Clinical Information (Web App)

Why Use This Function:

The Gynaecological History Panel provides a detailed overview of the Patient’s reproductive and general health history, supporting more accurate clinical decisions. By recording past pregnancies, menstrual cycles, genetic risk factors, and infection history, Practitioners can identify patterns, manage risks, and offer appropriate care. Having this information available in one place helps guide treatment, track changes over time, and improve Patient outcomes.

💡Please Note: This panel will only be available to female Patients.

The Contents of This User Manual:

• Past Pregnancies Sub Panel
• Menstrual History Sub Panel
• Genetics Screening/Teratology Counselling Sub Panel
• Infection History Sub Panel

• This user manual will start on the Medical History screen.

• For more information on how to navigate to the Medical History screen, please refer to the user manual: Clinical Screen: Navigation and Use.
  
  
• Click on the Gynaecological History panel.

• The Gynaecological History panel will expand.

Past Pregnancies Sub Panel

Capturing a Patient’s pregnancy history helps Practitioners assess reproductive risks, identify complications, and guide future pregnancy care.

• Total: The total number of Pregnancies.
• Abortion Spontaneous: The number of pregnancies that ended in miscarriage.
• C-Section: The number of deliveries completed by Caesarean section.
• Full Term: The number of pregnancies carried to full term.
• Abortions Induced: The number of pregnancies that were medically or surgically terminated.
• Pre-Term: The number of pregnancies that ended before reaching 40 weeks of gestation.
• Ectopics: The number of pregnancies where the fertilised egg implanted and developed outside the uterus.
• Living: The number of children born alive and currently living.
• Multiple Births: The number of pregnancies resulting in more than one baby, such as twins or triplets.

• Click on the Add Pregnancy button to add a Pregnancy.

• A Pregnancy panel will open.

• Click on the added Pregnancy panel to expand more options.

• Click on the Date field to select the date the Pregnancy ended from the date picker that becomes available.

• Click on the GA Weeks field to enter the Gestational Age in weeks.

• Click on the Length of Labour text field to enter the exact time of labour in either days, hours or minutes.

• Click on the Birth Weight (kg) field to enter the weight of the infant.

• Click on the Sex drop-down menu to select the gender of the infant.

• Click on the Anaesthesia field to enter the details if Anaesthesia was administered, including the amount.

• Click on the Place of Delivery field to enter where the delivery took place.

• Click on the Delivery Type drop-down menu to select the type of delivery that was done.

• Tick the Ectopic checkbox if the birth was Ectopic, meaning the fetus developed outside the uterus.

• Tick the Multiple Births checkbox if there were more than one birth, for instance, twins.

• Tick the C-Section checkbox if the birth was a C-section. 

• Click on the Comments/Complications field to enter any related notes to the birth or any complications.

• Click on the Remove button to remove the Pregnancy information.

Menstrual History Sub Panel

Recording menstrual history allows for better insight into hormonal patterns, fertility tracking, and can assist in diagnosing reproductive or systemic issues.

• Click on the Definite date field to enter the confirmed date of the Patient’s last menstrual period from the date picker that becomes available.

• Click on the Approximate (month) field to enter how many months ago the Patient believes their last period occurred if the exact date is unclear.

• Click on the Unknown date field to capture a date when the Patient is unsure of their last menstrual period from the date picker that becomes available.

• Click on the Normal Amount/Duration field to enter how many days the Patient’s menstrual cycle usually lasts.

• Click on the Final date field to capture the date of the Patient’s final menstrual period from the date picker that becomes available.

💡Please Note: This field is only relevant to Patients entering menopause.

• Tick the Monthly checkbox to indicate whether the Patient’s menstruation occurs regularly each month.

• Click on the Prior (date) field to enter the date of a previous menstrual period if it is relevant to the Patient's cycle history.

Genetics Screening/Teratology Counselling Sub Panel

This sub-panel helps identify inherited conditions or risk factors that may affect the health of the Patient or infant, allowing for early intervention or informed choices.

• Tick the Patient's Age is Greater Than 35 Years checkbox if the Patient is over 35, which can increase the risk for genetic abnormalities.

• Tick the Thalassemia checkbox if the Patient has ancestry from Italian, Greek, Mediterranean, or Asian backgrounds and meets the blood test criteria (MCV < 80).

• Tick the Neural Tube Defect checkbox if there's a known history of conditions like Meningomyelocele, Spina Bifida, or Anencephaly.

• Tick the Congenital Heart Defect checkbox if a heart defect has been diagnosed in the Patient or family.

• Tick the Down Syndrome checkbox to indicate any family history or risk of Down Syndrome.

• Tick the Tay-Sachs checkbox for relevant heritage (Jewish, Cajun, French Canadian) or known diagnosis.

• Tick the Sickle Cell Disease or Trait (African) checkbox if there's a known sickle cell trait or diagnosis, especially in African backgrounds.

• Tick the Haemophilia checkbox if there’s a history of this bleeding disorder in the family.

• Tick the Muscular Dystrophy checkbox for any known muscular degenerative conditions.

• Tick the Cystic Fibrosis checkbox if there’s a diagnosis or family history of this condition.

• Tick the Other Inherited Genetic or Chromosomal Disorder checkbox to capture conditions not specifically listed; this is for additional relevant disorders. 

• Tick the Maternal, Metabolic Disorder checkbox if there are conditions like diabetes or PKU present.

• Tick the Huntington Chorea checkbox if there’s a known or suspected diagnosis of this neurological disorder.

• Tick the Recurring Pregnancy Loss or Stillbirth checkbox if the Patient has a history of such outcomes.

• Tick the Mental Retardation / Autism checkbox to indicate a history or concern around developmental disorders.

• When this checkbox is ticked, an additional option will appear. 

• Tick the Was Person Tested for Fragile X checkbox if the person was tested for Fragile X.

• Tick the Patient or Baby’s Father had a Child with Birth Defects checkbox if there’s a history of congenital anomalies.

• Tick the Medications / Street Drugs / Alcohol Since Last Menstrual Period checkbox if the Patient has taken any of these substances. 

• When this option is ticked. Another field will appear where the Agents can be listed.

• Tick the Any Other checkbox to indicate any additional factors that may affect fetal development or pregnancy. 

• Click on the Comments/Complications text field to enter any additional information and notes regarding the parents' Genetics.

Infection History Sub Panel

Tracking infections supports safer care during pregnancy by helping Practitioners avoid complications and protect both the Patient and the infant from preventable risks.

• Tick the High Risk Hepatitis B / Not Immunised checkbox if the Patient has not been immunised against Hepatitis B or falls into a high-risk group.

• Tick the Patient or Partner has History of Genital Herpes checkbox if either the Patient or their partner has previously had genital herpes.

• Tick the Live with Someone with TB checkbox if the Patient currently lives or has lived with someone diagnosed with Tuberculosis.

• Tick the Exposed to TB checkbox if the Patient has had any known exposure to Tuberculosis.

• Tick the History of STD, GC, Chlamydia, HPV, Syphilis checkbox if there is a known history of any sexually transmitted infections.

• Tick the Rash or Viral Illness Since Last Menstrual Period checkbox to note any recent infections or skin rashes that could affect pregnancy. 

• Tick the Human Immunodeficiency Virus checkbox if the Patient has tested positive or been diagnosed with HIV.

• Tick the Acquired Immune Deficiency Syndrome checkbox if the Patient has been diagnosed with AIDS.

• Tick the Other checkbox for any infectious condition not listed here that may be medically relevant.

• Click on the Comments text field to add any other necessary information regarding the Infection History.

• Click on the Save button to save all changes.