Prenatal notes are a running record, not a one-off SOAP
EGA, fundal height, fetal heart, glucose testing, Tdap, and Rhogam live on a flowsheet. Missing one item in the narrative is how a late-term gap shows up in review.
Obstetrics & Gynecology
Prenatal visits, problem pregnancies, and GYN procedures — GTPAL, GDM, and colposcopy detail drafted from the encounter, not reconstructed after clinic.
The problem
EGA, fundal height, fetal heart, glucose testing, Tdap, and Rhogam live on a flowsheet. Missing one item in the narrative is how a late-term gap shows up in review.
Cesarean notes need indication, uterine incision, EBL, counts, and neonatal status. A clinic template cannot be stretched into that op note.
Indication, cytology, transformation zone, biopsies, and ECC have to match ASCCP logic. ‘Colpo done’ does not survive an audit.
How Augustun fits
Antepartum problem visits capture GDM, hypertension, and fetal testing; well-woman and GYN visits keep a separate structure.
Session Prep surfaces last EGA, labs, and risk stratification so today’s visit continues the prenatal care plan instead of restarting it.
Pregnancy complication ICD-10 and colposcopy/delivery CPTs are proposed from documented indication and findings.
Antepartum problem notes, cesarean operative notes, risk-stratified prenatal plans, and colposcopy procedure notes.
Outcomes
2+
Hours saved per OB/GYN per day across clinic and L&D notes
GTPAL
Obstetric history elements captured in the prenatal record
400+
EHRs via browser extension (Epic, athena, ModMed)
FAQ
Yes. Dating, fetal assessment, labs, and problem-pregnancy issues discussed in the visit are structured into the antepartum note.
Yes. Indication, procedure details, and neonatal status are drafted into an operative-note format you review before signing.
Yes. Indication, findings, biopsy/ECC, and plan are structured for ASCCP-style follow-up.
Free templates
Ready-to-use SOAP, BIRP, and specialty note templates you can copy into your workflow today.
Start free — no credit card required. Most clinicians are live in under 10 minutes.
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