Gynaecology software: antenatal care and outpatient visits in one record

A general clinic program suits many consultations, but much of gynaecology's work is counting and comparing: weeks of pregnancy, this scan against the last, a smear result that arrives a fortnight later. The signs that the record no longer fits:

• The due date lives on a cardboard wheel, and the weeks are counted again by hand at every visit.
• The only complete antenatal history is in her handbag. When she forgets the card, the visit starts from memory.
• Scan findings are buried in prose. “Endometrium thin” cannot be set against last year's scan, and a fibroid moves with whoever describes it.
• Smear results arrive on paper and stay there, so nobody can say which women still need a call.
• Anyone with a login can read the notes, the same people who see the vaccination list.

Software for gynaecology practices earns its place by keeping these facts as dates, numbers and named categories that it can count, print and compare.

A good gynaecology record lets the next clinician carry on with the pregnancy, or the screening, without asking the woman to tell her story again.

The list is vendor-neutral: use it to compare any programs, paper forms included.

One antenatal contact in the gynaecology department of OPALEVI, from booking to printed card. Bold text is what the screen says.

1. 1

   Book the visit

   Reception chooses Add appointment, picks the woman, the clinician and the time, and ticks Email the patient a reminder the day before if she has an email address on file.

2. 2

   Take the vital signs

   A nurse or midwife fills in Vital signs: weight, blood pressure, pulse, oxygen saturation and glucose. Nurses prepare the visit; the clinician writes the clinical record.

3. 3

   Write the history

   Under Obstetric history: Pregnancies (G), Births (P), Abortions (A), the Last menstrual period (first day) and, when relevant, Contraception.

4. 4

   Tick the pregnancy

   Tick Currently pregnant. The Examination date takes the visit's day, and OPALEVI shows the Estimated due date, 280 days after the last period began, and the Gestational age (weeks+days), written 12+3. Unticked, both stay empty, so a contraception visit never prints a due date.

5. 5

   Fill in the card

   Add Blood group and Rh, the Date of first antenatal visit and, if the scan's dating is followed, the Estimated due date by ultrasound. Today's line goes under Antenatal contacts, which holds up to forty lines.

6. 6

   Mark the abdomen

   On the Obstetric map, pin where the fetal heart is heard and choose its position, the lie and the presentation. Two pins mean twins.

7. 7

   Print and rebook

   Save, press Antenatal card for the card she carries, and under Next steps use Book a follow-up appointment.

Three things stay with the clinician: contact-line weeks are typed; when the two due dates differ, OPALEVI prints both and does not choose; and a new visit starts empty, so the obstetric history, the last period and earlier contact lines are typed again.

Know where the record stops, too: there is no labour or birth record, partograph or CTG, and no fetal biometry; obstetric scan measurements go in the examination text or an attached report. The newborn's Apgar scores and examination belong to the paediatric record: see paediatric clinic software.

Most visits are not pregnancies. The same Gynaecological examination record holds the yearly check, the scan for heavy bleeding and the colposcopy after an abnormal smear.

Pelvic ultrasound as numbers

Pelvic ultrasound records Uterine dimensions in millimetres, Endometrial thickness and, for both Ovaries, length, width and follicle count. The Uterus map places what numbers cannot, such as a polyp, a cyst or a fibroid with its size, the fibroid also by wall position or FIGO fibroid type (0–8).

Smear and HPV results

Under Cervical screening, the Pap smear (Bethesda) is one Bethesda category, from NILM to an unsatisfactory specimen, and the HPV test is negative, positive for 16/18, positive for other high-risk types, or not performed. OPALEVI records the category; what follows an ASC-US stays the clinician's call.

Colposcopy on a clock face

The visit's colposcopy tab holds the findings text and a photographed cervix with the external os at the centre. Each mark records the finding, its Grade (IFCPC) and whether a biopsy was taken; the record adds the indication, the Transformation zone type, the impression and the plan.

The Pelvis map and the Breast map complete the examination. Like every section above, they are drawn only for a female patient; a partner seen in the department keeps the prescription, the referral letter and the charts.

Each document comes from the saved visit and carries your letterhead once it is set up:

• Antenatal card: blood group, G/P/A, the last period and both due dates, today's findings, the contacts table, and a line asking her to bring the card to every visit and to the birth.
• Colposcopy report: the indication, the smear result, the assessment, the clock drawing with numbered marks, a table of each mark's finding and biopsy, the impression and the plan.
• Print prescription: each medicine with its dose, route, frequency, duration and instructions.
• Print referral letter: Referred to, Urgency and the reason, with the visit's diagnosis and therapy added for you.
• The visit report: vital signs, the doctor's report, the record's lines and the charts across visits.

Measurements across visits draws blood pressure, weight and glucose from each visit's vital signs, so over a pregnancy the charts build themselves.

Gynaecology shares the desk, the laboratory and the cash box with the rest of the clinic.

• Privacy first. With two or more departments, Record privacy offers each one The whole clinic, The department or Only the clinician. Gynaecology starts at The department: its staff, the clinician the visit is assigned to and the administrators. Others see only that a visit happened, when, and with whom. A single-department practice chooses between everyone in it and Only the clinician.
• Reception books and takes payment. The visit's payment panel shows billed, paid and remaining, with Print receipt; the desk's day is covered in clinic reception software.
• The laboratory. With a laboratory in OPALEVI, analyses are requested from the visit's Analyses card and read under Analysis results. An outside laboratory's smear is entered as its Bethesda category, with the report attached as a PDF. See medical laboratory software.
• Referrals. In a clinic with several departments, Refer to a department sends a request to the right worklist.
• Follow-ups. Create follow-up task puts “call her with the smear result” on a colleague's list.

Each section shows who wrote it and when, and Change history keeps the before and after of every save.

Ask them of any program, OPALEVI included, using a real week of your visits.

Shared modules are on the features page; for a checklist that suits any clinic, read how to choose clinic software.

Register as a private practice, or as a clinic or hospital, and the First steps checklist on the Today screen leads the way:

1. 1

   Set your prices

   Under Add your services and prices, replace the starter list with your consultations, scans and smears.

2. 2

   Put your name on the paper

   Set up the report letterhead so the card, the letters and the reports carry your name and address.

3. 3

   Invite the team

   Invite your colleagues with their own accounts; give midwives and nurses the gynaecology department, so its privacy lets them in.

4. 4

   Check who reads the records

   With two or more departments, confirm gynaecology's Record privacy under Settings → Department setup.