Effective clinical documentation is critical for midwives, ensuring comprehensive patient care and continuity. The antenatal visit document should follow a structured approach to capture all relevant details. Here's how to use the provided template to create a well-organized and informative record.

Patient Information

Begin by recording the Date and Time of the Nursing Assessment and the Location. For example:

Date and Time of the Nursing Assessment: 2023-10-15 10:00 AM
Location: Maternity Clinic, Room 5

Subjective

This section captures the patient's reported experiences and concerns. Include details like gestation weeks, Braxton Hicks contractions, and any mental health issues. For instance:

• Gestation in weeks: 32 weeks

• Braxton Hicks contractions details: Occasional, mild contractions noted

• Mental health reported: Feeling anxious about delivery

Objective

Document measurable and observable factors. Key elements include measurements like fundal height and vital signs. Example:

• Fundal height measurement: 32 cm

• Blood pressure: 120/80 mmHg

• Foetal heart rate: 140 bpm

Assessment

Summarize the assessment of the pregnancy status and any known medical conditions. For example:

Pregnancy status and gestation: Healthy pregnancy at 32 weeks

Plan

Outline the management and follow-up actions. Include discussions on labor management and equipment use:

• Labour management discussion details: Discussed signs of labour and when to call the clinic

• Next appointment focus: Monitoring foetal growth and maternal well-being

Interventions

Detail any educational topics or interventions provided to the patient:

• Provided education on: Signs of labour, Pain management techniques

Evaluation

Reflect on the patient's engagement and understanding of the birth plan:

Patient and partner engagement and understanding: Both engaged and understanding of birth plan

Plan for Continuing Care

Document plans for follow-up care and any additional tests:

Routine ultrasound at 36 weeks

Additional Notes

Include any pertinent additional information, such as community involvement:

Patient's community involvement: Active in prenatal yoga class

The process of documenting antenatal visits can be significantly enhanced using AI medical scribes like Notis. This tool is designed to streamline and automate the creation of SOAP notes, ensuring efficiency and accuracy in midwifery care.

Time Efficiency

Notis reduces documentation time by up to 80%, allowing midwives to focus more on patient interaction and care. This reduction translates to saving approximately 2 hours daily on administrative tasks, thereby enhancing productivity and reducing burnout.

Ease of Use

With its integration into WhatsApp, Notis provides an intuitive interface that requires no additional software or learning curve, making it accessible for midwives.

High Accuracy and Comprehensive Documentation

Utilizing advanced voice-to-text technology, Notis ensures a 99% accuracy rate in transcribing medical notes. It converts consultations into structured SOAP notes, supporting midwives in maintaining comprehensive patient records.

Conclusion

AI medical scribes like Notis offer a revolutionary approach to patient documentation in midwifery. By automating and enhancing the quality of clinical notes, they enable midwives to dedicate more time to patient care, ultimately improving outcomes in antenatal visits.