Screenshots: Charting Prenatal Care

Dating US

Dating & Ultrasound Screen – click to enlarge in new window

Dating & Ultrasound screen

1 – Record menstrual cycle length, LMP, conception date

2 – A variety of ways to determine EDD: Naegle’s from LMP, from conception date, from ultrasound, or your own custom calculation

3 – Record first positive pregnancy test, first fundal height and FHTs, quickening to assist in calculating unsure dates

4 – Record all ultrasounds in pregnancy and see important information at a glance. Ultrasound reports are uploaded directly to the chart here.


Labs

Labs Screen – click to enlarge in new window

Labs

1 – Add more labs and results to the convenient list of common tests performed during pregnancy

2  – Quick view of commonly repeated labs in chronological order

3 – Lab results for baby (as with all newborn records, these print separately from the mother’s chart)


Physical Exam - click to enlarge in a new window

Physical Exam – click to enlarge in a new window

Physical Exam / Well Woman Exam
1 – SOAP Notes area
2 – Body system reviews
3 – Create default values for “normal” responses that fill in with a click!

Prenatal Screen - click to enlarge in new window

Prenatal Screen – click to enlarge in new window

Prenatal Care Screen
1 – Easy to view prenatal flow
2 – Notable Issues to alert birth team during care
3 – Consultations with other providers
4 – Significant Events for each client
5 – Options to print only the Prenatal Flow or Prenatal Notes, or both

Prenatal Entry - click to enlarge in new window

Prenatal Entry – click to enlarge in new window

Entering a Prenatal Visit
1 – Enter the date and the gestational age is calculated for you
2 – Landmark dropdowns for early fundal height; dropdown menu for fetal position
3 – Dropdown menu offers quick review of systems and complaints/discomforts
4 – Urine dipstick results are easy with dropdown options
5 – Create your own note templates to ensure comprehensive charting – then by clicking “Apply”, the template is inserted into your note window
6 – Assess risk at every prenatal visit