Medical History: Pregnancy History

The Pregnancy History page provides a tool to display and add or edit the patient's pregnancy history. For each Pregnancy item you can add a delivery, edit the pregnancy information, remove the pregnancy, or view the change log. The following topics are discussed on this page. Use the links to jump to the desired subject:

About Pregnancy History

For each Pregnancy, you have the following options:

And, for each delivery (under the pregnancy), you have the following options:

	Edit button: Click to edit a delivery. See Making changes to delivery items.
	Remove button: Click to remove a delivery from the pregnancy list. See Making changes to delivery items.
	View Change Log button: Click to view the details of the delivery and any changes. See Making changes to delivery items. To return to the Pregnancy History List, click Back.

To add Pregnancy

To add a pregnancy to the list, select Add Pregnancy. The Add Pregnancy box is displayed.
In the Name/Description field, type the description of the pregnancy, i.e. Pregnancy #1.
In the Gravida field, enter the number of times the mother has been pregnant.
In the Para field, enter the number of viable (>20 wks) births. Pregnancies consisting of multiple births, such as twins or triplets, count as ONE birth for this purpose.
In the LMP field, select the start date of the mother's last menstrual period.
In the Due Date field, enter the determined due date, if currently pregnant.
If applicable, enter additional comments in the Notes field.
Click Save.

To generate the CCD (Continuity of Care Document)

The CCD is a clinical summary document generated from the patient's clinical information, including insurance providers, advance directive information, problem list, and medication information. This document opens in a new browser tab, where it can be e-mailed, saved, and/or printed to the patient and/or another healthcare provider. To generate the CCD, click Generate CCD.

To verify Pregnancy History (No Change)

The No Change option allows you to indicate that you have reviewed and verified that the pregnancy history is correct and hasn't changed since the last assessment/review.

Click No Change located at the upper or lower right-hand corner of the window.
A message box is displayed with the message, Would you like to mark all pregnancy as being reviewed and verified? Select Yes to indicate you have reviewed and verified the pregnancy list, and click Save; or select No or click Close if you do not want to perform the verification at this time. Once reviewed, the user name and date/time displayed in the Verified field is updated.

To add a delivery

To add a delivery to the pregnancy, select the Add Delivery button. The Add Delivery box is displayed.
In the Labor field, enter the number of hours for labor.
In the Pregnancy Duration field, enter the point in the term when the delivery occurred, i.e. 32 weeks, 40 weeks, etc.
In the Birth Date field, use the calendar to select the date of birth.
In the Birth Time field, type the exact time of birth using military time, e.g. 1437.
In the Breast Feeding field, select one of the available options from the drop-down list.
In the Birth Status field, select one of the available options from the drop-down list.
In the Gender field, select one of the available options from the drop-down list.
In the Delivery Method field, select one of the available options from the drop-down list. (The drop-down list is created and maintained in Clinical Documentation > Master Files > Patient Chart > Summary > OB Delivery Methods.)
In the Birth Weight fields, enter the appropriate information in the lbs and oz fields. The conversion in kg is automatically displayed in the kg field. Or, enter the value in the kg field and the lbs and oz fields are automatically updated.
In the Complications field, use the drop-down list to select applicable complications that occurred during the delivery. (The drop-down list is created and maintained in Clinical Documentation > Master Files > Patient Chart > Summary > OB Delivery Complications.)
Click Save.

Making changes to delivery items

To edit a delivery: Click the edit button () located to the right of the delivery information. The Edit Delivery box is displayed. Make the appropriate changes as described in To add a delivery, click Save. For example, once the delivery is complete and the baby has been named, you can return to edit the Delivery Name to the child's name.
To remove a delivery: Click the remove button () located to the right of the delivery information. The Remove Delivery is displayed. Select a reason for removing the delivery in the Reason field. Click Save.
To view the change log for a delivery: Click the View Change Log button () located to the right of the delivery. The Delivery Change Log is displayed. Click the Show Details button next to the delivery to expand the details section. Or, check the Show All Details box to display details for all delivery items in the list. Click Back to return to the Pregnancy History list.

To edit pregnancy

1. Click Edit Pregnancy next to the pregnancy you want to edit. The Edit Pregnancy box is displayed. Edit any of the fields as needed. See To add pregnancy above for field descriptions.
2. In the Reason field, use the drop-down list to select a reason for the edit. To enter a reason that is not listed, select Other (See notes) from the list and type in the required free-text reason in the Other Reason field.
3. Click Save to save your changes and return to the Pregnancy History list, or click Close if you want to cancel your changes.

To remove pregnancy

1. 1. Click Remove Pregnancy next to the pregnancy you want to remove. The Remove Problem box is displayed.
  2. In the Reason field, use the drop-down list to select a reason for removing the pregnancy. To enter a reason that is not listed, select Other (See notes) from the drop-down list and type the required free-text reason in the Other Reason field.
  3. Click Save to continue. You are returned to the Pregnancy History list with the pregnancy now removed.

To view the change log

1. A change log is available to view all details of a pregnancy change. The log records when a pregnancy is added, edited, or removed, and contains the login name of who made the change, a reason for the change, and both the original and new values of the pregnancy.
2. There are two ways to access the change log:
  - Click View Change Log at the top of the screen to view changes to all pregnancy items.
  - Click Change Log next to a particular pregnancy to view changes for only that one item.
3. On the Pregnancy Change Log page, items are displayed according to the date/time they were changed, with the most recent change first. You can alter your view to display only added, edited, or removed items, as well as, sort the items by date/time, user, or pregnancy description. To change your view, use the drop-down lists in the Filter and Sort fields to select your desired view options. Once selected, the list is resorted accordingly.
4. The default view allows you to view a quick list of changes showing only the date/time, user, pregnancy item, and action (added, edited, or removed). Click the show details icon next to a particular item to display additional details for that item. Click Show All Details to display additional details for all the item changes.
5. Click Back to leave the change log and return to the Pregnancy History list.