Clinical - Obstetrics
In this article Clinical, you will learn how to manage obstetrics for female patients. Obstetrics may include both past and present pregnancies, complications during pregnancy or birthing, and the outcome at time of birth.
The Obstetrics page in a patient's clinical record is divided into two sections - Current Pregnancy and Past Pregnancies - and each of these sections will be covered individually in this article.
Current Pregnancy
By default, the Obstetrics page lands on the Current Pregnancy section of obstetrics. If the patient does not have a current pregnancy recorded, there will be no information stored on this page. However, if the patient is currently pregnant, there will be a summary of the current pregnancy displayed. The summary is covered later in this tutorial.
To Add a New Current Pregnancy, click New Current Pregnancy to open the new pregnancy form.
There are three tabs at the top of the new pregnancy form - New Current Pregnancy, Outcome and Births. Each of these tabs contains a form that will need to be completed as the pregnancy progresses (Outcome and Births are covered at the last stage of the Current Pregnancy section of this tutorial).
Enter in an LMP Date or Scan Date and click the Tick-box to select whether the Gestational Age is by LMP or by Scan. The Pregnancy Details will be automatically filled in once the gestational age has been selected.
Click the IVF tick-box if the patient used an IVF treatment to achieve pregnancy.
Click the Confidential tick-box to make the record confidential, so that only you can see it.
The details of the record will be added to the current consultation's notes by default unless the Add to Today's Notes Tickbox is unticked.
Click Save once the pregnancy form is complete.
*NOTE
The newly created current pregnancy will now by displayed in the Current Pregnancy summary.
If the patient already had a current pregnancy recorded, this is the summary that would be displayed when the Obstetrics page opens.
To Edit a Current Pregnancy, click Edit to open the pregnancy form.
Update the form with all the required details, and click Save to apply the changes.
To Add New Results, click New Results to open the results form.
Fill in the 1st Visit section of the form with all the required details, and click Save.
Each time you click Results to add more results, the same form will open, with details of the results from previous visit recorded on it.
To Print a Pregnancy, click Print to open a copy in PDF format in another tab or window (depending on your web browser settings).
If the page does not open, you need to Allow pop-ups for MediRecords in your web browser settings.
Navigate to your web browser's menu, (usually in the left or right-hand corner) and click Print
To Save a PDF Copy of a Pregnancy, click Print to open a copy in PDF format in another tab or window (depending on your web browser settings).
If the page does not open, you need to Allow pop-ups for MediRecords in your web browser settings.
Navigate to your web browser's menu, (usually in the left or right-hand corner) and click Save.
To Delete a Current Pregnancy, click Delete to permanently delete record of the pregnancy.
*Note: Deleting a pregnancy will also delete record of all associated results and antenatal visits. If a pregnancy failed due to miscarriage, stillbirth or other complications, the pregnancy should still be recorded in the patient's clinical record.
Click Yes to acknowledge the pregnancy will be deleted.
To Delete the Pregnancy Results, click More to reveal a drop-down list. Click Delete Results to permanently delete the results associated with the pregnancy.
Click Yes to acknowledge the results will be deleted.
During the course of a new pregnancy, the patient will attend multiple antenatal visits with the treating doctor. Antenatal visits can only be recorded when the patient has an active current pregnancy on their clinical record. Antenatal visits are directly related to the current pregnancy, and upon completion of the pregnancy, the antenatal visits will be filed into Past Pregnancies, alongside their corresponding completed pregnancy.
To Add a New Antenatal visit, click New Antenatal to open the antenatal form.
Fill in the antenatal form with all the required details, add any relevant clinical observations or comments, and then click Save.
*NOTE Like a New Pregnancy record, a new antenatal record will be automatically added to that consultation's notes unless the Add to Today's Notes Checkbox is unticked.
The newly created antenatal visit will now be visible in the Antenatal summary within the Current Pregnancy.
To Edit an Antenatal visit, click the Tick-box next to the name to reveal a list of options. Click Edit to the open the antenatal form.
Update the form with all the required details, and click Save to apply the changes.
To Delete an Antenatal visit, click the Tick-box next to the name to reveal a list of options. Click Delete to permanently delete the antenatal visit from the patient's record.
Click Yes to acknowledge the antenatal visit will be deleted.
Once a current pregnancy has been completed, you will need to add an outcome and details of the birth to the pregnancy form, which will then finalise the current pregnancy record and move it, with all related results and antenatal visits, to past pregnancies .
To Add Details of the Outcome and Birth/s to a Current Pregnancy, click Edit to open the pregnancy form.
Click Outcome to record the details of the outcome of the pregnancy.
Complete the Outcome form with all the required details, and add any relevant clinical notes or comments.
DO NOT CLICK SAVE
Click Births to record to the details of the baby's name, weight, gender and feeding habit.
Complete the Births form with all the required details. Click the Create Patient Record tick-box to create a new patient record for the baby.
