Chapter 9 OB Labs each Entering Ultrasounds

Transcription

1 Chapter 9 OB Labs The OB patient s prenatal labs may be entered from the nurses interface by sections directly into the prenatal record. There are several sections to the prenatal labs: Initial Lab 8-18 Wks Wks Wks Optional Labs Select the lab section in which information should be entered. Enter results, comments or additional labs within the particular section. You must click on Submit at the end of each section to save information. This information may not be changed once the reviewed box is ( ) by the physician. Entering Ultrasounds It is important that first/second trimester ultrasound information be entered in the 8-18 week ultrasound section. (Date, weeks, day and grams. This field is linked to the Physician Interface s prenatal record, page 3. Once the information is entered in this field, the system will automatically calculate the estimated due date for the physician. The grams entered will be graphed in the Physician Interface. The weeks ultrasound applies the same.

2 To enter additional Ultrasounds and Labs select the Option Labs If additional ultrasound is required, select Additional Ultrasound and an extra Ultrasound field will be added. Remember to always Submit to save in each section. For additional Ultrasounds, click on the Additional ultrasound button and an EXTRA ULTRASOUND field will be added. NOTE: All extra ultrasound will NOT be calculated in the prenatal labs, Pg 3.

3 OB Discharge Delivery postpartum form Once a patient delivers or the pregnancy is discontinued, this form should be filled out completely from the Nurses Interface. Routinely, the nurse will get delivery information from the Physician s delivery notes. It is recommended that this form be filled out before the patient s post partum visit. Otherwise, the Physician will not be able to convert the patient back to GYN for the visit. When a physician converts the delivered patient to GYN, the system automatically adds delivery, postpartum, and baby information to the patient s history and a Pregnancy Care Summary Report will be created in the patient s chart, which includes the (4) pages of the prenatal record, followed with the delivery information page for that particular pregnancy. This is why it is important that the form be filled out completely. The delivery date MUST be entered. This information will also be part of the Physician s EDD report. Click on Submit on each section to save information.

4 To discontinue Pregnancy Care this feature should be used when an OB patient needs to be converted back to GYN, without delivering. For example, if a patient has a missed AB, a termination, or leaves the practice. For instructions, refer to the. New Orders Each nurse is linked to a Physician. Once a physician reviews test results, if there are orders to be completed, these will be directed to their assigned nurse. There are (2) types of orders sent to the nurse: - Abnormal test results, requiring actions to be completed - All normal prenatal lab results that require entry into the patient s prenatal record To take action a NEW ORDER select the New Order sub-menu. Click on Action. This will bring up the document. Select the Report (left side of screen) created by the physician to read his document reviewed report/orders. Click on the Date to read the Document Review Report. When finished with an order, the nurse MUST mark ( ) completed.

5 Enter action or comments in this field, then click on Submit to save. When finished with order, mark ( ) completed. Select here to print a Prescription ordered, if necessary. All reviewed documents will have a Document review Report attached. All notes or comments will be added to the Document Review Report under Nurse Action. Completed Actions Once a New Order is completed it becomes a completed action. Changes of a completed action may be made from this sub-menu. Vital Signs - Nurses record vital signs under this sub-menu. To enter vital signs Search for patient s chart, enter information on the fields provided, then, click on Save Vital Signs to Save. Previous vital signs by be viewed by selecting the date of service.