You can document information in the Prenatal Visits panel for the current pregnancy.
The Prenatal Visits panel contains a grid with data entered from all previous prenatal visits for the current pregnancy. The comments can be viewed in two ways.
- Open the Prenatal Visits panel.
- Select the row with an asterisk in the comments column, and view the full text of the comment in the Progress note field below the grid.
- Select the Progress Note Summary button.
The Pregnancy Note Summary template opens.
- Select the OB Initial Exam link.
The OB Initial Physical Exam window opens.
- Select the Default normal checkbox.
All physical exam items up to the
Adnexa item are marked as normal except for the
Uterus size item. Any item that is not normal can be manually changed. Uterine size must be manually entered. Other exam items can be entered as needed.
Note: If the initial exam is completed at the initial visit, the Lock (complete)initial physical exam checkbox indicating that the exam is complete can be selected. If this checkbox is not selected, the provider can complete the exam at the next visit.
- Enter information in the Abnormal findings/additional comments field, if needed.
- In Tests section, document PAP smear and STI screenings, if needed.
- Select Save & Close as needed.
Note: The Ob Initial Physical Exam template is generally used during a pregnancy. Physical exam findings during a routine prenatal visit are entered directly on the OB flowsheet for that day on the Prenatal Visits panel.
- To enter a note or reminder, select the Patient note checkbox.
Information entered on this yellow sticky note displays for all future visits until the information is removed or until the Patient note checkbox is cleared. This information is not printed in the document.
