are available.

4. Enter the following:

a. Enter the delivery type (required field)

b. Check the ‘Postpartum Tubal Ligation’ check-box then click on the blue drop down box to select what labor induction. (enter information if obtained)


              

5. Check all radio buttons that apply. After selecting will appear in the comment box.

6. After entry, click the ‘Add to Grid’ button.


Entry will display on the pregnancy grid at bottom of the window. Highlight desired entry to update or remove.