Important Content Update Message
We are currently updating the OP Help Center content for the release of OP 20. OP 20 (official version 20.0.x) is the certified, 2015 Edition, version of the Office Practicum software. This is displayed in your software (Help tab > About) and in the Help Center tab labeled Version 20.0. We appreciate your patience as we continue to update all of our content.

Newborn History

Version 14.19

Overview

This section will introduce the users to the section of the visit note that is used to document or review newborn history. You will be guided through the fields to easily review and document additional information.

Add or Edit Newborn History

  1. From an open well visit note, click History
  2. Click the Newborn tab. All previous documented newborn history is displayed.
  3. Click the Newborn History heading to view additional history points or select the Show all questions checkbox to include Maternal Perinatal History

  1. Click N/A to mark as + positive or click a second time to mark as - negative.
  2. Add additional information into the Comments field.

Add Custom Newborn History Questions

  1. Click in the Custom question field
  2. Select Newborn History from the Custom question menu
  3. Enter the history question in the field
  4. Click the Add button
  5. Repeat the steps for additional history questions.

Add Newborn History to Problem List

  1. Select the History Question
  2. Click the Add  button in the last column
  3. A Warning pop-up box is displayed, click the New button

  1. Select the radio button that designates the Status of the problem (default selection is Active)
  2. The Onset date will default to the date the problem is entered. Click the Onset date field and enter a date or click the drop-down menu and select a date from the calendar.

  1. Click the Problem field. Begin entering the name of the problem then press the Enter key or click the drop-down menu.
If the problem is not found:
  1. Click the Full Search button
  2. To expand the search, select the Complete radio button
  3. If the problem is not in the complete list, select the Master radio button

  1. Once the problem is found, highlight and click the Select button.
  1. Click the code and click Select
  2. Click the ICD code field. Begin entering the name or code then press the Enter key or click the drop-down menu.
  3. Click the code and click Select
  4. (Optional) In the Refer/coord: field, enter the name of the specialist or facility that is handling the care for the entered problem. You may also:
  • Click the Address Book button  and search and select from the address book entries
  • Or, click the Coordination of Care button  and select from the list that has been associated to the patients record.
  1. (Optional) Click the drop-down arrows to select Stage/Severity, Quality of life and Symptoms.
  2. (Optional) Add additional comments or pertinent information in the Notes field.
  3. (Optional) Click the drop-down menu for Visibility: if the privacy level is higher than Any staff member.
Version 14.10

Overview

This section will introduce the users to the section of the visit note used to document or review newborn history. You will be guided through the fields to easily review and document additional information.

Add or Edit Newborn History

  1. Click the History tab
  2. Click the Perinatal History tab and the Newborn History tab is displayed.
  • Newborn History and Maternal Perinatal History is displayed.
  1. Click a heading to view additional history points.
Note:  If Newborn History is not displayed, select the Show all questions checkbox.


  1. Click N/A to mark as + positive or click a second time to mark as - negative.
  • Add additional information into the Comments field.

To add history questions that are not included:
  1. Click the Custom question drop-down menu
  2. Select Newborn History from the drop-down menu
  3. Enter the history question
  4. Click the Insert Question  button to save the entry. The new entry is displayed as a + positive entry.