Within an encounter, there is a Pregnancy History section that can be utilized. There, within the encounter, a chart’s pregnancy history can be recorded or updated. The Pregnancy History optional encounter section is available on charts where demographic information states Female and age is older than 12 years old.
To record or edit Pregnancy History information within the encounter, simply click anywhere on the Pregnancy History grey title section area to expand open that section.
Use the free text fields, speech to text dictation icon, or use the previous value quick text or library macros on the far right to quickly get the Pregnancy History documented.
Pregnancy History - Flowsheet
The pregnancy history encounter section can instead point to a specific flowsheet configured in the system. A configured flowsheet named Pregnancy Details in the flowsheet editor will display contents for the encounter Pregnancy History section. Using a Pregnancy History flowsheet allows your system to capture unique or custom information for your practice to document in an encounter within the Pregnancy History encounter section.
To utilize a flowsheet method in Pregnancy History, a flowsheet named Pregnancy Details must exist with contents.
Delete / Edit / View Pregnancy History Captured Data
You can edit, delete, add to, or view the specific documented Pregnancy History data from the encounter section.
Hover Options
Once Pregnancy History data has been documented, one can edit, add to, or delete data for the specific Pregnancy History data that was captured. If you do not have security permission to edit or add to observations, then you will not be able to.
From the section’s collapsed summary view, simply click on the values/data of the specific Pregnancy History line item to edit on or add to. The data will be displayed in a border box where you can begin modifying or typing in more information.
Also while the encounter section is in summary collapsed view, icon options next to the stored data will display.
Trash Can icon: will immediately delete the stored data for the pregnancy history line item. Pregnancy history data stores as observations. If you do not have security permission to delete observations, the trashcan icon will still display, but upon click, the system will not allow the data to be deleted.
Eyeball icon: will pop-up the View Observation window to view more specific details of the specific pregnancy history data. Revisions, trending, and entry information will be seen. Pregnancy History data stores as observations.
Expanded Encounter Section
Pregnancy History data can also be edited on, added to, or cleared/deleted from the expanded encounter summary section. Once Pregnancy History data has been documented, the encounter section can be expanded open by clicking anywhere on the grey title section bar. Then, the data can be clicked to edit & add to, or can click X to clear the data out of the field. If you do not have security permission to edit or delete observations, the system will not allow you to modify.
Encounter Stored Document
The encounter section does become part of the encounter visit note document once closed and archived.
Pregnancy History Summary Dashboard Portlet
Pregnancy History data stores as observations within the chart. Most recent recorded pregnancy history is also visible within a portlet on the Summary chart tab dashboard.
Pregnancy History can be updated from the portlet by using the pencil icon.
That then opens the separate chart tab Past Medical History where the Pregnancy History section is offered. Clicking the grey title bar area (like within an encounter section behavior) is where the pregnancy history fields will open for recording data or updating data.
