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Symptoms, Case Info, and Previous Pregnancies

Where to record symptoms, case information, pregnancy counts and previous pregnancies, and which record each one belongs to.

Written by Jonathan Marbutt

Use the field's record context to decide where to save information. Case history, visit findings, the client's pregnancy counts and previous pregnancies are separate records.

Open the client's visit, select Workspace, then open the Medical History chart tab. It covers medication, substance use, smoking, and vaping, and saves to the case's Case Info fields listed below. Viewing Medical History requires the Visits View permission; see User Groups: What Staff Can Open and Change.



Quick answer

Information

Where to work

Medication/Drug Usage and Abuse Info

The case's Case Info section

Physical Symptoms choice

Case Info, in the Birth Control Information group

Birth Control Type

Case Info, in the Birth Control Information group. You can select more than one type

Type of STD

Case Info, in the STD Information group

Gestational age, LMP and due date estimates

Case Info, in the Dating group at the top of the tab. These are read-only summaries calculated from the case's pregnancy test and ultrasound visits, not fields you type into; to change them, update the source visit

Pain, pain rating, bleeding/spotting and prenatal care

The existing clinical Vitals/symptom fields; these have not all returned to Case Info

Current STI tests and results

The visit's STI Tests section

How many times the client has been pregnant before (pregnancies, carried, miscarriages, abortions, other)

The Pregnancy History group on the client's Client Info tab, also shown in the visit's Client section

Details of each past pregnancy (test, outcome, birth)

The client's Previous Pregnancies collection



Pregnancy History and Previous Pregnancies

Pregnancy centers record a client's past pregnancies in two places. Both describe pregnancies before the current one. The current pregnancy is tracked on the case and its visits.

  • Pregnancy History is a quick count of the client's past pregnancies: Pregnancies, Carried, Miscarriages, Abortions and Other. It is on the client's Client Info tab and in the Client section of the visit's Workspace. Do not count the current pregnancy. CoolFocus 3 called these fields Previous pregnancies (not including this one).

  • Previous Pregnancies is an optional, detailed list with one entry per past pregnancy: test date and result, outcome and outcome date, weeks pregnant, decision, and baby details. On the visit's Workspace tab, open Previous Pregnancies in the Client & case group and choose Add. The same list appears below the counts on the client's Client Info tab. Entries are shared across all of the client's cases and visits.

Neither one fills in automatically from cases or visits, and adding a Previous Pregnancies entry does not change the counts. Keep the counts up to date when a client returns, and add detailed entries when your center wants them.

The Health History chart also has a group named Pregnancy History. That group is different: it records history of tubal ligation, history of ectopic pregnancy, whether an IUD is in place, and the age the client became sexually active.



Avoid duplicate entries

Standard Visit Record sections let staff edit standard care fields directly. An additional chart document is for its own questions and workflow. Existing documents may contain historical answers or mapped questions, but do not create another chart solely to reach Case Info or current test results.



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