Prenatal Flowsheet

 

This subsection appears in the Ob Episode tab of the patient chart

 

 

What is an OB episode?

athenaOne refers to the clinical and billing time period of a patient's pregnancy as an OB episode; the OB episode is a mechanism to track OB enrollments and information about clinical outcomes. Enrollment, EDD, and delivery reports organize information captured in the OB episode. Once saved, OB episode information is available for reporting. You can report on three main items: enrollment, EDD, and deliveries.

 

OB episode and athenaClinicals

In the patient chart, click the Menu icon and select Start OB episode. To view and edit an existing OB episode, click Pregnancy Problems in the Problems tab of the patient chart.

Note: To help you care for your transgender and nonbinary patients, the Start OB episode option is available when the Assigned sex at birth field is set to any of these values: Female, Choose not to disclose, or Unknown.

 

After you create an OB episode, the patient banner displays the following information about the episode: gravidity and parity, duration of pregnancy expressed as "weeks.days," estimated date of delivery (EDD), and blood type.
Note: If your practice has different chart sharing groups, the OB episode information appears only when viewing the patient chart with the open OB episode.

 

The top section of the OB Episode tab is used to track initial information about the pregnancy and to estimate the patient's EDD. After the initial data is saved, the Prenatal Flowsheet section also appears in the OB Episode tab.

 

After this information is completed and the OB episode is closed, the Past Pregnancies section and Obstetric History section of the patient's chart are automatically updated according to the OB episode outcome.

 

Note: When a provider orders a RhoGam injection (using any order type that is considered RhoGam), an entry appears on the Results section of the patient's OB Episode tab indicating the date of the injection. This information also prints on the OB Episode form.

 

 

If you make a free-text amendment to a prenatal flowsheet in a closed encounter, we recommend that you update the prenatal flowsheet entry from the encounter amendment first, and then make the same update to the OB episode. This ensures that documentation remains in sync, because updates you make to prenatal flowsheet entries from the OB episode do not automatically update a closed encounter.

 

Note: If the prenatal flowsheet amendment is structured, edits you make directly in the encounter automatically update the OB episode, so there is no need to update the OB episode manually.

 

 

 

You can click Expand All Notes to view all recorded notes. Similarly, click Collapse All Notes to collapse expanded notes.

 

athenaOne truncates notes if they exceed 4 lines. Truncated notes only show the first 4 lines of the whole note.

 

 

The table shows all possible prenatal flowsheet elements. However, the options you see depend on the flowsheet elements selected on the Configure Prenatal Flowsheet page.

Column Headings
Fundus	The fundal height in weeks or cm.
Pres	Presentation of the fetus: Vertex, Breech, Transverse, Cephalic, or Oblique.
FHR	Fetal heart rate in beats per second.
FM	Fetal movement (Yes, No, Decreased, or Increased).
PLS	Preterm labor signs. Options are none, Backpain, Bleeding, Cramping, Uterine Contractions, Other (see comments), Pressure, or Braxton Hicks.
Cervix Exam	Cervix Exam: Dilation/Effacement/Station of the cervix.
BP	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.
Wt	Patient weight in pounds. You can select the Not Performed option to indicate that you did not record the patient's weight at this visit.
Glucose	Amount of glucose in the urine (none, trace, 1+, 2+, 3+, or 4+).
Albumin	Amount of albumin in the urine (none, trace, 1+, 2+, 3+ or 4+).
Ketones	Urine ketone value (negative, small, moderate, large, or trace).
Leukocytes	Indicates leukocytes found through a urinalysis dipstick (none, trace, 1+, 2+, or 3+).
Edema	Edema (none, trace, 1+, 2+, 3+, or 4+).
Blood	Indicates blood found through a urinalysis dipstick (neg, trace, 1+, 2+, or 3+).
Protein	Indicates protein found through a urinalysis dipstick (neg, trace, 1+, 2+, 3+, or 4+).
pH Urine	pH level found in the urine.
Bishop Score	Bishop Score.
Modified Bishop Score	Modified Bishop Score.
Pain Scale	Value on the pain scale.
Nitrite	Positive or Negative.
Estimated Fetal Weight	Estimated fetal weight. Options include 2000g, 2500g, 3000-3500g, 3500-4000g, 4000-4500g, or 5000g.
Specific Gravity, Urine	Specific gravity found in the urine.
Comments	Comments appear for the row at the far left (no column heading for comments).
Source	Historical or Encounter — depending on whether the pregnancy was entered via Health History or through documentation in athenaClinicals.

Data Entry Fields
Gest. Age	The number of weeks gestation of the fetus at the encounter date. Defaults based on EDD.
BP	Blood pressure. Two sets of fields for entering blood pressure. If more than two blood pressure readings are taken in the vitals section, the first two appear on the flowsheet.
Glucose	Select an option to indicate the amount of glucose in the urine (none, trace, 1+, 2+, 3+, or 4+).
Ketones	Select an option to indicate specific urine ketone value (negative, small, moderate, large, or trace).
Edema	Select an option to indicate edema (none, trace, 1+, 2+, 3+, or 4+).
Protein	Select an option to indicate protein found through a urinalysis dipstick: neg, trace, 1+, 2+, 3+, or 4+.
Bishop Score	Enter the Bishop Score.
Pain Scale	Enter a value on the pain scale.
Estimated Fetal Weight	Select an option to indicate estimated fetal weight: 2000g, 2500g, 3000-3500g, 3500-4000g, 4000-4500g, or 5000g.
Provider	Enter the name of the rendering provider for the current encounter.
Wt	Enter the patient's weight in pounds.
Albumin	Select an option to indicate amount of albumin in the urine (none, trace, 1+, 2+, 3+, or 4+).
Leukocytes	Select an option to indicate leukocytes found through a urinalysis dipstick (none, trace, 1+, 2+, or 3+).
Blood	Select an option to indicate blood found through a urinalysis dipstick (neg, trace, 1+, 2+, or 3+).
pH Urine	Enter the pH level found in the urine.
Modified Bishop Score	Record the Modified Bishop Score.
Nitrite	Select an option to indicate nitrite: Positive or Negative.
Specific Gravity, Urine	Record the specific gravity found in the urine.
Fundus	Specify the fundal height in cm or weeks.
FHR	Specify the fetal heart rate in beats per second. Select a present/absent option from the menu (in addition or in place of entering a number).
PLS	Select an option to indicate preterm labor signs. Options are none, Backpain, Bleeding, Cramping, Uterine Contractions, Other (see comments), Pressure, or Braxton Hicks.
Pres	Select an option to indicate the presentation of the fetus: Vertex, Breech, Transverse, Cephalic, or Oblique.
FM	Select an option for fetal movement: Yes, No, Decreased, or Increased.
Cervix Exam	Cervix Exam Dilation/Effacement/Station. Select an option from each menu to document dilation, effacement, and station of the cervix.
Comments	Comments entered in this field also appear in the consolidated flowsheet view.