PowerChart Maternity: Pregnancy Summary Page 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 04.24.12 Page Number 2 2 7 9 10 11 11 13 16 17 18 18 19 21 22 22 22 23 23 23 24 24 24 25 25 Page 1 PowerChart Maternity: Pregnancy Summary Page 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 04.24.12 Page 2 PowerChart Maternity: Pregnancy Summary Page 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. 04.24.12 Page 3 PowerChart Maternity: Pregnancy Summary Page 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. 04.24.12 Page 4 PowerChart Maternity: Pregnancy Summary Page 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). 04.24.12 If Last Menstrual Period is selected, you can click on Show Additional Details to reveal extra fields for charting Menstrual History. Page 5 PowerChart Maternity: Pregnancy Summary Page 9. When required fields have been completed, notice EDD calculation. Click OK. 04.24.12 Page 6 PowerChart Maternity: Pregnancy Summary Page 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. 04.24.12 Page 7 PowerChart Maternity: Pregnancy Summary Page 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 04.24.12 Page 8 PowerChart Maternity: Pregnancy Summary Page 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. 04.24.12 Page 9 PowerChart Maternity: Pregnancy Summary Page 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. 04.24.12 Page 10 PowerChart Maternity: Pregnancy Summary Page 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 04.24.12 Page 11 PowerChart Maternity: Pregnancy Summary Page 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. 04.24.12 Page 12 PowerChart Maternity: Pregnancy Summary Page 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. 04.24.12 Page 13 PowerChart Maternity: Pregnancy Summary Page 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. 04.24.12 Page 14 PowerChart Maternity: Pregnancy Summary Page 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. 04.24.12 Page 15 PowerChart Maternity: Pregnancy Summary Page 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. 04.24.12 Page 16 PowerChart Maternity: Pregnancy Summary Page 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).. 04.24.12 Page 17 PowerChart Maternity: Pregnancy Summary Page 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. 04.24.12 Page 18 PowerChart Maternity: Pregnancy Summary Page 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. 04.24.12 Page 19 PowerChart Maternity: Pregnancy Summary Page 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. 04.24.12 Page 20 PowerChart Maternity: Pregnancy Summary Page 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. 04.24.12 Page 21 PowerChart Maternity: Pregnancy Summary Page 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. 04.24.12 Page 22 PowerChart Maternity: Pregnancy Summary Page 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. 04.24.12 Page 23 PowerChart Maternity: Pregnancy Summary Page 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. 04.24.12 Page 24 PowerChart Maternity: Pregnancy Summary Page Procedure History Displays previously documented information. 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 Displays previously documented information. 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. 04.24.12 Page 25 PowerChart Maternity: Pregnancy Summary Page 04.24.12 Page 26
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