PowerChart Maternity: Pregnancy Summary Page

Transcription

The Pregnancy Summary Page is an interactive page that allows you to view pregnancy information
on one page. This information has been pulled from previously charted data in various locations in
PowerChart. You can also add information, and can easily navigate to other PowerChart locations by
clicking links on this page.
The following instructions will describe how to view information on the page, how to add information,
and how to navigate throughout the chart from the page. See Table of Contents for details.
Table of Contents:
Instructions
How to navigate to the Pregnancy Summary page
How to open a current pregnancy
Appearance of Pregnancy Summary Page
Sections
Links
How to Customize
Description of Sections
Overview
 Current Pregnancy
 Contact Information
Vitals and Measurements
Labor Exam
EDD Maintenance
o How to add EDD method
o How to set EDD method as authoritative
o How to modify EDD method
Pregnancy History
Fetal Monitoring
Birth plan
Genetic Screening Counseling
New Orders
Consolidated Problems
Documents
Labs
Medications
Home Medications
Immunizations
Education
Allergies
Microbiology
Pathology
Social History
Procedure History
Past Medical History
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How to navigate to the Pregnancy Summary Page
1. With patient’s chart open, click on Pregnancy Summary in the Menu to open the Pregnancy
Summary Page.
2. If the patient does not yet have a pregnancy opened, this page will appear blank and will display
the notice There are currently no active pregnancies for this patient. You must document
confirmation of pregnancy to open a pregnancy so that information will display on the Pregnancy
Summary Page.
How to open a current pregnancy
1. Click the Add Pregnancy button - Add Pregnancy box will open.
2. Enter information in following fields:
Responsible provider – defaults to current user; change as needed.
Confirmation – defaults to Confirmed; change as needed. The following options are
available to click:
Onset: Date – is a required field. Use LMP (first day of Last Menstrual Period) if known,
otherwise use date patient found out she was pregnant.
o This date serves as the first bookend date for the pregnancy when labs and
other results display on the page.
Confirmed Date – defaults to today’s date
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Confirmation Method – not required, but can click on choices:
Comments – Type free-text information, as needed.
3. To complete process and save information, click OK.
Data is saved and active pregnancy is initiated for the patient.
Pregnant is listed as an Active Problem on the patient’s Problem List.
4. To add Pregnancy as a Diagnosis on the current Visit (FIN) number, click Add to Problem &
Diagnosis button next to the OK button.
5. You are returned to the Pregnancy Summary Page, which now displays the Active Pregnancy
information. All sections on page are activated and in view. Now you must add information to
calculate the EDD.
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6. Click blue link - Add EDD (Estimated Due Date) to open EDD Maintenance window
7. EDD Maintenance history displays at top with no information at this time. It will display methods
as they are added.
8. Add EDD Maintenance information is at bottom. Enter information in following fields:
a. Method – Click drop down to click selection. Additional fields will become required,
depending on Method selected. EDD will be calculated when the required fields are
completed. See examples below.
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

Date of Method – required field
Confirmation – defaults to Confirmed; click drop down to change, as needed.


EGA – enter weeks and days
EDD – will automatically populate when other fields are completed
Exception – when Unknown is selected as Method, you must enter EDD.
Comments – type, as needed.
Description – will change depending on type of Method chosen. See examples
below.
If Final is selected, no new estimates will be allowed for this pregnancy (To do so,
you can Modify the Final method to remove Final checkmark).




