Using the OB Header and Flowsheets

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Using the OB Header and Flowsheets

A header containing key pregnancy data and several OB flowsheets may appear at the top of a encounter note. The data that can be captured and displayed in the header and flowsheets is similar to data captured on the forms most obstetric physicians use for pregnancy visits.

Note: The OB header and flowsheets, as well as features for entering or printing the data, display only for Providers, Clinicians, and Clinical Office Staff when the patient is currently, or was previously, identified as being pregnant. For more information about enabling or disabling OB header and flowsheet features for a particular patient by managing their pregnancy status, see Enabling or Disabling OB Features.

Pregnancy Header

The pregnancy header is populated with information entered in the Enter OB Data dialog box. While the patient is identified as being pregnant, any data in the most recent encounter note is automatically included in the pregnancy header and the body of new encounter notes created for the patient. The data which display in the OB header are as follows:

• Last Menstrual Period (LMP)	• Gestational Age (GA) If the Date of Service is changed and the gestational age (GA) is available, the GA is automatically updated based on the new service date.
• Estimated Date of Delivery (Initial EDD or Final EDD)	• Date Anti-D Immune Globulin was given (Anti-D IG Admin Date) Note: Anti-D IG Admin Date does not appear if the D (RH) Type value is Positive.
• Past pregnancy information	• D (Rh) Type value
• High Risk conditions	• Antibody Screen value Note: Antibody Screen does not appear if the D (RH) Type value is Positive.

OB Flowsheets

The OB flowsheets are populated with data that has been entered into the patient’s encounter notes over the previous 12 months, based upon the date of service. For example, if the date of service is November 10, 2012, the flowsheets display data collected between 11/10/2011 and 11/10/2012. If the date of service is changed for an in progress note, the flowsheets are automatically updated based on the new service date, so that only data from encounter notes created within 12 months of the new service date are included. The available flowsheets are as follows:

Pregnancy Flowsheet. Displays the following data:

• Date	• Blood Pressure (BP)
• Gestational Age (GA)	• Weight (Wt)
• Fundal Height (FH (cm))	• Urine Albumin
• Presentation (Present.)	• Urine Glucose
• Fetal Heart Rate (FHR (BPM))	• Pain 0-10
• Fetal Movement (FM)	• Next Appt (wks)
• Preterm Labor Signs and Symptoms (PTL S/S)	• Pregnancy-related comments (if comments are available, appears in the Comments column; placing the pointer over the icon opens a dialog box containing the comment details)
• Cervix Exam Data: • Dilation (Dil.) • Effacement (Eff. %) • Station • Ultrasound Length (US (cm))

Note: With the exception of gestational age, blood pressure, and weight, all other Pregnancy flowsheet data can be entered using the Enter Pregnancy Flowsheet dialog box. For information about entering patient header data (including gestational age), patient vitals, and Pregnancy flowsheet data from a encounter note, see Document Pregnancy Header Information , Document Pregnancy Flowsheet Data, and Document Patient Vitals.

Labs flowsheet. Displays the following data:

• Test. Name or description of the test ordered.

• Ordered. The date that the patient’s order(s) were placed in the system, or the date manually entered by a user identifying when lab tests were ordered.

• Gestational Age. The gestational age, calculated using the lab’s ordered date, as well as the EDD data and gestational age calculation method specified in the Enter OB Data dialog box. For more information about entering data using the Enter OB Data dialog box, see Document Pregnancy Header Information .

• Results/Notes. The lab-related comments or results manually entered by a user, or a link to the results associated with an order. System-received lab results display the following information, as appropriate:

• Out of range symbol (). Indicates that one or more of the results are outside of the normal range.

• Priority out of range symbol (). Indicates that a result for a requisition contains data which is priority out of range (high or low) and should be reviewed.

• See Report message. Indicates that one or more of the results has an unknown status (normal or out of range is not specified). The See Report message only appears if the corresponding requisition does not contain out of range or priority out of range results.

Notes:

• Labsflowsheet data can be added manually in a encounter note by clicking the Other OB Tests link, or by clicking the Add Other OB Tests button in the Labs flowsheet tab of a new or in progress note. Lab orders can also be initiated from the Labs flowsheet tab of a new or in progress note by clicking the Order Labs button. Any lab orders placed in Care360 EHR for a patient, including those placed outside of the encounter note within the last 48 hours, will automatically appear in the Labs flowsheet and in the encounter note body. In addition, system-received or manually entered lab results will also appear in the Labs flowsheet. For information about manually entering pregnancy-related labs data from a encounter note, see Document Other OB Lab Tests. For information about placing lab orders, from within or outside of a encounter note, see Order Entry.

• If the same test was ordered multiple times, each occurrence of the test and its associated data will display in the flowsheet.

• Labs flowsheet data which is manually entered or edited in the encounter note appears in the Labs flowsheet tab as soon as you click Save.

• You can view a list of suggested labs tests for different periods of a patient’s pregnancy by clicking the Standard of Care Labs link in the Labs flowsheet tab.

If you would like to share the OB header and Pregnancy and Labs flowsheet data with the patient, or other providers, you can print the header, Pregnancy flowsheet, and Labs flowsheet. The patient Education flowsheet cannot be printed. You can choose to print the header or flowsheet data while viewing a particular encounter note which contains OB data, or you can print an antepartum report which can include header and flowsheet data.

Review the OB Header and Flowsheets

Print the OB Header and Flowsheets