OB Episode Tab

Used to track multiple gestation pregnancies. If more than one fetus is present, additional columns are inserted into the flowsheet to track findings specific to each fetus: presentation, fetal heart rate, and fetal movement.

The patient's department of care.

Populated automatically from a lab result, if the Ob tab field was not already populated. If the blood type is populated from a lab result, a link to that lab result appears.

If the blood type is updated directly from the Ob tab, the link to the lab result disappears.

Updates to the Ob tab fields do not affect the original lab result data. The blood type on the lab result remains the same.

Populated automatically from a lab result, if the Ob tab field was not already populated.

If the Rh status is populated from a lab result, a link to that lab result appears. If the Rh status is updated directly from theOb tab, the link to the lab result disappears.

Updates to the Ob tab fields do not affect the original lab result data. The Rh status on the lab result remains the same.

The patient's pre-pregnancy weight (this field also displays the metric conversion).

Name of the child's father.

Name of the patient's husband or domestic partner.

The pediatrician can be entered predelivery. Only one pediatrician can be entered per OB episode (even if there is more than one fetus).

After delivery, however, the field is available for each fetus, with the original pediatrician as the default.

Enter or select the date of the first day of the patient's last menstrual period. Use the Definite field to record whether the date is definite.

Note: An LMP is not required to save the OB Episode tab information.

Indicates whether or not the patient has a monthly menstrual cycle.

Age at which first menstruation occurred.

Additional field to document date of last menstrual period.

Indicates whether or not the patient was on hormonal birth control at conception.

Date on which patient had positive urine or serum pregnancy test.

Enter or select the date of the first day of the patient's last menstrual period. Use the Definite field to record whether the date is definite.

Enter or select the date of the initial OB exam. This value defaults to the day that the OB episode is opened, but it can be updated. The provider performing the initial exam enters the number of weeks gestation based on physical exam into the "weeks gestation" field on this line.

Enter or select the date of the first ultrasound used to confirm EDD.

Calculated EDD date based on the information entered above.

Auto-calculated based on Last menstrual period, Initial exam date, and Initial ultrasound date. The OB episode tab uses this date field only if the Final EDD date field is not populated.

Auto-calculated based on Last menstrual period, Initial exam date, and Ultrasound date. The OB episode tab uses this date field if it's populated. If the EDD has not yet been calculated, the OB episode tab uses the Initial EDD date, if available. If neither the initial EDD nor the final EDD have been calculated, the OB episode tab does not display an EDD calculation.

Select this option to display hidden pregnancy problems in this section.

The SNOMED-CT term for the pregnancy problem.

Click inside the drop-down field to display your short list of problems, or enter the first few letters of a problem and select it from the list.

Your short list of SNOMED-CT pregnancy problems is administered on the Configure Pregnancy Problems page.

Enter the onset date of the problem.

Enter the end date of the problem.

Select a resolution plan.

Enter any notes about this problem and resolution.

Click the remove link to remove a problem from the list.

Select this option to hide the problem in the list.

Note: You can select the Show Hidden option at the top of the list to display hidden pregnancy problems.

If you want to add this problem to the Problems section of the patient chart, select this option.

Use this free-text field to track problems that may not be tied to a specific problem and diagnosis code. These notes appear on the OB Episode form.

The fundal height in weeks or cm.

Presentation of the fetus: Vertex, Breech, Transverse, Cephalic, or Oblique.

Systolic and diastolic blood pressure measurement. Provides a linked encounter date when the blood pressure measurement was taken, with the rendering provider's username.

You can select the Not Performed option to indicate that you did not record the patient's blood pressure at this visit. When you select this option, you must select a reason from the menu.

• Not indicated — Select this option when, for example, a patient returns for a follow‑up visit shortly after a previous visit.
• Not tolerated — Select this option when, for example, a patient comes in for a quick nurse visit and becomes angry or agitated when asked to have her blood pressure taken.
• Patient refused — Select this option when, for example, a patient comes in for a quick nurse visit and refuses to have her blood pressure taken because she's in a hurry.

Note: The Not indicated and Not tolerated reasons are considered medical reasons for not measuring blood pressure and, therefore, satisfy quality data reporting requirements. The Patient refused reason is not considered a medical reason and does not satisfy reporting requirements.

Indicates blood found through a urinalysis dipstick (neg, trace, 1+, 2+, or 3+).

Comments appear for the row at the far left (no column heading for comments).

Historical or Encounter — depending on whether the pregnancy was entered via Health History or through documentation in athenaClinicals.

Date of delivery or termination of pregnancy.

Select Yes or No.

Menu to indicate what, if any, anesthesia was used during labor and delivery. Options include General, Local, Regional, or None.

Select the name of the provider who delivered the baby from the menu. This provider name appears in closed OB episodes and on the fax and print versions of the episode.

Note: The Delivered By menu displays the providers in your organization (listed on the Providers page). If a provider outside your practice delivered the baby, enter that information in the Comments field.

Select the location (site) of the delivery. If not listed, enter the site in the Other field.

The number of weeks gestation of the patient at the time of delivery.

Length of labor in hours.

Enter any notes in this field. For example, if the baby was delivered outside your practice, you can enter information about the provider who delivered the baby in this field.

Sex of the baby (repeats for multiple gestation pregnancies).

Birth weight of the baby in pounds and ounces (repeats for multiple gestation pregnancies).

Outcome of the delivery (repeats for multiple gestation pregnancies).

The baby's race. Select a race from the menu, or select the Patient Declined option. To select more than one race, click the plus icon .

Select an ethnic group from the menu, or select the Patient Declined option. To select more than one ethnicity, click the plus icon . By default, a short list of the values that you most commonly select appears. To select a different value, enter the first few letters of the desired option and select it from the list.

Select the type of delivery. The options in this menu are administered on the Delivery Types page.

Maternal HGB/GCT level upon discharge

Feeding method upon discharge

Contraceptive method upon discharge

Select a reason to close the OB episode.

Note: A patient cannot have more than one open OB episode at any given time. To enforce when the pregnancy history section is incremented, you should close the OB episode after that pregnancy is completed (by delivery, termination, or transfer of patient to another provider's care) and indicate the outcome and/or reason for closure.