How to View OBGYN History?

Patient > Clinical > History > OB/Gyn

OB/ GYN History of a patient can be added/edited by clicking on the ‘OB/Gyn History’ link. In case the patient has no significant OB/Gyn History, the user can check the ‘Unremarkable’ checkbox. If the patient is pregnant, users can enable the checkbox labelled ‘Patient is Pregnant’. This prompts a dropdown to appear besides the checkbox and a section labeled ‘Past Pregnancies’ is displayed at the bottom of the page.

From the dropdown, select ‘Yes’ or ‘No’ to specify whether the pregnancy was planned or not.

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OB/ GYN History

Similarly, add a pregnancy in the ‘Past Pregnancy’ section and fill out the relevant details.

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OB/ GYN History

Select a status (planned/unplanned) for this pregnancy.

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OB/ GYN History

Additionally, this feature can also be specified via the Case Review section. Add a new Case Review and select an option from a dropdown named ‘Is Pregnancy planned?’

Patient > Clinical > Case Review

OB/ GYN History of a patient can be added edited by clicking on the OB/Gyn History link. In case the patient has no significant OB/Gyn History, the user can check the ‘Unremarkable’ box. The user can mark if the patient is currently pregnant by checking the ‘Patient is pregnant’ box.

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OBGYN History

The following enhancements have been made to the OB/ GYN report to improve overall user experience.

  • The negative values in OB/ Gynecology History are highlighted in red on the SOAP note
  • The date, comments for DEXA and Colonoscopy under “gynecological” section of the OB/ GYN History

To view the changes in the OB/ GYN History, follow the steps described below.
Suppose the following selections are made while recording the OB/ GYN History:

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OBGYN History test results
  • When the SOAP note is created for this patient, the negative values of the OB/ GYN history appear highlighted on it.
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OBGYN History Negative Values Highlighted on SOAP Note
  • In the Gynecology History section, fields for DEXA and Colonoscopy are added below Mammogram.
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Fields for DEXA and Colonoscopy on OB- GYN History Screen
  • Add the relevant information in these fields and click on Save button. The SOAP note is updated accordingly.
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DEXA and Colonoscopy values on the SOAP note.
  • Colposcopy field is added in the Gynecology History section. User can add date and comments for Colposcopy in the respective fields.
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Colposcopy
  • Upon saving the changes, SOAP note is updated accordingly.
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Colposcopy in SOAP Note

The following enhancements have been made to the OB/ GYN report to improve overall user experience:

  • The negative values in OB/ Gynecology History are highlighted in red on the SOAP note
  • The date, comments for DEXA and Colonoscopy under “gynecological” section of the OB/ GYN History

To view the changes in the OB/ GYN History, follow the steps described below.

  • Navigate to: Patient > Clinical > History > Gynecological
  • Suppose the following selections are made while recording the OB/ GYN History:
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OB/ GYN History test results
  • When the SOAP note is created for this patient, the negative values of the OB/ GYN history appear highlighted on it.
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OB/ GYN History negative values highlighted on SOAP note
  • In the Gynecology History section, fields for DEXA and Colonoscopy are added below Mammogram.
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Fields for DEXA and Colonoscopy on OB/ GYN History Screen
  • Add the relevant information in these fields and click on Save button. The SOAP note is updated accordingly.
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DEXA and Colonoscopy values on the SOAP note
  • Colposcopy field is added in the Gynecology History section. User can add date and comments for Colposcopy in the respective fields.
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Colposcopy
  • Upon saving the changes, SOAP note is updated accordingly.
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Colposcopy in SOAP Note

A dropdown of ‘Reason for No BCM’ is added in the OB/GYN History.

‘Reason for No BCM’ dropdown values can be added from settings. To view more, click here.

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OB GYN

User selects a value from the dropdown as a Reason for No BCM

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OB GYN

Upon saving, the Reason for No BCM is displayed under the OB/GYN History Section.

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OB GYN

On selecting a ‘Current BCM’ the ‘Reason for no BCM’ drop down gets disabled.

This prevents user from recording logically contradictory information in patient history. Once a current BCM is recorded the option to enter a reason for no BCM becomes unnecessary.

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OB/GYN Tab

Similar enhancement is made in the ‘Social History’. To view more, click here.

User can add comments in the overall comments box in the OB/Gyn History component. new_symbol

Additional patient information can be recorded here.

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Comments Section

Similar enhancement is made in the provider notes. To view more, click here.