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Care module This visit Maternal & Reproductive Health

Suggested: General OPD • Final: Maternal & Reproductive Health

Step 2

Consultation

Maternal & Reproductive Health

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CESJUJM2606014

Sex —
Age —
Phone —
Allergies —

Maternity module: chief complaint uses the maternity symptom list (search below). Follow-up questions load from the maternity menu. Use the next tab for menstrual, obstetric, antenatal/postnatal, and related history.

Presenting symptoms (maternity list)

Select every symptom that applies. Use the tabs below to explore each one in turn—complete all tabs. Add free text for complaints not listed.

Quick pick from list

Maternal & reproductive health — Fields below apply to the maternity module (antenatal / postnatal / reproductive care).

Menstrual history

ANC contact schedule — 8 contacts

Contact 1 12 weeks

Screening & investigations

These fields will be automatically populated from Step 5 — Investigations (and Step 3 for obstetric examination) once completed.

Human immunodeficiency virus (HIV) test result
Will populate from Step 5 — Investigations
Hepatitis B surface antigen result
Will populate from Step 5 — Investigations
Syphilis — rapid plasma reagin test result
Will populate from Step 5 — Investigations
Tuberculosis (TB) screening result
Will populate from Step 5 — Investigations
Anaemia — full blood count / haemoglobin result
Will populate from Step 5 — Investigations
Asymptomatic bacteriuria — midstream urine result
Will populate from Step 5 — Investigations
Gestational diabetes mellitus result
Will populate from Step 5 — Investigations
Ultrasound scan (before 24 weeks) result
Will populate from Step 5 — Investigations
Obstetric examination result
Tenderness — epigastric Tender, flanks Not assessed; Lie/presentation: Transverse / Breech; FHR no; Liver Not palpable / normal, spleen Enlarged

First contact — LNMP & booking

Gestational age (from LNMP)
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EDD
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Booking
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Currently on supplements?

Preventive treatments & supplements

These fields will be automatically populated from Step 7 — Treatment once completed.

Daily iron (30–60 mg) + folic acid (400 µg) given
Will populate from Step 7 — Treatment
Intermittent iron (120 mg) + folic acid (2.8 mg) weekly alternative
Will populate from Step 7 — Treatment
Calcium (1.5–2.0 g daily) given
Will populate from Step 7 — Treatment
Vitamin A supplementation given
Will populate from Step 7 — Treatment
IPTp-SP — malaria prophylaxis (first dose at 13 weeks) given
Will populate from Step 7 — Treatment

Assessments

Complications during this pregnancy?

Complications in past pregnancies?

Recorded at first contact only — not repeated on Contacts 2–8.

Obstetric summary

Past obstetric history

Record each previous pregnancy: outcome, GA at birth, mode of delivery, Apgar score, birth weight, complications, and any additional comments.

Year Outcome GA at birth Mode of delivery Apgar score Birth weight Complications Comments

Postnatal history

Sexual history (optional — may skip)

Contraceptive history

Continue to Past medical & surgical and the following tabs for general history (same as non-maternity visits).

Past medical and surgical history
Drug / medication history

Allergies & drug sensitivities

Check before prescribing — record any known allergy or adverse drug reaction.

Family history
Personal and social history
Notes
Who is entering?

Optional. Use when the person entering data differs from the logged-in user, or for documentation.

Complete registration Back

Further visit steps after examination include differential diagnosis, diagnostics, definitive diagnosis, then Treatment (medicines, disposition, and completing care).