Document the OBGYN Synopsis Template

The OBGYN link is available for female patients above the age of eight years. On the OBGYN Synopsis template, you can document information on the patient's menopause status, hysterectomy details, gynecological and pregnancy history, abnormal Pap, and contraception information.

Note: The providers use OBGYN Synopsis only during a Gynecology visit and not during an OB prenatal visit.

You can access the following templates from the OBGYN Synopsis template.

Pap and HPV Details
Pregnancy Outcomes
Previous Pregnancy Problems
OBGYN Confidential Info Social Hx

On the Patient Information Card in NextGen® Enterprise EHR, select OBGYN.
The OBGYN Synopsis template opens.
Select the patient's Primary OBGYN provider.
Select one of the following options.
- Detailed document. To include the gynecological and pregnancy histories in the document.
- Reviewed, no changes. If you have reviewed the details documented in the previous encounter and no changes were made.
- Reviewed, updated. 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.
To enter details in the OBGYN Confidential Info Social Hx template, select the OBGYN Confidential Information link.
Enter the age of menarche and details of, LMP, menopause, surgery, and hysterectomy details in the Gynecologic History section.
The Last Pap, Last Mammogram, Last DEXA scan and Last colonoscopy fields display the most recent performed date, result received date or completed date of these tests documented in orders, as described.
- The performed date is used if a result is documented with the received date or completed date, and the performed date is recorded.
- The received date is used if a result is documented with the received date or completed date, but the performed date is not recorded.
- The completed date is used if a result is documented with the completed date, but the performed and received dates are not recorded.
Note: You can select the information icon to view the priority order of the date displayed.
To open the Pap and HPV Details template, select Add/Update Detail.
The details appear in the Pap Result, HPV Detail and Treatment grid.
To document the sexual orientation and birth control methods of a patient below the age of 18 years, select View Pregnancy History and Safer Sex Information/Contraception History. For an adult patients, these fields appear without selecting the link.
In the Pregnancy History section, you can do the following:
1. Select the desired Currently pregnant option.
  
  Note: If no option is selected, it is assumed that the patient is not pregnant.
2. To view previous pregnancy problems, select Previous Pregnancy Problems.
  The Previous Pregnancy Problems template opens displaying the previous pregnancy problems, if any. All the information is read-only.
  Important: You can view only the previous pregnancy problems, you cannot view the current pregnancy problems.
3. To open the Pregnancy Outcomes template, select Add/Update Detail.
  The documented details appear in the Pregnancy history grid.
4. Select the applicable boxes to document information.
5. To close the Previous Pregnancy Problems template, select Save & Close.
Select Save & Close.

Document the OBGYN Synopsis Template

Note: The providers use OBGYN Synopsis only during a Gynecology visit and not during an OB prenatal visit.

You can access the following templates from the OBGYN Synopsis template.

Pap and HPV Details
Pregnancy Outcomes
Previous Pregnancy Problems
OBGYN Confidential Info Social Hx

On the Patient Information Card in NextGen® Enterprise EHR, select OBGYN.
The OBGYN Synopsis template opens.
Select the patient's Primary OBGYN provider.
Select one of the following options.
- Detailed document. To include the gynecological and pregnancy histories in the document.
- Reviewed, no changes. If you have reviewed the details documented in the previous encounter and no changes were made.
- Reviewed, updated. 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.
To enter details in the OBGYN Confidential Info Social Hx template, select the OBGYN Confidential Information link.
Enter the age of menarche and details of, LMP, menopause, surgery, and hysterectomy details in the Gynecologic History section.
The Last Pap, Last Mammogram, Last DEXA scan and Last colonoscopy fields display the most recent performed date, result received date or completed date of these tests documented in orders, as described.
- The performed date is used if a result is documented with the received date or completed date, and the performed date is recorded.
- The received date is used if a result is documented with the received date or completed date, but the performed date is not recorded.
- The completed date is used if a result is documented with the completed date, but the performed and received dates are not recorded.
Note: You can select the information icon to view the priority order of the date displayed.
To open the Pap and HPV Details template, select Add/Update Detail.
The details appear in the Pap Result, HPV Detail and Treatment grid.
To document the sexual orientation and birth control methods of a patient below the age of 18 years, select View Pregnancy History and Safer Sex Information/Contraception History. For an adult patients, these fields appear without selecting the link.
In the Pregnancy History section, you can do the following:
1. Select the desired Currently pregnant option.
  
  Note: If no option is selected, it is assumed that the patient is not pregnant.
2. To view previous pregnancy problems, select Previous Pregnancy Problems.
  The Previous Pregnancy Problems template opens displaying the previous pregnancy problems, if any. All the information is read-only.
  Important: You can view only the previous pregnancy problems, you cannot view the current pregnancy problems.
3. To open the Pregnancy Outcomes template, select Add/Update Detail.
  The documented details appear in the Pregnancy history grid.
4. Select the applicable boxes to document information.
5. To close the Previous Pregnancy Problems template, select Save & Close.
Select Save & Close.

Document the OBGYN Synopsis Template

Recommendations

Document the Pap and HPV Details Template

Document the Pregnancy Outcomes Template

Manual Entry of Parity Values

Documenting Pregnancy Outcomes

Initial Prenatal Visit

Viewing Patient Confidential History

Document the OBGYN Synopsis Template

Document the Pap and HPV Details Template

Document the Pregnancy Outcomes Template

Manual Entry of Parity Values

Documenting Pregnancy Outcomes

Initial Prenatal Visit

Viewing Patient Confidential History