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If Last Menstrual Period is selected, you can click on Show Additional Details to
reveal extra fields for charting Menstrual History.
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9. When required fields have been completed, notice EDD calculation. Click OK.
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10. EDD will now appear on Pregnancy Summary Page. Additional EDD methods can be entered
through EDD Maintenance section. (See instructions below in description of EDD Maintenance
section.)
Appearance of Pregnancy Summary Page
Sections
o Display information pulled from previous documentation in various locations in PowerChart.
o Click arrow at right of green section heading to open or close section to view data.
Links
o Section headings serve as links to click to navigate to various locations in the chart.
o Information displayed in blue also serves as a link to click to navigate to the source of the
information.
o You can also hover on blue information to view details, such as date/time of entry, who
documented, etc.
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Hover over blue EDD
date to see details.
How to Customize
o Location of top 4 sections is stationary - Overview, Vitals and Measurements, Labor
Exam, Results Timeline.
o You can customize remaining sections and move them to locations of your choice:
 Click Customize
 Left click and hold and drag section to desired location.
 To default the section information open, click the arrow to point up. If arrow is
pointed down, section information will be out of view upon opening the page, so you
must click arrow to point up and open section.
 Click Save Preferences
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Section with arrow
pointing up will
default open for
viewing.
Left click on section
heading and drag to
desired location.
Description of Sections
Overview
Current Pregnancy tab displays current pregnancy information from previous charting, along with
demographic information from IDX.
Contact Info tab displays demographic information from IDX.
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To update pregnancy, click Update Pregnancy drop down button to reveal choices:
o Cancel
 Click to Cancel pregnancy. Pregnancy Summary page will be out of view.
o Close
 Click after pregnancy has ended.
 Close Pregnancy box will open for you to enter delivery information.
 Neonatal Outcome field is required (Live Birth, Fetal Death, Neonatal Death), and
will update Para Living status.
 Click OK
 Pregnancy Summary Page will now be out of view.
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o Modify –
 Click to view Modify Pregnancy box, which is same box as Add Pregnancy box
described above.
 Modify, as needed.
 Click OK to save information.
Vitals and Measurements
Scroll to right to view entire display
Click View Graph drop down button to select and view graphs for Fundal Height or Labor
Graph
Labor Exam
Displays data from patient exam documented in PowerNote or I-View, with most recent at top.
EDD Maintenance
Displays Information previously entered
o Number in parentheses - number of confirmation methods entered
o Status – Initial, Authoritative, Non-Authoritative
o EDD – determined by method with Authoritative Status
o EGA on Method Date (Estimated Gestational Age)
o Method – LMP, ultrasound, etc.
o Date of Method
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Hover on blue EDD date to view more information.
Hover on blue EDD
date to view more
information.
How to add EDD method
a. Click blue + to view EDD Maintenance window.
b. Click drop down to select method.
c. Enter information in yellow required fields to calculate EDD. See instructions above in How
to Open Current Pregnancy
d. Click OK.
How to set specific EDD method as authoritative
a. Click Use this estimate for EDD calculations.
b. If Final is selected, it is always designated the authoritative EDD.
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

