This article will introduce the users to the section of the visit note used to document or review birth information. The user will be guided through the fields to easily review and document additional information.
- Click the History tab.
- Click the Perinatal History tab.
- Click the Birth Info tab.
- Enter the information in each of the fields.
|Birth time||Click into the field to enter the time of the child's birth. The format is HH:MM AM/PM. Prior to the time entry there will be a 24-hour checkbox to the right of this field. Click if you wish to use military time.|
|Part of a multiple birth||Click the checkbox if the child was part of a multiple birth.|
|Apgars||Enter a numeric value from 1-10 for the Apgars score.|
|Gestational age||Click the drop down arrow and select from the list. Gestational age is important when a child was born premature. An entry for a premature gestational age will prompt for the preemie growth chart when evaluating growth measurements.|
|Synagis indicated||Click the checkbox if Synagis is indicated. When selecting this checkbox the Immunization record will be updated for this child setting the Synagis indicator.|
|Type of delivery||Click the dropdown arrow and select from the list.|
|Feeding||Click the dropdown arrow and select from the list.|
|Infant blood type||Click the dropdown arrow and select from the list.|
|Coombs||Click the dropdown arrow and select POSITIVE or NEGATIVE for the Coombs test.|
|Hearing screen||Click the dropdown arrow and select from the list.|
|Newborn screen #||If known, enter the Newborn screen #.|
|Adopted at months||Click the checkbox if the child was adopted. Enter the numeric value for how old the child was at adoption in months.|
- Select the Birth place from the drop down or type in the free text field.
- Enter the birth and discharge measurements.
- Select inches/lbs or cm/kg radio button as applicable.