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Charting / Prenatal Records
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Prenatal Records

This guide outlines how to chart Alberta prenatal record in a step by step process.

There will be one prenatal record for each pregnancy of the patient.

Prerequisites:
Before starting, make sure you have done the following

  • You have added the Alberta Prenatal Record to your flowsheets. You can do this under My Account -> Flowsheets -> Browse Templates. Find the Alberta Prenatal Record and click the black plus icon it to add it to your collection.

Starting a Record

Follow these steps if it is the first time you are opening a prenatal record for a patient’s pregnancy. If you are adding a note to an existing prenatal record, please see the steps further below under the header Adding to an Existing Record.

1. On the patient’s chart click the plus icon on the Clinical Notes section

Clinical Notes section with 'Plus' button labeled with a large red arrow

2. Ensure the Alberta Prenatal Record is selected in the dropdown. Then click Select Flowsheet

Select Note / Flowsheet Template section with 'Flowsheet' and 'Most Commonly Used' sections labeled with large red arrows

If the patient has had a prenatal flowsheet on their chart from another pregnancy, you will need to select the plus icon to create a new flowsheet.

Alberta Prenatal Record section with large red arrow pointing to 'New Flowsheet' button

3. Enter in the date of the last menstrual period (LMP), select the most responsible physician/employee, and select the correct clinic

Tip: Click in the Last Menstrual Period box to trigger a calendar popup. Use this calendar to easily chose the last menstrual period date.

Alberta Prenatal Record form with Last Menstrual Period, MRP/Employee, Clinic fields labeled with large red arrows

4. Set the Note Date, Employee, Clinic, and Appointment in the Current Note section

This section of the prenatal flowsheet will be specific to each visit. For example, if the patient see’s the physician on one visit, the employee will be set to the physician. The second time the patient comes in, they may see the nurse. In that case, the employee will be set to the nurse.

Current Note fields with four string fields labeled by large red arrows

5. Click the green Save button at the bottom of the flowsheet to activate the autosaving feature

6. Fill out the rest of the note as needed and press Save when done

Click on each section header to reveal the section details.

Pregnancy Details section with fields labeled 'LMP', 'EDB by LMP', 'ED8 by US' and toggles below
The text entered into the Extra Notes box will not show up on the printed/faxed version of the prenatal record. If you need to send more information, we recommend using a simple note template to record the extra text and print/fax it.

7. To print the prenatal record, click the printer icon beside the note in the Clinical Notes section

Clinical Notes section with print button labeled by a large red arrow

Adding to an Existing Record

If your clinic has started a prenatal record for a patient’s pregnancy, you will want to add on to this record for all visits that relate to that pregnancy.

The first two steps are the same as the first two steps of starting a flowsheet for the first time.

1. On the patient’s chart click the plus icon on the Clinical Notes section

Clinical Notes section with 'Plus' button labeled with a large red arrow

2. Ensure the Alberta Prenatal Record is selected in the dropdown. Then click Select Flowsheet

Select Note / Flowsheet Template section with 'Flowsheet' and 'Most Commonly Used' sections labeled with large red arrows

3. Select the flowsheet that corresponds with the patient’s current pregnancy by clicking on the Last Menstrual Period

Alberta Prenatal Record section with large red arrow pointing to 'New Flowsheet' button

This will open up a new note to which you can add new information.

4. Follow steps 4-7 from the Starting a Record section of this article.

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