Newborn History (Encounters)

Version 14.19

Overview

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

Add or Edit Newborn History

  1. Click the Chart button.
  2. Search for and select the patient.
  3. Click the Encounters tab.
  4. Open or create an encounter note.
  5. Click the History tab.
  6. Click the Perinatal History tab and the Newborn History tab opens.
Note:  If additional Newborn History needs to be documented, 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.

Note:  To include pertinent newborn history on the Encounter note summary, select the checkbox in the Pert column.

Add Custom Question

  1. Click the Custom question dropdown arrow.
  2. Select Newborn History.
  3. Type the question in the text field.
  4. Click the Add question (green plus icon) button to insert the question and save the entry.

Version 14.10

Overview

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

Add or Edit Newborn History

  1. Click the Chart button.
  2. Search for and select the patient.
  3. Click the Encounters tab.
  4. Open or create an encounter note.
  5. Click the History tab.
  6. Click the Perinatal History tab and the Newborn History tab opens.
Note:  If additional Newborn History needs to be documented, 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.

Note:  To include pertinent newborn history on the Encounter note summary, select the checkbox in the Pert column.

Add Custom Question

  1. Click the Custom question dropdown arrow.
  2. Select Newborn History.
  3. Type the question in the text field.
  4. Click the Add question (green plus icon) button to insert the question and save the entry.