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
2. Ensure the Alberta Prenatal Record is selected in the dropdown. Then click Select Flowsheet
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.
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.
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.
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.
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
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
2. Ensure the Alberta Prenatal Record is selected in the dropdown. Then click Select Flowsheet
3. Select the flowsheet that corresponds with the patient’s current pregnancy by clicking on the Last Menstrual Period
This will open up a new note to which you can add new information.
