Antepartum Care Card

What: 

ChartLogic has added a specific card for capturing data during pregnancy.  These elements were captured from the general pregnancy care information from the ACOG requirements. 

Why: 

Specialties that provide pregnancy care need specific data fields to manage their patient’s care  

How: 

You can add the antepartum care card in the note configurations or on the fly within the chart and note. 

This card can be edited with the same functionality as the other card edits allowing for the user to change the order or remove items. 

The card elements consist of the following  

General section that will default information from the last antepartum care data. These are elements that are usually captured once during the length of the pregnancy 

• Initial EDD – Date field for the initial expected delivery date 
• Final EDD – Date field for the final expected delivery date 
• Anesthesia Plans – Yes or No 
• Genetic Counseling – Yes or No
• Number of fetus – Drop down selector 1-10 

The ultrasound section has elements important to capture when the tests are performed.  The data elements are as follows. 

• Presentation – free text field to describe the presentation
• Placenta – free text field to describe the details of the placenta
• AFI – free text field to capture the amniotic fluid index 
• EFW – free text field to capture the fetal weight 
• Composite GA – free text field to capture the calculation for the Gestational Age 
• Location/Hospital – free text field to capture where the US was performed 

The encounter section are data elements captured during each pregnancy encounter. The data elements are as follows. Each section has a note box for capturing additional information. 

• Fundal Ht – free text field for the measured height of the fundus 
• FHR – free text field to capture the Fetal Heart Rate 
  • When there is more than one fetus this can be captured by baby #1, baby #2 or a new care card instance on the same day with descriptions 
• Cervical Exam – drop down with yes or no and a note section to add more details
• Preterm SX – yes or no drop down with a notes field to add more data when tracking pre-term labor symptoms
• Edema – yes or no to capture evidence of edema
• Quickenings – yes or no drop down to capture fetal movement 

The orders and test section are used to capture when specific tests are done important to the pregnancy care. 

• AFI 
• Amino 
• Chlamydia
• Diabetic Screening
• Group B Strep
• GTT
• HCT/HGB
• HIV
• Pap Test
• PPD
• Urine Analysis
• VDRL 

These are a multi selection when more than one test is done or needed.