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SmartOB Prenatal Forms

 

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This is the 4th form of the SmartOB Version 3 forms. As with all the SmartOB Forms, this form has been designed to perform optimally with a Tablet computer using just the pen as the input device in most instances. This facilitates workflow during the prenatal visit. Most of the form is self-explanatory. The details to the right are for clarification of the items that might need some added explanation.

When this form loads for the first time during a session, a Warning box pops up reminding the user to document any missing data based on the EGA as calculated from the Final EDD, the computer date and the Preferences set by the user if not already warned. As with the other forms, pop-up boxes facilitate data entry.

As with all the other forms, the Header should be customized to your name and logo.

Pt Name, DOB and Number are carried over from Form 1.

The 1st column is for the Date, the 2nd, for the Progress Notes and the 3rd for the Signature. When the PROGRESS NOTES field is entered, the Progress Notes Builder automatically pops up (see below).

You may enter notes directly into the field and the notes word-wrap automatically. New lines can be created by the key combination "Alt-Enter" but each date should have only one Progress Notes field..

This sheet may become very long in appearance but will divide as many times as necessary when printed or converted.  

This form appears when the Progress Notes field is entered on Form 4. It allows you to build >90% of your Progress Notes quickly and effortlessly with a few mouse clicks. You don't ever have to use this form but I find it very helpful, especially when using a Tablet PC. The default button is Finish, so hitting the Enter key if using a keyboard will close this form.

As reminders, the Problem List from Form 3 and the current Reminders are displayed on top.

Choose the Category and the available pre-written Notes will be displayed on the left. You will be able to be create most of your Progress Notes using just the default ROUTINE Category.

Clicking the "Add to Notes" button will add the selected notes from the "Notes" list on the left or the "Reminders" list to the location of the cursor in the Progress Notes field. The "Delete from Notes" button will delete the highlighted selection from the notes wherever it is located. "Copy Previous" will copy the previous notes into the Progress Notes field.

   

This form was developed to to assist in the rapid creation of most progress notes using the pen of a Tablet computer but is by no means complete. There will be times when you will need to type directly into the Progress Notes field. Hopefully, those times should be rare.

Hitting the key combination "Ctrl-Enter" will add a new line to the Progress Notes field.

When you select the Physical Category, the Temperature box appears. Select the temperature (e.g., 98.8) and when you click Add to Notes, "Temp - 98.8 F" will be added to the Progress Notes at the cursor position. By default, the cursor is positioned to the end of the last insertion point.

   

If the patient has diabetes, selecting the DIABETES Category will reveal the relevant Notes to the left.

If you select Insulin, the Insulin dosage choices appear. After you select the dosages, click Add to Notes button and Insulin along with the selected doses will be added to the Progress Notes at the cursor position.

If you select Glyburide or Glucophage, you may then choose the dosages. Hitting the Add to Notes button will then add the selection and the selected doses to the Progress Notes at the cursor position.

If  any of the above is selected and you hit Delete from Notes, the medication and its associated doses are deleted from the Progress Notes wherever they may be located.

When you select Insulin, Glucophage, Glyburide or Lantus the Meds, Add Rx and Show Rx buttons appear. Clicking the Meds button will enter the selected medication to the Medications List on Form 3. Clicking the Add Rx button will add the medication and the dosages to the Prescription form. Clicking the Show Rx will reveal the prescription form.

   

The Insulin Calculator button above appears when Insulin is selected. Clicking the Insulin Calculator button reveals the built-in Insulin dose calculator. The patient's last weight is automatically added from Form 3. Entering the number of units of Insulin per kg./day and hitting the Enter key will calculate the dose for that value and weight according to the formula 2/3 of the dose in am (2/3 NPH & 1/3 Reg) and 1/3 of the dose in pm (1/2 NPH & 1/2 Reg).

Clicking the Add Insulin Doses button will transfer the doses to the Progress Notes Form and return you to that Form.

   

As with Glyburide or Glucophage above, when you select a medication listed in the MEDS Category, the dosage boxes will be revealed. The doses in the pull-down lists are appropriate for the selected drug. After selecting the desired doses, frequency, and duration, clicking the Add to Notes button will add the drug along with the desired doses, frequency, and duration to the Progress Notes at the cursor position.

Selecting a drug and clicking Delete from Notes will remove the drug and the associated doses, frequency and duration from wherever they are located in the Progress Notes.

When you select a medication, the Meds, Add Rx and Show Rx buttons appear. Clicking the Meds button will enter the selected medication and the associated dosage to the Medications List on Form 3. Clicking the Add Rx button will add the medication and the dosage to the Prescription form. Clicking the Show Rx will reveal the prescription form.

 

 

 

Clicking the Show Current Meds button reveals a color-coded Current Meds window without having to close the Form and switch to a different sheet. Clicking the Show Allergies button reveals a color-coded Allergies window. Clicking the Hide button of the same color will close that window and return to the Problem List and Reminders windows.

 

 

User Defined Documentation is a new Category in version 3.16. This Category allows the user to customize any documentation that is of interest to his or her individual practice and therefore used routinely but not available as part of the standard SmartOB documentation.

For example, the user may wish to document whether the patient plans to breast feed after the delivery. By customizing the Notes in this Category to include "Patient plans to breast feed," then that information may be easily documented in every pregnancy using this Category without the need to type that statement.

Selecting Edit Documentation allows the user to add or delete documentation from the Notes and brings up the screen below.

 

 

The user may save any custom documentation that is of interest to the clinician in this list. This list is copied by the SmartOB Customization Utility that is part of all SmartOB forms, v3.16 and above. This user customized list will then be available for routine use in the documentation of all pregnancies, increasing efficiency by eliminating the need to type the statements.

 

 

You may need to write a prescription for the medications that you are entering into the Progress Notes and adding to Form 3. The built-in prescription utility allows you to quickly create and print the prescription with minimal effort.

As explained above, clicking the Add Rx button adds the medication and dosage to the Prescription Form. Clicking the Show Rx button opens the Prescription Form. The Patient's Name, Number, DOB and Address are automatically filled in. The Practitioner's Name, License Number and DEA are filled in when the Practitioner is selected.

Clicking the Practitioner Management button reveals a form that allows the addition and/or deletion of up to 30 Practitioners. These should be entered into your template forms.

The Name of the Practice, Address and Phone numbers are user customizable.

The text of the prescription was programmed to print in blue on a color printer. If you are using a B&W printer or you have purchased security paper, you can change the wording at the bottom of the script. You can get security paper here.

 

 

This form appears when an empty Signature field is selected on Form 4. It allows for entering a Signature without a keyboard and provides management of the Signatures on the Forms. It is recommended that you use the first initial and the last name as the signature; e.g., J. Davis.

Once you enter the Signatures of those who will be typically using the forms, you may save them as part of the template forms so you don't have to keep entering them with every new patient.


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SmartOB is a registered trademark and SmartOB Prenatal Forms are Copyright Charles S. Bloom, MD
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Last modified: 01/04/15