No new estimates will be allowed for this pregnancy when Final is selected.
If you need to add additional estimates to a Final EDD, click on date to open for
modifying. Remove Final check mark and click OK.
c. If multiple methods exist, and Final is not selected, and no method has been marked Use
this estimate for EDD calculations, the system will calculate the EDD by selecting the
method with the latest date/time.
How to modify EDD method
a. Click on method’s blue date to view EDD Maintenance window.
b. Make changes and click OK.
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Pregnancy History - Displays historical pregnancies previously documented.
1. To add information, click on heading link to go to Histories
2. Click Pregnancy tab
3. Click Add
4. Do not adjust numbers in fields at top
5. Enter information under Baby A tab
a. Complete yellow required fields.
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b. Although not required, enter information into Gestation at Birth fields for Preterm and
Fullterm calculations.
c. When exact date is unknown or fuzzy, click blue Delivery/Outcome Date/Time to select
Month or Year.
Avoid entering numbers in fields at
top of screen. Enter information
into required fields below for history
calculations.
Enter Gestation for
Preterm and Fullterm
calculations.
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When exact date is not know, click on
blue Delivery/Outcome Date/Time to
change field to Month or Year.
6. If multiple births, click + Add Baby button to enter information for other babies.
7. Click OK to update Pregnancy History (or OK & New to add another pregnancy).
Fetal Monitoring – contains archived fetal monitoring episodes
1. Place check mark in desired episode.
2. Click Show.
3. FetaLink will open for viewing.
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Birth Plan
Displays information previously documented by nurses (clinic I-View or Triage Admission or
L&D Admission PowerForms) or by providers (Prenatal Record PowerForm)..
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Genetic Screening Counseling
Displays information from I-View Prenatal Record-Education and provider’s Prenatal Record
PowerForm.
New Orders
Click heading link to navigate to PowerOrders.
Providers can enter orders from this section in three ways:
o Click blue + to open Add Order window to enter new orders.
o Click on Favorites tabs (Meds, Labs, Imaging, Billing, Other) to view and select personal
Favorites. Selected orders will display under Orders for Signature before Signing.
o If Diagnosis is required on order, click Dx Table button to view Diagnosis Table for
Unsigned Orders to quickly associate a diagnosis to each order.
o Click Modify button to add or modify order details, as needed.
o Click Sign to complete signing process.
o If you wish to remove selected orders and NOT sign, click on black check mark next
to order to remove it. Order will drop off upon Refresh.
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1-Click tab to show Favorites.
2-Click to select order.
3-Order appears for signature.
4Click Dx Table to add Diagnosis,
or click Modify to modify details,
Click Sign to complete process.
o To quickly enter orders not listed in Favorites tab, type in quick search field above favorite
tabs. After clicking desired order, it will display under Orders for Signature where you can
add Dx or Modify, before Signing, as described above.
Consolidated Problems
Displays information charted on Problems and Diagnoses.
Click heading link to move to Problems and Diagnoses.
You may enter a Diagnosis for this visit in the Add New As This Visit (diagnosis) field.
Diagnoses are Visit specific, so will clear with each different Visit.
o Type diagnosis in quick search field.
o Click to select desired diagnosis.
o Diagnosis will appear under This Visit Diagnosis.
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Type diagnosis and click to select..
Diagnoses will appear here.
Diagnoses are visit-specific, so this
field will be clear with each visit.
You can drag Probems up into This Visit
(Diagnosis field).
To enter a Problem, change the search field by clicking next to the Add New As field on This
Visit (diagnosis) to view and select different search choice:
o This Visit (Diagnosis) and Active Problems – you can enter both at once
o Active Problems
o Historical Problems and Diagnoses
Click to view and select different search criteria, such as Active Problems.
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Reminders:
o Diagnoses are Visit specific, so will clear with each Visit.
o Problems remain on Problems list for all Visits.
o Only providers can enter Problems in patient’s PowerChart.
Providers can click on a Problem or Diagnosis and drag it to the other section. Or can highlight
problem or diagnosis and click drop down arrow to move items from one section to the other.
Drop down arrow also displays choices for managing diagnoses and problems, such as Remove,
Resolve, Inactivate, or Cancel.
Highlight problem or diagnoses.
Click small drop down arrow to view
choices, such as Cancel.
Documents
Displays PowerNotes, including OB Fetal Well Being PowerNote.
Click on this link to go to Document Viewing.
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Labs
Displays labs reported after opening date of Pregnancy Summary page
Medications
Displays inpatient meds, organized by categories in image below.
Click blue + to open Add Order window to order meds.
Click heading link to navigate to Medications List.
Home Medications
Displays previously documented Home Medications.
Click blue + to open Add Order window.
Click heading link to navigate to Medications List.
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Immunizations
Displays immunizations
Click heading to navigate to Immunizations
Education
Displays previously documented education in I-View by clinic nurse, organized by trimester
Click on heading to navigate to I-View
Allergies
Displays current patient allergies.
Click heading link to navigate to Allergies.
Click blue + to open Add Allergies window to add Allergies.
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Microbiology
Displays recent Microbiology results.
Click on heading link to navigate to Microbiology Viewer.
Pathology
Does not display information.
Click on this link to go to Pathology.
Social History
Displays previously documented information.
To view details, hover over Details.
To add information, click heading link to navigate to Histories in Menu, then click on Social
History tab.
Hover on Details to view
more information about
specific item.
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Procedure History
To view details, hover over procedure name.
To add information, click heading link to go to Histories in Menu, then click on Procedure
History tab.
Hover on procedure to
view more details.
Past Medical History
To view details, hover over item.
To add information, click heading link to go to Histories in Menu, then click on Past Medical
History tab.
Hover to view details.
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PowerChart Maternity: Pregnancy Summary Page

Transcription

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