Document the Obstetrics and Gynecology Synopsis Template

The Obstetrics and Gynecology (OBGYN) Synopsis template provides the details of female patients.

1. On the Patient Information Card in NextGen® Enterprise EHR, select OBGYN.
   The OBGYN Synopsis template opens.
2. Select from Primary OBGYN provider.
3. Select from the following options.
   • Detailed document: Select this to include the gynecological and pregnancy histories in the document.
   • Reviewed, no changes: Select this option if you have reviewed the details documented in the previous encounter and no changes were made.
   • Reviewed, updated: Select this if you have reviewed and updated the details documented in the previous encounter.
   • History unobtainable: If OBGYN details are unobtainable, enter a reason in Reason Unobtainable.
4. To enter confidential information in the OBGYN Confidential Info Social Hx template, select the OBGYN Confidential Information link.
5. In Gynecologic History, enter the age of menarche and last menstrual period (LMP), menopause, surgery, and hysterectomy information.
   The Last Pap, Last Mammogram, Last DEXA scan and Last colonoscopy fields display the most recent date when the procedure was performed, when results were last received, or when the procedure was last completed.
6. To enter pap and HPV information, select Add/Update Detail.
   The details appear in the Pap Result, HPV Detail and Treatment grid.
7. To document the sexual orientation and birth control methods of a patient under the age of 18 years, select View Pregnancy History and Safer Sex Information/Contraception History.
   For an adult patients, these fields appear by default.
8. In Pregnancy History, indicate whether the patient is currently pregnant, and review the patient's pregnancy history.
9. Select Save & Close.