Click Add to add the baby's name to the pregnancy below. In the cases of twins or multiple babies, add the names to record using the same process.
Click Save once complete.
To current pregnancy now has been moved over to the Past Pregnancies section of Obstetrics.
Past Pregnancies
The second section of Obstetrics is Past Pregnancies.
This section displays a summary of all the patient's past pregnancies that have been recorded on their file. A patient's past pregnancies can be recorded regardless of whether they were being treated at your clinic at the time or if the pregnancy was successful or not. Past pregnancy details available within the summary includes the birth number, LMP, weeks of gestation, EDC, provider, hospital, outcome and the end date.
Click Past Pregnancies to switch the Obstetrics summary to past pregnancies.
To Add a New Past Pregnancy, click New Past Pregnancy to open the pregnancy form.
*Note: There are three separate tabs on the form, and all of them must be complete to record a new past pregnancy.
The pregnancy form opens on the New Past Pregnancy tab.
Fill in the New Past Pregnancy section of the form with all the required details.
DO NOT CLICK SAVE.
Click the Outcome tab at the top of the form to proceed to the next section.
Fill in the Outcome section of the form with all the required details.
DO NOT CLICK SAVE.
Click the Births tab at the top of the form to proceed to the next section.
Fill in the the Births section of the form and type in the Name, Weight, Gender and Feeding habits of the child. Click Add to include the details in the pregnancy record, and click Save to finish.
To Edit a Past Pregnancy, click the Tick-box next to the name to reveal a list of options. Click Edit to open the pregnancy form.
Click to switch between any of the Three Tabs. Update the form with all required details, and click Save to apply the changes.
To Delete a Past Pregnancy, click the Tick-box next to the name to reveal a list of options. Click Delete to permanently delete the pregnancy from the patient's record.
*Note: Deleting a pregnancy will also delete all associated results and antenatal visits.
Click Yes to acknowledge the pregnancy will be deleted.
To Delete Multiple Pregnancies, click the Tick-box next to the names to reveal a list of options. Click Delete to permanently delete the pregnancies from the patient's record.
Click Yes to acknowledge the pregnancies will be deleted.
To Print a Pregnancy, click the Tick-box next to the name to reveal a list of options. Click Print to open a copy in PDF format in another tab or window (depending on your web browser settings).
If the page does not open, you need to Allow pop-ups for MediRecords in your web browser settings.
Navigate to your web browser's menu, (usually in the left or right-hand corner) and click Print.
To Print Multiple Pregnancies, click the Tick-boxes next to the names to reveal a list options. Click Print to open copies in PDF format in another tab or window (depending on your web browser settings).
If the page does not open, you may Allow pop-ups for MediRecords in your web browser settings.
Navigate to your web browser's menu, (usually in the left or right-hand corner) and click Print.
To Save a PDF Copy of a Pregnancy, click the Tick-box next to the name to reveal a list of options. Click Print to open a copy in PDF format in another tab or window (depending on your web browser settings).
If the page does not open, you may Allow pop-ups from MediRecords in your web browser settings.
Navigate to your web browser's menu, (usually in the left or right-hand corner) and click Save.
To Save a PDF Copy of Multiple Pregnancies, click the Tick-boxes next to the names to reveal a list of options. Click Print to open copies in PDF format in another tab or window (depending on your web browser settings).
If the page does not open, you may Allow pop-ups for MediRecords in your web browser settings.
Navigate to your web browser's menu, (usually in the left or right-hand corner) and click Save.
To View the Results associated with a past pregnancy, click the Tick-box next to the name to reveal a list of options. Click More to reveal a drop-down list, and then click View Result to open the results form.
Once you have finished viewing the results, click the X in the right-hand corner to close the results form.
To Delete the Results associated with a past pregnancy, click the Tick-box next to the name to reveal a list of options. Click More to reveal a drop-down list, and then click Delete Result to permanently delete the results record from that pregnancy.
Click Yes to acknowledge the results will be deleted.
To Add a New Antenatal Visit to a past pregnancy, click the Tick-box next to the name to reveal a list of options. Scroll to the bottom of the list of past pregnancies, and click New Antenatal to open the antenatal form.
Fill in the antenatal form with all the required details, add any relevant clinical observations or comments, and then click Save.
The newly created antenatal visit will now be visible in the Past Pregnancy summary when the Tick-box of the related pregnancy is checked.
To Edit an Antenatal Visit of a past pregnancy, click the Tick-box next to the name of the pregnancy. Scroll down to the list of antenatal visits, and click the Tick-box next to the name to reveal a list of options. Click Edit to open the antenatal form.
Update the form with all the required details, and click Save to apply the changes.
To Delete an Antenatal Visit of a past pregnancy, click the Tick-box next to the name of the pregnancy. Scroll down to the list of antenatal visits, and click the Tick-box next to the name to reveal a list of options. Click Delete to permanently delete the record of the antenatal visit from the pregnancy.
Click Yes to acknowledge the antenatal visit will be deleted.
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